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Obesity and Type 2 Diabetesin Northern Ireland

REPORT BY THE COMPTROLLER AND AUDITOR GENERALNIA 73/08-09 14 January 2009

Report by the Comptroller and Auditor General for Nor thern Ireland

Ordered by the Northern Ireland Assembly to be printed and publishedunder the authority of the Assembly, in accordance with its resolution of27 November 2007

Obesity and Type 2 Diabetes inNorthern Ireland

NIA 73/08-09 BELFAST: The Stationery Office £5.00

This report has been prepared under Article 8 of the Audit (Nor thern Ireland) Order 1987 forpresentation to the Nor thern Ireland Assembly in accordance with Ar ticle 11 of that Order.

J M Dowdall CB Northern Ireland Audit Of ficeComptroller and Auditor General 14 January 2009

The Comptroller and Auditor General is the head of the Nor thern Ireland Audit Of ficeemploying some 145 staf f. He, and the Nor thern Ireland Audit Of fice are totally independentof Government. He certifies the accounts of all Gover nment Departments and a wide range ofother public sector bodies; and he has statutor y authority to repor t to the Assembly on theeconomy, efficiency and effectiveness with which depar tments and other bodies have used theirresources.

For further information about the Nor thern Ireland Audit Of fice please contact:

Northern Ireland Audit Of fice106 University StreetBELFASTBT7 1EU

Tel: 028 9025 1100email: [email protected]: www.niauditoffice.gov.uk

© Northern Ireland Audit Of fice 2009

Contents

Obesity and Type 2 Diabetes in Nor thern Ireland

Executive Summary 1

Part One: Introduction 3

Obesity Levels in Nor thern Ireland have grown rapidly 4

Weight gain is a major influence on the prevalence of T ype 2 Diabetes 4

Audit Objective 5

Part Two: Impact of risk factors on Type 2 diabetes 7

Type 2 diabetes is a growing problem 8

Need for action 11

Obesity and diabetes can have costly consequences 12

Part Three: The public health approach to preventing Type 2 diabetes 13

Prevention is an essential par t of efforts to control Type 2 diabetes 14

The changes that prevention seeks to bring about are simple to describe, 14but difficult to achieve

A number of prevention initiatives are currently under way in Northern Ireland 15

Part Four: Strengthening the approach to public health 19

A coherent policy framework 20


Appendices 25

Appendix One: Adult overweight and obesity in the Eur opean Union 26

Appendix Two: Public Accounts Committee Recommendations on Obesity, 2007 27

Appendix Three: Type 2 diabetes risk assessment for m 29

Appendix Four: Advantages and disadvantages of PHO-Brent-ScHARR 30diabetes population prevalence model

Abbreviations


BMI Body Mass Index

CREST Clinical Resource Efficiency Support Team

IDF International Diabetes Federation

PSA Public Service Agreement

SMART Specific Measurable Achieveable Realistic T ime-bound

WHO World Health Organisation

Executive Summary

Executive Summary

2 Obesity and Type 2 Diabetes in Nor thern Ireland

1. Today, some of the major threats to goodhealth are largely avoidable. On a globalbasis, physical inactivity, unhealthy eatingand being overweight are importantpreventable causes of chronic diseasessuch as Type 2 diabetes. The social andeconomic costs of this disease areenormous and have the potential toincrease significantly over the comingyears.

2. Health promotion activities aim to reducethe incidence of chronic disease byencouraging people to adopt healthierlifestyles. The audit examined whatcontribution the Department of Health,Social Services and Public Safety’s(Department) investment in healthpromotion had made in preventing theoccurrence of Type 2 diabetes.

3. The increasing levels of obesity anddiabetes in Northern Ireland are ofconcern to the Depar tment, and the linkbetween the two conditions is well knownand acknowledged. The need to addressobesity through addressing lifestyle factorssuch as physical activity and eating habitsis also well established and theDepartment told us that it has been par t ofits overall public health approach to theissue for a number of years – reflected inthe work carried out in the mid-1990s inrespect of a physical activity strategy andwork to develop a food and nutritionstrategy. More recently, as the evidencebase for childhood obesity has becomeclearer, the Department has put increasedfocus on tackling childhood obesitythrough a cross-departmental strategy FitFutures1. In addition, a Public Ser vice

1 Fit Futures: Focus on Food, Activity and Young People, Report to the Ministerial Group on Public Health, December 2005.2 Foresight – Tackling Obesities: Future Choices, Government Office for Science, Depar tment of Innovation, Universities and

Skills, DIUS/2K/10/07/NP, October 2007.

Agreement target has been establishedaimed at halting the rise in childhoodobesity.

4. Following the publication in Great Britainof Foresight – Tackling Obesities: FutureChoices2 in October 2007, theDepartment adopted a life coursestrategic approach to obesity, putting inplace an Obesity Steering Group,supported by four Advisor y Groupsaddressing the issues of physical activity,food and nutrition, education andprevention, and data collection andresearch. These groups will take forwardthe Fit Futures recommendations and alsoadvise the Department on thedevelopment of a long-term life coursestrategic framework to address obesityacross the whole of the Nor thern Irelandpopulation.

