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Waltham Forest Healthy Weight Strategy 2014-2019

Appendix A

Healthy Weight Strategy 2014- 2019

Healthy Weight for all in Waltham Forest

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Contents Page

Executive Summary ……………………………………………………………. 4

Part One: 1.1 Introduction ………………………………………………….…………………. 4

1.2 Our Vision……………………………………………………………………….. 9

1.3 Our Objectives ………………………………………………………………… 9

1.4 The National Strategic Context ………………………………………………. 10

1.5 Public Health Responsibility Deal ………………………….……………… 10

1.6 Policy Drivers ……………………………………………………………….. 10

1.7 Public Health Outcomes Framework……………………………………… 12

Part Two:

2.1 Background ……………………………………………………….……….... 13

2.2 Benefits of Reducing Obesity………………………………………………... 13

2.3 Who is most at risk …………………………………………………………… 13

2.4 The causes of obesity ……………………………………………………… 14

2.5 Obesity: the burden of disease ……………………………………………... 15

2.5.1 Health Burden………………………………………………………….. 15

2.5.2 Social Burden …………………………………………………………. 16

2.5.3 Economic Burden……………………………………………………… 16

Part Three: 3.1 The Picture Nationally and Locally…………………………………………… 17

3.2 National Overweight and Obesity Levels……………………………………… 17 3.3 Obesity and Overweight in Waltham Forest …………………………………. 17

3.2.1 Children………………………………………………………………… 17

3.2.2 Adults …………………………………………………………………… 17

Part 4: 4.1 The Way Forward ……………………………………………………………. 18

4.2 Our approach …………………………………………………………………. 19

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4.3 Where are we now: Service Mapping…………………………………. ….. 19

4.4 Mini Holland ……………………………………………………………………. 21

4.5 Initial identified gaps in service………………………………………………… 21

4.6 Challenges Locally ……………………………………………………………… 22

4.7 Next Steps………………..……………………………………………………… 22

4.8 Existing related strategies….…………………………………………………… 23

4.9 Strategy Implementation……………………………………………………….. 23

4.10 Monitoring and Evaluation…………………………………………………….. 23

APPENDICES

Appendix 1

Definition of overweight and obesity………………………………………………….. 24

What is Healthy Weight? .......................................................................................24

Figure 1: Trend in the prevalence of obesity in Reception Year in Waltham Forest,London and England 2007/08 to 2012/13…………………………………………… 25

Figure 2: Trend in the prevalence of obesity in Year 6 in Waltham Forest, London and England 2007/08 to 2012/13 ……………………………………………………. 25

Figure 3: Prevalence of obesity among adults in London Boroughs in 2012……… 26

Appendix 2

Weight Management Commissioning Landscape 2013-14………………………… 28

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Executive Summary

Introduction

Obesity is a major public health problem. The number of obese of people in the UK has trebled in the last 20 years, with one in four men and one in five women now obese.

The numbers of children who are overweight and obese is rising rapidly. If current trends continue, up to half of children will be overweight or obese by 2020.

If the trends continue, the current generation of children will have a shorter life expectancy than their parents had.

Obesity: the burden of disease

Health Burden

Overweight and obesity increase the risk of a wide range of diseases and illnesses, including coronary heart disease and stroke, type 2 diabetes, high blood pressure, metabolic syndrome, osteoarthritis and some cancers. For older adults the benefits of not being obese include functional independence, less risk of falls and fractures and protection from age related diseases.1

A Health Impact of Physical Inactivity (HIPI) tool has been developed by Public Health England. This tool estimates the number of cases of certain diseases that could be prevented in each local authority if the population aged 40-79 were to engage in recommended amounts of physical activity. For Waltham Forest the HIPI estimated:

122 out of 671 deaths could be prevented if 100% of the resident population were physically active.2

Social Burden

When obesity becomes severe, it can inflict bodily pain and affect normal daily activities. A person with severe obesity may find their ability to perform their chosen occupation so compromised that they qualify for disability. This disability can have resource implications for social care services including housing adaptations, trained carers and provision of suitable transport and facilities.

People who are obese are more likely to suffer from prejudice and discrimination in some situations for example employment, travel and healthcare. It is also linked to poor academic success, social exclusion in schools and in some instances teasing and bullying.

Economic Burden

The costs of obesity to the NHS, as predicted by the Foresight Report are outlined in Table 2 (page 15). Costs were calculated at 2004 prices and predicted increases do

1 The Toronto Charter for physical activity: A global call for action, May 20102 Health Impact of Physical Inactivity (HIPI), Burden of Disease and Death from physical inactivity ages (40-79), by county and unitary authority, http://www.apho.org.uk/addons/_122359/atlas.html

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http://www.apho.org.uk/addons/_122359/atlas.html


not account for increases due to inflation. The table shows how Waltham Forest compares with two of our statistical comparators. Croydon has higher estimated annual cost of diseases related to overweight and obesity than Waltham Forest and Greenwich.

Current services and gaps in Waltham Forest

A mapping exercise and stakeholder event were carried out recently, which highlighted that

there is a lack of integration and central co-ordination of services monitoring and evaluation of services is not consistent some services are underutilised by residents some services under resourced to achieve sufficient scale.

The extent of the problem demands that a population approach is taken to tackling obesity. We will use a life course approach to address the gaps in our service provision and services will need to be at scale to ensure sufficient impact.

