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Obesity

Introduction

Background

Obesity is a condition characterised by excess body fat, which has accumulated to an extent that health may be adversely affected. It is extremely prevalent and is a major cause of ill-health and premature death. Obesity is commonly defined by body mass index (BMI), which is calculated by dividing an individual’s weight in kilograms by the square of their height in metres (kg/m2). A BMI of 30 or greater is considered obese.

Figure 1: NICE classification of overweight and obesity in adults

Weight classBMI = wt(kg)/ht(m)2
Underweight<18.5
Normal18.5 – 24.9
Overweight25 – 29.9
Obese30 – 39.9
Morbidly Obese>40

Source: National Institute for Health and Clinical Excellence (2006)

There has been some debate regarding different classifications of obesity for different ethnic groups due to some ethnic groups having higher cardiovascular and metabolic risks at lower BMIs. In comparison to the general UK population with the same age, gender and BMI, Asian populations, in particular, have a higher proportion of body fat (Department of Health (DH), 2008). Due to the lack of worldwide consensus, NICE (2006) recommends that the current universal cut-off points for the general adult population (see figure 1) should be used for all population groups, in line with WHO recommendations, in addition to recommending that trigger points for public health action for adults of Asian origin should be 23kg/m2 for increased risk and 27.5kg/m2 for high risk. NICE (2006) recommend that health care professionals should use their clinical judgment when considering risk assessing those from Asian population groups, whose BMIs fall below the current BMI classification.

Causes and consequences of obesity

It is considered to be a ‘lifestyle disease’, a result of modern living which has lead to the creation of an ‘obesogenic environment’, one which negates the need for hard physical work due to the introduction of labour-saving devices and the availability of energy dense and cheap food (Foresight, 2007). The main cause of obesity is an imbalance between energy intake (increased food consumption) and energy expenditure (reduced physical activity). Although individuals have a responsibility over the lifestyle choices they make, it is important to consider the complexities of the origin of obesity in that many factors will affect these decisions. These include genetic, economic, social, psychological, environmental and cultural factors (Foresight, 2007).

Both overweight and obesity are associated with an increased risk of numerous chronic and severe health problems including heart disease, diabetes, some cancers and other debilitating conditions, which contribute to a reduced life expectancy and impacts negatively upon quality of life (WHO, 2003). The National Obesity Observatory (2010) estimates suggest that life expectancy is reduced by an average of 2 to 4 years for those with a BMI of 30 to 35 kg/m2, and 8 to 10 years with a BMI of 40 to 50kg/m2. Obesity can also cause psychological and social problems, particularly in children. Findings of a longitudinal study, revealed that overweight in adolescence resulted in increased morbidity and mortality in adulthood, independent of adult weight status. (Must et al, 1992).

The financial costs of obesity

The financial consequences of obesity for the NHS and for the economy as a whole are great. In 2007, it was estimated that the total annual cost to the NHS for obesity alone was £2.3 billion and £4.2 billion for overweight and obesity combined. For the wider economy, costs for overweight and obesity combined were estimated at £15.8 billion. Further estimates suggest that by 2050, obesity alone could cost the NHS £7.1 billion and overweight and obesity £9.7 billion, with the cost to the wider economy totalling £49.9 billion per year (McPherson et al, 2007). The estimated annual costs to NHS Haringey of disease related to overweight and obesity in 2010 were £76.5m. This cost has been estimated to increase to £81.8m by 2015 (DH, 2007).

Link to physical activity, childhood obesity, and maternity sections.

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Key issues and gaps

  • The prevalence of adult overweight and obesity in Haringey is estimated to be higher than the England average.
  • The Nutrition and Dietetic Service provide a service for patients who require nutrition and dietetic support who have long term conditions, for example, diabetes.
  • There are community-based weight management programmes to treat obesity for those aged 40-74 years following an NHS Health Check.
  • The acute trust provides services to treat the morbidly obese in the form of dietetic support and counselling. Certain acute trusts provide surgical treatment for obesity (bariatric surgery).
  • There needs to be more emphasis on primary prevention of obesity.
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Who is at risk and why