5. While we acknowledge that addressingthe problem of obesity has been aDepartmental priority since the mid-1990s, the full impact of its primar yprevention strategies on reducing theburden of Type 2 diabetes has still to berealised. Against this background, ourreview looked at how health pr omotionactivities could be strengthened in orderto deliver behavioural inter ventionscapable of providing cost-ef fectivebenefits. In addition, our examination alsofound that there was scope to improve theevidence base and the targeting andmonitoring of effort.

Part One:Introduction

Part One:Introduction


Obesity levels in Nor thern Ireland havegrown rapidly

1.1 Over the last 30 years, lifestyle changesin exercise and eating habits havecontributed to more people in Nor thernIreland becoming overweight or obese.The prevalence of obesity in all agegroups poses such a serious problem thatthe World Health Organisation hasdescribed it as a “global epidemic”. 3

Body mass index (weight (kg)/height (m) 2)is a commonly used definition ofoverweight and obesity. A cut-off pointof 25kg/m2 is recognised internationallyas definition of adult over weight, and30kg/m2 for adult obesity.

1.2 The Health and Social Wellbeing Survey2005-064 found that a quar ter of all menand 23 per cent of women in Nor thernIreland were obese. The Sur vey findingsalso show that this represents an overallincrease of 26 per cent in adult obesitysince 1997 – a rise in the region of 47per cent for males and 15 per cent forfemales.

1.3 Appendix 1 sets Nor thern Ireland obesitylevels in the context of other EuropeanUnion countries. While this data is helpfulin illustrating that obesity is aninternational problem which af fects somecountries more than others, the sur veys onwhich the data is based ar e notcomparable because of dif ferences intime periods covered, age range of thosesurveyed and methodology. Moreover, theinclusion of self-reported survey data mayunderestimate the true prevalence of

3 www.who.int (accessed September 2007)4 NISRA Health and Social Wellbeing Survey 2005-065 Type 1 diabetes is an autoimmune disease in which the body produces little or no insulin, a hor mone needed to conver t

food into energy. To survive, people with Type 1 diabetes must regularly inject themselves with insulin. Most oftendiagnosed in children or young adults, this for m of diabetes accounts for between 10-15 per cent of all cases. T ype 1diabetes itself is not preventable, although many of its complications can be pr evented by careful management.

obesity. Given the impor tance of obesityas a health issue, the data compiled inAppendix 1 demonstrate that, in general,there is a lack of comprehensive, up todate comparative data on this issue. In2007, the Public Accounts Committee atWestminster reported on obesity amongchildren in England. It also drew attentionto a delay between the collection of dataand the publication of results. A summar yof the Committee’s conclusions andrecommendations is included atAppendix 2.

Weight gain is a major influence on theprevalence of Type 2 diabetes

1.4 Taken together, physical inactivity andunhealthy eating are impor tantpreventable causes of chronic diseaseand their impact is increasing. The rise inType 2 diabetes is one example of achronic disease that is closely connectedto these risk factors. Type 2 diabetes isthe most common form of diabetes.5 Itoccurs because the body produces toolittle insulin and is unable to pr operly usethe insulin that is secreted. It usuallyoccurs in older people although it isbecoming more common amongstyounger people, partly due to lifestylefactors such as diet, lack of physicalactivity and obesity. Type 2 diabetesaccounts for approximately 85-90 percent of all cases of diabetes in Europeancountries.

1.5 These risk factors also underpin a numberof other chronic diseases. For example,

Obesity and Type 2 Diabetes in Nor thern Ireland 5

6 Prevention and early detection of vascular complications of diabetes, S. Marshall and V. Flyvbjerg, British Medical Journal,Vol. 333, pp 475-480, September 2006.

7 Prevention of Type 2 diabetes mellitus by changes in lifest yle among subjects with impaired glucose tolerance, J. Tuomilehtoet al, New England Jour nal of Medicine, Volume 344: 1343-1350, No.18, May 2001

without adequate management of thecondition a person with Type 2 diabetesis two to five times more likely than thegeneral population to have a hear t attackor stroke.6 Action on diabetes preventionwould thus also reduce the incidence ofother diseases such as cardiovasculardisease, certain cancers and asthma. Thefailure to prevent diabetes, and delays indiagnosing diabetes, lead to severecomplications such as amputation,blindness and kidney failure. Thesecomplications have an enormous impactboth on the person suf fering from thedisease and their family. Theseunnecessary complications put greaterpressure on health systems and budgetsand represent a very large share ofpreventable hospital treatments.

1.6 The effect of weight change is crucial inthe prevention of diabetes. A study inFinland7 concluded that a weight increaseof between 2-3 kilogrammes doubles therisk of an overweight person developingType 2 diabetes. On the other hand, thediabetes risk of an over weight person isreduced by 80 per cent if he/shesucceeds in losing 10 kilogrammes.Appendix 3 outlines the factors taken intoaccount in assessing diabetes.

Audit Objective

1.7 The objective of the review will be toexamine the effectiveness of theDepartment’s health promotion strategiesin influencing the risk factors of unhealthyeating and physical inactivity which can

lead to the occurrence of a chronicdisease such as Type 2 diabetes.