A life course approach is the study of long-term effects on chronic disease risk of physical and social exposures during gestation, childhood, adolescence, young adulthood and later adult life. It includes studies of the biological, behavioral and psychosocial pathways that operate across an individual's life course, as well as across generations, to influence the development of chronic diseases.3

The initial gaps in services were identified in the following areas, which underpin the emerging commissioning intentions.

Services for overweight and obese pregnant women Prevention activities into early years setting e.g. infant feeding support and

dietetic input into children centres Specialist weight management service (Tier 4) for children Adequate weight management services (Tier 2) for children and adults Specialist weight management services (Tier 3) for children and adults

This strategy does not have the capacity to deal with the issue of ‘underweight’; however we recognise that this too can pose a substantial health risk. Hence it has been addressed in our care pathways. It is for this reason that we are committed to communicating the message of ‘achieving and maintaining a healthy weight’ rather than encouraging ‘weight loss’.

Waltham Forest Healthy Weight Strategy

The Healthy Weight Strategy will be the main driver for future actions to prevent and manage overweight and obesity in Waltham Forest. In order to reduce health inequalities this strategy will use a life course approach to tackle obesity including disabled people (including people with learning disabilities), looked after children, young parents and people with mental health needs.

Vision

3 Int. J. Epidemiol. (2002) 31 (2): 285-293 http://ije.oxfordjournals.org/content/31/2/285.full (date accessed 14/11/14

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http://ije.oxfordjournals.org/content/31/2/285.full


Our long term vision is to provide an environment that enables all our residents to make healthy food choices, to stay physically active and to maintain a healthy weight across their lives.

Objectives

Our strategic objectives are:

To increase participation in physical activity by creating social, cultural and physical environments that enables people to make healthy choices in relation to physical activity and food.

To promote healthy eating by increasing the availability of and access to healthy food choices and reducing the availability of and access to foods that are high in fat, sugar and salt, specifically in early years setting and schools/education establishments

To create healthy organisations that encourage and support physical activity and healthy eating.

To provide consistent, evidence based information, education and advice on how to maintain a healthy weight.

To ensure that services and interventions adhere to the best available

evidence and guidance, and are provided in the most appropriate settings.

To increase access to a wide range of weight management services, particularly targeting those at highest risk and greatest health inequalities

To support the Healthy Schools Programme and lead the development and delivery of multidiscipline weight management services for children and families

Strategy Implementation

The action plan will outline the key actions that need to be taken over the next five years to implement the strategy to prevent and manage overweight and obesity. These actions will begin to bear down on the rising trend in overweight and obesity in Waltham Forest and will contribute to meeting our targets. Much of the infrastructure is already in place to deliver the strategy, and the action plan will be developed by the Healthy Weight Steering Group.

Monitoring and Evaluation

The Healthy Weight Steering Group will monitor the implementation of this strategy. This will be done at the quarterly meetings and reports sent as appropriate to the Health and Wellbeing Board.

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PART ONE:

1:1 Introduction

The obesity epidemic is a public health problem that experts have stated is comparable with climate change, both in terms of scale and complexity. There has been a clear rise in obesity rates, which accelerated in the late 1980s and early 1990s and is a trend repeated almost universally in developed and increasingly developing nations.4 Obesity is the fifth leading cause of global death.5

Almost two-thirds of adults and a third of children in England are either overweight or obese (see Appendix 1 for definitions of overweight and obese). Work by the Government for Science’s Foresight programme suggests that, without clear action, these figures will increase to almost nine out of ten adults and two-thirds of children by 2050. The trend of increasing weight problems in children is of particular concern because evidence suggests a ‘conveyor belt’ effect in which excess weight in children continues into adulthood.6

People do not choose to become overweight or obese; many aspects of life affect the amount and types of food eaten and the physical activity taken.

The rising levels of overweight and obesity are associated with changes in:

Work and leisure time Town and transport planning Food production and marketing Commercial messages Inequalities

Three aspects of obesity combine to make it a public health problem: its impact on health, its prevalence and its resistance to change. It has been identified as one of the most important preventable challenges to health, second only to smoking.7

Obesity also plays a role in widening health inequalities. As rates of adult and childhood obesity have increased, so too have inequalities. There are higher rates of obesity amongst individuals from poorer backgrounds, particularly for women and girls. The contribution of obesity to a range of chronic health problems links it with the broader health inequalities agenda, further strengthening the need for action.8

However, this situation can be reversed. It is possible for people to control their weight, take control of their diet and take part in physical activity. This includes encouraging the development of a healthier environment to help healthier choices become easier.

4 Department of Health (2008) Healthy Weight, Healthy Lives: A Cross-Government Strategy for England, DH, London5 World Health Organisation, Overweight and obesity, fact sheet No 311; 6 Department of Health (2008) Healthy Weight, Healthy Lives: A Cross-Government Strategy for England, DH, London7 Foresight (2008) Tackling Obesities: Future Choices, Government office for Science8 DH Public Health Research Consortium (2007) Law C, Power C, Graham H, Merrick D, Obesity & Health inequalities. Obesity Reviews;8(Suppl.1):19-22

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This draft strategy document is a local approach that provides a public health framework to prevent and manage overweight and obesity among adults and children in Waltham Forest.

