Tackling Obesity in England - National Audit Office

Tackling Obesity in EnglandREPORT BY THE COMPTROLLER AND AUDITOR GENERALHC 220 Session 2000-2001: 15 February 2001Thou seest I have more fleshthan another man, andtherefore more frailty... King Henry the Fourth, Part I - Act III. Scene III

The National Audit Officescrutinises public spendingon behalf of Parliament.The Comptroller and Auditor General,Sir John Bourn, is an Officer of theHouse of Commons. He is the head of theNational Audit Office, which employs some750 staff. He, and the National Audit Office,are totally independent of Government.He certifies the accounts of all Governmentdepartments and a wide range of other publicsector bodies; and he has statutory authorityto report to Parliament on theeconomy, efficiency and effectivenesswith which departments and other bodieshave used their resources.Our work saves the taxpayer millions ofpounds every year. At least £8 for every£1 spent running the Office.

Tackling Obesity in EnglandREPORT BY THE COMPTROLLER AND AUDITOR GENERALHC 220 Session 2000-2001: 15 February 2001LONDON: The Stationery Office£0.00Ordered by theHouse of Commonsto be printed on 8 February 2001

ContentsExecutive summary and 1recommendationsPart 1: Introduction 7What is obesity? 7Why we studied obesity 7The administrative context 7Study methodology 10Part 2: The prevalence and 11costs of obesity in EnglandA standard definition of obesity 11This report has been prepared under Section 6 of theNational Audit Act 1983 for presentation to the Houseof Commons in accordance with Section 9 of the Act.John BournNational Audit OfficeComptroller and Auditor General 7 February 2001The Comptroller and Auditor General is the head of theNational Audit Office employing some 750 staff. He, andthe National Audit Office, are totally independent ofGovernment. He certifies the accounts of all Governmentdepartments and a wide range of other public sectorbodies; and he has statutory authority to report toParliament on the economy, efficiency and effectivenesswith which departments and other bodies have used theirresources.About a fifth of the population is obese and nearly 11two thirds of men and over half of women inEngland are either overweight or obeseThe prevalence of obesity in England has almost 12tripled since 1980 and will increase further onpresent trendsEvidence suggests that obesity is increasing 12more rapidly in England than in other parts of EuropeThe distribution of obesity in the population 12Changes in eating patterns and increasingly sedentary 13lifestyles are the most likely explanation for theupward trend in obesityThe substantial human costs of obesity 14We estimate that obesity cost the National Health 16Service at least around £½ billion in 1998The indirect costs of obesity in England may be around 17£2 billion a yearOn present trends, the costs of obesity could increase 17by a further £1 billion by 2010For further information about the National Audit Officeplease contact:National Audit OfficePress Office157-197 Buckingham Palace RoadVictoriaLondonSW1W 9SPTel: 020 7798 7400Email: enquiries@nao.gsi.gov.ukWebsite address: www.nao.gov.uk

TACKLING OBESITY IN ENGLANDPart 3: Management of obesity 19in the National Health Servicea) Action by the Department of Health and the 19NHS Executiveb) Local strategies to address obesity 20c) Managing obesity in general practice 21i) Managing obesity in general practice: general 21advice, screening and personal adviceii) Managing obesity in general practice: drug 26therapyiii) Managing obesity in general practice: onward 26referrald) Interventions elsewhere in the National 29Health ServiceAppendices1 Audit methodology 472 The measurement of obesity 503 Global prevalence and trends in obesity 514 The demographic distribution of obesity in England 525 The human costs of obesity 556 Estimating the cost of obesity in England 577 Department of Health policies and initiatives which 63address obesity, diet and physical activityBibliography 65Part 4: Initiatives across 31Government to address theproblem of obesityThere is a substantial amount of joined up working 31across Government related to the prevention of obesityInitiatives addressing the population as a whole 33i. Promoting active transport 33ii. Promoting more active recreation in society 34iii. Identifying and promoting healthy patterns ofeating 36Initiatives targeting children and young people 39iv. Equipping young people for a healthy lifestyle 39v. Promoting a healthy school environment 40vi. Promoting healthy travel to school 40vii. Promoting sport and physical recreation in 41schoolsviii.Promoting healthy eating in schools 44Photographs by kind permission:Cover: Falstaff - Mary Evans Picture LibraryPage 4, 5 and 41: Walking Bus - Findlay KemberPage 14 and 15: British Heart FoundationPage 25: Carnegie International CampPage 25 and 35: Pedestrians Association - Jennifer BatesPage 35: Transport 2000

TACKLING OBESITY IN ENGLANDexecutive summary& recommendations1 Obesity occurs when a person puts on weight to the point that it seriouslyendangers health. Some people are more susceptible to weight gain for geneticreasons, but the fundamental cause of obesity is consuming more calories thanare expended in daily life.2 In 1980, eight per cent of women in England were classified as obese,compared to six per cent of men. By 1998, the prevalence of obesity had nearlytrebled to 21 per cent of women and 17 per cent of men 1 and there is no signthat the upward trend is moderating. Currently, over half of women and abouttwo thirds of men are either overweight or obese. The growth of obesity inEngland reflects a world-wide trend which is most marked in, though notrestricted to, developed countries. Most evidence suggests that the main reasonfor the rising prevalence is a combination of less active lifestyles and changesin eating patterns.3 Obesity has a substantial human cost by contributing to the onset of disease andpremature mortality. It also has serious financial consequences for the NationalHealth Service (NHS) and for the economy. Though there are inherentuncertainties in quantifying the link between obesity and associated disease, weestimate that it costs at least £½ billion a year in treatment costs to the NHS, andpossibly in excess of £2 billion to the wider economy (Figure 1 and Appendix 6).Key facts about obesity in Englandn 1 in 5 adults is obesen The number has trebled over the last 20 yearsn Nearly two thirds of men and over half of women are overweight or obeseThe four most commonproblems linked toobesity:n Heart diseasen Type 2 diabetesn High blood pressuren OsteoarthritisThe estimated humancost:n 18 million sick days ayearn 30,000 deaths a year,resulting in40,000 lost years ofworking lifen Deaths linked toobesity shorten lifeby 9 years on averageThe estimated financialcost:n £½ billion a year intreatment costs to theNHSn Possibly £2 billion ayear impact on theeconomy4 Obesity is not an easy problem to tackle, though even modest weight lossconfers significant medical benefits. Against a background of rising prevalence,halting the upward trend presents a major challenge. Part of the solution lies inpreventing people from becoming overweight and then obese, as much ashelping those who are already obese. As a lifestyle issue, the scope for policyto effect such changes in a direct way is very limited. The Department of Healthcannot by itself be expected to be able to 'cure' the problem.executive summary1

TACKLING OBESITY IN ENGLAND5 The Government believes, however, that prevention is important. TheDepartment of Health has prioritised the reduction of coronary heart diseaseand cancers, and is developing preventive strategies to improve diet andphysical activity. The NHS provides management of obesity, ranging fromgeneral advice on diet and exercise to onward referral for specialist help. OtherGovernment departments have an influence through school education and thepromotion of healthy eating and physically active travel and recreation.6 We examined the way in which the NHS manages the problem of obesity. Wefound that many health authorities reflected the problem in their local healthplanning, and some had dedicated strategies to address it. The National ServiceFramework for coronary heart disease, published in March 2000, signals theDepartment of Health's intention to ensure that, in future, all NHS bodies,working closely with local authorities, will develop and implement effectivepolicies for reducing overweight and obesity.7 Within the NHS, most contact with overweight and obese people occurs ingeneral practice. We surveyed general practitioners and practice nurses andfound that many provided valuable services in identifying those at risk fromweight gain and offering advice and support. But this was not universally thecase, and there is scope to clarify the role of the primary care team and spreadgood practice. There is uncertainty about which interventions are effective inpreventing and treating obesity, and our survey identified a widespread feelingamongst general practitioners that they need more information on how toaddress weight issues effectively, and that guidance would be valuable.8 We also assessed how well the various public sector agencies combine toinfluence the prevalence of obesity. We found that while Governmentdepartments are working closely together, particularly to encourage healthylifestyles amongst schoolchildren, there are opportunities to build further on thesuccess of joint working to date.9 One function of this report is to stimulate wider debate, and contribute to thedevelopment of longer term changes in which individuals are aware of theproblems of obesity. We view this in the same light as another lifestyle issue -smoking - where education and time have brought about significant changesfor the better. Our detailed findings and recommendations follow.Main findings and recommendations on themanagement of obesity in the NHS10 We found that while significant health benefits could be achieved throughinterventions that help people to lose excess weight, the management ofoverweight and obese patients within the NHS was patchy. Local strategies toaddress obesity had been developed in some areas, but not in the majority.2execuitve summary11 At the time of our research in Summer 1999, there were no national guidelinesfor health authorities on how their plans should address obesity. A largemajority of health authorities (83 per cent) had identified obesity as a publichealth risk in their Health Improvement Programme, but far fewer (28 per cent)had taken action to address it. About 50 per cent of health authorities told usthat, though they did not have a dedicated obesity strategy, their plans wouldhelp to prevent weight gain and obesity by promoting healthy eating andphysical activity as part of coronary heart disease or cancer preventionprogrammes. Health authorities' future plans are expected to take account ofguidance on effective strategies to address overweight and obesity, published inSeptember 2000 by the Health Development Agency in its report onimplementing the preventive aspects of the National Service Framework forcoronary heart disease.

TACKLING OBESITY IN ENGLAND12 Within general practice, there is a wide range of different methods whichgeneral practitioners and practice nurses use for managing overweight andobese patients, and many remain uncertain about which interventions are themost effective. Whilst drug therapy, for example, was used by about 40 per centof general practitioners in our survey, most of those we interviewed hadreservations about its effectiveness, despite recognising that it could be a usefulaid to accelerating weight loss for some patients. The National Institute forClinical Excellence is currently undertaking an examination of anti-obesitydrugs to enable it to advise on their clinical and cost effectiveness.13 We also found some confusion over roles and responsibilities, and evidence ofa lack of 'buy in' by general practitioners for helping overweight and obesepatients to control their weight. There are wide divergences between practicesover aspects of management, including their use of health promotion on weightcontrol, diet and physical activity, and the extent to which they try to assesswhich patients are at risk from excessive weight gain. Only a small minority ofpractices were using a protocol for the management of obese patients, but themajority said that they would find a national protocol or guidelines useful.14 In general, there is little NHS activity related to the management of obesityoutside general practice. Some hospitals provide a valuable service byscreening pre-operative patients for obesity, and referring those who mightbenefit from weight management to their general practitioner for advice andtreatment. There are also a number of specialist centres for the treatment ofobesity, normally offering drug therapy, and about 200 surgical interventionsfor cases of extreme obesity each year. Resource constraints prevent specialistcentres from treating more than a small minority of those obese patients whoseek help from the NHS. There may be scope for more patients to benefit fromsuch specialist treatments, although to date there is only limited evidence oftheir long term effectiveness.15 We conclude that the NHS has a key role in assessing the risks from obesity atthe national and local levels, and devising appropriate strategies to reduce itsimpact. But work is needed at the local level to develop and implement effectivepolicies to prevent overweight and obesity, and to tackle the wider healthimpacts of obesity through effective treatment programmes. In particular, theNHS needs to focus on identifying and helping those who are at high risk ofobesity. This would include targeting interventions at the large proportion of thepopulation already in the "overweight" category, and at those groups where theprevalence of obesity is highest, such as Black Caribbean and Pakistani women.16 General practitioners and their teams can play a key role in assessing the riskto patients, providing health promotion, and providing individual advice andonward referral to relevant specialists. However, these activities need to beundertaken on a more consistent basis across general practice than is currentlythe case. There are opportunities for identifying and spreading good practicemore widely.17 We recommend in particular that:nnin devising local strategies to reduce overweight and obesity, healthauthorities must have regard to the Health Development Agency's guidanceon which interventions have proved most effective;health authorities should ensure that they set realistic milestones and targetsfor improving nutrition and diet, for promoting physical activity and forarresting the rising trends in the prevalence of overweight and obesity. Theyshould also develop indicators of progress in reducing health inequalitiesthrough initiatives that target the population groups at highest risk;executive summary3

TACKLING OBESITY IN ENGLANDnnnthe Department of Health should commission an appraisal of theeffectiveness of interventions for treating overweight and obese people,both within general practice and through onward referral. This reviewshould include the potential role hospitals and specialist weight loss clinicscan play in assessment and treatment, and whether access to such servicesshould be broadened;the Department of Health should build on the plan in the National ServiceFramework for coronary heart disease for a full assessment of risk factors tobe carried out in general practice. The Department should work with itspartners and the professional bodies to clarify the responsibilities of generalpractitioners and the wider primary care team for identifying people at riskfrom excess weight;the Department of Health should liaise with the National Institute forClinical Excellence to draw together and ensure the effective disseminationof guidelines for the management of overweight and obese patients inprimary care. This report provides an initial guide of what general practiceswould find useful.Main findings and recommendations on cross-Government initiatives to prevent obesity18 We found a substantial amount of cross-departmental work in the areas that arecentral to addressing the rising prevalence of obesity - principally education,physical activity and diet. Much of this activity is targeted at schoolchildren.This promotes healthier lifestyles subsequently throughout adult life, andaddresses a section of the population for which obesity is becoming anincreasing problem.19 We conclude that there is a need for the departments involved in this jointworking to build on their successes and to involve other partners at the nationaland local level to develop and implement cohesive strategies for prevention,which encompass adults as well as young people. At the national level, this istaking place to an increasing extent, and departments should develop jointobjectives and performance targets relating to aspects of physical activity anddiet to ensure that this progress is consolidated. At the local level, healthauthorities are well placed to trigger such activity by developing HealthImprovement Programmes that involve a wide range of other partners inschemes to increase cycling, walking and physical recreation and to improvediet, such as through increased consumption of fruit and vegetables.4execuitve summary

TACKLING OBESITY IN ENGLAND20 We recommend in particular that:nnnnnnthe Department of Health should reinforce existing joint working over thecommissioning of relevant surveys and research by establishing a crossdepartmentaladvisory group to co-ordinate all research on obesity andmeasures to prevent it;the Department of Health should lead the development of a new cross-Government strategy to promote the health benefits of physical activity. Thisshould include work to develop and support alternative approaches forgroups where there are specific barriers to physical activity, such as thoseimposed by poverty, cultural beliefs or fears about personal safety;the Department of Health and the Department of the Environment,Transport and the Regions should continue to encourage other potentialpartners, in particular local authorities and health authorities, to adopt localtargets for cycling and walking which provide clear incentives to supporthealthy modes of travel. They should also put in place arrangements tomonitor centrally progress towards achieving these targets;based on the work of the School Transport Advisory Group, the Departmentof the Environment, Transport and the Regions, the Department of Healthand the Department for Education and Employment should work with localagencies to help them develop targets to increase the number of schooljourneys undertaken by bicycle, on foot or on public transport;the Department of Health and the Department for Culture, Media and Sportshould consider the adoption of joint performance targets for increasing thenumber of people participating in sport and physically active leisureactivities. This should build on the strategic target set by the Department forCulture, Media and Sport to raise significantly, year on year, the averagetime spent on sport and physical activity by those aged 5 to 16;the Department for Education and Employment should continue toencourage all schools to achieve the stated aspiration of at least two hoursphysical activity a week for all pupils. This aspiration should remain a coreaspect of the expectations set out in the National Healthy School Standard,and the Department for Education and Employment and the Department ofHealth should continue to develop ways in which the Standard can be usedto reinforce and strengthen physical activity in schools;executive summary5

TACKLING OBESITY IN ENGLANDnnnna joint advisory and co-ordinating group, such as the School Sport Alliance,should monitor the success of initiatives to increase physical activity inschools. The group should include representation from the Department forEducation and Employment, the Department of Health, the Department forCulture, Media and Sport, and Sport England. It should evaluate workcarried out to date and develop ways to build on progress already made;the Department of Health should give a high priority to implementing theinitiatives on nutrition listed in the NHS Plan, working with the foodindustry, including manufacturers and caterers, to improve the balance ofdiet;the Department of Health and the Department for Education andEmployment should work together, seeking the technical advice andsupport of the Food Standards Agency where appropriate, to establish waysto monitor the overall impact of initiatives to improve the nutritional qualityof food provided in school. They should consider developing a performancetarget for achieving an increase in the quantity of fruit and vegetablesconsumed in school;the Department for Education and Employment should work with theNational Consumer Council to strengthen guidance to schools oncommercial sponsorship to ensure that they take full account of thepotential disadvantages of participating in schemes that might promotebehaviours contrary to key messages on healthy eating.6execuitve summary

TACKLING OBESITY IN ENGLANDPart 1IntroductionWhat is obesity?1.1 Obesity is a condition in which weight gain has reachedthe point of seriously endangering health. While somepeople are more genetically susceptible than others, thedirect cause of obesity in any individual is always anexcess of energy intake over energy expenditure.Virtually all obese people develop some associatedphysical symptoms by the age of 40, and the majoritywill require medical intervention for diseases thatdevelop as a result of their obesity before they are 60 2 .Why we studied obesity1.2 Obesity has a substantial human cost by contributing tothe onset of disease and premature mortality. It also hasserious financial consequences for the NHS and theeconomy. These costs are increasing as around20 per cent of the population is now classified as obese,and the upward trend over the last 20 years iscontinuing 1 . We carried out this study:The administrative context1.3 Although obesity is intricately bound up withindividuals' lifestyles, a number of public sectoragencies play a potentially significant role in shapingthe policy response. Figure 2 gives an overview of therole of the various bodies described below.The Department of Health1.4 The management of public health risks such as obesityfalls within the Department of Health's strategicobjective "to reduce avoidable illness, disease andinjury in the population". Within this overall goal, thereare four relevant policy objectives:nnto work across Government and with local agenciesand groups on a range of measures designed toimprove the health of the public;to provide accurate and accessible information onhow to reduce the risk of illness, disease and injury;nnto identify and measure the human costs of obesity,and to estimate the financial costs to the NHS andthe wider English economy (Part 2);to assess how the NHS, and in particular the primarycare sector, is responding to the problem (Part 3);nnto encourage people to live healthily; andto raise standards and set targets to galvanise andencourage widespread improvements in publichealth, and a narrowing of current inequalities inhealth status.nnto examine how effectively different Governmentdepartments are working together to create anenvironment conducive to limiting the prevalence ofobesity (Part 4); andto make recommendations that might help to createa climate in which individuals are aware of theconsequences of obesity, and can make informeddecisions about their lifestyle. In this we draw aparallel with another serious lifestyle issue - smoking- where such an approach has been successful inreducing prevalence within the population as awhole, if not in all sections of it.1.5 In 1992, the Department of Health launched the cross-Governmental 'Health of the Nation' strategy 3 . Thisincluded 27 targets related to the achievement of betterhealth in England. Two of the Department's targetsrelated to the fat content of the diet, and two others tothe future prevalence of obesity for men and women.We reviewed progress towards these targets in 1996 4 .part one7

TACKLING OBESITY IN ENGLAND2The ways in which the public sector influences the prevalence of obesityIndicates influences onpolicy towards obesityDepartment of Health with responsibilities for public health and ensuring that appropriate treatments are availableand provided1999 Our Healthier Nation specifies priority health areas for which obesity is a significantrisk factor2000 National Service Framework for Coronary Heart Disease sets national standards anddefines service models2000 NHS Plan reflects priorities for disease prevention and reducing health inequalities2000 Cancer Plan includes action on dietINPUT FROMLocal Authorities& Social ServicesPrimary Care Groups(Primary Care Trustswhen established)Local agenciesand communitiesRegional Offices of the NHS Executive with overview of local public health planning andresponsibility for monitoring performance in the NHSHealth Authorities have the strategic lead for Health Improvement Programmesincluding action on obesityNHS TrustsOBESITYOTHER GOVERNMENTDEPARTMENTS WITHPOLICIES THAT CANINFLUENCE THEPREVALENCE OF OBESITYAGENCIES WHOSEROLES IMPACT ONHEALTHIER LIVINGDepartment for Culture,Media and SportDepartment for Educationand EmploymentDepartment of theEnvironment, Transport andthe RegionsMinistry of Agriculture,Fisheries and FoodFood Standards AgencyHealth Development AgencyHighways AgencySport England andthe Sports Councils8part one1.6 In 1999, the Department introduced a new cross-Government strategy, 'Saving Lives: Our HealthierNation' 5 , superseding 'Health of the Nation'. Thisfocused on four main priority areas of ill health andpremature death, including coronary heart disease andcancer. There are no specific objectives or targets in thenew strategy to reduce or limit the increase in theprevalence of obesity. The strategy does, however,recognise obesity as an important risk factor forcoronary heart disease and for some cancers. Theapproach is to address risk factors such as obesity byencouraging healthy living patterns, such as healthyeating and regular physical activity, which are key to theprevention of coronary heart disease and some cancers.1.7 In 2000, the 'National Service Framework for CoronaryHeart Disease' was published 6 . This document setsnational standards and defines service models for theprevention and treatment of coronary heart disease. Earlymilestones include the delivery of local programmes ofeffective policies on reducing overweight and obesity,promoting healthy eating and increasing physicalactivity. The 'NHS Plan: A Plan For Investment. A Plan forReform', also published in 2000 7 , further highlights theimportance of diet and nutrition to improve health andreduce health inequalities. The commitment is that by2004, there will be local action to tackle obesity andphysical inactivity, informed by advice from the HealthDevelopment Agency on what works.