Part Two:Impact of risk factors on Type 2 diabetes



Type 2 diabetes is a growing problem

2.1 The World Health Organisation (WHO)estimated that in 1985, 30 millionpeople worldwide had diabetes. Thisfigure rose to an estimated 135 million in1995 and an estimated 177 million inthe year 2000. These figures areexpected to rise to at least 366 million by20308. In 2003 the InternationalDiabetes Federation (IDF) e-Atlasestimated that there were 194 millionpeople between the ages of 20-79 yearsliving with (either diagnosed orundiagnosed) diabetes (both Type 1 andType 2). This equated to a globalprevalence rate of 5.1 per cent. By 2025these figures are expected to rise to 333million with a global prevalence rate of6.3 per cent9.

2.2 While available statistical data can var y,the seriousness and urgency of thechanges in obesity rates are alsoillustrated by the number of people inNorthern Ireland with Type 2 diabetes. In 2005 the Republic of Ireland andNorthern Ireland’s Population HealthObservatory (INIsPHO) set up a WorkingGroup to adapt the PBS model toestimate population prevalence ofdiabetes on the island of Ireland. The PBSDiabetes Population Prevalence Model(developed by Yorkshire and HumberPublic Health Observatory (YHPHO),Brent NHS Primary Care Trust, and theUniversity of Sheffield School of HealthRelated Research (ScHARR) and adaptedfor use on the island of Ir eland by the IrishDiabetes Prevalence Working Group) wasused to develop the forecasts of

8 Chronic disease information sheets – Diabetes, WHO, available from:http://www.who.int/dietphysicalactivity/publications/facts/diabetes/en/index.html

9 IDF estimates. Available from: http://www.eatlas.idf.org/Prevalence/All_diabetes/10 Making Diabetes Count: What does the futur e hold?, The Irish Diabetes Prevalence Working Group, The Institute of Public

Health in Ireland, May 2007.

population prevalence. The modelaccounts for age, gender, ethnicity andsocio-economic factors which are knownto affect the prevalence of diabetes.While the model provides a singlemethodology and has been rigorouslytested in England, it does have somelimitations. The advantages anddisadvantages of the model are outlinedin more detail at Appendix 4.

2.3 Forecasts were developed to account forchanges in the population structuretogether with three scenarios representingdifferent trends in Body Mass Index (BMI)distribution over the period 2005 –2015. Figure 110 shows that there wereover 62,000 people (5.1 per cent of thepopulation) with Type 2 diabetes in2005. Figure 1 also compares Nor thernIreland’s estimated prevalence of diabeteswith the Republic of Ireland at five yearintervals using three different scenarios.

2.4 Assuming the BMI levels remain at the2005 level (scenario 1) the modelforecasts that the population prevalence ofdiabetes in 2015 will be 5.3 per cent(70,464 adults) in Nor thern Ireland and4.6 per cent (160,002 adults) in theRepublic of Ireland, an increase of around8,000 and 31,000 adults respectively.This reflects population changes only.

2.5 If the levels of BMI do not r emain at the2005 level but instead obesity increasesin a linear fashion, with under weight/normal rates showing a slow exponentialdecrease (scenario 2), the modelforecasts that the population prevalence ofdiabetes in 2015 will rise to 5.9 per cent


(79,225 adults) in Nor thern Ireland and5.2 per cent (180,028 adults) in theRepublic of Ireland, an increase of justunder 17,000 and 51,000 adultsrespectively. These are the most realisticforecasts. If obesity increases at anexponential rate with the under weight/normal rates showing a slow exponential

decrease (scenario 3) then the modelforecasts that the population prevalence ofdiabetes in 2015 will be 6.1 per cent(81,767 adults) in Nor thern Ireland and5.4 per cent (186,132 adults) in theRepublic of Ireland, an increase of around19,500 and 57,000 adults respectively.

Figure 1: Forecasts of population prevalence of adult T ype 2 diabetes – 2010 and 2015

Northern Ireland Republic of Ireland

Scenario 1 Estimated Estimated Estimated Estimated Estimated Estimated Population* number Prevalence Population* number Prevalence

of cases % of cases %

2005 1,230,947 62,287 5.1 2,981,300 129,052 4.3

2010 1,287,592 65,169 5.1 3,222,976 140,502 4.4

2015 1,335,852 70,464 5.3 3,466,961 160,002 4.6

Scenario 2

2005 1,230,947 62,287 5.1 2,981,300 129,052 4.3

2010 1,287,592 69,217 5.4 3,222,976 149,283 4.6

2015 1,335,852 79,225 5.9 3,466,961 180,028 5.2

Scenario 3

2005 1,230,947 62,287 5.1 2,981,300 129,052 4.3

2010 1,287,592 70,600 5.5 3,222,976 152,407 4.7

2015 1,335,852 81,767 6.1 3,466,961 186, 132 5.4

Source: Irish Diabetes Prevalence Working Group, May 2007

* Due to lack of available data, the model and forecasts assume zero prevalence of T ype 2 diabetes in children and youngadults less than 20 years of age. This may cause a slight underestimate in prevalence, par ticularly by 2015.



2.6 In addition to prevalence rates beinghigher in Northern Ireland than theRepublic of Ireland, another interesting

feature of those who suffer from Type 2diabetes is that females display a higherincidence of the disease (Figures 2 and 3).