1.2 Our Vision

Our long term vision is to provide an environment that enables all our residents to make healthy food choices, to stay physically active and to maintain a healthy weight across their lives

1.3 Our objectives

Our strategic objectives are:

To increase participation in physical activity by creating social, cultural and physical environments that enables people to make healthy choices in relation to physical activity and food

To promote healthy eating by increasing the availability of and access to healthy food choices and reducing the availability of and access to foods that are high in fat, sugar and salt, specifically in early year setting and schools/education establishments

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To create healthy organisations that encourage and support physical activity and healthy eating

To provide consistent, evidence based information, education and advice on

how to maintain a healthy weight To ensure that services and interventions adhere to the best available

evidence and guidance, and are provided in the most appropriate settings

To increase the access to a wide range of weight management services, particularly targeting those at highest risk and greatest health inequalities

To support the Healthy Schools Programme and lead the development and delivery of multidiscipline weight management services for children and families

1.4 The National Strategic Context

1.5 Public Health Responsibility Deal

The Public Health Responsibility Deal aims to tap into the potential for businesses and other influential organisations to make a significant contribution to improving public health by helping shape a healthy environment. The Responsibility Deal involves organisations taking voluntary action in one or more of the following areas to help people lead healthier lives:

Alcohol Food Health at work Physical activity

The food pledges encourage organisations to agree to specific actions: calorie information for food and non-alcoholic drink, removal of ingredients that contain artificial Trans fats, reviewing portion sizes, education and information. The physical activity deal focuses on encouraging and assisting people to become more physically active.

1.6 Policy Drivers

The increase in the number of overweight and obese children and adults has been documented in a number of significant reports and Government White Papers. The policy issues raised have been translated into national delivery plans, National Service Frameworks and toolkits. These documents are designed to help partners to develop and support local action. They include:

Health Lives, Healthy People: A call to action on obesity in England (2011) (see below for further information)

Change4Life Three Year Social Marketing Strategy (2011) (see below for further information)

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Start Active, Stay Active, A report on physical Activity for Health for the four home countries’ Chief Medical Officers (2011)

‘Choosing Health White Paper’ and subsequent delivery plans, Delivering Choosing Health: Making Healthier Choices Easier’; Choosing a Better Diet: A Food and Health Action Plan; and ‘Choosing Activity: A Physical Activity Action Plan’ (2005)

Lightening the Load: Tackling Overweight and Obesity – A Toolkit for Developing Local Strategies to Tackle Overweight and Obesity in Children and Adults’ (National Heart Forum, Faculty of Public health and the NHS 2007)

National Service Framework for Children, Young People and Maternity Services, Standards 1,2, and 3 (November 2006)

Maternity Matters: Choice, Access and Continuity of Are in a Safe Service (April 2007)

Physical Activity and the Environment (National Institute for Health and Clinical Excellence (NICE), 2008)

Healthy Weight, Healthy Lives: A cross Government Strategy for England (January 2008)

Let’s Get Moving Commissioning Guidance A new physical activity care pathway for the NHS (September 2009)

In addition NICE has produced: NICE ph47 Managing overweight and obesity among children and young

people: lifestyle weight management services (October 2013)

Clinical Guidance Number 43: Obesity: the Prevention, Identification, Assessment and Management of overweight and Obesity in Adults and Children (November 2006)

NICE Dietary interventions and physical activity interventions for weight management before, during and after pregnancy (July 2010)

NICE guidance on promoting and creating built or natural environments that encourage and support physical activity

The rest of this section discusses the government’s two most recent documents on obesity.

Healthy Lives, Healthy People: A call to action on obesity in England

The key elements of the Call to action are:

In recognition of the importance of tackling obesity the White Paper moves beyond the previous focus on children to a life course approach that tackles obesity in all age groups.

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Given that most adults are already overweight or obese, treatment for those who need it will be increasingly important alongside preventative action

In line with the Foresight Report of 2007, that a range of partners have responsibility to help individuals and address the many determinant factors in obesity

Increasing physical activity is important but for most of us who are overweight and obese, eating less is key to weight loss

New levels of ambition to achieve are:

A sustained downward trend in levels of excess weight in children by 2020 A downward trend in the level of excess weight averaged across all adults by

2020

The Government will work with partners at a national level to support healthier food choices:

Providing calorie information for food and drink in out-of-home settings from 1 September 2011

A challenge to reduce national energy intake by 5 billion calories per day Enabling schools to make the best decisions about protecting the health of

their pupils Continuing to review the regulatory and voluntary conditions around

marketing and promotion of food to children.

The New Change4Life Strategy focuses on:

Putting local Change4Life supporters in the driving seat of the programme, with National Government supporting local initiatives.

Working with the commercial sector to increase size and scope of engagement.

These recommendations will inform our action plan and areas for new investment.

1.7 Public Health Outcomes Framework

The Public Health Outcomes Framework (PHOF) provides a monitoring mechanism regarding increasing healthy life expectancy and reducing differences overall between communities. Tackling obesity falls within Domain 2 and Domain 4 of the PHOF. Local Authorities will need to report on these indicators.

Domain 2: Healthy Improvement: People are helped to live healthy lifestyles, make healthy choices and reduce inequalities

Domain 4: Healthcare public health and preventing premature mortality: Reduced numbers of people living with preventable ill health and people dying prematurely while reducing the gap between communities

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Part Two: Background

2.1 Benefits of reducing obesity

Preventing obesity will maintain people’s health and quality of life. For people who are overweight or obese achieving moderate weight reduction has significant health benefits. Appendix 1 shows the benefits expected from a 10% weight loss in a person initially weighing 100kg.