TACKLING OBESITY IN ENGLANDRegional Offices of the NHS Executive andhealth authorities1.8 The Department of Health also assumes overallresponsibility for ensuring that appropriate treatmentsare identified and made available through the NationalHealth Service. The eight Regional Offices of the NHSExecutive work with health authorities to ensure thateach region has a set of Health ImprovementProgrammes which address local needs and areconsistent with the national priorities of the NHS.Health authorities have a strategic role to co-ordinatethe local health economy to deliver on the NHSpriorities, including by providing the standards andservice models set out in National Service Frameworks.In compiling its Health Improvement Programme, eachhealth authority is required to involve a wide range oflocal stakeholders including Primary Care Groups andTrusts, NHS Trusts, general practices, local authorities,and local agencies and communities.NHS providers1.9 As detailed in the National Service Framework forcoronary heart disease 6 , NHS Trusts and Primary CareGroups and Trusts are required to contribute to thedelivery of local programmes of effective policies forreducing overweight and obesity.1.10 General practices are where 95 per cent of patientcontacts with the NHS occur 8 . General practitioners arerequired to offer all newly registered patients aconsultation with a full physical examinationcomprising the measurement of height and weight.Thereafter, general practitioners are required to offerphysical examinations for the purpose of identifying andreducing the risk of disease. The National ServiceFramework for coronary heart disease sets out aprogramme of action to improve services for coronaryheart disease. The first priority is to identify and treatpeople with established cardiovascular disease. A laterstage will be to identify people at significant risk ofcardiovascular disease and to offer appropriate adviceand treatment to reduce their risks. This includes adviceon reduction in weight or referral to appropriatespecialists. General practices also provide a forum tooffer broad advice to patients on healthy living, such ason healthy eating and the benefits of physical activity.1.11 The NHS more widely finances and monitors specialisthelp for obese patients referred by general practitioners,involving dietetics, hospital-based clinics and, in somecases, surgery. Hospital admissions also provide anopportunity to assess health risks associated with excessweight and to refer patients for appropriate help.Other Government departments1.12 The Public Health Group of the Department of Healthliaises with the representatives of other Governmentdepartments in order to advise on policies and initiativesto improve health, in particular in relation to dietand nutrition, health education, transport andphysical recreation.1.13 Relevant Government departments and agenciesinclude the Department for Culture, Media and Sport,Sport England and the Sports Councils; the Departmentfor Education and Employment; the Department of theEnvironment, Transport and the Regions and theHighways Agency; the Food Standards Agency; and theMinistry of Agriculture, Fisheries and Food. They have ageneral duty to work with the Department of Health aspart of joining up government within the overallumbrella of the Modernising Government initiative 9 .They also have specific objectives that relate toprotecting the public health and promoting healthylifestyles, for example through improving diet, achievingwider participation in sport and physical activity, andencouraging healthy modes of transport.part one9

TACKLING OBESITY IN ENGLANDStudy methodology1.14 Our methodology is set out in detail in Appendix 1. The main features are:n literature review and consultation withrepresentatives of a wide range of interested parties,including voluntary bodies representing obesepeople;nnnadvice from a panel of eminent experts on obesity;a cost-of-illness study undertaken for us by theDepartment of Economics at City University.Appendix 6 contains the detailed methodology forthis study;a survey of all health authorities in the Summer of1999 to examine their role in planning and coordinatinginitiatives to address obesity and promotehealthy lifestyles;n a postal survey of a representative sample of 1,200general practitioners and 1,200 practice nursesin Summer 1999 to establish how overweightand obese patients visiting their general practiceare managed;nnnface-to-face interviews with 20 general practitionersand 16 practice nurses in November and December1999 to learn more about their experiences oftreating obese patients and their perceptions ofthe problem;interviews with policy personnel at the relevantGovernment departments to examine howeffectively departments were working together andwith other agencies to promote healthy lifestyles;andsite visits to examine local initiatives at schools andhospitals and specialist centres.part one10

TACKLING OBESITY IN ENGLANDPart 2The prevalence and costs of obesityin EnglandA standard definition of obesity2.1 Obesity is most commonly defined by clinicians interms of the body mass index (BMI). The BMI iscalculated as follows:Weight in kilogrammes = BMI(Height in metres) 22.2 A desirable body mass index is considered to be in theregion 20 to 25. Anything above this is defined as'overweight', and a BMI over 30 is defined as 'obese'.Figure 3 illustrates the range of BMI classifications andAppendix 2 provides further details.2.3 The health hazards of obesity are compounded by theinfluence of fat which is distributed around the waist,more typical of obese men than women. For this reason,the waist circumference and waist-hip ratio are alsoused to assess the risks associated with obesity. Thoughthere is no consensus about the cut off points that defineobesity using these indicators, a report by the WorldHealth Organization 10 suggests that increased risk ispresent when the waist circumference exceeds 94 cm(37 inches) for men or 80 cm (32 inches) for women.About a fifth of the population isobese and nearly two thirds of menand over half of women in Englandare either overweight or obese2.4 In 1998, the year for which most recent figures areavailable, 19 per cent of adults in England were obese,with a BMI over 30 1 . More women than men wereobese - 21 per cent of women compared to 17 per centof men. But more men than women were in theoverweight category (BMI between 25 and 30) -46 per cent compared to 32 per cent. Combining theoverweight and obese groups, in 1998 nearly two thirdsof men and just over half of women were eitheroverweight or obese.3Different categories of weight defined by Body Mass Index (kg/m 2 )125115105Morbidly Obese95Weight (kg)8575ObeseOverweightHealthy65Underweight5545part twoHeight (metres)Source: National Audit Office based on classifications used in the Health Survey for England 111

TACKLING OBESITY IN ENGLANDThe prevalence of obesity in Englandhas almost tripled since 1980 and willincrease further on present trends2.5 In 1980, eight per cent of women and six per cent ofmen were classified as obese. By 1998, the prevalenceof obesity had nearly trebled to 21 per cent of womenand 17 per cent of men, and there is no sign that theupward trend is moderating. This reflects a world-widetrend which is most marked in, though not restricted to,developed countries (Appendix 3).2.6 Given that the current level of obesity in England isunprecedented, it cannot be extrapolated forward withany degree of certainty. But if the average rate ofincrease in the prevalence of obesity between 1980 and1998 continues, over one fifth of men and about aquarter of women in England will be obese by 2005,and over a quarter of all adults by 2010 (Figure 4). Thiswould bring levels of obesity in England up to thoseexperienced now in the United States. Ourextrapolation is simple, but quite possibly realistic.Evidence suggests that obesity isincreasing more rapidly in Englandthan in other parts of Europe2.7 In the majority of European countries, where lifestylesand cultures are essentially comparable, theInternational Obesity Task Force estimates that theprevalence of obesity increased by between 10 to40 per cent from the late 1980s to the late 1990s 11 . InEngland, however, prevalence nearly doubled over thisperiod. This means that, whilst in the late 1980s the4 Trends in the prevalence of obesity amongst men andwomen in England extrapolated to 20103025prevalence of obesity in England was towards the lowerend of the range for European countries, by the late1990s it had moved to near the top of the range.(Although directly comparable figures for individualcountries are not available, the Task Force estimates thatprevalence varies between different countries in Europefrom 10 to 20 per cent for men, and from 10 to25 per cent for women).The distribution of obesity in thepopulation2.8 Some people are at a high risk of becoming obese forvery specific reasons. For example, children who have atleast one obese parent are at higher risk of being obesethemselves, reflecting general household patterns ofeating and physical activity 12 , as well as genetic factorsthat may explain differences in the way individualsrespond to similar lifestyles. Other high risk groupsinclude recent successful weight reducers, who areprone to regain weight unless they sustain changes totheir lifestyle in the long term, and people who haverecently stopped smoking who may experience aheightened appetite 13 . People with physical or learningdisabilities may also be at high risk of becoming obese,in particular when opportunities for exercise arerestricted.2.9 A detailed analysis of the distribution of obesity inEngland is given in Appendix 4. The main points are:nnnnobesity in the population increases with age;the prevalence of obesity amongst schoolchildrenappears to be increasing, which potentially bearsmajor risks for the health of the future adultpopulation;people in lower socio-economic groups, particularlywomen, have an increased risk of obesity;there is a higher prevalence of obesity amongcertain ethnic groups, in particular among BlackCaribbean and Pakistani women; and% obese (BMI >30)201510nobesity is a growing problem in all regions inEngland. Prevalence in 1998 ranged from18 per cent of adults in the lowest regions to22 per cent in the highest, and in all regions hadrisen since it was previously measured in 1996.50part two12Note:Source:1980Men19851990Women1995Year20002005Figures beyond 1998 were extrapolated on a straight line bythe least squares method on the basis of data from 1980National Audit Office analysis of data from the Health Survey forEngland 12010

TACKLING OBESITY IN ENGLANDChanges in eating patterns andincreasingly sedentary lifestyles are themost likely explanation for the upwardtrend in obesity2.10 The rapid increase in obesity levels has occurred in tooshort a time for there to have been significant geneticchanges within the population. It is therefore likely thatthe global obesity problem has been brought aboutprimarily by environmental and behavioural changeswhich have led to a more energy-dense diet and a risein the level of sedentary behaviour.Eating patterns2.11 Both total energy intake and the composition of the dietare important factors in influencing changes in bodyweight. The relationship between changes in eatingpatterns and the increasing prevalence of obesity is notclear. Data from the National Food Survey 14 show thathousehold energy intake increased from the late 1950sto a peak in 1970, and since then has declined. On thisbasis, the major increase in the prevalence of obesity inEngland, since 1980, has occurred at a time when theenergy consumed from food appears to have beendecreasing.2.12 However, it is important to note that the falling trend inenergy intake suggested by the National Food Surveydoes not take account of alcoholic and soft drinks andconfectionery brought home, or food and drinkpurchased and eaten outside the home. In 1998, thesecomponents, which have only been recorded since1994, accounted for about an extra 20 per cent ofenergy intake. Eating outside the home is becomingincreasingly popular, and surveys indicate that the foodeaten out tends to be higher in fat than food consumedin the home. Fat has a higher energy density than othercomponents, and fatty foods tend not to satiate theappetite as quickly as foods that are high incarbohydrates. Exposure to high fat foods is thought tobe largely responsible for the 'over-eating effect', alsoknown as 'passive over-consumption', where theappetite fails to regulate adequately the amount ofenergy consumed 10 . The ready availability andextensive marketing of highly palatable, energy-densefoods may be contributing to an increasing tendencytowards over-consumption for those people who do notconsciously regulate their diet.Physical activity patterns2.13 Though comprehensive data on trends in the level ofphysical activity in the population are not available, theupward trend for obesity appears to parallel a reductionin physical activity and a rise in sedentary behaviour.A study commissioned by Sport England, for example,showed that the proportion of young people spendingtwo or more hours per week in curricular school sporthad decreased from 46 per cent in 1994 to 33 per centin 1999 15 . Similarly, between 1986 and 1996 theproportion of under 17 year-olds walking to school fellfrom 59 per cent to 49 per cent, whilst the number ofcar journeys to school nearly doubled 16 . At the sametime, there has been an increase in the number of hoursdevoted to many sedentary activities. For example, theaverage person in England watched over 26 hours oftelevision a week in the mid-1990s, compared with13 hours in the 1960s 17 .2.14 There is also increasing evidence that many people arenot taking sufficient exercise to have a significant benefitto their health. Data from studies undertaken in Englandin 1998 1 demonstrated that, using a criterion of lessthan one 30 minute period of moderate activity perweek, 23 per cent of men and 26 per cent of womenwere sedentary. A quarter of women and just over a thirdof men engaged in regular, moderate activity. Morerecently, the National Diet and Nutrition Survey,published in 2000, which measured physical activitylevels of young people aged between 7 and 18, showedthat most young people in this age group were inactive,as indicated by time spent in moderate or vigorousintensity activities 18 .2.15 A number of factors may have contributed to areduction in the amount of physical activity 10 . Theseinclude:nnna reduction in occupational exercise. The extraphysical activity involved in daily living 50 yearsago, compared with today, has been estimated to bethe equivalent of running a marathon a week;a reduction in exercise due to greater use of the carand wider car ownership;the decline of walking as a mode of transport. Onereason for this is heightened fears about personalsafety, which affect some groups of the populationmore than others. For example, children, womenand older people, especially those living in innercities, are likely to feel particularly vulnerable;nan increase in energy-saving devices in publicplaces, such as escalators, lifts and automatic doors;part two13

TACKLING OBESITY IN ENGLANDnnnless opportunities for young people to take physicalexercise. Factors influencing this include increasingfears among parents about their children's safetywhen unsupervised, and a reduction in the amountof physical education and sport undertaken insome schools;the substitution of physically active leisure withsedentary pastimes such as television, computergames and the internet;fear of racial harassment and cultural beliefs whichmay prevent people from certain black and minorityethnic groups from taking exercise. Differentavenues may therefore be required to promotephysical exercise for these groups.2.17 Figure 5 indicates the extent to which obesity increasesthe risks of developing a number of these diseasesrelative to the non-obese population. The relative risksare based on a comprehensive review of internationalliterature which we carried out to provide the bestestimates that could be applied to the Englishpopulation (Appendix 6). The basis of the estimatesvaries due to differences in the methodologies of thestudies selected, but the table gives a broad indicationof the strength of the association between obesity andeach of the main secondary disease types.5Estimated increased risk for the obese of developingassociated diseases, taken from international studiesDisease Relative risk - women Relative risk - menThe substantial human costs of obesity2.16 Obesity is an important risk factor for a number ofchronic diseases that constitute the principal causes ofdeath in England, including heart disease, stroke andsome cancers. It also contributes to other serious lifeshortening conditions such as Type 2 diabetes. As wellas physical symptoms, the psychological and socialburdens of obesity can be significant: social stigma, lowself-esteem, reduced mobility and a generally poorerquality of life are common experiences for many obesepeople 10 . Appendix 5 provides an analysis of thespecific links between obesity and the most commonserious diseases with which it is associated.Type 2 Diabetes * 12.7 5.2Hypertension 4.2 2.6Myocardial Infarction 3.2 1.5Cancer of the Colon 2.7 3.0Angina 1.8 1.8Gall Bladder Diseases 1.8 1.8Ovarian Cancer 1.7 -Osteoarthritis 1.4 1.9Stroke 1.3 1.3* Non-insulin dependent diabetes mellitus (NIDDM)Note: The BMI range for the obese and non-obese groups used toestimate relative risk varies between studies, which limits thecomparability of these data.Source: National Audit Office estimates based on literature review (Appendix 6)part two14

TACKLING OBESITY IN ENGLANDThe links between obesity and mortality2.18 In addition to increasing the risk of ill health, obesitysignificantly increases the risk of mortality at any givenage 10 . One recent study has shown that the degree bywhich this risk is increased varies depending on physicalfitness: an obese person with a low level of cardiorespiratoryfitness has a higher mortality risk than anobese person who is otherwise physically fit 19 .2.19 Evidence from studies suggests that for young adults ingeneral the risk of mortality for someone with a BMI of30 is about 50 per cent higher than that for someonewith a healthy BMI (20 to 25), and with a BMI of 35 therisk is more than doubled (Figure 6). Whilst thisrelationship between relative mortality risk andincreasing BMI is strongest until the age of about 50, theeffect of overweight on mortality persists into the ninthdecade of life 10 . There is also a link between mortalityrisk and the duration of overweight - those who havebeen overweight for the longest are at highest risk.Obesity accounted for 18 million days ofsickness absence and 40,000 lost years ofworking life in 19982.20 We estimate that in 1998 there were over 18 milliondays of medically certified sickness absence attributableto obesity and its consequences (Appendix 6). Thisfigure is likely to be an underestimate. It excludes bothself-certified and uncertified sickness absence, and takesno account of sickness due to diseases for which theproportion of cases attributable to obesity cannot bequantified. Back pain associated with obesity isexcluded, for example, as there are no data on relativerisk on which to base estimates. Back pain is one of themost common causes of sickness absence and itsinclusion could increase our estimate significantly.6 The relationship between body weight, measured by BMI,and the relative risk of mortalityRelative risk32.521.510.50BMINote: This figure is based on data from a study of female nurses inthe United States. Studies for all adults imply a similarrelationship between BMI and risk of mortality in men.Source: Manson J. E., Willet W. C., Stampfer M. J. (1995). "Bodyweight andmortality among women" - New England Journal of Medicine.part two15

TACKLING OBESITY IN ENGLAND2.21 As a stated reason for sickness absence from work,418,000 certified days were attributed directly toobesity in 1998. The remaining 17.6 million days ofcertified sickness absence from secondary diseasesattributable to obesity are broken down at Figure 7. Thethree biggest contributors were Type 2 diabetes,hypertension and angina, accounting together for threequartersof days of sickness attributable to obesity in1998.7Estimated days of certified sickness absence from thosecases of secondary diseases attributable to obesity inEngland in 1998Stated reason for work absence Estimated days of certifiedsickness absence attributableto obesity (000)Type 2 Diabetes 5,960We estimate that over 30,000 deaths wereattributable to obesity in 19982.22 In addition to the associated illness, we estimate thatover 30,000 deaths in England were attributable toobesity in 1998, approximately six per cent of all deathsin that year. This compares to about 10 per cent of alldeaths due to smoking, and less than one per cent fromroad accidents. In total, this amounted to 275,000 lostyears of life - in other words, on average, each personwhose death could be attributed to obesity lost nineyears of life.2.23 Some 9,000 of the deaths related to obesity occurredbefore state retirement age, resulting in a loss of over40,000 years of working life by the time most peopleaim to have retired.part two8Hypertension 5,160Angina Pectoris 2,390Myocardial Infarction 1,230Cancers* 970Osteoarthritis 950Gout 530Stroke 440Gallstones 20Total 17,650*Note: Endometrial cancer, colon cancer, rectal cancer, ovariancancer and prostate cancer combinedSource:National Audit Office estimates based on data on claims for certifiedIncapacity Benefit supplied by the Department for Social Security(Appendix 6)The estimated direct costs of treating obesity and itsconsequencesCost componentCost (£million)Treating obesityGeneral practitioner consultations 6.8Ordinary admissions 1.3Prescriptions 0.8Outpatient attendances 0.5Day cases 0.1Total costs of treating obesity 9.5Treating the consequences of obesityPrescriptions 247.2Ordinary admissions 120.7Outpatient attendances 51.9General practitioner consultations 44.9Day cases 5.2Total costs of treating the consequences of obesity 469.9Total Direct costs 479.4Source: National Audit Office estimates (Appendix 6)We estimate that obesity cost theNational Health Service at leastaround £½ billion in 19982.24 Illness associated with obesity gives rise to costs to theNHS. Direct costs of obesity arise from NHSconsultations, drugs and treatments of diseasesattributable to obesity. Figure 8 sets out our estimates ofthese costs, amounting in England in 1998 to£480 million, or about 1.5 per cent of NHS expenditurein that year (Appendix 6). Of this total, the cost oftreating obesity itself was £9.5 million, mainly driven bythe cost of consultations with general practitioners. Thebulk of the cost arose from treating conditions caused byobesity.2.25 Figure 9 provides an analysis of the direct NHS costsattributable to obesity by type of illness. The 'big three'cost drivers are hypertension, coronary heart disease,and Type 2 diabetes, which account for £386 million.Osteoarthritis and stroke account for a further£52 million of costs.The direct costs of obesity are more likelyto exceed than fall below our estimate of£½ billion a year2.26 Our estimate of the costs of treating obesity and itsconsequences is low compared to the findings of studiesundertaken overseas. International research estimatesthat, in countries where the prevalence of obesity issimilar to that in England, the direct costs of obesity arebetween two and six per cent of national health carebudgets 20 . If this range applied in England, the directcosts to the NHS of treatment for obesity and itsconsequences would have been between £0.7 and£2.1 billion in 1998.16