Figure 2: Estimated prevalence of Type 2 diabetes in adult males 2010 - 2015




2005 589,721 23,790 4.0 1,469,300 51,719 3.5

2010 618,626 25,542 4.1 1,585,357 57,926 3.7

2015 642,413 27,779 4.3 1,706,745 66,652 3.9

Scenario 2

2005 589,721 23,790 4.0 1,469,300 51,719 3.5

2010 618,626 27,419 4.4 1,585,357 62,183 3.9

2015 642,413 31,862 5.0 1,706,745 76,448 4.5

Scenario 3

2005 589,721 23,790 4.0 1,469,300 51,719 3.5

2010 618,626 28,739 4.6 1,585,357 65,175 4.1

2015 642,413 34,419 5.4 1,706,745 82,585 4.8


* Due to lack of available data, the model and forecasts assume zero prevalence of T ype 2 diabetes in children and youngadults less than 20 years of age. This may cause a slight underestimate in prevalence, par ticularly by 2015.


11 These figures relate to episodes of care and, therefor e, do not relate to individuals. Patients may be admitted to hospitalmore than once in a year

Need for action

2.7 Failure to adequately address the rise in achronic disease such as diabetes willaffect individuals and their families, andthe wider community, in terms of higherhealth care costs and reducedproductivity. Figure 4 shows the hospitaladmissions11 and bed days relating topatients whose primary condition isdiagnosed as diabetes. Currently there

are around 4,000 hospital admissions ayear, with patients taking up about15,000 bed days. While there has beenan increase of 12 per cent in admissionssince 2001-02, there has been an 8 percent reduction in bed days over the sameperiod. The Department pointed out thatthe reduction in emergency admissionswas indicative of success in the bettermanagement of the condition.

Figure 3: Estimated prevalence of Type 2 diabetes in adult females 2010 - 2015




2005 641,226 38,497 6.0 1,512,000 77,333 5.1

2010 668,966 39,626 5.9 1,637,619 82,576 5.0

2015 693,439 42,685 6.2 1,760,216 93,350 5.3

Scenario 2

2005 641,226 38,497 6.0 1,512,000 77,333 5.1

2010 668,966 41,798 6.2 1,637,619 87,101 5.3

2015 693,439 47,363 6.8 1,760,216 103,581 5.9

Scenario 3

2005 641,226 38,497 6.0 1,512,000 77,333 5.1

2010 668,966 41,861 6.3 1,637,619 87,232 5.3

2015 693,439 47,348 6.8 1,760,216 103,547 5.9


* Due to lack of available data, the model and forecasts assume zero prevalence of T ype 2 diabetes in children and youngadults less than 20 years of age. This may cause a slight under estimate in prevalence, particularly by 2015.



Obesity and diabetes can have costlyconsequences

2.8 The Health Select Committee12 atWestminster estimated that the economiccost of obesity in England was between£3.3 and £3.7 billion per year, of which£1 billion was directly attributable to thecosts of treating obesity and itsconsequences. In Northern Ireland thecost attributable to lack of physical activityincludes over 2,100 deaths per annum,equivalent to over 18,000 life years lostand 1.2 million working days lost eachyear.13 No robust estimate of the overallhealth care costs of treating diabetes wasavailable from the Department, however,Diabetes UK14 recently published a repor t

12 Obesity, Third Report of Session 2003-04. House of Commons Health Committee. HMSO, 2004.13 Investing for Health, DHSSPS, 200214 Diabetes: The Silent Assassin, Diabetes UK, October 2008

which stated that ten per cent of NationalHealth Service spending in Great Britain– or £1 million per hour - went on treatingthose suffering from diabetes.

2.9 Given the expensive medicalconsequences of diabetes, the ef fectivetargeting of health promotion strategiescan help to reduce the overall cost burdenof the disease. Par t 3 reviews the actionswhich have been taken in promotingphysical activity and healthy eating toprevent Type 2 diabetes.

Figure 4: Admissions to hospital of patients with aprimary diagnosis of diabetes

2001-02 2006-07

Admissions:

Elective 2,140 2,703

Emergency 1,536 1,427

Other 51 45

Total 3,727 4,175

Bed Days:

Elective 3,652 3,945

Emergency 11,286 10,118

Other 1,089 747

Total 16,027 14,810

Source: Department

Part Three:The public health approach to preventing Type 2diabetes

Part Three:The public health approach to preventing Type 2 diabetes


Prevention is an essential par t of efforts tocontrol Type 2 diabetes

3.1 The prevention of Type 2 diabetesrequires a focus on controlling theenvironmental factors that pre-disposeindividuals to the disease, and onencouraging people’s capacity to improvetheir health. In the case of Type 2diabetes, preventative action first needs toaddress risk across the entir e population,as it is dif ficult to identify with cer taintywho will develop the disease. Pr eventionwill then need to identify specificpopulations that are at an increased riskof developing Type 2 diabetes, and useearly detection and inter ventionprogrammes to inform and help thosepopulations.