Obesity is responsible for 30,000 deaths a year in England, of which 9,000 are premature deaths. In the UK, the prevalence of obesity has more than doubled in the last 25 years. In 2009 almost a quarter of adults in England, equating to 22% of men and 24% of women aged 16 years or over were classified as obese (BMI >30). A further 44% of men and 33% of women were overweight (The NHS Information Centre, 2011). It is estimated that by 2050, the vast majority of the UK population could be mainly obese, with some 40% obese by 2025 and nearly 60% obese by 2050 (Foresight, 2007). The prevalence of overweight and obesity disproportionately affects the lower socio-economic groups and socially disadvantaged groups (particularly women). Obesity is also linked to ethnicity and is most prevalent among Black African women (38%) and least prevalent among Chinese and Bangladeshi men (6%) (The NHS Information Centre, 2006).

Those disproportionately affected include:

  • Children from low-income families and children from families where at least one parent is obese (see child obesity section)
  • Individuals of Asian origin (particularly those of south Asian origin)
  • Ethnic groups with a higher than average prevalence of obesity (most prevalent among Black African women, Black Caribbean women, Pakistani women, Black Caribbean men, and Irish men)
  • Adults in semi routine and routine occupations
  • People with physical disabilities (particularly in terms of mobility which makes exercise difficult)
  • People with learning difficulties
  • Older people

Regarding individuals, there are also times when people are more likely to put on weight, including:

  • Men in their late 30’s
  • Women entering long term partnerships
  • Women during and after pregnancy (see maternity section)
  • Women at the menopause
  • People giving up smoking
  • People who retire
  • People suffering from psychosocial problems (eg stress and depression)

In addition, people diagnosed with a severe and enduring mental illness, particularly schizophrenia or bipolar disease, are at increased risk of greater levels of obesity and are almost twice as likely to die from coronary heart disease (CHD) as the general population.

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The level of need in the population

Adult obesity is on the increase. As measured by the Health Survey for England ((HSE) (2009), obesity increased in men from 13% in 1993 to 22% in 2009, and in women from 16% in 1993 to 24% in 2009. It has tentatively been suggested that the obesity trend may be levelling, albeit temporarily, although it is too soon to determine with certainty whether this is in fact the case.

There is a link between deprivation and obesity. Applying HSE (2007) data to Haringey deprivation profiles suggests there will be more obese people in Haringey than there are nationally, as the Haringey population is more deprived than the national average.

The National Obesity Observatory (2010) has estimated BMI classifications by deprivation quintile nationally (see figure 2). Having applied these estimates to the population of Haringey, the following estimates of BMI classification have been derived along with estimated prevalence for males and females (see figure 3).

Figure 2: Prevalence of overweight and obesity among adults aged 16 and over by Index of Multiple Deprivation 2007 quintile


Source: Health Survey for England 2007-2008

Figure 3: Estimates of Obesity, overweight and healthy weight in Haringey based on deprivation.


Source: National Obesity Observatory (2010) / Health Survey for England 2007-2008

The data indicates that obesity prevalence is higher in Haringey at 27.6% than in England at 23%. It further indicates that locally, the prevalence of overweight is higher in men than in women, whilst obesity is higher amongst women than men.

Morbid Obesity

According to the HSE 2007 data, the proportion of people that are morbidly obese is 1.8%. The rates are higher for women (2.2%) than for men (1.3%). Using these figures to estimate the number of morbidly obese adults living in Haringey suggests that there are 1189 men and 1952 women who are morbidly obese. However, due to the small proportions there is a margin of error which means that the data should be interpreted with caution (HSE, 2007).

Maternal Obesity

Obesity in women increases with age, such that obesity in women aged 16-24 is estimated at 10.4%, which increases to 19.0% for women aged 25-34, and 23.6% amongst women aged 35-44. When applied to the Haringey population this suggests that there are 9,821 women of child-bearing age that are likely to be obese. Since obesity is linked with deprivation this is likely to be an underestimate of the number of women of child-bearing age who are obese in Haringey (HSE, 2007). (See maternity section).