TACKLING OBESITY IN ENGLAND9 Breakdown of the estimated cost of treating the major secondary diseases attributable to obesity in 1998Hypertension £135mCoronary Heart Disease £127mType 2 Diabetes £124mOsteoarthritis £35mCancers £19mStroke £17mCost (£ million)Source: National Audit Office estimates (Appendix 6)2.27 We have deliberately produced conservative estimatesto raise their credibility as the basis of further discussionof this report in the face of a number of uncertainties(Appendix 6). For example, the potentially high costsassociated with treating obesity related depression andhyper-lipidemia have been excluded because ofinadequate data on relative risk. Even a small proportionof the cost of anti-depressants (£279 million per year)and lipid-regulating drugs (£190 million per year) wouldsignificantly increase our estimate of direct costs. Theanalysis also excludes other public expenditure notborne directly by the NHS, such as the costs of socialcare for obesity related stroke patients.The indirect costs of obesity inEngland may be around £2 billiona year2.28 The indirect costs of obesity are defined in terms of lostoutput in the economy due to sickness absence or deathof workers. This involves making assumptions abouthow the economy responds when members of theworkforce become sick or die. If it is assumed that theeconomy adjusts quickly, for example if job vacanciesare filled rapidly following a death, ultimately fromamong the non-employed labour force, or if workforceproductivity increases, then the impact on the economyis 'frictional' and small, in direct proportion to the speedof adjustment.2.29 Modelling the macroeconomic impact on the economyof sickness and premature death among the obese in thenecessary detail is not feasible. We have therefore madeestimates on the basis of work time lost through sicknessand premature death resulting from obesity, togetherwith data on average incomes. This 'human capital'based approach is the standard one adopted in theliterature (Appendix 6), but it is subject to largeuncertainty and will give higher estimates than thefriction cost method. These cannot be modelled otherthan by using a range of arbitrary assumptions.2.30 Within these limitations, we estimate that the indirectcosts of obesity in England in 1998 were £2.1 billion, ofwhich £1.3 billion (61 per cent) was due to sicknessabsence attributable to obesity, and the remainder(£0.8 billion) due to premature mortality. Despite theuncertainties about the impact at the level of the wholeeconomy, the human costs to individuals in terms oftheir illness and premature death are very substantialindeed.On present trends, the costs of obesitycould increase by a further £1 billionby 20102.31 Combining the estimates of direct and indirect costs, thetotal estimated cost of obesity in England in 1998 was£2.6 billion. If the prevalence of obesity continues torise at the present rate until 2010, when it wouldapproach the levels of obesity now seen in the UnitedStates, these annual costs would increase by £1 billion,or over a third, to around £3.6 billion, by that year.part two17

TACKLING OBESITY IN ENGLANDPart 3Management of obesity in theNational Health Service3.1 In this part we consider the roles and activities of theDepartment of Health and NHS bodies, at national andlocal level, which contribute to the twin objectives oftreatment and prevention of obesity. We look at fourdistinct areas of activity:a) Action by the Department of Health and the NHSExecutive;b) Local strategies to address obesity;c) Managing obesity in general practice; andd) Interventions elsewhere in the NHS.a) Action by the Department of Healthand the NHS Executive3.2 Responsibility for policy on public health aspects of dietand nutrition and physical activity, including obesity,falls to the Department's Public Health Group.Appendix 7 provides details of policies and initiativescommissioned or supported by the Department ofHealth since 1997 which address aspects of obesity andthe related areas of diet and physical activity.3.3 Some of the key initiatives that demonstrate theimportance attributed by the Department of Health tothe prevention of obesity include the following:nnnThe NHS Plan 7 . This states the intention to tackleobesity and physical inactivity, informed by advicefrom the Health Development Agency. Action isplanned over the next five years to improve diet,including by increasing fruit and vegetableconsumption and reducing salt, fat and sugar intake;The National Service Framework for coronary heartdisease 6 . This focuses on local action designed toprevent coronary heart disease, such as bypromoting healthy eating and physical activity andreducing overweight and obesity;The annual Health Survey for England 1 . Thisprovides an important source of trend data onphysical activity, eating habits, height, weight andbody shape;nnExercise referral schemes. These give patients whowould benefit from increased physical activityaccess to a subsidised exercise programme throughtheir general practitioner. The Department of Healthplan to release guidance on 'General PractitionerReferral Frameworks' in 2001;Dissemination of the report 'Tackling Obesity- aToolbox for Local Partnership Action', produced bythe Faculty of Public Health Medicine of the RoyalColleges of Physicians 21 . This provides a frameworkfor developing local action plans to prevent andcontrol obesity. The Department paid for this reportto be sent to all health authorities.Central guidance on the management ofobesity3.4 There are no national guidelines for health authoritieson the way in which their plans should address obesity.The most relevant guidance was published inMarch 2000 as part of the National Service Frameworkfor coronary heart disease 6 . The Framework identifiesthe need for each health authority to develop, byApril 2001, effective policies for promoting healthyeating and physical activity and reducing overweightand obesity, and by April 2002 to have in placearrangements for monitoring their implementation. TheHealth Development Agency has produced guidelinesto support the Framework which cover interventionsrelated to lifestyle issues such as physical activity,healthy eating and obesity prevention.3.5 The National Service Framework also identifies the roleof general practitioners and primary care teams intackling overweight and obesity. It sets out a 10 yearprogramme of action with a first priority of treating andadvising those with established cardiovascular disease.A later stage will be to identify and treat those at highrisk of developing cardiovascular disease, but who haveyet to develop symptoms, and to offer appropriateadvice and treatment to reduce their risks. The adviceshould include information about these risks and howthey can be reduced as well as advice about physicalactivity, diet and weight management.part three19

TACKLING OBESITY IN ENGLAND3.6 The main source of guidance to health careprofessionals and the NHS on the effectiveness ofinterventions to treat obesity was published in 1995 inan 'Effective Healthcare Bulletin' commissioned by theDepartment from the NHS Centre for Reviews andDissemination at the University of York 22 .b) Local strategies to address obesityOver four fifths of health authorities hadidentified obesity as an issue in their HealthImprovement Programmes as at April 19993.7 Health authorities are required to co-ordinate thedevelopment of Health Improvement Programmes fortheir local area, identifying local health priorities, andtaking account of national strategic directions includingNational Service Frameworks 23 . We undertook a surveyof all 100 health authorities in England (Appendix 1) inthe Summer of 1999 to identify to what extent they hadaddressed obesity in their plans. At the time of oursurvey, there were no milestones set centrally for thedevelopment of local policies for the reduction ofoverweight and obesity.3.8 We found that a substantial majority of healthauthorities had included obesity, healthy eating orphysical activity in their Health ImprovementProgrammes produced in April 1999. Eighty-threeper cent identified obesity either as a risk to publichealth in its own right or as a risk factor for a specificdisease area such as coronary heart disease or diabetes.The extent to which health authorities had developedand implemented relevant strategies, however, variedconsiderably.Some health authorities have action in handto address obesity3.9 Whilst most health authorities had identified obesity asa health risk in their Health Improvement Programme,far fewer saw it as a priority area to be addressedthrough local action. In total, 32 health authorities(34 per cent of the 94 that responded) told us they hadidentified obesity as a local priority, of which 26 saidthat they had taken action to address it. Thirteen had putin place a dedicated strategy or action plan to preventand treat obesity whilst, in the other 13, actions toaddress obesity had been incorporated into widerstrategies to address associated diseases.3.10 Of those health authorities without an obesity strategy,14 were in the process of developing one. For those notdoing so, this was most commonly because the healthauthority had more urgent priorities. About half of thehealth authorities without an obesity strategy told us thattheir plans addressed obesity implicitly by encouragingphysical activity or healthy eating as part of coronaryheart disease or cancer prevention programmes.3.11 The expectation of the Department of Health is that thepublication of the National Service Framework forcoronary heart disease, coupled with the HealthDevelopment Agency's guidance on implementingpreventive measures of proven effectiveness, willencourage all NHS providers and local authorities todevelop such strategies by April 2001.Some health authorities have developedlocal targets for the reduction of obesity3.12 We found a number of examples of quantified andmeasurable targets directly addressing obesity, some ofwhich were based on sub-regional baseline surveyscarried out by the health authority to assess the extent ofthe problem. Most of these targets involved a significantreduction in the local prevalence of obesity, over a fiveto 10 year period, to well below national levels.3.13 Target-setting demonstrates a commitment to take theissue of obesity seriously. However, there is a risk that,unless an obesity prevention strategy is already wellestablished,local targets to reduce the prevalence ofobesity significantly in the medium term may beunrealistic, given the steeply rising trend throughoutEngland. A more realistic five year aim might be to keepthe local prevalence of obesity constant, which itselfwould require effective interventions in order to arrestthe rising trend.3.14 A few health authorities had developed local targets forincreasing physical activity and improving diet. Someexamples are provided in Figure 10. In the short term,targets that provide a direct measure of the effectivenessof interventions in influencing behaviour amongst thelocal population may be the most useful milestones toindicate progress towards halting the rise in theprevalence of overweight and obesity. Clearly, suchtargets must be both realistic and measurable if they areto have any benefit.part three20

TACKLING OBESITY IN ENGLAND10Examples of local targets for the promotion of physicalactivity and healthy diet set by individual health authoritiesnnnIncrease, by 30% by 2005, the numbers of people who haveregularly walked continuously for a mile at a brisk paceThe percentage of people eating a poor diet according to thecriteria used in the Baseline Survey will be reduced from 29%to 25% by the year 200550 practice nurses will be trained in the dietary component ofHelping People Change by the year 2000c) Managing obesity in generalpractice3.15 General practices are important in the management ofoverweight and obese persons as they are often the firstport-of-call for persons seeking help. They are where mostpeople, obese or not, come into contact with medicalservices 8 , and where there is the potential to tackle issuesof being overweight or obese, possibly as part of aconsultation not initially related to weight problems.Within the primary care setting, general practitioners maysee patients, either directly because of overweight andobesity problems, or because of the associated illnesses,or indeed because of some condition not related at all toexcess weight. Practice nurses, dietitians, health visitorsand school nurses can also play a valuable role inidentifying patients with weight problems and providingadvice and support on weight control and lifestyle changein a more relaxed environment.3.16 The first objective in the management of obesity is toprevent further weight gain 24 . Once weight is stabilised,the second objective is to achieve some level of weightloss. Weight loss goals should be realistic andachievable. For many obese persons, achieving a bodymass index in the ideal range and within a reasonabletime is hard.3.17 This does not imply a counsel of desperation. A weightloss of 5kg (11 lbs) is equivalent to a loss of somesix per cent in body weight for a man or woman ofaverage height with a body mass index of 30, on theboundary between the overweight and obesecategories. This degree of weight loss can reduce backand joint pain, breathlessness, and the frequency ofsleep apnoea, and improve lung function 24 . It may alsoresult in psychological benefits, such as the alleviationof depression and anxiety 25 .3.18 A report by the Royal College of Physicians in 1998 25lists the following potential benefits that can accruefrom a slightly greater weight reduction of 10 per centfrom an initial weight of 100kg in those patients withassociated diseases:nnnnnna substantial fall in systolic and diastolic bloodpressure;a fall of 10% in total cholesterol;a greater than 50% reduction in the risk ofdeveloping diabetes;a 30-40% fall in diabetes related deaths;a 40-50% fall in obesity related cancer deaths;a 20-25% fall in total mortality.3.19 We surveyed a sample of 1,200 general practitionersand 1,200 practice nurses, stratified to be representativeof the range of general practitioners in England, using apostal questionnaire (Appendix 1). We also visited20 general practitioners and 16 practice nurses to carryout face-to-face interviews. The responses showed thatmanagement of obesity within general practice consistsbroadly of three types, depending on the degree ofobesity and the extent of clinical complications. Inascending order of intervention, these are:i) general advice within the surgery, and personaladvice on weight control, diet and physical exerciseaimed at influencing lifestyle;ii) personal advice on weight loss and lifestyle changesupported by drug therapy prescribed by the generalpractitioner; oriii) onward referral by the general practitioner to aweight loss specialist, possibly involving drugtherapy and, in extreme cases, surgery.i) Managing obesity in general practice:general advice, screening and personaladvice3.20 Advice on weight control, diet and physical exerciseprovided by the general practitioner or practice nurse isthe most common approach in primary care. This mayinclude:nadvice on how to modify diet and lifestyle in orderto build in more physical activity;nthe provision of specialised diets and diet plans;nnreferral to exercise programmes, such as throughexercise on prescription (paragraphs 3.35-3.39below); andongoing support, including goal-setting and weightmonitoring.part three21

TACKLING OBESITY IN ENGLANDThe majority of practices promote healthy eating andphysical activity through general information3.21 Our survey indicated that over three quarters ofpractices made general information on healthy diet andphysical activity available to all patients who visited thesurgery, normally in the form of a waiting room displayor leaflets available in the waiting room. Approximatelyhalf provided general information in this way to educatepatients specifically about the issue of weightmanagement (Figure 11).3.22 A small minority of practices - around seven per cent ofthose that reponded - had not in the last year providedany general information in the surgery to promotehealthy eating, physical activity or weight management.Patients attending these surgeries, not necessarily forweight problems, would therefore only receiveimportant messages about healthy eating, exercise andweight control should they be raised in the course of aconsultation with the general practitioner or practicenurse.3.23 Whilst many general practices take the opportunity topromote healthy lifestyles through the provision of suchmaterial, little is known about the effectiveness of thisapproach. None of the general practitioners or practicenurses we interviewed had evaluated the extent towhich such material was used by patients or its impacton lifestyle. However, given the rate at which theprevalence of obesity is increasing in England, theremay be benefits for all general practices, rather thanaround half as at present, to make information availableto all patients on the risks of obesity and how to manageone's weight.11 Percentage of practices that made general information ondiet, physical activity and weight management available toall patientsPercentage of practices10080604020Many general practitioners seek to identify thosepatients at risk of obesity, but not the majority3.24 General practitioners are in a position to assess whichpatients might benefit from advice or treatment to helpthem manage their weight. These patients might beidentified based on an already elevated body massindex or waist measurement, lifestyle factors that mightput them at high risk of weight gain, or the risk ofassociated diseases such as coronary heart disease,diabetes or hypertension. In March 2000, the NationalService Framework for coronary heart disease waspublished 6 , which includes plans for generalpractitioners and primary care teams to identify allpeople at risk of cardiovascular disease, includingbecause of their weight, and to offer them appropriateadvice and treatment to reduce their risks.3.25 At the time of our survey (which pre-dated the NationalService Framework), we found that almost all practicesrecorded the height and weight of all patients. Inaddition, about 95 per cent recorded the body massindex of all patients. A small minority took a moreproactive approach to identifying those patients at riskby recording other indicators of body fat: aroundfour per cent recorded waist circumference, andthree per cent recorded waist:hip ratio.3.26 However, only 40 per cent of general practitioners toldus that they attempted to identify those patients athighest risk of excessive weight gain. They looked forrisk factors such as a high or rising body mass index,family history or associated health risks such as diabetesor heart problems.Most general practices accept a responsibility fortreating obesity or referring patients to appropriatespecialists3.27 General practitioners decide whether to treat patientswho would benefit from weight loss personally, orwhether to refer them on to appropriate specialists. Twothirds of general practitioners in our survey felt thattreating patients for excess weight or obesity was theresponsibility of the primary care team. A greaterproportion - three quarters - thought they had a role inreferring obese persons to appropriate specialists fortreatment. However, a small number of generalpractitioners (two per cent) neither treated obesepatients personally to help them achieve weight loss,nor referred them to specialists.part three0Healthy diet Physical activity Weight ManagementSource: National Audit Office based on responses to postal survey (Appendix 1)22

TACKLING OBESITY IN ENGLAND3.28 Views on who should be responsible for promotinghealthy lifestyles in general showed a similar picture.Some 60 per cent of general practitioners said thatpromoting a healthy lifestyle was the role of the primarycare team as a whole, while 30 per cent thought thatpromoting healthy lifestyles was the role of healthauthorities or the Government. The National ServiceFramework for coronary heart disease 6 clarifies theimportant role of general practitioners and primary careteams, as well as Primary Care Groups and Trusts, forimplementing effective preventive policies in the future.The 'whole practice' approach3.29 In practices that accept responsibility for themanagement of obesity, it is often handled on a teambasis, comprising the general practitioner, the practicenurse and possibly a dietitian. Many practice nurses andpractice-based dietitians run weight managementclinics to monitor patients' progress whilst at the sametime helping them to remain motivated and reinforcingadvice on diet and exercise to promote effective weightcontrol.General practitioners and practice nurses provide arange of advice and monitoring for obese patients3.32 General practitioners and practice nurses respond to theproblem of obesity mainly through regular weightmonitoring and the provision of advice on diet orphysical activity (Figure 12).3.33 Almost all practices that treat obese patients providethem with personal oral advice. In most cases, this iscombined with written advice to take away from thesurgery to use as the basis for changes in lifestyle.Practice nurses played a greater role in providinglifestyle advice, particularly written advice, than generalpractitioners. The written material supplied to patientson diet and physical activity came from a variety ofsources, including custom-made advice prepared by thegeneral practitioner or practice nurse, and leafletspublished by the Health Education Authority, healthcharities, and food manufacturers.3.30 When managing their overweight and obese patients,70 per cent of general practitioners told us they alwaysinvolved other members of the practice or did so formore than half of their patients. Almost all involved thepractice nurse, while just over half also involved apractice dietitian. Our interviews confirmed that thereare advantages to the 'whole practice' approach thatcould usefully be obtained more widely, particularly byinvolving practice nurses in the management of peoplewith weight problems:nnnsome patients listen better to the nurse than to thedoctor;practice nurses are better at doing things that shouldbe done regularly, such as monitoring patients'weight;the practice nurse has more time to do follow-up.3.31 The National Service Framework for coronary heartdisease 6 also emphasises the important role of thebroader primary care team, including health visitors,school nurses and other health professionals working inthe community, in developing and implementingstrategies to reduce overweight and obesity and improvepatterns of diet and physical activity.3.34 Regular checks on people with weight problems canprovide patients with an incentive to keep their weightdown between consultations, and ensure that associatedproblems are kept under review and action taken toprevent or treat them. Where surgeries treat obesity,almost all practice nurses provide monitoring services,as do many general practitioners.Well-designed exercise on prescription is a practicalway of achieving health benefits for obese individuals,but more evaluation is needed3.35 Exercise on prescription is an initiative that allowsgeneral practitioners to refer patients for free orsubsidised exercise programmes under the supervisionof a qualified trainer. Our survey indicated that14 per cent of general practitioners and 33 per cent ofpractice nurses referred patients to a trained exercisespecialist or specific exercise programme.part three23

TACKLING OBESITY IN ENGLAND12 Most commonly used interventions for treating overweight and obese patients in primary care10080Percentage6040200Oral advice on diet and/orphysical activityRegular check-ups andweight monitoringWritten advice on diet and/orphysical activityGeneral PractitionersPractice NursesSource: National Audit Office based on responses to postal survey (Appendix 1)part three243.36 The exercise model used varies from scheme to scheme.Case Study 1 shows how a well-designed scheme,incorporating rigorous pre-programme assessment,progress monitoring and follow-up, can help patients tolose weight and improve fitness.3.37 The largest evaluation of exercise on prescriptionschemes in England was undertaken by the HealthEducation Authority in 1998 26 . This review estimatedthat there were over 200 referral-based exerciseschemes in operation in England. The evaluationincluded a systematic review of empirical data relatingto the effectiveness of schemes and three case studies ofexisting schemes.3.38 The Health Education Authority found some evidence ofimprovements to physical activity patterns. They alsonoted, from case studies, wider impacts from theschemes, including social and psychological benefits forparticipants. However, there was a wide variety in thetype and quality of exercise programmes provided. Noneof the programmes employed an accepted model forhelping people to achieve lifestyle change, and manywere not the most appropriate for helping people withweight problems. The Health Education Authorityconcluded that such schemes should include morerigorous evaluation, which would involve systematicgathering of quality data using carefully chosen outcomemeasures to provide better evidence on effectiveness.3.39 In June 2000, the Department of Health announcedplans to publish new guidelines to help generalpractitioners to start such schemes for their patients. Todo this, they have commissioned experts in physicalactivity and health to produce a National QualityAssurance Framework for Exercise Referral Systems. Theframework will provide guidelines for best practicewithin the whole referral process, from selection ofpatients to exercise programming, evaluation and longterm follow-up. The aim is to improve the quality ofphysical training provided, thus maximising the benefitsto patients, and to establish indicators to demonstratehow closely the guidelines are being followed.General practice offers a range of innovative butuntested help3.40 Some practices provided other forms of help, includingslimming groups and exercise programmes at thepractice, and in a very few cases offered alternativetherapies such as yoga, meditation or hypnosis. Twoexamples of innovative practice are illustrated below inCase Study 2. Although these examples have not beenindependently audited for either clinical or economiccost effectiveness, evidence from self-evaluationssuggests that they may be promising developments.There is uncertainty about what comprises effectiveintervention for obesity3.41 Our survey found widespread uncertainty amongstgeneral practitioners about the effectiveness of thedifferent interventions at their disposal. Their viewsreflected general uncertainty about which interventionsare effective in preventing and treating obesity. Seventythreeper cent of general practitioners believed therewas a lack of proven, effective interventions available toassist them in determining the most appropriatetreatment pathway for their patients. And 64 per centbelieved the range of treatments available to them wasof little or no effectiveness. Practices told us, both in ourvisits and in responses to our postal questionnaire, thatthey would like more information on what were themost effective ways to help obese patients lose weight.