3.2 Primary prevention is essential becausethere are no simple solutions to Type 2diabetes. Indeed prevention of thedisease is backed by compelling researchevidence:

• a Finnish diabetes prevention study(see footnote 7) achieved a 58 percent relative risk reduction betweenthe intervention and the controlpopulations through a combined dietand exercise programme. Thisinvolved relatively limited weight loss(about 5kg)

• an American diabetes preventionprogramme15 tested both a lifestylemodification intervention andmedication to reduce the developmentof diabetes. It found that the lifestyle

15 Reduction in the incidence of type 2 diabetes with lifestyle inter vention or metformin, W.C. Knowler, E. Barrett-Connor, S.E.Fowler, R.F. Hamman, J.M. Lachin, E.A. Walker and D.M. Nathan, Diabetes Prevention Program Research Group, NewEngland Journal of Medicine, 346: 393-403, 2002

16 Impaired glucose tolerance and its r elationship to ECG-indicated coronary heart disease and risk factors among Chinese,X.R.Pan, Y.H. Hu, G.W. Li, P.A. Liu, P.H. Bennett and B.V. Howard, Diabetes Care, Vol 16, Issue 1 150-156, 1993,American Diabetes Association.

modification programme achieved a58 per cent reduction in the incidenceof diabetes and this was moreeffective than the use of medication(only a 38 per cent risk reduction)

• the Chinese Da Qing ImpairedGlucose Tolerance and DiabetesStudy16 also achieved reductions ofbetween 31 per cent and 46 per centusing different interventions involvingdiet and exercise.

The changes that prevention seeks to bringabout are simple to describe, but dif ficult toachieve

3.3 Many people carry a geneticpredisposition to developing Type 2diabetes. Although they cannot changetheir genetic make-up, they may be ableto minimise the conditions that induce theirgenetic make-up to be expressed. To dothis they would have to maintain a healthyweight and be physically activethroughout their lives, ideally from infancyon. In particular, they would have toavoid abdominal obesity – that is, puttingon excess fat deposits around the waist.

3.4 Several steps of prevention are veryobvious, such as being physically activeand reducing calorie intake. But clearly,as trends in recent years demonstrate,taking these simple steps is easier saidthan done. Studies consistently show thatmost children are no longer as physicallyactive as they should be, and that activitydeclines further with age. At the same


17 Physical Activity: an investment in public health, Health Promotion Agency for Nor thern Ireland, 1996

time, rates of excess weight and obesityin the population are rising, andabdominal obesity is increasing evenfaster.

3.5 Effective prevention is dif ficult to achievebecause the factors that shape people’shealth are complex and inter twined. Stepchanges are required in both social normsand social settings. Indeed primar yprevention has had only a few largescale successes: for example, decliningsmoking rates and the reduction intolerance of drinking and driving. Theformer is a good example of successfulprevention. For several decades thegovernment has made a concer ted effortto reduce the percentage of people whouse tobacco through a range of strategiessuch as banning adver tising, requiringwarning labels on cigarette packets andbanning smoking in public places.

3.6 This part of the repor t examines whatinterventions have been put in place inNorthern Ireland to address the linkedproblems of obesity and Type 2 diabetes.

A number of prevention initiatives arecurrently underway in Northern Ireland

Physical Activity

3.7 In the late 1990s the gover nment inNorthern Ireland invested heavily in newinitiatives to encourage healthier lifestyles.With relevance to obesity, this includedinvestment of approximately £500,000 ayear in support of a Physical Activity

Strategy17 which set two targets by whichto measure progress towards improvedhealth of the population. These sought toreduce the number of people who weresedentary and to increase the number ofpeople who exercised to recommendedlevels:

• by 2002 the propor tion of men andwomen aged 16+ who are classifiedas sedentary should be reduced from20 per cent to 15 per cent; and

• by 2002 the propor tion of men andwomen aged 16+ who achieverecommended age-related activitylevels should be increased from 30per cent of men and 20 per cent ofwomen to 35 per cent of men and25 per cent of women.

3.8 These targets proved dif ficult to achieve,however, and a review of the Strategy in2002 concluded that there was acontinuing need for a future Strategy withSMART aims, objectives and targets. Anew draft Strategy and Action Plan wasprepared and a series of targets set for2010; this process was, however, thensubsumed within the development of FitFutures (see paragraph 3). This wasassociated with a new Public Ser viceAgreement Target of aiming to reduce therise in childhood obesity by 2011. This isdescribed in more detail below. Otherinitiatives with relevance to physicalactivity include the Workplace HealthStrategy, the Promoting Mental HealthStrategy and Action Plan, the TobaccoAction Plan, the impending Food and

Part Three:The public health approach to preventing type 2 diabetes


Nutrition Strategy & Action Plan, local fallprevention strategies, the Nor thern IrelandCycling Strategy, the Northern IrelandWalking Action Plan, the development ofthe Long Term Athlete Development modeland the Community Suppor t Programme.

Obesity

3.9 More recently, the Northern IrelandAssembly’s Programme for Governmentidentified working for a healthier peopleas one of five overarching priorities. This

included commitments to increase physicalactivity and to provide oppor tunities formore active lifestyles by developing cycleand pedestrian networks, and to promotethe benefits of spor t. The cross-departmental public health strategy,Investing for Health, was published inMarch 2002 and sets out how thesecommitments are to be met. The strategyoutlines the approach to improving healthand wellbeing, reducing healthinequalities and also provides aframework for efforts to achieve this. The

Figure 5: Fit Futures Priorities for Action

Priority Area Issues / Action required

Develop joined-up healthy public policy • address disjointed approach to promotion of physical activity, sport and leisure

• address conflicting policies sometimes being promoted by government departments and agencies in relation to food policy and the food industr y

Provide real choice • food industry should respond to introduction of controls on advertising and promotion of foods to children

• food industry should introduce agreed nutritional signposting system

• create demand for healthy options through public sector food procurement

• tackle barriers to healthy food• opportunities for active play should be available and accessible

Support healthy early years • extend healthy schools programme to early years settings• establish common standards for nutrition and physical activity in

these settings and monitor compliance

Create healthy schools • integrate health improvement planning into school development planning

• develop active schools programme

Encourage development of healthy • community based approaches such as Health Action Zonescommunities

Build an evidence base • systematic surveillance of obesity levels, nutrition and activity levels

Source: Department


18 Fit Futures: Focus on Food, Activity and Young People, Report to the Ministerial Group on Public Health, December 2005

problem of high obesity levels isaddressed specifically through a PublicService Agreement target:

• by March 2010, halt the rise inobesity.