2.2 Who is most at risk?

Some sectors of the population are at considerably higher risk of developing obesity, with an associated increase in the incidence and prevalence of related co-morbidities. Data from the National Child Measurement Programme (NCMP) shows that there is a strong link between deprivation and childhood obesity. Obesity prevalence in children in reception and year 6 increases with increased socioeconomic deprivation9.

Specific groups at risk are:

People living on a low income where, for example 14% of women in social class 1 are obese compared with 28% in social class V

Children from certain ethnic minority groups such as Bangladeshi, Black Caribbean and Black African were found to be at a higher risk of obesity but analysis by the National Obesity Observatory suggests that ethnicity is not as strongly linked to obesity as deprivation because weight differences between ethnic groups may be linked to differences in body composition and other physical categories such as height10.

Older people: Increasing age is associated with increasing prevalence in obesity up to the age of 64 years, when a decline in the prevalence begins.

Certain points in life have also been found to be associated with weight gain: pregnancy, menopause and smoking cessation.11

More recently, people who use mental health services, in particular those with a diagnosis of schizophrenia or dipolar disorder, have been identified as being at increased risk of greater levels of obesity and associated conditions, such as heart disease and diabetes12

Looked after children are more likely to be overweight and obese compared with their peers.13

9 PHE, Health inequalities, http://www.noo.org.uk/NOO_about_obesity/inequalities, date accessed 13/11/1410 GLA Intelligence Unit 2011 Childhood obesity in London

11 NICE (2006) Obesity: Full guidelines – section 3 Prevention – evidence, statements & reviews12 Department of Health (2006) Choosing Health: Supporting the physical health needs of people with severe mental illness, DH, London13 Hadfield, S.C. & Preece, (2008), Obesity in looked after children:is foster are protective to the dangers of obesity?Child:Care,Health & Development,Vol 34(6):pp710-712

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http://www.noo.org.uk/NOO_about_obesity/inequalities


Young mothers (under 21) of white ethnicity are significantly less likely to initiate breastfeeding than any other ethnic group.14 There is evidence that weaning earlier than current recommendations leads to rapid weight gain in infancy which may in turn increase the risk of child obesity.15 Early weaning has also been found to be associated with increased weight and body fat at age 7 years.16 Exclusive breastfeeding has been found to be associated with a modest reduction in childhood obesity risk.17

In addition to the groups at risk listed above, it is important to also consider the needs of those disadvantaged groups for whom barriers to accessing services are known to exist, including: people with mental health problems, people with a disability and people for whom English is not their first language.

2.3 The causes of obesity

The increase in obesity among the UK population can be accounted for by energy imbalance; people’s energy intake through eating and drinking exceeds their energy expenditure. It has been estimated that the average adult with a daily energy input 60 calories higher than their energy output will become obese within 10 years.18 A balanced diet and physical activity are both essential to maintaining health and a healthy weight.

The Foresight report 2007 identified 7 key factors that influence obesity19

Biology: an individual’s starting point - the influence of genetics and ill health; Activity environment: the influence of the environment on an individual’s

activity behaviour, for example a decision to cycle to work may be influenced by road safety, air pollution or provision of a cycle shelter and showers;

Physical Activity: the type, frequency and intensity of activities an individual carries out, such as cycling vigorously to work every day;

Societal influences: the impact of society, e.g. the influence of the media, education, peer pressure or culture;

Individual psychology: e.g. a person’s individual psychological drive for particular foods and consumption patterns, or physical activity patterns or preferences;

Food environment: the influence of the food environment on an individual’s food choices, e.g. a decision to eat more fruit and vegetables may be influenced by the availability and quality of fruit and vegetables near home;

Food consumption: the quality, quantity (portion sizes) and frequency (snacking patterns) of an individual’s diet

2.5 Obesity: the burden of disease

14 Baker, D, Garrow A, & Shiels C (2008), Child Health and Ethnicity in Manchester. Centre for Public Health Research, Institute for Health and Social Care Research, University of Salford15 Sloan S, et al (2007) Early weaning is related to weight and weight gain in infancy, child care, health and development, 34,1,59-6416 Wilson AC et al(1998) Relation of infant diet to childhood health: seven year follow up of cohort of children in Dundee infant feeding study, BMJ, 31621-2517 Armstrong J,Reilly J (2002) Breastfeeding and lowering the risk of childhood obesity. The Lancet; 359:2003-200418 Department of Health (1999) Saving Lives: Our Healthier Nation, London19 Tackling Obesity: Future Choices – Foresight Report 2007

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2.5.1 Health Burden

Overweight and obesity increase the risk of a wide range of diseases and illnesses, including coronary heart disease and stroke, type 2 diabetes, high blood pressure, metabolic syndrome, osteoarthritis and some cancers. For older adults the benefits of not being obese include functional independence, less risk of falls and fractures and protection from age related diseases.20

A Health Impact of Physical Inactivity (HIPI) tool has been developed by Public Health England. This tool estimates the number of cases of certain diseases that could be prevented in each local authority if the population aged 40-79 were to engage in recommended amounts of physical activity. For Waltham Forest the HIPI estimated:

122 out of 671 deaths could be prevented if 100% of the resident population were physically active.21

The evidence suggests that there are associations between limiting long-standing illness and body mass index (BMI). A recent Canadian survey found that among those who are morbidly obese (BMI >35), one in six have been diagnosed with depression or anxiety. More than half report having low self-esteem and recognise that their weight problems have an impact on many daily activities and on their relationships.22 There is some evidence to suggest that levels of obesity are higher in people with learning disabilities and those with mental health problems.23