TACKLING OBESITY IN ENGLANDCase Study 1: Exercise on Prescription Scheme in North West EnglandIn partnership with North West Lancashire Health Authority and Preston Borough Council, two leisure centres in Preston haveset up an exercise on prescription scheme they call "Exercise Your Options". There are over 20 practices enrolled in thescheme, and both general practitioners and practice nurses from those practices can refer patients.Prior to referring patients, the general practitioner carries out a health check, recording height, weight, blood pressure andresting pulse. The patient is then referred to a LifeStyle Fitness Officer who carries out a health screening and fitnessassessment. The LifeStyle Fitness Officer will then tailor an exercise programme to meet the patient's needs and level offitness.After four to five weeks a mid-programme check is made by the general practitioner or practice nurse. At the end of the eightweek programme the LifeStyle Fitness Officer will re-test the patient and the results will be discussed with the generalpractitioner. If the programme has been satisfactorily completed, a further four weeks of free exercise is available. After12 weeks patients may be re-prescribed exercise if the programme has proved beneficial.The programme is free to patients. To ensure commitment of the patients, a "contract" is signed by both the patient and theprescribing general practitioner or practice nurse.The scheme is evaluated yearly. Since 1995, when the scheme was initiated, over 2,000 patients have been referred.Forty-three per cent of these patients completed the programme. Of the 779 patients who provided follow-up data,58% experienced a decrease in weight, and 94% showed a decrease in body fat.Source:National Audit Office survey of general practiceCase Study 2: Innovative approaches to the management of excess weightThe Surgery GymA general practice in Saltash in Cornwall has set up a gymnasium at thesurgery for the use of patients and the wider community over the age of14. The gym is open during surgery hours and is staffed on a part time basisby a qualified fitness instructor. It was set up by the general practitionerusing private funds and savings from the drug incentive scheme. Thesurgery charges a £10 induction fee and £2 per week for an unlimitednumber of visits, with all profits reinvested in the gym. The gym is small,but is equipped with commercial quality equipment and can take three tofour persons per hour, who book in advance to use the facilities. While thesurgery has not done a formal audit of gym use, it is often fully booked andthey estimate that 150 patients, 10% of their patient list, and many morenon-patients use the gym.Source:National Audit Office survey of general practiceThe Health Walks ProjectOne surgery has organised a Health Walks Project to increasesignificantly the fitness and well-being of an entire community, usingthe resources of the local environment. The philosophy underpinningthe project is that walking in the local environment is the most basicform of exercise, involving no special equipment, no cost and isavailable to all. Walking routes are mapped, and group walks aregraded to encourage all levels to participate.Patients who would benefit most from increased activity are encouragedto participate - those who are sedentary, or those with chronic healthconditions, such as coronary heart disease risk factors.The surgery also offers organised group cycle rides on a twice weekly basis and provides maps of local cycle routes.Evaluation of the project found that 61 per cent of those using Health Walks reported that they were more likely to walkshort distances as a result of the project. The project was developed with the support of the Countryside Commission andthe British Heart Foundation.part threeSource: Active Transport 2725

TACKLING OBESITY IN ENGLANDpart three26ii) Managing obesity in general practice:drug therapy3.42 Drug therapy may be used in tandem with a calorierestricteddiet to accelerate weight loss in obesepatients 25 . Health concerns led to the withdrawal in1997 of fenfluramine type anti-obesity drugs, but a newgeneration of anti-obesity drugs is now emerging,beginning with Orlistat, which was licensed in Europein 1998. A necessary condition for prescribing this drugis that the person concerned has been able to loseweight without using the drug, as an indicator ofmotivation and the ability to adhere to a calorierestricteddiet.Many general practitioners are uncertain about theappropriateness and effectiveness of drug therapy3.43 Drug therapy was used by two fifths of generalpractitioners responding to our survey, and by nine ofthe 20 general practitioners we interviewed.3.44 None of those interviewed had had more than a fewpatients taking weight-loss drugs at any one time. Theirattitudes to the use of drug therapy varied. Most felt itwas a useful aid in accelerating weight loss for aminority of patients, but they had some reservations. Inparticular, concerns were expressed about how to assesswhich patients were sufficiently motivated to benefitfrom therapy, and the likelihood of weight regain whenthe drug therapy was terminated.3.45 Since we began our study, the National Institute forClinical Excellence (NICE) has announced that part of itsprogramme in 2000-01 will be to examine the clinicaland cost effectiveness of the anti-obesity drugs, Orlistatand Sibutramine. NICE are expected to issue guidanceon the use of Orlistat in February 2001. This will helpensure that general practitioners are better informedabout the costs and potential benefits of drug therapy fortheir obese patients.iii) Managing obesity in general practice:onward referral3.46 The specialist expertise often necessary in the treatmentof obese patients is normally found outside generalpractice. The six most commonly used options forreferral of patients are shown in Figure 13. The optionmost frequently used was referral to a state-registereddietitian, though long waiting lists were mentioned bysome as a problem.3.47 Not all of these options are available to all NHS patients.About a quarter of general practitioners felt that therange of referral options at their disposal was limited orinadequate. Access to suitable treatments for obesitycan depend on factors such as the prosperity of thepatient and geographical location. For example, patientsreferred to private sector slimming groups do not receivefinancial assistance in meeting the costs of attendance,which may preclude this option for many. And not allgeneral practitioners have local access to a physicianspecialising in weight problems, a suitable communitybasedprogramme, or a surgical consultant ableto advise on the suitability of surgery to achieveweight loss.There is uncertainty about the effectiveness of referraloptions3.48 General practitioners identified a range of factors thatwould assist them in referring patients more efficientlyand effectively, particularly better information aboutproven, effective interventions (Figure 14).Overcoming knowledge constraints in themanagement of obesity3.49 Our survey asked general practitioners and practicenurses what factors might help them in developingfurther their approach in the treatment of overweightand obese patients. Figure 15 shows their most frequentresponses. Action is in hand to address some of theseissues, particularly access to exercise regimes.Obesity protocols are not widely used in primary careand need further development3.50 We asked whether or not national clinical guidelines ora protocol for managing overweight and obese patientswould be a useful tool. Sixty-three per cent of generalpractitioners and 85 per cent of practice nurses believedthat such guidelines would be "useful" or "very useful".However, a minority of the general practitioners andpractice nurses we interviewed suggested that theypreferred more flexibility to recognise individualpatients' needs. This demonstrates that any clinicalguidelines that might be developed need to containsufficient flexibility to allow general practitioners toexercise a degree of judgement over the mostappropriate course of treatment for each patient.3.51 There are two main sets of guidelines currently availablein Britain, and used by some general practitioners inEngland, that are relevant to the management of obesityin general practice. In Scotland, 'Obesity in Scotland:Integrating Prevention with Weight Management', waspublished by the Scottish Intercollegiate GuidelinesNetwork in 1996, and updated in 1997 24 . And in 1998,the Royal College of Physicians of London published'Clinical Management of Overweight and ObesePatients, with particular reference to the use of drugs' 25 .

TACKLING OBESITY IN ENGLAND13 Referral options most commonly used by general practitioners0 10 20Percentage of general practitioners30 40 50 6070State-registered dietitiansPrivate sector slimming organisationPhysicianCommunity-based programme/self -help groupTrained exercise specialistSurgeonSource: National Audit Office based on responses to postal survey (Appendix 1)14 Factors which general practitioners said would assist them in referring patientsBetter information about proven, effective interventionsPercentage of general practitioners0 10 20 30 40 50 60Improved access to community-based programmes or self-help groupsBetter information on available referral optionsGuidelines on the management of overweight/obese patientsImproved access to trained exercise specialistImproved access to dietitianBetter training on the management of overweight/obese patientsImproved access to specialist physicianImproved access to pyschologistAvailability of trained practice nurseSource: National Audit Office based on responses to postal survey (Appendix 1)15 Factors which general practitioners and practice nurses said would assist them in advising and treating patientsPercentage0 10 20 30 4050 60 70 80Guidelines on the management ofoverweight/obese patientsImproved access for general practitionerreferral to exercise regimesAvailability of better patient advicematerials for use by general practitionersand practice nursesBetter training for general practitionersand practice nurses on the management ofoverweight/obese patientsGeneral PractitionersPractice Nursespart threeSource: National Audit Office based on responses to postal survey (Appendix 1)27

TACKLING OBESITY IN ENGLAND3.52 We found that very few general practitioners used theprotocols proposed in either of these guidelines. Indeed,only four per cent of general practitioners used aprotocol for managing overweight or obese patients,and many of those in use had been developedindependently by the practice.3.53 We assessed the potential usefulness of 35 protocolsprovided by practices against four criteria developed inconsultation with members of our expert panel. Weexamined whether the protocol:nnnnhad a clearly expressed aim or objective;defined which patients to target for advice ortreatment;identified clear treatment and referral criteria;had a timetable and instructions for review andfollow-up.3.54 Three of the 35 protocols satisfied all the criteria, and afurther 16 satisfied at least two. The majority had notimetable or instructions for review and follow-up, andhalf did not have clear treatment and referral criteria.Improvement and standardisation of protocols bybuilding on best practice offers the scope to producebetter outcomes for obese patients.3.55 From our survey of health authorities, we found twoexamples of guidance for primary care teams on whento refer overweight and obese patients to a dietitian, oneof which had been developed by a health authority(West Sussex Health Authority), the other by an NHScommunity trust (North Mersey Community NHS Trust).Such guidance informs local general practitioners aboutthe service offered, to ensure consistent management ofpatients, and to make the best use of dietetic resourcesprovided in the local community.3.56 Our analysis indicates that, even where some form ofprotocol was in use, it rarely constituted acomprehensive framework for the management of obesepatients and those at risk of obesity. And none of theprotocols in use had been independently evaluated toestablish its effectiveness. In the absence of suchinformation, general practitioners and practice nursesdo not have clearly defined criteria for the managementand treatment of overweight and obese patients, andthere is no guarantee that patients, even within the samesurgery, will obtain consistent and effective treatment.part three28There is a clear view as to what guidance shouldcover3.57 We asked the general practitioners and practice nurseswe interviewed what they would like to see included ina national protocol or guidelines on obesity, if one weredeveloped. All said that they would like guidance whichcovered the topics set out in Figure 16.

TACKLING OBESITY IN ENGLAND16Topics suggested by general practitioners and practice nursesfor inclusion in guidance on the management of overweightand obesity in primary careTopics for inclusion in guidancena definition of which patients to target for advice and treatment3.60 There are already examples of good practice here. Forexample, Stockport Acute Services NHS Trust has set upa patient screening programme for pre-operativepatients, whereby obese patients are identified andreferred to their general practitioner if it is felt they wouldbenefit from advice and treatment (Case Study 3).nnnnnguidance on how to assess current physical activity and theadvice to be given to people on a weight maintenanceprogrammea protocol for deciding the most appropriate treatment pathwayfor each patientinformation on effective interventions in primary care for weightmaintenance and increased physical activitya protocol for deciding the most appropriate referral option foreach patientguidance on the development of care plans to meet the needsof individuals on a weight maintenance programmeSpecialist centres for the treatment of obesitymay be a cost effective way to address therising prevalence and associated ill health3.61 An unpublished survey carried out by the NHS ClinicalObesity Group in May 1998 identified 12 obesity clinicsin England, eight of which were run by physicians andfour by surgeons. Additionally, there were fourphysicians and 28 surgeons in England seeing patientsfor their obesity outside obesity clinics.nnnnndietary recommendations for those patients to be placed on aweight management programmeguidance on the appropriate intervals between consultations formonitoring of treatment and follow-upprotocols for follow-up weight maintenanceguidance on setting up registers for overweight and obesepatientscase examples of good practiceSource: National Audit Office interviews (Appendix 1)d) Interventions elsewhere in theNational Health Service3.58 Hospitals and specialist clinics provide other settings toidentify persons at risk of becoming overweight or obeseand for obese persons to seek help. There is, however,very little obesity-related activity within the NHS at thesecondary and tertiary care level.Hospital admissions provide an opportunityto undertake screening for obesity3.59 The link between obesity and associated diseases suchas coronary heart disease and Type 2 diabetes meansthat hospital admissions provide an opportunity,additional to screening undertaken in general practices,to identify patients who would benefit from treatmentfor obesity. Whilst it is common practice for hospitals toassess risk factors that might be contributing to thecondition for which the patient has been admitted, suchas obesity, arrangements need to be made to follow thisup through referral for appropriate treatment afterdischarge from hospital.3.62 Surgery to promote weight loss normally involvesplacing physical constrictions on the opening of thestomach, or reducing the size of the stomach. It is usedrarely, and there are probably no more than 200operations performed in England each year on the mostsevere cases of obesity 28 , many of them fundedprivately. Surgery is normally an effective way ofproducing weight loss, but places major limitations onwhat the patient may eat. This can be hard for patientsto tolerate and in some cases results in further surgery toreverse the procedure. There is also some risk thatsurgery will lead to clinical complications, includingnutritional deficiencies 10 .Case Study 3:Screening at Stockport Acute NHS TrustUnder the screening programme all patients,when admitted for a pre-operative assessment,are requested to complete a health educationquestionnaire with the assistance of a nurse. Thequestionnaire covers basic statistical data andlifestyle related issues including height, weight,body mass index, and eating and physicalactivity habits. One purpose of the questionnaireis to help patients stay healthy after theiroperation. The questionnaire is analysed andappropriate referral suggestions are made. Forexample, if there is an indication ofinappropriate eating habits or a sedentarylifestyle, combined with a high body mass index,the patient will be referred to their generalpractitioner for advice and treatment.Source: National Audit Office site visitpart three29

TACKLING OBESITY IN ENGLAND3.63 Specialist obesity clinics use a combination ofinterventions to achieve weight loss, normally includinga very low calorie diet and drug therapy, in some caseswith input from a psychologist. The majority of clinicsare highly constrained by resources and thus thenumber of patients they can treat. For example, a typicalphysician-led clinic in London operated on one half dayper week, seeing between six and eight new patientseach time, while another in Bedfordshire opened forone half day per fortnight, admitting three new patientseach time. The physicians leading these clinics told usthat the waiting list for admitting patients was long, oftenin excess of six months. They were therefore only ableto admit the minority of patients who could demonstratea very strong motivation to make changes to theirlifestyle in order to lose weight. Case Study 4 providesan example of the type of treatment offered within aspecialist obesity clinic.3.64 Specialist centres can play a potentially important rolein the management of obesity for those patients whohave sufficient motivation to benefit. However, there isonly limited evidence of their effectiveness. Selfevaluationsundertaken by physicians operating obesityclinics suggest that they are effective in helping mostpatients to achieve medically significant weight loss, butthat this is rarely sustained in the long term 30 .Case Study 4:Inside an obesity clinicThe clinic is offered as part of acute medical services through the general medical clinics of diabetes and endocrinology andis staffed by a consultant physician, a clinical psychologist and a senior dietitian. It is held fortnightly.Patients are referred by their general practitioner. Potential patients are sent a detailed questionnaire and returned questionnairesare analysed. If the analysis suggests that the patient suffers from a significant lack of motivation or readiness for lifestyle changeor a significant eating disorder, the patient is directed back to their referring general practitioner and no appointment is offered.The consultant physician assesses those patients selected for treatment on their first visit. They will then see the psychologistand dietitian. A joint decision is made as to an appropriate treatment plan. The treatment options are:nnnnnnna group behaviour modification and low calorie liquid diet programme, the programme about half the clinic patientsfollow;dietetic-led management, used with most patients with uncomplicated obesity, which involves three or moreappointments with the dietitian followed by an appointment with the doctor;medically-led management, which involves a series of three appointments with the doctor and one appointment withthe dietitian, and is offered to approximately 20% of the patients, in particular those with obesity-related medicalcomplications;clinical psychology assessment, where patients attend two or three appointments to explore their suitability for othertreatment options at the clinic. Less than five per cent of patients require long term psychological intervention and arereferred to the psychology services offered by the local Community Health team;pharmacological intervention, where patients are prescribed a course of anti-obesity drugs;referral to other units for surgical intervention, an option offered to less than one per cent of patients when appropriate;recruitment into clinical research programmes where appropriate.An evaluation of the low calorie liquid diet programme undertaken by the clinic in 1998 found that on average patients lost12 per cent of their body weight during the course of the programme. It was difficult to draw conclusions about long termeffectiveness, however, as of the 91 patients who completed the programme, only nine returned for follow-up 18 monthslater.Source: National Audit Office site visit and self-evaluation report by the clinic 29part three30

TACKLING OBESITY IN ENGLANDPart 4Initiatives across Government toaddress the problem of obesity4.1 Part 2 of this report demonstrates the considerableburden of disease and wider costs to society that resultfrom a high prevalence of obesity in the population.These costs will continue to increase unless action istaken to prevent the prevalence of obesity from risingfurther. As shown in Part 3, treatment to help obesepeople control their weight can significantly reduce therisks of associated disease and improve the quality oflife of those affected. However, as for other chronicconditions, treatment of people who are already obesecan only have a marginal effect on population-wideprevalence, particularly as only a minority of obesepatients who enter treatment achieve and sustain a BMIbelow 30 in the long term. To address prevalence, thereis a need to focus more on those who are at risk but notyet obese. Prevention targeted at children and youngpeople is a key component to the success of such astrategy.4.2 There is a wide range of organisations and groups, bothwithin and outside the public sector, that have animportant influence on the elements of lifestyle -principally diet and physical activity - which affect bodyweight (Figure 17). The Department of Health can havelittle impact acting in isolation, and joined upapproaches are required. The role of the Departmentinvolves liaising with the key representatives of otherGovernment departments in order to advise on policiesand initiatives to improve health, in particular in relationto diet and nutrition, health education, transport andphysical recreation.There is a substantial amount of joinedup working across Government relatedto the prevention of obesity4.4 We interviewed staff in the relevant Governmentdepartments (Appendix 1) to establish the mainmechanisms they used for working together, howeffective collaboration had been, and what the keyoutputs were in terms of jointly-sponsored research,projects and initiatives. We also sought examples oflocal initiatives and joint working, involvingorganisations such as local authorities, healthauthorities, schools, and local providers of health andsocial services, which demonstrated this cross-cuttingapproach.4.5 Overall, we found a substantial amount of co-operativeand cross-departmental work related to obesity. We lookat these activities in paragraphs 4.6-4.64 below under anumber of themes, firstly those addressing thepopulation as a whole:i) promoting active transport;ii)iii)promoting more active recreation in society; andidentifying and promoting healthy patterns ofeating.And secondly, those targeting children and youngpeople:4.3 In this part of our report we examine preventiveinitiatives. We look at how far common objectivesrelevant to prevention of obesity have been adopted andaddressed through joined up working. To do this wehave identified themes where there is the potential for ajoined up approach, and examined the actions takenand outputs achieved. There is limited evidence on theeffectiveness of interventions, but we have used casestudies to illustrate what is possible and as an aid tospreading good practice.iv)equipping young people for a healthy lifestyle;v) promoting a healthy school environment;vi)vii)viii)promoting healthy travel to school;promoting sport and physical recreation inschools; andpromoting healthy eating in schools.We looked in particular for evidence of the maincategories of cross-cutting intervention identified in theCabinet Office report, 'Wiring it up' (2000) 31 .part four31

TACKLING OBESITY IN ENGLAND17Public and private sector stakeholders with the potential to influence lifestyle and bodyweightDepartment of Healthn Sets national priorities toimprove health andreduce healthinequalitiesn Commissions researchon the effectiveness ofinterventionsHealth Development Agencyn Provides evidence andguidance on what worksn Develops the capacity andcapability of the publichealth workforceHealth authorities, localNHS bodies and generalpracticesn Set local priorities andplansn Promote healthylifestylesn Identify high risk groupsand individualsn Advice and treatment foroverweight and obesepeopleHealth professionsn Disseminateresearch/informationn Guidelines on bestpracticeLocal authoritiesn Local transport plansn Provision of land andbuildings for recreationaluseDepartment of theEnvironment, Transport andthe Regionsn Oversees and regulatestransport infrastructuren Sets environmentalpoliciesn Promotes the use ofalternatives to the carDepartment for Educationand Employmentn Issues broad guidelinesfor schoolsn Sets targets for schoolsn Supports healthy lifestyleinitiativesLocal Education Authoritiesand schoolsn Education on healthylifestylesn Provide school mealsn Physical education forschool childrenn Influence school travelSport Englandn Promotes sportingexcellence and widerparticipation in sportDepartment for Culture,Media and Sportn Sets national prioritiesand objectivesn Promotes and supportsthe infrastructure forphysical recreationFood Standards Agencyn Food standards andlabellingn Surveys, research andeducation on dietMedia and advertisingn Influence society'sperceptions of desirablebody shapen Influence attitudestowards obese peoplen Forum for masspromotion of healthyliving messagesMinistry of Agriculture,Fisheries and Foodn Regulates the foodindustryFood industryn Producing,manufacturing, retailingand marketing of foodn Influences what peopleeatn Healthy eatingpromotions andproductsEmployersn Influence work-relatedmodes of transportn May provide catering forstaff and/or facilities forexerciseConsumer representativesn Influence public opinionn Disseminateresearch/informationn Lobby government onfood/transport policySpecialist voluntary bodies(eg Association for theStudy of Obesity)n Forum for expertsn Disseminate researchn Lobby governmentPrivate sector slimmingindustryn Slimming clubs,magazines, diet food anddrinks, diet and exerciseregimes, obesity camps,health farmsNote:Source:This figure shows only the roles of stakeholders that impact on lifestyle and, therefore, may influence bodyweight. It is not intended to represent thefull range of their objectives or activities.National Audit Officepart four32