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Current services in relation to need

A strategic approach is being taken in Haringey to address obesity/diet and nutrition within the context of reducing the gap in life expectancy. The draft Haringey Health and Wellbeing Strategy has identified several key priority work programmes related to obesity/diet and nutrition, namely physical activity, alcohol and cardiovascular disease and cancer prevention. The Haringey Adult Obesity Care Pathway is a tool to help guide health care professionals to manage people with varying levels of overweight and obesity.

The following services are in place:

  • The Adult Obesity Care Pathway is a tool which incorporates local and national guidance and helps with the management of clinical risk. It meets the requirements of evidence-based practice to enhance quality of care and helps to reduce variations in patient care and health outcomes. The pathway covers first line advice through to bariatric surgery and maintenance.
  • The Nutrition and Dietetic Service provide a service for patients who require nutrition and dietetic support who have long term conditions, for example, diabetes.
  • The Health Trainer Service is a community-based service which provides one-to-one support to people who are interested in making lifestyle changes to benefit their health in the areas of alcohol, physical activity, smoking and healthy eating. All Haringey residents can access this service, though the service is operational within the east of the borough only.
  • A community-based weight management programme has been commissioned for people with a BMI of 30. Only people who have had an NHS Health Check are eligible to access this service. This service is only accessible to people living/registered with a GP in the east of the borough.
  • Bariatric surgery: Treatment is currently offered in Haringey to people with a BMI of 50 or of 45 with co-morbidity. There is a waiting list and there were 65 referrals and 27 operations in 2010. Before considering surgery, all other alternatives on the obesity care pathway (diet, physical activity and pharmacotherapy), must have been tried for a period of at least 5 months, expect in exceptional circumstances. NICE recommends bariatric surgery after a number of other non-surgical treatments have been tried and failed, in people with a BMI of 35 and two or more co-morbidities associated with obesity, or with a BMI of 40 or more if they have no co-morbidities. It recommends bariatric surgery for people with a BMI of 50 or more as a first line option.
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Expert opinion and evidence base

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Projected service use in 3-5 years and 5-10 years

General

The Foresight Modelling Obesities report provides predictions for obesity prevalence. It is estimated that by 2015, 36% of men and 28% of women will be obese and in 2020 these figures are predicted to rise to 41% and 31% respectively. However, these estimates are based on national figures are likely to be underestimates as they do not take account for deprivation and ethnicity factors which are linked to obesity.

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Unmet needs and service gaps

  • Community-based weight management services for obese adults (except for those following an NHS Health Check, aged 40-74)
  • Specialist services for morbidly obese people to avoid bariatric surgery
  • Health Trainer Service in the west of the borough, particularly for lower economic groups
  • Dietetic service for obese patients unless they have co-morbidities
  • Primary prevention of obesity programmes.
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Recommendations for commissioning

In order to successfully prevent obesity and treat it in those who are already overweight or obese, a range of interventions are required:

  • Update and implement the obesity care pathway

Prevention:

  • Raise the profile of the importance of healthy eating/physical activity in achieving/maintaining a healthy weight amongst the general population using a range of local media channels, in a culturally appropriate manner
  • Commission brief intervention and healthy lifestyle training for a range of frontline staff
  • Review resources and health gain achieved by extending Health Trainer Service to the west of the borough
  • Work with fast food outlets to make their food healthier and explore planning avenues to reduce the proliferation of fast food outlets
  • Strengthen physical activity schemes (see physical activity section)

Treatment:

  • Commission a community-based weight management which follow best practice guidelines for people with a BMI of 30.
  • Commission a specialist service for morbidly obese people to avoid bariatric surgery.
  • Increase the provision of bariatric surgery (and supporting services) to approach NICE guidance recommendations. NICE recommends bariatric surgery, after a number of other non-surgical treatments have been tried and failed, in people with a BMI of 35 and two or more co-morbidities associated with obesity, or with a BMI of 40 or more if they have no co-morbidities. It recommends bariatric surgery for people with a BMI of 50 or more as a first line option.
  • Implement obesity care pathway in primary care including prescribing of obesity pharmacotherapy.
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Key contact

Vanessa Bogle
Senior Public Health Commissioning Strategist - Adults
Email: vanessa.bogle@haringey.gov.uk

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Reference

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Page Last Updated: 24 April 2013

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