3.10 In response to the obesity crisis, a cross-departmental taskforce was established inAugust 2004, to examine options forpreventing the rise in levels of over weightand obesity in Nor thern Ireland. Thetaskforce reported in December 2005.18

It identified six priorities for action (seeFigure 5).

3.11 An implementation plan for Fit Futur es wasdrafted during 2006 and consulted on inearly 2007. This set out a range of keytasks and target dates under the sixpriority areas. A Fit Futures ProgrammeBoard, led by the Depar tment, wasestablished in April 2007 to overseeimplementation. (For more recentdevelopments, see paragraph 4.4).

Diabetes

3.12 The incidence of Type 2 diabetes can bereduced by preventative healthcarestrategies. In addition, many people withType 2 diabetes remain undiagnosed andthis can increase the risk of developingcomplications by the time of diagnosis.The prevention and early detection ofdiabetes is the responsibility of all thoseprofessionals who deliver diabetes care inthe community and in hospitals, as wellas the Department and the four health

and social services Boards, which have astrategic role in shaping andcommissioning services.

3.13 A shift towards prevention and earlydetection has been given impetus by ajoint Diabetes UK (NI)/Clinical ResourceEfficiency Support Team (CREST) taskforcewhich was set up in Nor thern Ireland in2001. Its remit was to review progr esssince a previous CREST repor t in 1996on diabetic services, and to develop aframework for diabetic ser vices inNorthern Ireland. The taskforce reportedin June 2003 and identified pr eventionand early detection and targeting ofvulnerable groups as two of five areas fordevelopment in diabetic ser vices withinthe region. The Department told us thatresources provided to general practiceshad enabled primary care teams to detectdiabetes more effectively, particularly aspart of cardiovascular risk assessment.Primary care professionals are alsoexpected to target high risk groups suchas the obese, those from ethnic minorities,and those with a strong family histor y.

Part Four:Strengthening the approach to public health



4.1 Today our society enjoys the benefits ofchoices such as sedentar y computergames and the easy availability ofcalorie-rich food - choices whose sideeffects will lead to increasing levels ofType 2 diabetes. The increase inprevalence will continue unless significantinterventions occur. Some positive stepshave been taken to address these issuesand there are plans to do mor e.However, to date, the combined ef forts ofthe Department and other agencies havenot significantly slowed the increase inobesity which has underpinned a similarrise in preventable Type 2 diabetes.

4.2 Given the long term nature ofprogrammes in place to achieve theDepartment’s general policy goal ofpreventing the occurrence of Type 2diabetes, we do not think it useful or ,indeed, feasible to make detailedrecommendations on the way for ward.Instead we recommend an organisedprocess for taking action to bring aboutimprovement.

A coherent policy framework

4.3 Investing for Health and Fit Futuresprovide a coherent structure and commonbranding for a wide range of healthpromotion programmes. They were set upas the whole-of-government initiative tocoordinate action on obesity. So far, theMinisterial Group on Public Health whichhas responsibility for implementing andmonitoring Investing for Health hasfocused on pulling existing initiatives into

a consistent framework and encouragingcross-agency coordination.

4.4 The Department has now put in place anObesity Prevention Steering Group. Thiscross-sectoral group, with representationfrom practitioners, policy makers andresearchers, monitors the implementationof the 70 recommendations in Fit Futures(see paragraph 3). It is also developing aStrategic Framework for addressingobesity across the life course, followingclosely the recommendations in theForesight Report (see paragraph 4) whichdemonstrated the complexity of the issue.As part of this approach, four PolicyAdvisory Groups have been established –these cover physical activity, food andnutrition, education and prevention, anddata and research. This will facilitate aninformed, research-led integratedapproach to addressing obesity andassociated conditions.

4.5 To ensure that the Department continuesto take forward its strategy for obesityand diabetes effectively, we considerthat the process will need to:

• include and deliver programmesdemonstrated by research to beeffective;

• provide enough resources to deliverprogrammes with real impact andsufficient coverage of the region;

• ensure effort and investment can besustained long enough to get results;


• set specific objectives and targetsrelating to healthy eating for targetpopulation groups;

• provide ongoing measures ofsuccess;

• have the flexibility to reallocate orincrease resources in response toemerging evidence on per formanceand the target outcomes; and

• ensure that the governancearrangements covering the whole-of-government nature of its approach toobesity and diabetes are capable ofdriving effective outcomes.