TACKLING OBESITY IN ENGLANDInitiatives addressing the population asa wholei. Promoting active transportThe Department of the Environment, Transport and theRegions works with the Department of Health and otheragencies4.6 Government can encourage people to take more physicalactivity by enabling them to build it into their dailyroutines, principally through active forms of transport suchas walking and cycling. The 'New Deal for Transport'White Paper, published in July 1998 32 , acknowledged theimpact of different modes of travel on the nation's health,and on the risk factors for coronary heart disease inparticular. It signalled the Government's intention to makeit easier for people to stay fitter through walking andcycling by providing a safer and more integrated networkof appropriate routes, footpaths and cycle lanes. There isclear congruence between the Department of theEnvironment, Transport and the Regions' objective tomake it easier to walk and cycle and thereby reducereliance on cars, and the Department of Health's objectiveto promote physical activity to reduce ill health.4.7 To support these shared policy objectives, there is regularformal and informal consultation between staff working inrelevant areas of each department, backed up by jointteams and working groups on specific issues, such asschool travel (paragraphs 4.41-4.45). The departmentshave also jointly sponsored research on integrating healthand transport policy at the local level, and commissionedjoint publications. In addition, both departments arerepresented on the Inter-Ministerial Group to ImproveChildren's Diet and Activity, set up in July 2000. Some ofthe key ways in which the two departments have workedtogether are illustrated in Figure 18.4.8 The Department of the Environment, Transport and theRegions has consulted with colleagues from theDepartment of Health on issues including the transportWhite Paper, national cycle forum, and the walking workinggroup. These links were maintained in developing the 'Areyou doing your bit?' campaign, a national, multi-mediainitiative to encourage the public to make differences totheir lifestyles that will help the environment. The re-launchof the campaign in 1999 sought to promote healthytransport choices by encouraging people to reconsider theiruse of the private car and adopt healthier modes of transportsuch as cycling and walking. These themes continue to bepart of the campaign in its 2000/01 phase.4.9 Work to promote this message was led by a physicalactivity expert seconded from the Health EducationAuthority to the Department of the Environment, Transportand the Regions specifically to develop stronger linksbetween transport and health policy. This secondmenthelped to ensure consistency with the central messages ofthe Health Education Authority's 'Active for Life'campaign, which ran concurrently and was the maininitiative to promote physical activity commissioned bythe Department of Health. This physical activity expert isnow providing consultancy advice to both departments onexploring ways to integrate health and transport and otherphysical activity policies.18 The links between health and transportHealth AuthoritiesPromoting healthytransport locallyLocal AuthoritiesDepartment of HealthTo improve healthand reduce healthinequalitiesEncourage and facilitatewalking and cyclingDepartment ofthe Environment,Transport & the RegionsTo make it easier to walkand cycle and therebyreduce reliance on carsHealth Health DevelopmentAgency AgencyTo To To provide provide evidenceand and guidance on on onwhat what works worksto to to improve health healthn Regular consultation on policy issuesn Joint teams on specific issuesn Sharing informationn Seconding staff to encourage collaborationn Joint publications and guidancen Inter-Ministerial GroupHighways AgencyTo improve accessto the road systemfor cyclists andpedestriansHealth DeveAgenTo provide eand guidawhat woto improvepart fourSource:National Audit Office33

TACKLING OBESITY IN ENGLANDPerformance targets for healthy transport4.10 The policy commitment is supported within theDepartment of the Environment, Transport and theRegions by a target to quadruple the level of cycling,against a 1996 base, by the year 2012.4.11 At the operational level, the Highways Agency, withresponsibility for motorways and trunk roads, has anobjective to improve conditions on the roads for cyclists,pedestrians and equestrians. Whilst the Agency has notset a quantified performance target for access forcyclists, its management plan includes operationaltargets for four accessibility schemes costing over£100,000, and a further 15 costing under £100,000.Setting a strategic performance target to measure itssuccess in delivering accessibility would provide theAgency with a further incentive to work closely with theDepartment of the Environment, Transport and theRegions to improve access and safety for cyclists.Integrating health and transport plans locally4.12 Health authorities and local authorities provide themain links in translating Government policy on health,transport and the environment into local action: healthauthorities are responsible for identifying the healthneeds of the local population and for seeking to addressthem through co-ordinating the local HealthImprovement Programme; and local authorities makethe planning decisions which affect the localenvironment and transport infrastructure. Joint workingon these issues at departmental level needs to bemirrored by collaboration at the local level todevelop and implement integrated health andtransport strategies.4.13 To develop these links, the Department of theEnvironment, Transport and the Regions and theDepartment of Health jointly sponsored a report called'Making The Links: Integrating Sustainable Transport,Health and Environmental Policies', published in 1999by the Health Education Authority 33 . The report aimedto promote joint working between local authorities andhealth authorities by identifying common themes innational transport, health and environmental policies,by providing guidance on the development of integratedstrategies, and by disseminating good practice.Case Study 5 illustrates what can be done.4.14 Local Transport Plans will provide an opportunity toapply this integrated approach more widely. They wereintroduced by the 'New Deal for Transport' WhitePaper 32 as a centre piece for local action and key to thedelivery of integrated transport. They are five-year planson which local authorities are required to consultwidely, including with health care providers. Some localauthorities have set their own targets to increase cycling,in line with the Department of the Environment,Transport and the Regions' national objective, and areworking with local user groups to achieve them.4.15 In developing their policies on walking and cycling, anumber of local authorities have designated 'Walking'and 'Cycling' Officers in order to develop plans andimplement schemes on the ground. Walking and cyclingare also being promoted through Green Transport Plans,which were introduced by the 'New Deal for Transport'White Paper as a means of delivering changes in travelmodes to and during the course of work. Through suchplans, employers are encouraged to promote the use ofwalking and cycling by offering incentives andproviding the equipment and facilities to make thesemore attractive options. As part of the National ServiceFramework for coronary heart disease 6 , NHS and localauthority employers are required to develop GreenTransport Plans by April 2002.4.16 As a sister publication to 'Making The Links', the HealthEducation Authority published a further report in 1999called 'Active Transport' 27 , designed to helpprofessionals working at community level to developlocal initiatives to promote walking and cycling. This isa practical document which makes extensive use of casestudies to disseminate good practice in developinghealthy transport initiatives. Some examples from thereport are described in Case Studies 6, 7 and 8.ii. Promoting more active recreation insociety4.17 Another way in which Government can encourage morepeople to take more exercise is by promoting physicalrecreation. The Department for Culture, Media andSport has a lead role in promoting participation in sportand in ensuring that adequate opportunities for activeleisure and play are provided for the whole population,including the socially disadvantaged. The Department'sPublic Service Agreement with the Treasury published in2000 includes a strategic objective to raise significantly,year on year, the average time spent on sport andphysical activity by those aged 5 to 16.part four34

TACKLING OBESITY IN ENGLANDCase Study 5: Integrated health and transport strategies in LiverpoolLiverpool Health Authority identified action areas on "transport, air, planning and landuse" in its Health Improvement Programme (1999). These included:nnnnnnThe health impact assessment of new transport plansImplementing a cycle users' programmeDeveloping a targeted and cohesive transport strategy, linked to the cycling strategyIncorporating health and sustainability into local planning guidanceReducing the amount of long-stay car parking and promoting the health benefits ofthe car parking strategySecuring organisational commitment for implementing green commuter plans,including incentives to use public transport and walking.Merseyside local authority's transport strategy had a section devoted to transport andhealth, and a health impact assessment of the regional transport strategy was conducted.Projects included:nnnnnHealthy transport plans at NHS sitesGreen commuter plans for NHS staff and links to "health at work" programmesA TravelWise regional campaign, with transport/health promotionsCycling and walking route development and promotion, linked to physical activity programmes"Safer routes to school" and links to children's health.Source: Making The Links 33Case Study 6: Health promotion by encouraging the use of stairsA study was undertaken by researchers at Glasgow University and Glasgow Health Board to encourage the use of stairs ratherthan an escalator at a city centre underground station. The aim was to test whether incidental physical activity could beincorporated into the daily routines of members of the public.Posters with the slogan " Stay Healthy, Save Time, Use the Stairs" were placed in prominent positions at the point of choicewhere an escalator and two flights of fifteen steps ran side by side.Prior to the erection of the posters, stair use was around eight per cent. During the three week period when the sign waspresent, stair use went up to between 15-17 per cent. Twelve weeks after the removal of the posters, stair use remainedsignificantly above the level recorded prior to the erection of the posters. The Health Education Board for Scotlandsubsequently distributed motivational stair walking posters throughout Scottish workplaces.Source: Active Transport 27Case Study 7: Promoting Walking and Cycling in StockportA unique NHS project has been established in Stockport to promote walking and cyclingthroughout the borough. A Project Officer is employed to promote walking and cyclingas part of every day living.A range of programmes has been established including adult cycling classes, a resourcepack to support school talks, a cycling festival and a cycle leasing scheme whichencourages NHS Trust staff to cycle to work. This scheme enables staff to rent one of 85bicycles purchased by the Trust. It aims to increase fitness and activity levels among staff,as well as alleviate parking problems at hospital sites.The scheme has proved to be extremely popular, with far more staff cycling to work thanpreviously as all the bikes have been rented out. It is part of a broader sustainabletransport plan produced by the local Transport Working Group- an alliance betweenStockport NHS and Stockport Metropolitan Borough Council.part four35Source: Active Transport 27

TACKLING OBESITY IN ENGLANDCase Study 8: British AerospaceBritish Aerospace (Bristol) employs over 5,000people on a vast site that accommodates offices,manufacturing facilities and a research centre. Topromote cycling among staff British Aerospacehas invested in showers, changing facilities andadditional bike parking.The company Bicycle User Group reports thatcurrently 10 per cent of staff cycle to work butthe numbers are increasing as the improvementprogramme unfolds. The company also sponsorsa public Project Bike helpline for general cycleroute advice, and in 1998 sponsored the BristolBike Festival.Source: Active Transport 274.18 Much of this activity takes place through the fundingprovided by the Department to organisations such asSport England and the Central Council of PhysicalRecreation, who themselves fund local providers suchas local authorities and sports clubs. Within its fundingagreement with the Department for Culture, Media andSport, for example, Sport England has objectives toinvolve more people in sport and to increase thenumber of places in which sport is played. Theagreement places particular emphasis on increasingparticipation amongst young people.4.19 These aims fit with the Department of Health's objectiveto improve health by encouraging more people to takemore physical activity. Although there has beenrelatively little formalised joint working between theDepartment of Health and the Department for Culture,Media and Sport to date, there is frequent ad hocworking level contact to discuss issues and projects ofmutual interest and to ensure consistent approaches(Figure 19). More formalised joint working relationshipsare now being established, in particular through theInter-Ministerial Group to Improve Children's Diet andActivity, set up in July 2000. In addition, Sport Englandhas employed for the first time a consultant to advisethem on improving integration with the health sector.4.20 Much of the joint working to increase participation insport, particularly amongst socially disadvantagedgroups, is centred around school-based activities indesignated Sports Action Zones. More detail on theestablishment of these zones and related initiatives isprovided at paragraphs 4.51-4.52.iii. Identifying and promoting healthypatterns of eating4.21 Encouraging healthy eating is a key component in tryingto address the rising prevalence of obesity. It is also animportant part of the Department of Health's strategy toimprove health and reduce health inequalities byaddressing priority disease areas, in particular coronaryheart disease and cancers. The Ministry of Agriculture,Fisheries and Food and, since April 2000, the FoodStandards Agency, play an important role in ensuring theadequate provision of safe and healthy foods, helping toeducate the public about diet and encouraging healthyeating. The Ministry has a high level objective "Tosafeguard the continuing availability to the consumer ofadequate supplies of wholesome, varied and reasonablypriced food and drink".4.22 The creation of the Food Standards Agency in April 2000explicitly acknowledged the links between health anddiet. The Agency brought together former policy staff onaspects of nutrition from the Department of Health andthe Ministry of Agriculture, Fisheries and Food, and is19 The links between health and physical recreationDepartment of HealthTo improve healthand reduce healthinequalitiesEncourage and facilitate sportand physical activity for allDepartment forCulture, Media and SportTo improve quality of life forall through cultural andsporting activitiesMore participation in sportby more peoplepart fourHealth DevelopmentAgencyTo provide evidence andguidance on what worksto improve healthn Ad hoc consultation on topics ofmutual interestn Inter-Ministerial GroupSport EnglandTo lead developmentof sport in Englandby influencingand serving thepublic, private andvoluntary sectors36Source:National Audit Office

TACKLING OBESITY IN ENGLANDaccountable to Health Ministers. The Agency has nospecific objective to address the effect of diet on weightgain or obesity, though the following objectives of theAgency are relevant to encouraging healthy eating:nencouraging innovation and diversity in the range offoods available, backed up by clear and informativelabelling to enable consumers to make properlyinformed choices.nnnto define a healthy diet (in other words, the ranges ofdietary intakes which minimise the risk of adverseeffects including nutrient deficiencies) and to putthis in the context of other lifestyle factors such asexercise;to ensure that information provided to consumersabout the food they buy is accurate, adequate andnot misleading; andto secure the greatest possible level of consumerchoice and value for money.4.23 The core activities of the Agency include:nnnncommissioning research into human nutrition andthe factors that affect food choice;providing up-to-date educational material andadvice on healthy eating for health professionals andthe public;maintaining and disseminating information on thenutrient composition of food;monitoring the diet and nutritional status of people;and4.24 Figure 20 shows the main ways in which theDepartment of Health and the Food Standards Agencywork together to identify and promote healthy eatingpatterns.4.25 Prior to the establishment of the Food Standards Agency,the Ministry of Agriculture, Fisheries and Food wasalready active in pursuing research topics related to theissue of obesity and its prevention. A strategic review ofresearch undertaken in 1996 identified the desirabilityof the Department of Health establishing a cross-cuttinggroup to co-ordinate research on obesity.4.26 The Food Standards Agency now works closely with theDepartment of Health to commission research onnutrition and the effects of diet on health. Research thatmight inform both food and health policy is alsoconsidered by the Diet and Health Research FundersGroup, which meets annually to discuss researchprogrammes, exchange information and explorelinkages and possible overlaps. The group includesrepresentatives of the Department of Health, the FoodStandards Agency and the related Research Councils.20 The links between health and dietMinistry of Agriculture,Fisheries and FoodTo provide good qualityfood which meetsconsumers' requirementsDepartment of HealthTo improve healthand reduce healthinequalitiesTo promote andfacilitate healthy eatingFood Standards AgencyTo improve the diet of thewhole populationHealth DevelopmentAgencyTo provide evidence andguidance on what worksto improve healthn Concordats providing framework for co-operationn Regular consulation on topics of mutual interestn Sharing information on scientific research/survey datan Joint planning and funding of surveys and researchn Scientific Advisory Committee on Nutritionn Inter-Ministerial GroupSource:National Audit Officepart four37

TACKLING OBESITY IN ENGLAND4.27 The National Diet and Nutrition Survey is a programmeof cross-sectional surveys to assess the diet andnutritional status of different age groups within thepopulation of Great Britain. The Food Standards Agencyand the Department of Health work together to design,commission and manage the surveys to ensure that theresults support the implementation and monitoring ofnutrition policy. The surveys are funded jointly by theAgency and the Department.4.28 The Department of Health's Nutrition Researchprogramme is funding a number of projects relevant toobesity:nna systematic review of the characteristics of childrenwho become obese adults;the development of a family based intervention toprevent obesity in a high risk group;4.30 The 'Balance of Good Health' plate is a diagrammaticrepresentation of the types and proportions of foods thatmake up a healthy, balanced diet. This model depictsGovernment advice on healthy eating in the form offoods rather than in terms of nutrients. The FoodStandards Agency is considering plans for furtherdissemination of the model.4.31 In July 2000, the Department of Health announced aspart of the NHS Plan 7 proposals to improve diet andnutrition by a series of measures by 2004 including:nna five-a-day programme to increase fruit andvegetable consumption, and a new national schoolfruit scheme;reform of the welfare foods programme to ensurechildren in poverty have access to a healthy diet,and increased support for breast feeding;nthe extent to which energy and fat consumption canbe estimated from supermarket receipts; andna hospital nutrition policy to improve the outcome ofcare for patients;na longitudinal analysis of child and adolescentpredictors of adult obesity based on the 1958 birthcohort.4.29 The Food Standards Agency, in consultation with theDepartment of Health, is also sponsoring research intofood acceptability and choice, aiming to encourage ashift away from fatty foods and towards a greaterconsumption of starchy foods and fruit and vegetables.nnwork with industry- including producers as well asretailers- to increase provision and access to fruitand vegetables with local initiatives, wherenecessary, to establish local food co-operatives; andinitiatives with the food industry- includingmanufacturers and caterers- to improve the overallbalance of diet including salt, fat and sugar in food,working with the Food Standards Agency.21 The Balance of Good Healthpart fourSource:Food Standards Agency38

TACKLING OBESITY IN ENGLANDInitiatives targeting children and youngpeopleiv. Equipping young people for a healthylifestyle4.32 For most people, the values, perceptions and patterns ofbehaviour that are formed during childhood andadolescence are an important influence on their lifestylein adulthood. Moreover, levels of fatness seem to beincreasing amongst schoolchildren 34 , and the NationalDiet and Nutrition Survey, published in 2000 18 , givescause for concern about children's diets, nutritionalstatus and physical activity levels. Young peopletherefore need an understanding both of the risks thatobesity poses to health, and of the ways to maintain ahealthy weight.4.33 The Department for Education and Employment is amajor player at central Government level inencouraging the education of young people in thebenefits of a healthy lifestyle, including the benefits ofphysical activity and a healthy diet. The Department alsohas a role in ensuring that a healthy environment isprovided in schools: in particular that schools offernutritious lunches, such as by providing fruit andvegetables and avoiding an excess of foods with a highfat, salt or sugar content; and that they provideopportunities and encouragement for physical activity.These aims fall within the Department's generalobjective to ensure that all young people reach 16 withthe skills, attitudes and personal qualities that will givethem a secure foundation for lifelong learning, work andcitizenship in a rapidly changing world. They are alsocongruent with the Department of Health's objective toencourage people to live healthily.4.34 Figure 22 illustrates where the policy objectives of thetwo departments intersect in relation to diet andphysical activity, and shows which type of cross-cuttingintervention they have used.4.35 The Department of Health and the Department forEducation and Employment consult one another to worktowards achieving these mutual objectives. Thisinvolves:nnnnhigh level consultation on policy issues, such aswhen a White Paper or draft legislation is prepared;ongoing liaison at a working level over relevantaspects of the school curriculum, in particularbefore any changes are made;staff secondments or loans to raise mutual awarenessand encourage collaboration. This includes the longstandingarrangement in which the Department ofHealth has provided a member of medical staff tocontribute to policy and services, and advise theDepartment for Education and Employment onaspects of the education system where a knowledgeof health issues and policy is needed; anddetailed liaison, including through setting up jointteams and working groups, to consider specificissues. For example, the recent development ofnutrition standards for school meals necessitatedalmost daily informal contact at a working level overa period of several months.4.36 The Department for Education and Employment told usthat there were four main areas of the curriculum wherechildren have the opportunity to acquire the knowledgeand skills that will help them to live healthily: personal,social and health education; physical education;nutrition; and food technology. We examine physicaleducation, nutrition and food technology at paragraphs4.46-4.64 overleaf.22 The links between health and educationDepartment of HealthTo improve healthand reduce healthinequalitiesEnsuring that education is providedon health, diet and physical activityand that the school environmentpromotes healthy lifestylesDepartment forEducation and EmploymentTo ensure young peoplereach 16 with the skills,attitudes and personalqualities to give them asecure foundation forlifelong learning, workand citizenshipHealth DevelopmentAgencyTo provide evidence andguidance on what worksto improve healthn Regular consultation on aspects of the school curriculumn Sharing information to increase mutual awarenessn Joint teams on specific issues (eg school travel and school meals)n Seconding staff to encourage collaborationn Joint publications and guidancen Inter-Ministerial Grouppart fourSource:National Audit Office39