Physical inactivity is the fourth leading cause of chronic disease (such as heart disease, stroke, diabetes, cancers) mortality; contributing to over three million preventable deaths annually worldwide. People who are least active are those at greatest risk of ill health. Physical inactivity also contributes to the increasing level of childhood and adult obesity. Inactivity affects 60-70% of the population: a larger percentage than obesity, alcohol misuse and smoking combined.24 Physical activity can benefit people of all ages. People who are physically active reduce their risk of developing major chronic diseases by up to 50%, and the risk of premature death by about 20-30%.25

WHO also highlighted that there is a clear causal relationship between the amount of physical activity people do and all-cause mortality.26

20 The Toronto Charter for physical activity: A global call for action, May 201021 Health Impact of Physical Inactivity (HIPI), Burden of Disease and Death from physical inactivity ages (40-79), by county and unitary authority, http://www.apho.org.uk/addons/_122359/atlas.html 22 Canadian Obesity Network (2011) Obesity Survey Report23 DH (2011) Healthy Lives, Healthy People: A call to action on obesity in England24 DH (2009), Let’s Get Moving Commissioning Guidance: A new physical activity care pathway for the NHS25 DH (2004) At least five a week: Evidence on the impact of physical activity and its relationship to health, DH London26 WHO (2010) Global Recommendations on Physical Activity for Health, WHO

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http://www.apho.org.uk/addons/_122359/atlas.html


2.5.2 Social Burden

When obesity becomes severe, it can inflict bodily pain and affect normal daily activities. A person with severe obesity may find their ability to perform their chosen occupation so compromised that they qualify for disability. This disability can have resource implications for social care services including, housing adaptations, trained carers and provision of suitable transport and facilities.

People who are obese are more likely to suffer from prejudice and discrimination in some situations for example employment, travel and healthcare. It is also linked to poor academic success, social exclusion in schools and in some instances teasing and bullying.

Overweight and obesity have a substantial human cost by contributing to the onset of disease and premature death.

2.5.3 Economic Burden

The cost to the State for treating obesity is great. Currently, around 5-6% of its total budget is spent on the disease consequences of overweight and obesity. Earlier modelling has shown that the costs to the NHS of the consequences of excess weight were £4.2bn in 2007, with a potential rise up to £6.4bn in 2015 and up to £9.7bn in 205027. A more recent analysis of the economic burden of a range of risk factors for chronic disease estimated that overweight and obesity now cost the NHS £5.1bn per year.28

The costs of obesity to the NHS, as predicted by the Foresight Report are outlined in Table 2. Costs were calculated at 2004 prices and predicted increases do not account for increases due to inflation. The table shows how Waltham Forest compares with two of our statistical comparators. Croydon has higher estimated annual cost of diseases related to overweight and obesity than Waltham Forest and Greenwich. Table 2: Predicted cost of obesity locally and nationally

Estimated annual costs to NHS of diseases related to

overweight and obesity (£ million)

Estimated annual costs to NHS of diseases related to

obesity (£ million)

2010 2015 2010 2015 Waltham Forest 70.6 75.5 38.2 43.9Greenwich 75.8 81.0 41.0 47.1Croydon 92.2 98.6 49.9 57.3

Source: Healthy Weight Healthy Lives, Tool D3

27 Foresight (2008) Tackling Obesities: Future Choices, Government office for Science28 Scarborough P,Bhatnagar P, Wickramasinghe K et al (2011) The economic burden of ill health due to diet, physical inactivity, smoking, alcohol and obesity in the UK: an update to 2006-07 NHS cost, Journal of Public Health

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Part Three: The Picture Nationally and Locally

3.1 National Overweight and Obesity Levels

In England, currently 24.7% of adults (aged 16 years and over) are obese, and a further 37% are overweight. This means a total of 62% of adults have excess weight.29 The prevalence of obesity among adults in England has increased from 15% to 25% between 1993 and 2012.30

By 2050 obesity is predicted to affect 60% of adult men, 50% of adult women and 25% of children.31 The implications of these trends are that today’s children could have a shorter life expectancy than their parents

3.2 Obesity and Overweight in Waltham Forest

3.2.1 Children

Childhood obesity has increased significantly in London in the past fifteen years. The height and weight of every school child (Reception and year six classes) in London is assessed as part of the National Child Measurement Programme.

In Year 6 22.9% of children in Waltham Forest were classified as obese, worse than the average for England in 2012/13

3.2.2 Adults

Unlike the National Child Measurement Programme (NCMP), there is no national measurement programme for adults. In 2012, Waltham Forest 54.6% of our adults are overweight or obese, London (57.3%) and England (63.8%).32

29 Health Survey for England (2012)30 Health Survey for England (2012)31 Foresight (2007) Tackling Obesisites: Future Choices – Project Report. Government Office for Science32 PHE (Feb 2014) London Update Briefings, PHOF –Obesity data, Tobacco Profiles Longer Lives, Public Health Outcomes Framework (Indicator 2.12 - Excess Weight in Adults) www.phoutcomes.info

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Part Four: The way forward

4.1 Our Approach

The primary focus of our local strategy is on the prevention of obesity through a life course approach that tackles obesity in all age groups - and promoting the maintenance of a healthy body weight because prevention is more effective than management.