4.6 The initiatives outlined in Par t 3demonstrate that the Depar tment iscommitted to action across primar yprevention, early detection andintervention in relation to both obesity andType 2 diabetes. However, its ability tolink these mutually reinforcing initiatives inthe management and prevention of achronic disease like Type 2 diabetes willbe an important contribution to success.Addressing the risk factors underpinningthe rise in obesity and Type 2 diabetesrequires that the two policy directions areframed so that progress measures andoutcomes can be aligned.

4.7 An important aspect of per formancereporting is making clear how themeasure being reported links toDepartmental activity. Thus, where thereare targets set for lifestyle changes, suchas increased physical activity

levels/reduced obesity levels, explainingtheir potential impact on the prevention ofType 2 diabetes will be an impor tant partof making these targets meaningfulaccountability tools.

4.8 Comprehensive performance reportingwill need to include meaningful measuresfor each type of prevention initiative. Asnoted at paragraph 3.9, a PSA targethas been set which is aimed at haltingthe rise in obesity by March 2010.While this measure provides a good,high-level target, we consider that it needsto be expanded in breadth, for example,to focus on gender dif ferences, childrenand socio-economic groupings. Moreover,we also note that cur rently there are noPSA targets which relate to reducing theincidence of diabetes. Rather, theDepartment’s Priorities for Action planningdocument 2006-08 includes two targetswhich are aimed at more effective carearrangements for those managing thedisease and retinopathy screening.

4.9 In our view, the setting of measurabletargets that align with those for obesitywill be crucial to ensuring there isdecisive action to tackle diabetes.Headline measures which may be usedin this process include:

• the proportion of people consumingat least the recommended daily fruitand vegetable intake;

• the proportion of people suf ficientlyphysically active to obtain a healthbenefit;



• the proportion of people overweightor obese; and

• potentially preventablehospitalisation.

Some illustrative targets which havebeen established in Australia19 shouldalso be given serious consideration:

For cost-effective early detection andintervention: reducing the number ofundiagnosed persons with Type 2diabetes and reducing the risk of peopleprogressing to Type 2 diabetes; and

For secondary care: reducing theproportion of avoidable hospitaladmissions associated with Type 2diabetes.

4.10 We acknowledge the progress made bythe Department, working with par tnerbodies, in defining and implementing astrategic response to the challenge ofType 2 diabetes. At the same time, ther eis a continuing need to consolidate andbetter co-ordinate current activities inrelation to tackling obesity and Type 2diabetes. For instance, Fit Futuresidentified gaps in the information onobesity risk factors, par ticularly at thelocal level that would help planning. Wewould reiterate its view that there is aglaring need to build the evidence foreffective intervention and to ensure that itinforms the design and deliver y of primaryprevention programmes. This will r equire

19 National Reform Agenda: Victoria’s plan to address the gr owing impact of obesity and Type 2 diabetes, Council ofAustralian Governments, April 2007.

a surveillance system to provide strategicand timely support to the implementationand review of reforms under thesepolicies and provide robust capacity tomeasure achievements against agreedphysical activity and healthy eatingtargets.

4.11 The Health and Social Wellbeing Surveyfor 2005-06 for the first time providedself-reported information on obesity riskfactors in children and young people. TheDepartment told us that it had also fundedthe inclusion of a “booster” sample fromNorthern Ireland as part of the NationalDiet and Nutrition Sur vey which providesa cross-sectional picture of the dietar yhabits and nutritional status of thepopulation of Great Britain. However,apart from these sources of infor mation,there are currently no independent,ongoing objective measurements ofphysical activity and eating habits or theassociated biomedical indicators of risk(for example, body mass index, highblood sugar and high blood cholesterol).

4.12 Fit Futures called for measures to ensurethat an effective evidence base on obesityrisk factors was developed. Howeverafter three years, progress on thisrecommendation has been slow. In ourview, the Department has to be at theforefront of efforts to define andimplement a regional sur veillance strategyfor obesity and its links with chronicdisease, in particular Type 2 diabetes. Itis important that the Depar tment takestimely action to introduce a healthmonitoring survey to better understand the


eating habits, physical activity and relatedbiomedical health indicators of thepopulation of Northern Ireland.

4.13 From September 2007, the Depar tmenthas provided funding to collect andrecord, through the School NursingService, BMI measurements of all Year 8and Year 9 pupils. The Depar tment toldus that it also commissions sur veys,typically every three to four years,covering issues such as dietar y habits,physical activity and a range ofassociated lifestyle behaviours amongchildren and adults. In addition, it hasincreased the Northern Ireland sampleincluded within the United Kingdom Dietand Nutrition Survey.

4.14 We strongly support this work. It isimportant that the Depar tment has anobjective appreciation of obesity riskfactors and the pattern of obesity whichthey underpin. It needs to ensure that itsapproach to surveillance is bothcomprehensive and timely to adequatelyinform it and other depar tmental partnersabout these risk factors.