TACKLING OBESITY IN ENGLANDpart four404.37 The objective of personal, social and health education isto provide a foundation for the personal development ofyoung people in preparing them for adult life. Thissubject became part of the core curriculum for the firsttime in September 2000. In developing this subject, thecurriculum division within the Department forEducation and Employment liaised with the Departmentof Health, in part through the Medical Advisor, to definethe necessary elements that would provide a balancedcoverage of health issues. As regards obesity, thepersonal, social and health education curriculumincludes coverage of the components, such as diet andexercise, that constitute a healthy lifestyle, and of thehealth risks associated with a body weight which isabove or below the healthy range. Case Study 9provides an example of the benefits of personal, socialand health education in schools.v. Promoting a healthy school environment4.38 Beyond the formal curriculum, the Department forEducation and Employment also has a role in ensuringthat the environment in schools reinforces healtheducation messages by encouraging appropriate extracurricularactivities and promoting healthy living.4.39 The Department for Education and Employment and theDepartment of Health have worked closely to promotegood practice. In May 1998, Ministers from the twodepartments jointly launched the Healthy SchoolsProgramme, designed to encourage and promotehealthy lifestyles through the school culture andenvironment. They announced a commitment to workacross Government, the private and voluntary sectors, andwith local agencies and communities, to help schoolsbecome healthier schools through supporting thedevelopment and improvement of local programmes.Case study 9: Personal, Social and Health Educationacross the curriculum - Chapel Break First SchoolAt Chapel Break First School in Norfolk, acentral plank of its strategy to become a HealthySchool was to build its personal, social andhealth education into other curriculum areas.The reception class worked on a different healthrelatedtopic each term, including "me andlooking after my body".Over four years in which it worked towards theHealthy Norfolk Schools Award (achieved in1998), the school's academic results steadilyimproved. In Science, it attained the highestgrading compared with equivalent primaryschools nationally. Teachers felt the boost inresults, particularly Science, was thanks tointegrating health issues into the curriculum.Source:National Healthy School Standard: Getting Started - AGuide for Schools’ 354.40 A key part of the Healthy Schools Programme is theNational Healthy School Standard, which was launchedin October 1999 to offer support for local programme coordinatorsand provide an accreditation process foreducation and health partnerships. The Standard,managed by the Health Development Agency, has beendisseminated to schools, local authorities and healthauthorities through guidance 35,36 , which providesexamples of good practice. Key components of theStandard are to encourage physical activity, throughschool travel and physical recreation, and healthy eating.vi. Promoting healthy travel to school4.41 The number of children walking or cycling to school hasdeclined dramatically over the last two decades. In themid-1980s, two thirds of children aged between 5 and 10years walked to school, and more than six per cent of11-16 year-olds cycled to school. By the late 1990s, thishad fallen to just over half of children (5-10 years)walking to school, and less than two per cent of pupils(11-16 years) cycling 37 .4.42 The Department of Health, the Department forEducation and Employment and the Department of theEnvironment, Transport and the Regions have workedtogether to promote healthy school travel. Figure 23illustrates the intersecting policy responsibilities of thesedepartments for school travel, and the key initiatives thathave emerged from their collaboration.4.43 As a central forum for debate and joint working betweenthe departments, the School Travel Advisory Group wasset up in 1998, including representatives of the health,transport and education sectors. The Group includes thethree key Government departments and a wide range ofstakeholders from local Government, voluntary andprivate organisations. In 1999, the Group reported toMinisters on a range of measures intended to improvesafety on the journey to and from school, provide avariety of healthier travel choices and encourage moreyoungsters to walk, cycle or take public transport.4.44 In 1999, the three departments worked together tocommission the Transport 2000 Trust to produce guidanceon school travel, entitled 'A Safer Journey to School' 38 . Thisguidance advises local authorities, schools and parents onbuilding a safe environment for pupils to walk and cycle ortake public transport to school, including measures to calmroad traffic, enhance footpaths and cycle lanes, andprovide facilities for the storage of bicycles and accessories.4.45 A further incentive for schools is that promoting safe andhealthy school travel can also be a key component inachieving accreditation under the National Healthy SchoolStandard developed by the Department of Health and theDepartment for Education and Employment. At primaryschool level, this is backed up by a training guide helpingtrainee teachers to teach children about physically activemodes of travel as part of the primary school curriculum. To

TACKLING OBESITY IN ENGLANDoffer financial support, the departments also launched the'Safe and Sound Challenge' in January 1999, with a secondphase announced in December 2000 to focus on initiativesin Education Action Zones. This scheme encouragesschools to develop ideas for safe travel to school usingalternatives to the car by offering cash prizes for the mostinnovative ideas. Case Studies 10 and 11 illustrate the typeof action that can be taken.Case Study 10: The walking bus at WheatfieldsJunior SchoolCase Study 11: Llwynu Primary School CyclingClub, AbergavennyLlwynu primary school is situated a mile fromAbergavenny town centre. The Cycling Club atthe school was established by two members ofstaff in 1998. The primary aim was to encouragefitness and independence, to help theenvironment through reducing car trips, and toaddress aspects of cycle proficiency. Staff reportthat the pupils greatly enjoy the cycleproficiency sessions, parents are positive aboutthe Club and it is hoped that the training willhelp with cycling skills and encourage a cultureof cycling among the pupils.Source: Active Transport 27vii. Promoting sport and physical recreationin schoolsThe walking bus is an organised walking group led byadults. Parents wait at a series of "bus stops" for trainedvolunteers to escort their children to school. The schemehas a conductor who supervises the children and a driverwho wheels a trolley carrying the children's bags. Eachroute is between ½ and 1 mile long.Children who use this route to school are rewarded byvouchers or stickers they can use to trade for free goodsfrom the school bookshop.4.46 Providing opportunities and encouragement for sport inschools can help make young people more active andprovide them with the skills and motivation to remainphysically active into their adult lives. Here the policyresponsibilities of the Department of Health, theDepartment for Culture, Media and Sport and theDepartment for Education and Employment overlap.Figure 24 illustrates where these responsibilitiesintersect and the main initiatives to have sprung fromjoint working in this area.Source:School Travel: Strategies and Plans - a Best PracticeGuide for Local Authorities 3923 Intersecting policy objectives and key initiatives relating to school travelDepartment of HealthTo improve healthand reduce healthinequalitiesPromotion ofwalking and cyclingPromoting educationand healthy schoolsHealthy and safejourneys to school"Safer"Saferjourneysjourneystotoschool"school""Safe"Safeandandsoundsoundchallenge"challenge"SchoolSchooltraveltravelplansplansHealthy Schools Programmeand National HealthySchool StandardSafe transportto schoolsDepartment forEducation and EmploymentTo ensure young peoplereach 16 with the skills,attitudes and personalqualities to give them asecure foundation forlifelong learning, workand citizenship"Are you doing your bit?"campaignDepartment ofthe Environment,Transport & the RegionsTo make it easier to walkand cycle and therebyreducereliance on carspart four41Source:National Audit Office

TACKLING OBESITY IN ENGLAND24Intersecting policy objectives and key initiatives to promote sport in schoolsDepartment of HealthTo improve healthand reduce healthinequalitiesTo promote andfacilitateactive leisurePE in the curriculumPersonal, Social and Health EducationHealth Schools ProgrammeTo teach young people aboutthe benefits of physcial activityTo encourage young people tobe active by participating insports within andbeyond schoolTo encourage youngpeople to acquire skills andparticipate in school sportDepartment forEducation and EmploymentTo ensure young peoplereach 16 with the skills,attitudes and personalqualities to give them asecure foundation forlifelong learning, workand citizenshipDepartment forDepartment forCulture, Media and Sportthe Environment,To improve quality of life forTransport & the Regionsall through cultural andTo reduce reliance on carssporting activitiesand make it easier to walkMore participation in sportand cycleby more peopleSports Action ZonesSpecialist Sports CollegesSports Co-ordinatorsSports Mark AwardSporting AmbassadorsSource:National Audit Officepart four4.47 The primary aim of physical education in the curriculumis to increase pupils' physical competence andconfidence in a range of physical activities. It can equippupils with the skills to take part in physical activityoutside school and foster positive attitudes to physicalactivity. Schools also provide an important setting forparticipation in physical recreation through extracurricularactivities.4.48 Physical activity specialists have raised concerns inrecent years about a decline in the time spent onphysical education and extra-curricular sport in schools.These concerns were based on evidence that in manyschools the priority attached to physical education hadfallen, and that in some schools pupils were spendingless than an hour a week in sports lessons. Theimportance of providing opportunities for physicalactivity in school was emphasized by the finding fromthe National Diet and Nutrition Survey, published in2000 18 , that most young people were inactive, asindicated by time spent in moderate or vigorousactivities. Girls were less active than boys, and activitylevels fell with increasing age within the range surveyed(young people between the ages of 7 and 18).4.49 In launching a review of the National Curriculum in1999, the Secretary of State for Education andEmployment announced the Government's intention toaddress these concerns, and made it clear that twohours of physical activity a week should be an aspirationfor all schools. The Department for Education andEmployment is working with other departments, inparticular through the Inter-Ministerial Group toImprove Children's Diet and Activity, to increaseopportunities to participate in sport, both through theformal curriculum and in the wider school setting.4.50 To enhance physical education in the curriculum, theDepartment for Education and Employment hasincreased from September 2000 the range of physicalactivities available through the curriculum to pupilsaged between 14 and 16. The high number of pupils inthis age group who were opting out of school sports ledthe Department to consult physical activity specialists inthe other departments and elsewhere on ways toencourage wider participation. This consultationsuggested that alternatives to competitive team sportswould be more attractive to many pupils. Thus, bybroadening the range of activities schools can offerthrough the curriculum, the Department hopes toencourage young people, who might not otherwise havedone so, to participate in different forms of physicalrecreation.42

TACKLING OBESITY IN ENGLAND4.51 To enhance physical activity in the wider school setting,the Government announced significant additionalfunding in September 2000 on a major programme ofinitiatives to improve the infrastructure for sport and toencourage participation both within and beyond schoolhours. The main application of the funding is to targetthe areas of greatest need in order to reach thosechildren who have been deprived of adequateopportunities to participate in sport. Based on acombination of indicators of deprivation, 12 SportsAction Zones have so far been established, and a further18 will be set up in 2001.4.52 The range of initiatives developed to increase theparticipation of young people in physical activityincludes:nnnnnna major programme of building and refurbishingschool sports facilities, for which £600 million willbe provided in England. These facilities will also bemade available for community use to encouragewhole families to participate in sporting activity;creation of more specialist sports colleges, in whicha positive attitude to sporting skills and achievementare embedded within the ethos of the school andhigh quality facilities are provided both for pupilsand the wider community;School Sport Co-ordinators, based in hub schools atthe centre of "families" of both secondary andprimary schools. The objectives of the Co-ordinatorsare to develop the framework of competitive sportsbetween schools, and to help develop the coachingand leadership skills of both teachers and olderpupils. The target is to establish 1,000 such Coordinatorsby 2004;the Sports Mark award and Sports Ambassadorsschemes, which use an awards system and visits toschools by sporting celebrities to spread the messageof the value of sport and provide role models toencourage wider participation;investment of around £7 million in the recruitment,training and placement of up to 55,000 SportVolunteers during 2002-04. The programme willfocus on building leadership skills in 14-19 yearolds,enabling them to act as role models foryounger pupils. It will also seek to attract adultvolunteers to encourage adults to return to physicalactivity and to promote participation across all ageranges; anda Green Spaces initiative to create spaces for playand sports in areas which lack such facilities.4.53 In addition, the National Healthy School Standard,launched jointly by the Department of Health and theDepartment for Education and Employment in October1999, provides a further incentive for schools to developa culture that places greater emphasis on physicalrecreation and sport. Physical activity is one of tenthemes of the Standard, under which schools areencouraged to:nnnndevelop a whole school approach to promotingphysical activity;offer all pupils a minimum of two hours physicalactivity a week within and outside the NationalCurriculum;learn about relevant initiatives and networks andtake advantage of appropriate opportunities topromote and develop physical activity; andencourage staff, pupils, parents, and sportsdevelopment officers to become involved inpromoting physical activity and develop their skills,abilities and understanding through appropriatetraining.4.54 Case Study 12 provides an example of how a school andits pupils can benefit from making physical activity andsporting achievement an integral component of theschool's values.4.55 To consolidate cross-Government work on thedevelopment of sport in schools, the Department forCulture, Media and Sport has recently established theSchool Sport Alliance, a joint advisory and coordinatingcommittee which will represent all the keyplayers with a role in funding and advising on schoolsports projects.Case Study 12: Raising standards through sport -Baverstock School, BirminghamBaverstock School is located in the Druid'sHeath area of Birmingham, in a housing estatewith very limited local amenities. The schoolethos places a high value on sportingachievement, and all pupils are encouraged toparticipate in the wide variety of different sportsthat the school offers. The school has prioritisedthe acquisition of good sports facilities, such asby creating a well-equipped gymnasium anddeveloping nearby wasteland into football andcricket pitches. As a result, it has become thefocus of the community, with local peoplemaking extensive use of the school's facilities atevenings and weekends. As well as being amongthe best schools in the country for many of the15 sports it plays, Baverstock School has seensporting success mirrored by a steadyimprovement in the self-confidence, conductand educational achievement of its pupils.Source: National Audit Office site visitpart four43

TACKLING OBESITY IN ENGLANDpart four44viii. Promoting healthy eating in schools4.56 The promotion of a healthy diet in schools can help toinstil healthy eating patterns that might persist intoadulthood. It is also necessary in order to address therising prevalence of overweight and obesity amongchildren. Figure 25 illustrates the intersectingresponsibilities of relevant Government departmentsand the main initiatives to have emerged from crosscuttingwork.4.57 The independent inquiry commissioned by theGovernment on 'Inequalities in Health', published in1998 40 , stressed the importance of providing a healthydiet in schools and recommended the provision of freeschool fruit. The most recent survey of the National Dietand Nutrition Survey programme, published in June2000 18 , focussed on the diets and nutritional status ofyoung people between the ages of 4 and 18 years. Itfound that:nnntaking fruit, vegetables and fruit juice together,average consumption was 188 grams per day. This iswell below the World Health Organisation'srecommendation for adults of 400 grams per day,which is considered optimum for protecting health;although 98 per cent of children reported eatingsome fruit and vegetables at least once during thesurvey week, 20 per cent did not consume any fruitand four per cent did not consume any vegetables;average intakes of saturated fatty acids and addedsugars were higher than recommended.4.58 To help address these deficiencies, the Department ofHealth announced in July 2000 funding of £2 million onschemes to encourage the consumption of fruit andvegetables among children and young people. TheDepartment is examining the practicalities of providingevery school child aged between four and six with a freepiece of fruit each school day. The Department forEducation and Employment has also led thedevelopment of nutrition standards for school lunches.The aim is to enhance food choice in schools byensuring that all school caterers meet minimumnutritional standards in the lunches they offer toschoolchildren. Regulations setting minimum nutritionalstandards for school lunches are being implementedfrom April 2001, supported by guidance for catererswhich includes advice on healthy cooking methods. Thestandards and guidance were developed throughextensive consultation with the Department of Healthand the Food Standards Agency, and the private andvoluntary sectors. All school lunches will have to meetthe new standards.4.59 The Department for Education and Employment is alsofunding the Child Poverty Action Group to conductresearch into why some children do not take up theirentitlement to free school meals, with the aim of makingavailable good practice guidance on maximising freeschool meal take-up.4.60 Curricular education in the areas of nutrition and foodtechnology is complementary. Nutrition teaches pupilsabout the importance of food for health, the essentialcomponents of diet, the nutritional content of differentfoods, and how to make sensible food choices. Foodtechnology covers the practical use and preparation offood.4.61 A sound knowledge of food and nutrition provides arange of teaching opportunities for primary schoolteachers across the whole curriculum, which can be amajor boost to diet and health education. To help newlyqualified primary teachers to cover food and nutritionaccurately and in depth, the Department of Health havepublished, in association with the Ministry ofAgriculture, Fisheries and Food and with assistance fromthe British Nutrition Foundation, a guide entitled 'Foodand Nutrition: Guidance on Food and Nutrition inPrimary Teacher Training'. The Department forEducation and Employment also receives advice andteaching aids from other industry and specialistorganisations which undertake research in this area,such as the Food and Drink Federation, the British MeatFederation, and the National Association of HomeEconomics.4.62 Schools also offer an environment for promoting healthyeating through extra-curricular activities involvingnutrition and cookery and through providing healthyoptions in tuck shops and breakfast clubs. These outletscan provide an important source of nutrition,particularly for those children at risk of poor nutrition athome. Cooking for Kids is a joint initiative between theDepartment of Health and the Department forEducation and Employment, led by Ministers, whichaims to teach practical cookery skills to pupils in astimulating way, using school facilities but outside ofschool hours. This range of initiatives is currently beingevaluated. The Healthy Schools Programme offersfurther encouragement for schools to develop suchactivities, as healthy eating is one of the ten themes ofthe National Healthy School Standard.

TACKLING OBESITY IN ENGLAND25Intersecting policy objectives and key initiatives to encourage healthy eating in schoolsDepartment of HealthTo improve healthand reduce healthinequalitiesDefine and promotehealthy dietMonitoring throughNational Diet andNutrition SurveySchools provide ahealthy diet and educationon nutritionYoung people eat a balancednutritious diet in schoolsNational Standards forschool lunchesFree fruit in schools(subject to pilots)Food technology andnutrition in curriculum"Cooking for Kids" campaignYoung people haveaccess to a choice offood in schoolsDepartment forEducation and EmploymentTo ensure young peoplereach 16 with the skills,attitudes and personalqualities to give them asecure foundation forlifelong learning, workand citizenship27Department forIntersecting policy objectives and key initiatives to encourage the healthy Environment,Food Standards eating Agency in schoolsTransport & the RegionsTo improve the diet of theTo reduce reliance on carswhole populationand make it easier to walkand cycleFood technology andnutrition in curriculum"Cooking for Kids" campaignSource:National Audit OfficeDepartment of HealthTo improve healthand reduce healthinequalitiesDefine and promotehealthy dietSource:businessesNationalcanAuditmakeOfficeto education, the Department forSchools provide ahealthy diet and educationon nutritionYoung people haveaccess to a choice offood in schoolsDepartment forEducation and EmploymentTo ensure young peoplereach 16 with the skills,attitudes and personalqualities to give them asecure foundation forlifelong learning, workand citizenship4.63 There is, however, a risk of inconsistency between Young people eat a balanced they become involved in sponsorship, advertising orcertain sponsorship activities of schools and initiatives nutritious diet in schools marketing schemes, or in any local business-linkedto promote a balanced diet for young people. In order National to Standards activity, for they should consider possible disadvantages. Itsupplement the resources to support literacy andschool lunchesadvises schools to follow the National ConsumerFree fruit in schoolsnumeracy, for example, schools have participated with Council's 'Sponsorship in Schools - Good Practice(subject to pilots)businesses in schemes to provide free books and maths Guidelines' 41 , which were developed with the help ofequipment in return for tokens from crisp and biscuit education, business and consumer groups. Thispackets. This type of commercial involvement, which guidance states that, when considering a sponsoredMonitoring throughhas the effect of directly promoting sales of particular resource or activity, schools should ask themselvesNational Diet andproducts, may encourage children Nutrition and Survey their families to whether, among other things, "children and teachers canbuy more snack foods with a high fat, salt and sugar participate without buying the sponsor's products", andcontent. This would act directly in opposition toDepartment forwhether it is "free of incentives to children to eat anthe Environment,initiatives to discourage over-dependence on suchFood Standards AgencyTransport & the Regions unhealthy diet or take part in unsafe/unhealthyTo improve the diet of theenergy-dense snack foods in favour of balanced mealsTo reduce reliance on carswhole population activities". The guidance recognises that schemes areand make it easier to walkand increased consumption of fruit and vegetables. and cycle4.64 Whilst welcoming the positive contribution thatEducation and Employment recognises the risk thatcommercial promotions of certain foods aimed atschools might have an adverse influence on pupils'eating habits. It therefore advises schools that, beforelikely to "meet some guidelines and miss others" andthat schools must therefore decide for themselveswhether "taken as a whole, the sponsorship offer hasintegrity and educational value". There is no informationavailable, however, on the extent to which schoolscomply with the guidance, which is currently underreview.part four45

TACKLING OBESITY IN ENGLANDAppendix 1 Auditmethodology1 The techniques used to examine the issues identified forthe study can be classified into five areas:nnLiterature review and consultation with experts;Cost-of-illness study;nnProfessor Peter Kopelman, Professor of ClinicalMedicine, St Bartholomew's & the Royal LondonSchool of Medicine & DentistryProfessor Ian Macdonald, Head of the School ofBiomedical Sciences, University of NottinghamnnnSurveys of health authorities, general practitionersand practice nurses;Review of policy objectives and initiatives acrossGovernment;Site visits to examine local initiatives.Literature review and consultation withexperts2 We carried out literature searches and a review ofpublished literature from the United Kingdom andabroad on all aspects of the study. A list of the papersreferenced in this report is at the Bibliography(page 65).3 We attended a number of conferences and seminars,including the 8th International Congress on Obesity,held in Paris in August 1998, and the 9th EuropeanCongress on Obesity, held in Milan in June 1999. Wealso attended a series of conferences and seminarshosted by the Association for the Study of Obesity,including a joint conference with the British Associationof Sport and Exercise Sciences held in Leeds inSeptember 1999.4 We convened a panel of experts to advise and assist usat strategic points throughout the study. The panelcomprised:nnnnnnDr Elizabeth Evans, Scientific Director, SlimmingMagazine ClubsDr Gene Feder, General Practitioner and Professor ofPrimary Care Research and Development,St Bartholomew's and the Royal London School ofMedicine and DentistryProfessor Ken Fox, Head of Exercise and HealthSciences, University of BristolProfessor John Garrow, Editor, European Journal ofClinical NutritionDr Andrew Hill, Senior Lecturer in BehaviouralSciences, Leeds University School of Medicine, andChairman, Association for the Study of ObesityProfessor Philip James, Chairman, InternationalObesity Task ForcennnMr Rae Magowan, Assistant Director of PublicHealth, Trent Regional Office, National HealthService ExecutiveDr Sue Martin, Team Leader of Police Training,Home Office (formerly Unit Head, Public HealthGroup, Department of Health)Dr Carolyn Summerbell, Reader in HumanNutrition, University of Teessiden· Professor Martin Wiseman, Head of Nutrition andRegulatory Affairs, Burson-Marsteller (formerly Headof the Nutrition Unit at the Department of Health).5 We also consulted more widely with importantstakeholders in issues related to the management andprevention of obesity, diet and nutrition, and physicalactivity. We consulted academics, clinicians,professional bodies in the health sector, voluntarybodies (including those established to represent obesepeople), and the private sector. This process includedthe following organisations:Adrian Davis AssociatesAssociation for the Study of ObesityBritish Dietetic AssociationBritish Heart FoundationBritish Medical AssociationBritish Obesity Surgery SocietyCentre for Obesity Research (Luton and DunstableHospital)Child Growth FoundationEurobesitasFood and Drink FederationInfant and Dietetic Foods AssociationInternational Association for the Study of ObesityKnoll PharmaceuticalsNational Heart ForumNational Primary Care Facilitation ProgrammeRoche PharmaceuticalsRoyal College of General PractitionersRoyal College of NursingRoyal College of PhysiciansRoyal College of SurgeonsSustainTesco Stores LtdThe Obesity Awareness and Solutions Trustappendix one47