The Healthy Weight Steering Group agreed that this will be achieved through:

Working in partnership with policymakers, local communities, service providers and business to deliver healthy weight initiatives to those most in need in the most appropriate way

Working across all settings where our residents are located e.g. hospitals, schools, children centres, workplace

Moving away from short-term to long-term sustainable solutions Making health everyone’s business through training of all frontline staff to

provide prevention advice and referrals and ensuring that all local authority policies and regulations are healthy weight friendly

Working at multiple levels - Individuals, Families, Communities, Organisations and Environments, using the three Es – environment, empowerment, and encouragement (See Figure 3) (Royal College of Physicians, 2004)

Ensuring interventions are at sufficient scale to make an impact Using pilots to provide learning to roll out effective interventions to wider

groups Increasing access to weight management services, particularly targeting

those at highest risk and greatest health inequalities Ensuring that services commissioned are evidence based or meet best

practice guidelines. All programmes being evaluated; this will determine service cost

effectiveness and future development of service

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Figure 4: Three E’s – Environment, Empowerment & Encouragement

Environment

EmpowermentEncouragement

Create an environment which predisposes to healthy eating and physical activity

Motivate and prompt people to make lifestyle changes

Empower people with the knowledge, understanding and skills to adopt healthier lifestyles

Source: RCGP 2004

4.3 Where are we now: Service mapping

Part of this development phase of the strategy involved mapping services commissioned by the Local Authority, Clinical Commissioning Group and NHS England and an obesity stakeholder’s workshop. These activities have been conducted through the Healthy Weight Steering Group.

Weight management services are categorised in Tiers. The Tiers are defined below according to the terminology from the 2013 Department of Health Tier 2 guidance:

Tier 1: Universal Interventions: - Client group - everyoneEnvironmental & population-wide services and initiatives, e.g. community based servicesTier 2: Lifestyle interventions: - Client group – overweight and obeseMulticomponent weight management service e.g. Exercise on referral, community based dietetic services, Tier 3: Specialist Services: - Client group - obese

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Multi-disciplinary team providing behavioral therapy, psychological services, medical supportTier 4: Surgery: - Client group – morbidly obeseBariatric surgery (adults)

NICE guideline CG43 states that surgical intervention is not generally recommended for children or young people. It may be considered for young people only in exceptional circumstances and if they have achieved, or nearly achieved physiological maturity33.

Figure 5 shows the results of the mapping exercise for both adults and children using the tier model outlined above. It only covers services commissioned by the three main commissioners of support services in Waltham Forest - London Borough of Waltham Forest, Waltham Forest Clinical Commissioning Group and NHS England. Appendix 2 provides further detail of these services. Section 4.5 contains an initial analysis of service gaps.

33 NICE Guidelines CG43(2006) Obesity, the Prevention, Identification, Assessment and Management of overweight and Obesity in Adults and Children

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Figure 5: Mapping of current weight management services in Waltham Forest (for more detail on services highlighted see appendix 2)

Locally there are other initiatives relevant to the healthy weight agenda (see appendix 2)

4.4 Mini Holland

Waltham Forest was one of three London boroughs to be awarded £30million of funding from Transport for London. Mini Holland is a programme which will build on the work of the Council’s Cycle Action Plan of improving safety, accessibility and introducing 20mph across the borough. The programme will be implemented over three years and will see our town centres and streets transformed to improve the infrastructure and create new and improved public spaces for residents to enjoy.

4.5 Initial identified gaps in service

The mapping exercise and stakeholder event highlighted that there is a lack of integration and central co-ordination of services monitoring and evaluation of services is not consistent some services are underutilised by residents some services are under resourced to achieve sufficient scale.

20


The extent of the problem demands that a population approach is taken to tackling obesity. We will use a life course approach to address the gaps in our service provision and services will need to be at scale to ensure sufficient impact.

The initial gaps in services were identified in the following areas, which underpin the emerging commissioning intentions:

Services for overweight and obese pregnant women Prevention activities into early years setting e.g. infant feeding support and

dietetic input into children centres Specialist weight management service (Tier 4) for children Adequate weight management services (Tier 2) for children and adults Specialist weight management services (Tier 3) for children and adults.

This strategy does not have the capacity to deal with the issue of ‘underweight’; however we recognise that this too can pose a substantial health risk. Hence it has been addressed in our care pathways. It is for this reason that we are committed to communicating the message of ‘achieving and maintaining a healthy weight’ rather than encouraging ‘weight loss.’

4.6 Challenges Locally

Achieving change on levels of obesity is clearly a long-term challenge and interventions must be sustainable.

Partnership commitment and communication given the breadth of the strategy Given the financial constraints keeping it high on the agenda will be a

challenge Funding and Staffing constraints Sustainability Having a robust structure of accountability for the implementation of the

strategy

4.7 Next Steps

The following steps will be led by the Healthy Weight Steering Group, accountable to the Health and Wellbeing Board:-

Develop a healthy weight care pathway for both adults and children, no doubt identifying further gaps in support. This will aid an integration of services including those provided by the Voluntary and Community Sector

Further develop the strategy ensuring shared ownership between partners across the health and social care economy, incorporating the views of elected members

To engage at risk groups, who are known to have a high prevalence of obesity

Cost the care pathway and wider strategy work and identify funding streams Draft action plan, with partners, based on the strategy Ensure that the Health and Wellbeing Board are given opportunities to input

on this work stream

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4.8 Existing related strategies

The issue of obesity, physical activity and healthy eating are already part of a wide range of local strategies, for example

• Health and Wellbeing Strategy• Best start in Life Children & Young People strategy• Waltham Forest Local Development Framework Core Strategy• Waltham Forest Hot Food Takeaway Planning • Joint Strategic Needs Assessment• Waltham Forest Catering School Meal Strategy• Convergence Framework and Action Plan 2011-15

The development of this strategy must ensure it takes a lead on obesity while taking into account the above.