TACKLING OBESITY IN ENGLANDappendix one48Cost-of-illness study6 We employed Medtap International Inc to advise on thefeasibility and to propose a methodology for a study toestimate the cost of obesity in England, both to theNational Health Service and to the wider economy. Wethen appointed City University to undertake the studyand to prepare a report to present their findings. Thedetailed methodology, results and conclusions drawnfrom this work are provided at Appendix 6.The surveysHealth authorities7 During the Summer of 1999 we carried out a postalsurvey of Directors of Public Health at all healthauthorities in England. The purpose of the survey was togather information about the extent to which healthauthorities had addressed the issue of obesity throughlocal strategies and action plans, and through supportfor local services and initiatives. We also asked howeach health authority had addressed obesity through itsHealth Improvement Programme as at April 1999. Atotal of 94 of the 100 health authorities at the time of thesurvey replied.Postal survey of general practitioners and practice nurses8 During July 1999, we carried out a survey of generalpractitioners and practice nurses. The objectives of thesurvey were:nnnnto learn what general practices were doing to helpprevent obesity and to manage both overweight andobese patients;to explore their perceptions of the problem ofobesity and to seek their views on what role theyshould play in helping to address it;to identify any factors that constrained the efforts ofgeneral practitioners and practice nurses to helpoverweight and obese patients, and to explore whatwould most help them to manage such patientsmore effectively;to identify potential examples of good practice.9 We sent two self-completion postal questionnaires to1200 practices across England. One questionnaire wasaddressed to a named general practitioner at thepractice, the other to the practice nurse. The sample wasstratified to provide a range of general practitioners byregion of practice, gender of practitioner, and size of thepractitioner's patient list.10 We calculated the sample size to provide us withsufficient data, working on the assumption that no morethan a third of general practitioners would return acompleted questionnaire. Many general practitionersurveys receive a considerably lower response rate, anda pilot survey indicated that we could expect about30 per cent to respond. This in part reflects the heavyday to day workload of general practitioners. Given thatgeneral practitioners are independent, self-employedprofessionals, they are under no obligation to respond.In the event, we received a satisfactory response rate of36 per cent (428 respondents) to the survey of generalpractitioners, and 52 per cent (627 respondents) to thesurvey of practice nurses.11 Figure 26 summarises the information requested in thequestionnaires.26Information requested in postal questionnairesBackground information about the general practitioner/practice nurseand the practiceQualitative interviews with generalpractitioners and practice nurses12 Following receipt of the self-completion postalquestionnaires, we selected a sample of generalpractitioners and practice nurses at 20 practices for faceto-face,structured interview. The purpose of theinterviews was to explore further the answers given tothe postal questionnaire and to:n examine in more depth the interviewees'perceptions of the issue of obesity;nnUse of, and attitudes to, protocolsRoles in weight managementAssessment and recording of body weight/shapeHealth promotion and preventionManagement of overweight and obese patients, including advice andtreatment provided by the practice and referral outside the practiceEffectiveness of prevention and treatment programmesunderstand how general practices determine theirapproach to the treatment of overweight and obesepatients;follow up examples of good practice.13 We selected the practices to ensure a geographicalspread in England, and to cover a wide spectrum fromthose general practitioners whose questionnaireresponse indicated that they spent relatively little timeadvising and treating overweight and obese patients, tothose who were very active in this area. The interviews,with 20 general practitioners and 16 practice nurses,were carried out late in 1999.

TACKLING OBESITY IN ENGLANDReview of policy objectives and initiativesacross Government14 Through discussion with policy staff at the Departmentof Health, we identified the other main players withinGovernment with an influence on the principal featuresof lifestyle that affect body weight: what we eat and howmuch exercise we take. These were:16 We looked in particular for evidence of the maincategories of cross-cutting intervention identified in theCabinet Office report, 'Wiring it up' (1999) 31 as follows:nnnOrganisational changeMerged structures and budgetsJoint teamsnnnDepartment for Culture, Media and SportDepartment for Education and EmploymentDepartment of the Environment, Transport and theRegionsn Food Standards Agency (from April 2000)n Health Education Authority (until March 2000)n Health Development Agency (from April 2000)nnnnnnShared budgetsJoint customer interface arrangementsJoint management arrangementsShared objectives and performance indicatorsConsultation to enhance synergies and managetrade-offsSharing information to increase mutual awareness.nMinistry of Agriculture, Fisheries and Food.15 We examined key documents and spoke to policy staffin each of these departments and agencies to identifyany objectives which might influence patterns of eatingand physical activity. We then undertook a series ofinterviews with the staff nominated within eachorganisation to establish the main mechanisms theyused for working with other departments and agencies,how effective collaboration had been, and what the keyoutputs were in terms of jointly-sponsored research,projects and initiatives. We also asked them wherepossible to provide examples of local initiatives andjoint working, involving organisations such as localauthorities, health authorities, schools, and localproviders of health and social services, whichdemonstrated this cross-cutting approach.Site visits17. We undertook a number of field visits to observe at firsthand how local initiatives operated in schools, hospitalsand specialist centres, and to interview the peopleinvolved. This included visits to:nnnnnnBaverstock School in BirminghamCarnegie International Camp (weight loss Summercamp for children), LeedsCentre for Obesity Research, Luton and DunstableHospital NHS TrustEast Hertfordshire NHS TrustStockport Acute Services NHS TrustStockport Healthcare NHS Trust.aappendix one49

TACKLING OBESITY IN ENGLANDAppendix2 Themeasurement of obesity1 Obesity is normally measured by clinicians in terms ofthe body mass index (kg/m 2 ). Figure 27 shows thedifferent classifications of body mass index (BMI) usedin England by the Department of Health. This shows thatthere are different degrees of excess weight, and ofassociated risk, above the range considered healthy(BMIs over 20 to 25). Obesity is defined by a BMI over30. People with a BMI over 40 are described as severelyor morbidly obese. At this level it is expected that someclinical complications associated with the obesity willbe present. Data produced by the Health Survey forEngland on the proportion of the population that isoverweight and obese use these definitions.27This table shows the way different BMIs are classified andthe relationship between BMI and risk of associated diseasesBody Mass Index Classification Risk of disease associated(kg/m2)with excess weightLess than 20 Underweight Low (but increased riskof other clinical problems)2 There is a range of other measures used to record bodyshape. Because the health risks of obesity arecompounded by the influence of fat which is distributedaround the waist, the waist circumference or waist:hipratio are sometimes used. In general, men are atincreased risk of obesity-related diseases when the waistcircumference reaches 94cm (37 inches), and womenwhen it reaches 80 cm (32 inches). This risk becomessubstantially increased at 102cm (40 inches) for men,and 88cm (35 inches) for women 10 .3 Classifying obesity in children is more complicated, andthere is no international consensus on the appropriatecut-off point for classifying a child as obese. In children,BMI changes substantially with age, rising steeply ininfancy, falling during the pre-school years, and thenrising again into adulthood. For this reason, child BMIneeds to be assessed against standards which makeallowance for age 10 . Proposed cut-off points have beenpublished based on an international survey of six largenationally representative cross-sectional growthstudies 42 .Over 20 to 25 Desirable or Averagehealthy rangeOver 25 to 30 Overweight IncreasedOver 30 to 35 Obese (Class I) ModerateOver 35 to 40 Obese (Class II) SevereSource:Over 40 Morbidly or Very severeseverely obese (Class III)BMI classifications from the Health Survey for England 1 with additionaldata on associated risk from the World Health Organisation 10appendix two50

TACKLING OBESITY IN ENGLANDAppendix 3Global prevalence and trends in obesity1 The picture in England reflects an upward world-widetrend. The International Obesity Task Force wasestablished to lead research on the global epidemic ofobesity and to help Governments to develop strategiesto address it. It is associated with the InternationalAssociation for the Study of Obesity which has 39constituent national bodies for research on obesitythroughout the world. The Task Force, working inpartnership with the World Health Organisation, hasgathered evidence on the prevalence and trends inobesity throughout the world. Figure 28 shows the TaskForce's estimates of the prevalence of obesity for menand women in a range of countries where broadlycomparable data were available.2 The Task Force has found that the rise in obesity is notrestricted to more developed countries 11 . Theprevalence of obesity is also rising amongst moreaffluent populations of less developed countries, eventhose with significant rates of under-nutrition. Ghana,for example, now has only slightly more underweightthan overweight people. There are also small populationgroups throughout the world with very high rates ofobesity. Amongst the urban population of WesternSamoa, for example, over half the men and threequartersof the women are obese, as are 44 per cent ofblack women living in the Cape Peninsular of theRepublic of South Africa. Thus, the upper limit on theproportion of people who may become obese in anypopulation is very high. This underlines the need to findways throughout the world to arrest the rising trend.28 Global prevalence of obesity in adults, 1991-92 (BMI>30)ChinaJapanBrazilAustraliaNetherlandsCanadaCountryEnglandCzech RepublicWest GermanySaudi ArabiaUSAEast GermanyKuwaitWestern Samoa (urban)Note:Source:There are differences in the timing and age ranges used in individual national studies, but the data used above represent the best estimates of thecomparative prevalence of obesity in adults in these countries in the period 1991-92International Obesity Task Force0 20 40PercentageMen Women60 80appendix three51

TACKLING OBESITY IN ENGLANDAppendix4The demographic distribution of obesity inEnglandMost people get fatter as they getolder1 In general, weight increases with age. Data from theHealth Survey for England 1 suggest that people of bothsexes gain weight most rapidly in their twenties andearly-thirties and continue to put on weight graduallyinto their seventies. Figure 29 shows the percentage ofoverweight and obese men and women of different ageranges as measured by Health Survey for England datafrom 1998.Obesity in children is increasing2 The only nationally representative British study of theheight and weight of primary school children was theNational Study of Health and Growth (1974-1994). Thisstudy shows that the prevalence of obesity in children islow, but has increased substantially since the mid1980s. The study estimates that overweight increasedbetween 1984 and 1994 from 5.6% to 9% in boys andfrom 9.3% to 13.5% in girls in England. The prevalenceof obesity increased correspondingly to 1.7% for boysand 2.6% for girls. 343 The presence of obesity in adolescence is highlycorrelated with chronic obesity in adulthood 12 . Therising trend of obesity in children and young peopletherefore has very serious implications for the futureprevalence of obesity in the adult population.People in lower socio-economicgroups are more likely to be obese4 Education, social class and prosperity have an importantinfluence on the risk of becoming obese. In general,obesity tends to be more prevalent in the lower socioeconomicand lower income groups. The most recent29 Percentage of overweight and obese men and women in 1998 by age range807060Percentage with BMI over 255040302010appendix four0MenWomenAge range52Source: National Audit Office analysis of Health Survey for England 1 data

TACKLING OBESITY IN ENGLANDHealth Survey for England 1 , in 1998, includedmeasurement of obesity by household income and bythe social class of the head of each participatinghousehold. Analysis of these data shows that theprevalence of obesity in both men and women increasesfrom the highest to the lowest income category. Obesityis also higher in manual than in non-manual socialclasses. In particular, there is a strong social classgradient in the prevalence of obesity in women: theprevalence was only 14 per cent in the highest socialclass (Social Class I), whereas in the lowest (SocialClass V), 28 per cent of women were obese (Figure 30).There is a higher prevalence ofobesity in certain ethnic groups inEngland5 Preliminary findings from the Health Survey for Englandfor 1999 43 also show a higher prevalence of obesityamong certain ethnic groups. In particular, prevalence ishigher among Black Caribbean and Pakistani womenthan among women in general.6 Certain ethnic groups may be more geneticallypredisposed to obesity than others. There is also a link todifferent cultural influences, which can affect both dietand the amount of physical activity undertaken. This hasbeen observed most clearly in recent migrantpopulations. Studies have shown that some migrantgroups who move to the United Kingdom become moreoverweight than the general population. This may bebecause of a combination of poor social conditions, lowlevels of physical activity and a sudden increase in theamount of fat in the diet 2 .Obesity is a problem throughoutEngland7 Data from the Health Survey for England in 1998 1indicate some regional variation in the prevalence ofobesity but they also show that it is a significant problemin all parts of England (Figure 31). At least 18 per cent ofadults - more than one in six - in all regions were obese,with the highest prevalence being 22 per cent in theWest Midlands. All regions showed an increase over thetwo years since the previous study, when the range wasbetween 15 and 19 per cent.30 Prevalence of obesity in men and women from each of the six social classes measured by the Health Survey for England 1998302520Percentage obese151050MenWomenIIINMSocial ClassIIIMappendix fourSource:National Audit Office analysis of Health Survey for England 1 data53

TACKLING OBESITY IN ENGLAND31 Prevalence of obesity in the regions of England2520Percentage obese151050RegionMenWomenSource:appendix fourNational Audit Office analysis of Health Survey for England 1 data54

TACKLING OBESITY IN ENGLANDAppendix 5 Thehuman costs of obesity1 Obese people are more likely to suffer from a number ofserious chronic diseases, many of which are lifelimiting.Besides the physical effects, the psychologicaland social burdens of obesity can also be debilitating.Diseases associated with obesityCoronary heart disease2 The most common cause of premature mortality amongobese people is coronary heart disease. Our work onthe costs of obesity in 1998 (the latest year for whichdata were available) suggests that approximately28,000 people in England suffered a heart attackin that year that was directly attributable to obesity(Appendix 6).3 In women, obesity is the third most powerful predictorof cardiovascular disease (after age and blood pressure).This is in part because it is strongly associated with otherimportant risk factors for heart disease such as highblood pressure and high cholesterol. The risk of heartattack for an obese woman is approximately three timesthat of a lean woman of the same age 44 .Osteoarthritis6 Osteoarthritis, or degenerative disease of the weightbearingjoints such as the knee, is a very commoncomplication of obesity, which causes a great deal ofdisability 47 . Pain in the lower back is also frequentlysuffered by obese people, and may be one of the majorcontributors to obesity-related absences from work. It islikely that the excess weight alone, rather than anymetabolic affect, is the cause of these problems.Respiratory disease7 Many respiratory disorders are related to obesity, themost serious of which is obstructive sleep apnoea.Sufferers experience the intermittent cessation ofbreathing during sleep, which causes broken sleeppatterns and may contribute to high blood pressure andheart disease 48 .Reproductive disorders8 Obese people of both sexes are more likely to sufferreproductive disorders, and for obese women there is anincreased risk of complications during pregnancy. 49Type 2 diabetes4 Of all serious diseases, Type 2 diabetes has the strongestassociation with obesity 10 . The metabolic problemswhich give rise to this type of diabetes most commonlyoccur as a result of excess weight. Indeed, the risk ofdeveloping Type 2 diabetes rises with increasing bodymass index well below the threshold of clinical obesity.Women who are obese are 12 times more likely todevelop non-insulin dependent diabetes than women ofa healthy weight. Diabetes itself predisposes people tohigh blood pressure and heart disease 45 .Cancer5 The link between obesity and cancer is less welldefined.Research suggests that the risk of a number ofcancers is increased by obesity, including: breast cancerand cancer of the endometrium, uterus, cervix, ovaryand gall-bladder in women; and cancer of the rectumand prostate in men 46 . The clearest association is withcancer of the colon, for which obesity increases the riskby nearly three times in both men and women.Social and psychological penaltiesStigmatisation9 In studies that have examined the reactions ofschoolchildren to various forms of physical disabilityand obesity, obese children were consistently rated theleast attractive by their peers. In one study of obeseschoolgirls, obesity was rated a social stigma by78 per cent of girls in the healthy weight range, and62 per cent of overweight girls 50 . Obese girls wereperceived by their peers to be less active, less attractive,less healthy, weak-willed and having inferior physicalabilities and poor self-control regarding dietary habits.10 Another study noted that in affluent societies, obesepeople are subject to intense prejudice anddiscrimination, and that children as young as sixdescribe obese children as "lazy, dirty, stupid, ugly,cheats and liars" 51 . Thus, the stigma of overweightappears to have two aspects: stigmatisation of theappearance of the body and stigmatisation of thecharacter of the person for the perceived moral failure ofnot controlling one's weight.appendix five55

TACKLING OBESITY IN ENGLANDImpact on mental health11 Obese people, and the severely obese in particular, aremore likely to suffer from a number of psychologicalproblems, including binge-eating, low self-image andconfidence, and a sense of isolation and humiliationarising from practical problems 10 .12 In a study that examined the psychological wellbeing ofextremely obese patients awaiting surgery to induceweight loss, many more patients listed social rather thanmedical considerations as their main reason for seekingsurgery. Of these patients, 40 per cent said they "always"or "usually" had experienced acts of discrimination atwork, within the family or in a public place; 77 per centfelt depressed and in low spirits daily or almost daily;and all patients considered themselves unattractive.13 It is difficult to separate cause from effect in therelationship between obesity and psychologicaldisorders. Whilst mental wellbeing may suffer as a resultof the pressures associated with being obese,psychological problems may equally contribute to thetype of behaviours, such as emotional and binge-eating,that can result in the onset of obesity.appendix five56

TACKLING OBESITY IN ENGLANDAppendix 6 Estimatingthe cost of obesity in EnglandIntroduction1 In setting out to examine the burden of obesity, wefound that there was no authoritative estimate of the costof obesity to the National Health Service or to the widerEnglish or United Kingdom economy. We thereforeworked with health economists to develop a suitablemethodology for evaluating the costs of obesity inEngland.2 This appendix sets out the methodology, findings andconclusions from our evaluation of the direct andindirect costs of obesity in England in 1998, the latestyear for which the necessary data were available. Wecommissioned this research from Professor AlistairMcGuire, Mr Stephen Morris and Ms Maria Raikou fromthe Department of Economics at City University,London.Methodology3 We describe below the methods used to calculate thecosts of treating obesity and its consequences. Togetherthese represent the direct costs of obesity. In addition,we describe the methods used to estimate the indirectcosts arising from the effect of obesity on individuals'capacity to function in their usual role. For the purposesof this analysis, obesity was defined as a body massindex of 30 kg/m 2 or greater.Direct costs4 The direct costs of obesity were defined as the costs tothe National Health Service of treating obesity and theassociated disease that can be attributed to it. We soughtto estimate the direct costs of obesity in England in 1998by taking a prevalence-based, cost-of-illness approachbased on extensive literature review and relying onpublished primary data.Cost of treating obesity5 This covered the cost of consultations with generalpractitioners related to obesity, the cost of hospitaladmissions and outpatient attendances, and the cost ofdrugs prescribed to help obese patients lose weight. Wetook the most recent published data on the incidence ofthese events in England 52,53,54 and multiplied them byunit cost data for 1998 55 . Prescription costs for obesitywere taken from Prescription Cost Analysis reports forEngland 56 .Cost of treating the consequences of obesity6 This covered the cost of treating cases of diseases suchas coronary heart disease which can be directlyattributed to obesity. The cost of treating these diseaseswas estimated by calculating the relevant populationattributable risk proportion. We undertook a systematicreview of the literature to establish for each disease thebest data available on the proportion of that disease inthe population that was attributable to obesity, andwhich in theory would be eliminated if obesity wereeliminated. This proportion was defined by the relativerisk of developing associated diseases for individualswith obesity compared to the risk for non-obeseindividuals.7 A search of the MEDLINE database returned3,537 studies with key words for obesity and thepotentially relevant diseases. These were reviewed andreduced to 48 studies which presented data on therelative risk of disease associated with obesity, andwhich calculated this risk between discrete groups of"obese" and "non-obese" individuals defined by bodymass index (kg/m 2 ). From the 48 retained studies,17 were selected to provide data for the baselineanalysis according to the following pre-determinedhierarchical criteria:nnnassociated diseases were considered only where anincreased relative risk for obese individuals wasunequivocal;cohort studies were selected in preference to casecontrolstudies, which were selected in preference tocross-sectional studies; andlarger study samples were selected in preference tosmaller samples.8 Limited data on relative risk were available from theUnited Kingdom, so most of the data used were takenfrom international evidence, especially from the UnitedStates. The effect of this on our estimates is discussed atparagraph 24.9 To establish the cost of treating associated diseases in1998, we first obtained published data on generalpractitioner consultation rates 52 , hospital inpatientadmissions 53 , and hospital outpatient attendances 54 inEngland. These were then multiplied by published dataon unit costs 55 to derive an estimate of the NHStreatment costs for each disease. Prescription costs weretaken directly from Prescription Cost Analysis reports forEngland 56 . These cost estimates were then applied toappendix six57

TACKLING OBESITY IN ENGLANDthe data on relative risk and age- and sex-specificprevalence of obesity published in the Health Survey forEngland 1998 1 to give an estimate of the cost of treatingthe consequences of obesity.Indirect costs10 We approximated the indirect costs of obesity byestimating the earnings lost due to obesity and itsconsequences. These costs have two components:earnings lost due to premature mortality; and earningslost due to sickness.Results and discussionDirect costs of treating obesity15 We estimated the known, direct costs of treating obesityin England in 1998 to be £9.4 million at 1998 prices(Figure 32).32The cost of treating obesity in England in 1998 (£)Contact Total contacts Unit cost Total cost(£) 55 (£m)appendix sixEarnings lost due to premature mortality11 We estimated earnings lost due to premature mortalityby first identifying from the literature review the bestdata on the proportion of all deaths that are attributableto obesity. These data were then applied to the numberof age- and sex-specific deaths in England (taken from'Key Population and Vital Statistics for England', Officeof National Statistics) to estimate the number of deathsattributable to obesity in England in 1998.12 Data on residual life expectancy by age and sex weretaken from the Annual Abstract of Statistics 57 andapplied to the number of deaths to give an estimate ofthe years of life lost due to obesity. Assuming an end ofworking life of 65 for men and 60 for women, we thenadjusted these data by labour market participation andemployment rates to estimate the years of working lifelost due to obesity. Finally, these figures were multipliedby mean annual earnings data and discounted topresent values at the rate of six per cent to arrive at thediscounted earnings lost due to premature death causedby obesity in 1998.Earnings lost due to sickness absence13 Lost earnings due to sickness attributable to obesitywere estimated using days of certified incapacity from1 April 1997 to 31 March 1998. Figures for sicknessattributed to obesity and its associated diseases weresupplied by the Department of Social Security, detailingdays of certified incapacity benefit by cause where aclaim to benefit was made, drawn from a one per centsample of claims to benefit in Great Britain.14 We multiplied the days lost due to associated diseasesby the data on the proportion of each diseaseattributable to obesity to give an estimate of the numberof days off work attributable to obesity. This was thenmultiplied by mean daily earnings figures to calculatelost earnings due to sickness attributable to obesity.General practitioner 519,486 13 6.8consultationsOrdinary 1,220 1,066 1.3admissionsDay cases 127 403 0.1Outpatient 4,829 102 0.5attendancesPrescriptions 0.8Total 9.416 By far the largest component of this cost was generalpractitioner consultations: over half a million suchconsultations were recorded in 1998 at a cost of£6.8 million. This is probably an under-estimate for tworeasons.17 First, the number of consultations for obesity is likely tohave been underestimated. The most recent data was for1991-92 and since then the prevalence of obesity hasrisen. If the number of general practitioner consultationsfor obesity increased since 1992 at the same rate as theincrease in the number of obese people, then thenumber of consultations would rise to nearly 700,000,with a cost of over £9 million.18 Second, no data were available on consultations withpractice nurses and dietitians in primary care. Evidencefrom the National Audit Office's survey of generalpractitioners and practice nurses carried out for thisreport suggests that the amount of time spent by practicenurses in monitoring and advising obese patientsexceeds that spent by most general practitioners.Therefore, the cost of primary care interventions forobesity is likely to be significantly greater than thatindicated by general practitioner consultations alone.58

TACKLING OBESITY IN ENGLAND19 There were relatively few hospital admissions oroutpatient attendances specifically for obesity: just over6,000, at a total cost of £1.8 million. The costs of drugsprescribed for weight loss was £0.8 million in 1998. Itshould be noted, however, that the gastro-intestinaldrug, Orlistat - which accounted for 85% of the total -was not licensed for use in the United Kingdom until thelast quarter of 1998. This suggests that the annual cost ofprescriptions in 1999 and beyond is likely to beconsiderably higher.Cost of treating the consequences of obesity20 We estimated the cost of treating the disease attributableto obesity to be £469.9 million (Figure 33).21 By far the biggest contributors to this cost were coronaryheart disease (angina pectoris and myocardialinfarction), Type 2 diabetes, and hypertension, whichtogether accounted for over 80 per cent of the total. Thenext most significant contributors were osteoarthritis,stroke, gall-bladder disease and colon cancer.22 There are a number of potentially important diseaseareas that were excluded from this analysis because of alack of data to allow us to estimate the proportion oftreatment costs that could be attributed to obesity. Forexample, depression, hyper-lipidemia and back painwere not included because no studies were identified inthe systematic review that reported the relative risk for33The costs of treating the consequences of obesity in England in 1998obese individuals of developing these conditions. Thisdoes not mean that obesity is not an important riskfactor for these conditions. Even a small proportion ofthe cost of antidepressants (£279m in 1998) and lipidregulatingdrugs (£190m in 1998) would significantlyincrease the estimate of direct costs.23 There are three further limitations to the analysis. Firstly,while the most widely accepted definition of obesity (abody mass index of 30kg/m 2 or above) was used as faras possible, some of the disease-specific studies fromwhich relative risk was taken had applied different cutoffpoints to define the obese and non-obese groups.This may have led to a degree of over- or underestimationof the obesity-attributable costs of particulardiseases, but there is no discernible bias either way inthe overall approach taken.24 Secondly, the data on relative risk for most associateddiseases were taken from international studies due to alack of comparable data in the United Kingdom.International studies will only give truly reliableindicators where the characteristics of the studypopulation broadly match the characteristics of theEnglish population. All but one of the studies used in theanalysis were undertaken in North America or WesternEurope. While the extent to which the same relative risksapply to the English population is uncertain, theynevertheless represent the best data available on whichto base relative risk estimates.Attributable cases Cost of General Cost of hospital Cost of Total cost Proportion of(% of total cases) Practitioner consultations contacts 1 prescriptions (£m) total costs (%)(£m) (£m) (£m)Hypertension 794,276 (36) 25.5 7.7 101.6 134.8 29Type 2 diabetes 270,504 (47) 7.9 36.7 78.9 123.5 26Angina pectoris 90,776 (15) 2.8 35.3 46.6 84.7 18Myocardial infarction 28,027 (18) 0.6 41.6 0.0 42.2 9Osteoarthritis 194,683 (12) 4.7 14.5 15.6 34.8 7Stroke 20,260 (6) 0.5 15.7 0.5 16.7 4Gallstones 8,384 (15) 0.2 10.2 0.4 10.8 2Colon cancer 7,483 (29) 0.4 10 0.0 10.4 2Ovarian cancer 1,543 (13) 0.1 3.8 0.1 4.0 1Gout 96,549 (47) 2.2 0.0 1.7 3.9 1Prostate cancer 809 (3) 0.0 0.9 1.7 2.6 1Endometrial cancer 834 (14) 0.0 1.1 0.1 1.2 0Rectal cancer 126 (1) 0.0 0.2 0.1 0.3 0Total 44.9 177.7 247.3 469.9 100appendix sixNote 1. Ordinary admissions, day cases and outpatient attendances combined59

TACKLING OBESITY IN ENGLAND25 Thirdly, it should be noted that the analysis of the directcosts attributable to obesity comprises only the costs oftreatment provided by the National Health Service. Itdoes not for example include the costs to SocialServices. Inclusion of other costs to the public sectorattributable to obesity, such as a proportion of the costsof social care for stroke patients, could increase thedirect costs of obesity considerably.Indirect costsEarnings lost due to premature mortality26 We estimated that over 31,000 deaths in England in1998 were attributable to obesity, approximatelysix per cent of all deaths. This represented over275,000 life years lost due to obesity. Some 9,000 ofthese deaths occurred before the age of 65, resulting ina loss of over 40,000 years of working life up to stateretirement age alone (Figure 34). The associated lostearnings due to obesity were £827 million.35Days of certified incapacity attributable to obesity inEngland in 1998Attributable days of certified incapacity (000)Type 2 diabetes 5,964Hypertension 5,156Angina pectoris 2,390Myocardial infarction 1,225Cancers 1 970Osteoarthritis 951Gout 531Stroke 440Obesity 418Gallstones 17Total 18,06234Deaths, years of life lost and years of working life lostattributable to obesity in England in 1998Note: 1. Endometrial cancer, colon cancer, rectal cancer, ovariancancer and prostate cancer combinedappendix sixAttributable deaths Attributable Attributable yearsyears of life lost 1 of working life lost 1Males 14,185 129,940 31,133Females 16,894 145,696 8,943Total 31,078 275,636 40,076Note: 1. Discounted at 6% per annum.Earnings lost due to sickness absence27 We estimated that there were over 18 million days ofsickness attributable to obesity (Figure 35). On thisbasis, lost earnings due to sickness absence attributableto obesity in 1998 were £1,322 million.28 This is almost certainly an underestimate for tworeasons. Firstly, the days of absence recorded werebased on medically certified days of incapacity where aclaim to benefit was made. No data on self-certifieddays of sickness were available. And secondly, due tothe lack of available information on the relative risk forobese individuals, sickness absence due to certainconditions known to be associated with obesity, such asback pain, was excluded from the analysis. Back pain isone of the most common causes of certified sicknessabsence and its inclusion could significantly increasethe estimate.29 There are two different theoretical approaches toestimating the value of production losses caused byillness and premature mortality. The more conservative"friction cost" approach assumes that loss of output fromindividuals is compensated for by adjustments in theeconomy. In the short term, absences from work may becompensated for by the worker on their return to workor by colleagues. And for long term absences, theemployer is likely to hire a replacement worker, whichhas only a marginal cost in an economy without fullemployment. This approach is not universally acceptedby academics, and it is in any case not possible to applydirectly in England because of the lack of suitable dataon labour market conditions. We have therefore used a"human capital" approach, which uses lost earningsthrough sickness or premature death as a proxy for thevalue of production losses. This is likely to yield higherestimates than the "friction cost" method.30 A limitation to these estimates is that calculating lostearnings due to obesity on the basis of mean averageearnings probably overstates the true cost. Data from theHealth Survey for England 1 show that the prevalence ofobesity is higher in people with a lower householdincome. This indicates that the obese group earns lessthan the mean average earnings of the population as awhole. In the absence of data on the mean earnings ofthe obese group, however, mean average earnings offerthe best proxy available.60

TACKLING OBESITY IN ENGLAND31 While the approach used may, for the above reasons,overestimate the indirect costs of obesity to theeconomy, the analysis nevertheless serves todemonstrate the substantial burden of obesity toindividuals in terms of sickness and mortality.Conclusion32 The direct cost of obesity to the National Health Servicein England in 1998 was at least £480 million, equivalentto about 1.5 per cent of NHS expenditure in that year.The direct cost is driven primarily by the costs of treatingthe secondary diseases attributable to obesity, whichaccounted for 98 per cent of the total. The mostsignificant cost drivers by far are hypertension, coronaryheart disease, and Type 2 diabetes, followed byosteoarthritis and stroke.33 Direct costs are probably under-estimated by thisanalysis due to the factors outlined in the discussionabove, in particular the potentially high costs associatedwith treating obesity-related depression and hyperlipidemia.It also excludes other public expenditure notborne directly by the National Health Service, such asthe costs of social care for obesity-related strokepatients.36Total cost of obesity in England in 1998Cost componentCost (£m)Cost of treating obesityGeneral Practitioner consultations 6.8Ordinary admissions 1.3Day cases 0.1Outpatient attendances 0.5Prescriptions 0.8Total costs of treating obesity 9.5Cost of treating the consequences of obesityGeneral Practitioner consultations 44.9Ordinary admissions 120.7Day cases 5.2Outpatient attendances 51.9Prescriptions 247.2Total costs of treating the consequences of obesity 469.9Total direct costs 479.4Indirect costsLost earnings due to attributable mortality 827.8Lost earnings due to attributable sickness 1,321.7Total indirect costs 2,149.5Grand total 2,628.934 The indirect cost of obesity in England in 1998represented by lost earnings was estimated to be£2,149 million, of which 61 per cent was due tosickness absence attributable to obesity, and theremainder to premature mortality. The amount ofsickness absence due to obesity may be under-estimateddue to the exclusion of back pain, a potentiallysignificant contributor. A friction cost approach tovaluing lost output would reduce the estimates,however.35 Combining our best estimates of direct and indirectcosts, the total cost of obesity in England in 1998 was£2.6 billion, or 0.3 per cent of UK Gross DomesticProduct. Direct costs accounted for 18 per cent of thetotal. The full results are summarised in Figure 36.appendix six61

TACKLING OBESITY IN ENGLANDStudies selected for baseline analysis (obtained fromsystematic literature review)abcdefghiManson JE, et al. A prospective study of obesity andrisk of coronary heart disease in women. N Engl J Med.1990 Mar 29;322(13):882-9.Reuterwall C, et al. Higher relative, but lower absoluterisks of myocardial infarction in women than in men:analysis of some major risk factors in the SHEEP study.The SHEEP Study Group. J Intern Med. 1999Aug;246(2):161-74.Tikly M, et al. Risk factors for gout: a hospital-basedstudy in urban black South Africans. Rev Rhum EnglEd. 1998 Apr;65(4):225-31.Shoff SM, et al. Diabetes, body size, and risk ofendometrial cancer. Am J Epidemiol. 1998Aug 1;148(3):234-40.Ford ES. Body mass index and colon cancer in anational sample of adult US men and women. Am JEpidemiol. 1999 Aug 15;150(4):390-8.Giovannucci E, et al. Physical activity, obesity, and riskof colorectal adenoma in women (United States).Cancer Causes Control. 1996 Mar;7(2):253-63.Farrow DC, et al. Association of obesity and ovariancancer in a case-control study. Am J Epidemiol. 1989Jun;129(6):1300-4.Andersson SO, et al. Body size and prostate cancer: a20-year follow-up study among 135006 Swedishconstruction workers. J Natl Cancer Inst. 1997Mar 5;89(5):385-9.Chan JM, et al. Obesity, fat distribution, and weightgain as risk factors for clinical diabetes in men.Diabetes Care. 1994 Sep;17(9):961-9.jklmCarey VJ, et al. Body fat distribution and risk of noninsulin-dependentdiabetes mellitus in women. TheNurses' Health Study. Am J Epidemiol. 1997Apr 1;145(7):614-9.Cooper C, et al. Individual risk factors for hiposteoarthritis: obesity, hip injury, and physical activity.Am J Epidemiol. 1998 Mar 15;147(6):516-22.Sahyoun NR, et al. Body mass index, weight change,and incidence of self-reported physician-diagnosedarthritis among women. Am J Public Health. 1999Mar;89(3):391-4.Kato I, et al. Prospective study of clinical gallbladderdisease and its association with obesity, physicalactivity, and other factors. Dig Dis Sci. 1992May;37(5):784-90.n Cairney J, et al. Correlates of body weight in the 1994National Population Health Survey. Int J Obes RelatMetab Disord. 1998 Jun;22(6):584-91.opqrHuang Z, et al. Body weight, weight change, and riskfor hypertension in women. Ann Intern Med. 1998Jan 15;128(2):81-8.Walker SP, et al. Body size and fat distribution aspredictors of stroke among US men. Am J Epidemiol.1996 Dec 15;144(12):1143-50.Rexrode KM, et al. A prospective study of body massindex, weight change, and risk of stroke in women.JAMA. 1997 May 21;277(19):1539-45.Calle EE, et al. Body-mass index and mortality in aprospective cohort of U.S. adults. N Engl J Med. 1999Oct 7;341(15):1097-105.appendix six62

TACKLING OBESITY IN ENGLANDAppendix7Department of Health policies andinitiatives which address obesity, diet andphysical activityInitiativeSummaryNHS Plan (July 2000)Five-a-day Pilot ProjectNational School Fruit SchemeGuidance on Implementing thePreventive Aspects of the NationalService Framework for CoronaryHeart DiseaseHealthy Schools ProgrammeBreakfast ClubsActive for Life ProgrammeThe National Alliance for PhysicalActivity (NAPA)Inter-Ministerial Group to ImproveChildren's Diet and ActivitySafe and Sound ChallengeTeacher Training Guide on Safe andActive School TravelThe Infant Feeding InitiativeHealth Survey for EnglandSystematic Review of Interventionsin the Treatment and Prevention ofObesityDirectory of Weight ManagementServicesEvaluation of Weight ManagementServicesDiet and nutrition and physical activity are important elements of the NHS Plan for improving health and reducinginequalities. Action is planned to tackle obesity and physical inactivity, informed by advice from the new HealthDevelopment Agency established in April 2000. The NHS Plan also includes action to increase fruit and vegetableconsumption and work with the food industry to improve the overall balance of the diet including salt, fat and sugar infood, working with the Food Standards Agency.Local initiatives are underway in five pilot sites to increase consumption of fruit and vegetables across the wholecommunity, particularly in poorer areas. Based on evidence of effective interventions, the national roll-out of the schemewill begin in 2002.The NHS Plan aims to establish a National School Fruit Scheme by 2004. Under the scheme every school child aged fourto six will be entitled to a free piece of fruit each school day, as part of a national campaign to improve children's diets.The practicalities of the scheme will be examined through pilots, beginning in Health Action Zones.The Health Development Agency has issued guidance covering the development of local strategies and interventions topromote healthy lifestyles, relevant to coronary heart disease prevention. This includes advice on physical activity, healthyeating and other measures to reduce the prevalence of overweight and obesity.This programme has been developed jointly with the Department for Education and Employment to improve educationalachievement and, in the longer term, to improve public health and address health inequalities. The programme encouragesschools to improve the health education and awareness of pupils, staff and the local community by developing healthyschool activities, including those which promote healthy eating and physical activity. All Local Education Authority areashave an Education and Health Partnership to support local programmes and assist schools working towards the NationalHealthy School Standard.Breakfast Club pilots were set up across the eight NHS Regions in 1999, with funding through to March 2001. TheDepartment has commissioned an evaluation of the pilots from the University of East Anglia to look at the contributionbreakfast clubs can make to health and educational improvement in schools, to examine their sustainability and cost, andto identify models of good practice.National health promotion campaign commissioned from the Health Education Authority from 1996 - 2000 to encouragemore people to take part in more physical activity. The programme involved the provision of training, guidance andpromotional material to health promotion units and physical activity campaigners across England, including advice onwhat works based on the Health Education Authority's effectiveness reviews. The campaign placed particular emphasis onactivities that were accessible to all and could be built into daily living, such as cycling and walking.NAPA was convened by the Health Education Authority, with funding and direction from the Department of Health. It metfrom 1996-2000 to provide a forum for debate on physical activity issues, and direction for the Active for Life programme.Members were drawn from across the physical activity world, including representatives from the main Governmentdepartments, sport, academia, the fitness industry, schools and local authorities. The group was disbanded following theclosure of the Health Education Authority, but the Department is considering convening a similar group in the future.The Group was set up in response to the findings of the National Diet and Nutrition Survey of Young People aged 4-18 18 ,published in June 2000. The group aims to map out cross-departmental action already taken to improve young peoples'diet and physical activity, to identify models of good practice, and to co-ordinate future projects and initiatives. The Groupis chaired by Ministers from the Department of Health and the Department for Education and Employment and involvesMinisters from several Government departments.The Safe and Sound scheme encourages schools to develop initiatives to promote healthy, active and safe modes of travelto school, with cash prizes awarded to the most innovative schemes. In 2000/01, the scheme has targeted schools insocially deprived areas.This document explains to trainee teachers how physically active modes of travel can be taught as part of the primaryschool curriculum.Research suggests that bottle-fed babies are 50 per cent more likely to become obese than babies breast-fed exclusivelyfor the first 3-4 months. The Infant Feeding Initiative was set up to reduce inequalities by encouraging those women leastlikely to breast-feed to do so.Annual survey on the health status of the people of England, including data on physical activity, eating habits, height,weight and body shape. It provides authoritative data on the prevalence of overweight and obesity analysed by gender,age group, socio-economic status, household income and geographical region.Review of published research commissioned by the Department from the NHS Centre for Reviews and Dissemination in1997. The aim of the review was to inform the work of the Department by identifying the latest state of knowledge ofobesity and highlighting future research needs.Directory of local weight management programmes compiled by self-completion pro-forma sent out by NHS RegionalOffices and published in March 1998. Contains details of several hundred initiatives, ranging from clinics and researchprogrammes to buses taking overweight and obese people to leisure centres and swimming pools.Analysis of 13 self-evaluations of weight management programmes, published in 1998. Concluded that successfulsustained clinically significant weight loss in obese patients was rare, and that more work was needed to developstrategies to improve long term weight maintenance.appendix seven63

TACKLING OBESITY IN ENGLANDInitiativeSummary"Fighting Fat, Fighting Fit" BBC seriesExercise on PrescriptionDissemination of report 'TacklingObesity - A Toolbox for LocalPartnership Action'Television series broadcast in early 2000 with support from the Department of Health to raise awareness of the risks ofobesity and educate people about ways to achieve and maintain a healthy weight.Scheme allowing patients who would benefit from physical activity to be referred by their general practitioner tosubsidised exercise programmes with a trained instructor. The Department is developing a National Quality AssuranceFramework for exercise referral systems to provide best practice guidelines and improve the quality of physical trainingprovided.Document produced by Faculty of Public Health Medicine of the Royal College of Physicians providing a practicalframework for developing local action plans to prevent and control obesity. The Department has paid for the toolbox to besent to all health authorities.Source: Department of Healthappendix seven64

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