4.9 Strategy Implementation

The action plan will outline the key actions that need to be taken over the next five years to implement the strategy to prevent and manage overweight and obesity. These actions will begin to bear down on the rising trend in overweight and obesity in Waltham Forest and will contribute to meeting our targets. Much of the infrastructure is already in place to deliver the strategy, and the action plan will be developed by the Healthy Weight Steering Group.

4.10 Monitoring and Evaluation

The Healthy Weight Steering Group will monitor the implementation of this strategy. This will be done at the quarterly meetings and reports sent as appropriate to the Health and Wellbeing Board.

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Appendix 1

Definition of Overweight and obesity

Overweight and obesity are terms used to describe increasing degrees of excess body fatness which can lead to increasingly adverse effects on health and wellbeing. Both are commonly assessed by using Body Mass index (BMI) which is defined as the person’s weight in kilograms divided by the square of their height in metres (kg/m²).34

Overweight and obesity are now so common among the world’s population that they are beginning to replace under nutrition and infectious disease as the most significant contributors to ill health.35

Table 1: WHO classifications to define weight in adults:Category BMIUnderweight <18.5Healthy weight 18.5 – 24.9Overweight 25.0 – 29.9Obesity I 30.0 – 34.9Obesity II 35.0 – 39.9Obesity III >40

Source: The Public Health England Obesity Knowledge and Intelligence Team

What is healthy weight?

Healthy weight has been defined as having the body weight most appropriate for an individual’s height, which produces the greatest health benefits. This complements the widely accepted, yet rather vague definition of overweight and obesity as abnormal or excessive fat accumulation that may be detrimental to health and wellbeing.

Table 1: Benefits expected from a 10% weight loss in a person initially weighing 100kg36

MORTALITY > 20% fall in total mortality> 30% fall in diabetes related deaths> 40% fall in obesity-related deaths

BLOOD PRESSURE Fall of approximately 10mmHg systolic pressureFall of approximately 20mmHg diastolic pressure

DIABETES Fall of 50% in fasting glucoseLIPIDS Fall of 10% in total cholesterol

Fall of 15% in low-density lipoproteins Fall of 30% in triglyceridesIncrease of 8% in high-density lipoproteins

34 National Heart Forum (2007) Lightening the Load Tackling overweight and obesity: A toolkit for developing local strategies to tackle overweight and obesity in children and adults, DH, London35 World Health Organisation (2003) Diet, Nutrition and the prevention of chronic diseases, Report of a joint WHO/FAO consultation, Geneva, WHO36 Scottish Intercollegiate Guidelines Network (SIGN) (1996) Obesity in Scotland: Integrating prevention with weight management, SIGN report No.8 Edinburgh: Royal College of Physicians

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Figure 1: Trend in the prevalence of obesity in Reception in Waltham Forest, London and England 2007/08 to 2012/13

Figure 2: Trend in the prevalence of obesity in Year 6 in Waltham Forest, London and England 2007/08 to 2012/13

Figure 1 and 2 above show the trend in prevalence of obesity in reception and year 6 in Waltham Forest, London and England 2007/08 to 2012/13. In Year 6, 22.9% of children were classified as obese, worse than the average for England in 2012/13

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Figure 3: Prevalence of obesity among adults in London Boroughs in 2012

The figure below shows the prevalence of obesity among adults in London Boroughs for 2012.

Source: Active People survey (data cover the period from mid-January 2012 to mid-January 2013)

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Waltham Forest Healthy Weight Strategy 2014-2019 26


Appendix 2

Weight Management Commissioning Landscape 2013-14

Introduction

Obesity is one of the biggest public health issues facing England. Obesity increases the risk of type 2 diabetes, cardiovascular disease, joint disease and some cancers. Our long term vision in Waltham Forest is to provide an environment that enables all our residents to make healthy food choices, to stay physically active and to maintain a healthy weight across their lives.

Over half of adults in London (57.3%) are overweight or obese; however this prevalence is lower than for England (63.8%)37. In Waltham Forest 54.6% of our adults are overweight or obese, lower than boroughs with similar populations such as Croydon at 62.1%, Enfield at 64.2% and Greenwich at 64.4%.38

The National Child Measurement Programme (NCMP) is part of the Government’s Healthy Weight, Healthy Lives strategy and is overseen by the Department of Health (DH) and Department for Children, Schools and Families (DCSF). Every year, children in reception year and year 6 are weighed and measured as part of the NCMP and this action is also part of the Healthy Child Programme. NHS Waltham Forest took part in the NCMP since 2006 until the PCT ceased as part of the Health and Social Care Act 2012.

For the 2012/13 school year in Waltham Forest in Reception year, the prevalence of obese children in Waltham Forest is 10.5%, higher than national average (9.3%), but similar to regional average (10.8%). For Year 6, the prevalence of obese children in Waltham Forest is 22.9%, higher than national average (18.9%) and regional average (22.4%). The proportion of obese children in Waltham Forest has declined from 23.5% in 2011/12 to 22.9% in 2012/13.

Weight Management services are divided into Tiers 1 -4.

Tier 1 services include community based interventions, leisure services, change for life and commercial weight management groups. Tier 2 services include exercise on referral service; community based dietetic services and prescription of anti-obesity drugs.

37 PHE Feb 2014, Public Health Outcomes Framework, Obesity data, Tobacco Profiles, Longer Lives,38 PHE Feb 2014, Public Health Outcomes Framework, Obesity data, Tobacco Profiles, Longer Lives

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Tier 3 services include involvement of a multidisciplinary team providing services such as behavioural therapy, psychological services and medical support.

Tier 4 services include Bariatric Surgery for adults. Bariatric Surgery for children is rare, however Rotherham Institute of Obesity (RIO) which has gained an international reputation has a Tier 4 residential camp for obese children (>96th centile) aged 8-17 years.

The table below is a mapping of current obesity services in Waltham Forest for both adults and children. This mapping only covers services commissioned by the three main commissioners of health services in Waltham Forest - London Borough of Waltham Forest, Waltham Forest Clinical Commissioning Group and NHS England. There are other weight management services in the borough that are not commissioned by these bodies. These have been excluded from the mapping due to time constraints.

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AdultsTier Name of

ServiceCommissioning Organisation

Provider BriefDescription of Service

1 6 Leisure centres

LBWF GLL Free swimming for over 60s and disabled residents.

Gym Station with cardiovascular and resistance equipment, free weights area and aerobics sessions

Healthy Vending Machines in Leisure centre

1 Parks and Open spaces including outdoor gyms, play areas & sports pitches

LBWF LBWF and Urbaser

Free sports & recreational activities

1 Disability Sport LBWF Various Archery, Athletics, Forest Flyer2 hockey, Multi Sports Session, Swimming

1 Our Parks LBWF Our Parks A free fitness classes which will be held in 4 parks. Each park will have 10 hours of free activities taking place every week. Our Parks is funded for 2 years

1 Active Travel (cycle Training)

LBWF Cycle Confident

Cycle trainers

1 Integrated food concerns into

LBWF Healthier Catering Commitments linked to High Street Regeneration

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policy

1 Mobile Green Grocer project

A food van providing affordably priced fresh produce within identified ‘food deserts’

1 Initiatives around nourishment from early years

LBWF Love Mums breastfeeding support programme

Maternal and new-born vitamin distribution

2 Exercise on Referral

LBWF – Public Health

GLL EOR involves structured exercise session with supervision from an NVQ-level 3 plus GP referral trained instructor

Level 4 – Cardiac Rehabilitation

2 Better weight management service

LBWF – Public Health

GLL Weight management service for clients BMI >25

2 Why Weight CCG NELFT 6 weeks Weight Management programme provided by the community dietician

2 1:1 session with Dietitian

CCG NELFT For Diabetic patients provided by the community dieticians

2 X-pert CCG NELFT 6wks session for newly diagnosed Type 2 diabetic clients

2 Prescribing NHS England GPs Prescribing Anti-obesity drugs

3 Multi- Discipline CCG Multi-disciplinary team providing behavioural therapy, psychological services and medical

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weight management service

support

Gap in service provision

4 Bariatric Surgery

NHS England Homerton University Hospital

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Children

Tier Name of service

Commissioning Organisation

Provider Brief Description of Service

1 Leisure services

LBWF GLL Free swimming for under 18s

Junior Gym for 11-15 years old

1 Community dieticians -

LBWF – Early Intervention & Prevention

NELFT Dieticians service in the children centres including food clubs and weaning sessions

1 Healthy Child Programme 0-5

(Health Visitors)

NHS England NELFT Universal preventative service, providing families with a programme of health and developmental reviews (10-14 days, 1 year and 2 years) including open child health clinics supplemented by advice around health, wellbeing and parenting and signposting.

1 Healthy Child Programme 5-19 & NCMP (School Nurses)

LBWF: Public Health

NELFT Universal and progressive services for children and young people to promote optimal health and wellbeing. Offers a variety of health reviews (reception, year 6/7 and mid-teen), screening tests, information and signposting including NCMP.

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1 Healthy Schools Programme

GLA London wide programme, LBWF: Public Health funds 1 support post £44K

Role of support program is to encourage and enable schools to participate in the programme, which leads to an increased emphasis on healthy eating and activity

£1 million set aside annually to fund breakfast clubs and healthy snack-packs for reception and year 6 pupils in schools, with 55 schools (69%) already signed up

Over £3million invested in improving school kitchens and dining facilities for 2013-17, plus reinvesting 50% of school-meal surplus income

Food For Life (FFL) Silver Catering Mark for primary school menus and Bronze for secondary

Joint 3rd achieved for leading in good food practice in the Good Food for London report 2013

40 schools signed up for the healthy schools London, with 11 achieving Bronze. Under the previous national Healthy Schools systems, 93% achieved Bronze or above

1 Restriction of Hot food takeaways

LBWF Planning policies in place which seek to reduce the proliferation of Hot food Takeaways, particularly near schools as a means of combating their known adverse impact on community health

2 Go For it & Teen Why Weight

CCG NELFT Go for it – 10 weeks weight management programme for children (7- 11 years old)and parents

Teen why weight - 4 weeks weight management programme for teenagers

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2 Universal dietetic services (1:1 sessions

CCG NELFT Overweight/obese children with co-morbidities e.g. children with diabetes and learning disabilities

3 Multi- Discipline weight manage-ment service

CCG Multi-disciplinary team providing behavioural therapy, psychological services and medical support

Gap in service provision

4 Bariatric Surgery

TBC Gap in service provision

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