Appendices

Appendix One: (paragraph 1.3)Adult overweight and obesity in the European Union


Country Year of Males Femalesdata % BMI % BMI Combined % BMI % BMI Combined

collection 25-29.9 ³ 30 BMI³ 25 25-29.9 ³ 30 BMI³ 25

Austria 2005-06 42.3 23.3 65.6 32.4 20.8 53.2Belgium* 2004 38.7 11.9 50.6 24.4 13.4 37.8Bulgaria* 2001 38.8 11.3 50.1 28.8 13.5 42.3Cyprus 2003 43.1 14.7 57.8 31.1 13.8 44.8Czech Republic 2005 42.0 18.0 60.0 29.0 17.0 46.0Denmark* 2001 40.1 11.8 51.9 26.9 12.5 39.4England 2006 44.7 24.9 69.5 32.9 25.2 58.0Estonia* 2004 32.0 13.7 45.7 28.4 14.4 42.8Finland* 2005 44.8 14.9 59.7 26.7 13.5 40.2France 2006 41.0 16.1 57.1 23.8 17.6 41.4Germany 2003 45.5 20.5 66.0 29.5 21.1 50.6Greece* 2003 41.2 26.0 67.1 29.9 18.2 48.1Hungary* 2004 41.8 17.1 58.9 31.3 18.2 49.4Ireland 1997-99 46.3 20.1 66.4 32.5 15.9 48.4Italy* 2005 42.5 10.5 53.0 26.1 9.1 35.2Latvia* 2006 32.3 12.3 44.6 27.5 18.1 45.6Lithuania* 2006 35.7 20.6 56.3 29.7 19.2 48.9Luxembourg 45.6 15.3 60.9 30.7 13.9 44.6Malta* 2003 46.5 22.9 69.4 34.3 16.9 51.2Netherlands 1998-02 43.5 10.4 53.9 28.5 10.1 38.6Poland 2001 41.0 15.7 56.7 28.7 19.9 48.6Portugal 2003-05 45.2 15.0 60.2 34.4 13.4 47.8Romania* 2000 38.1 7.7 45.8 28.6 9.5 38.1Scotland 2003 43.0 22.4 65.4 33.8 26.0 59.7Slovakia* 2002 51.5 17.8 69.3 27.9 19.4 47.2Slovenia* 2001 50.0 16.5 66.5 30.9 13.8 44.7Spain 2003 46.7 13.9 60.6 30.6 15.1 45.7Sweden 2002 43.5 14.8 58.3 26.6 11.0 37.6

Source: International Association for the Study of Obesity , London, July 2008

* self-reported figuresNote: The surveys are not strictly comparable because of dif ferences in age range and methodology. With the limited dataavailable, prevalences are not age-standardised. Self-reported surveys may under-estimate true prevalence.

Appendix Two: (paragraph 1.3)Public Accounts Committee Recommendations on Obesity, 2007


20 Committee of Public Accounts, Ninth Repor t of Session 2001-02, Department of Health: Tackling Obesity in England,HC 421; C&AG’s Report, Tackling Obesity in England, HC (2000-01) 220

1. The 2004 Health Sur vey for Englandshowed an overall rise in obesity amongstchildren aged 2-10 from 9.9 % in 1995 to13.4% in 2004. Despite the introduction of aspecific PSA target in July 2004 aimed attackling the growing problem of child obesity ,the Departments have been slow to react andhave still not published key sections of theDelivery Plan. The Depar tments need toincrease the pace of their response andimprove their leadership by, for example,appointing a senior, high profile champion, tolead and galvanise activity.

2. The three Departments have set up acomplex delivery chain for tackling childobesity involving 26 dif ferent bodies orgroups of bodies. Our predecessors’ reporton obesity identified confusion over r oles andresponsibilities both between dif ferentdepartments and others charged with tacklingthe problem.20 This confusion still exists. TheDepartments need to clarify responsibilitiesthroughout the delivery chain and introducemeasures to judge the per formance andcontribution of the respective parties, perhapssimilar to those under development for LocalArea Agreements.

3. Parents have not been engaged; the onlyinitiative planned by the Depar tments thatwill directly target parents and childr en is asocial marketing campaign which will notbe launched until 2007. The campaignshould be started as soon as possible. Itshould present some simple but high profilemessages and advice to parents, children andteachers, outlining the risks of obesity andshow simple ways in which children can makea difference to their lifestyles: for example, themessage that consuming one less chocolate

biscuit per day can help lead a child out ofobesity (the Departments’ own example).

4. Despite embarking on a nationalprogramme to measure children in allprimary schools in England the Depar tmentof Health is still not clear about whetherparents should be informed if their child isoverweight or obese. The Departmentsdecided originally that to protect children fromstigmatisation and bullying, parents should notbe informed. Reflecting the Committee’sconcerns, however, the Department is nowconsidering how and when parents could beinformed. The Department should movequickly to disclose the information in ways thatwill help parents to address the dietar y andexercise needs of their children.

5. There is a delay of up to two years betweenthe Health Survey for England andpublication of results, so Depar tments do notcurrently know what progress is beingmade towards halting the rise in childobesity. The Departments should use theannual data from weighing and measuring inschools as an interim measure of overallperformance, determining where most andleast progress is being made and using thisdata to identify factors which contribute toperformance.

6. The Department’s strategy of workingalongside the food industr y to influence itsapproach to the marketing of foods anddrinks that are high in fat, salt and sugarhas not been successful in changing the waythe majority of unhealthy foods aremarketed. The Departments should encouragethe growth in the market for healthy food anddrink for children. For example, they could

Appendix Two: (paragraph 1.3)Public Accounts Committee Recommendations on Obesity, 2007


introduce an accreditation scheme with readilyidentifiable badging and publicity materialwhich highlights those companies who aredoing most to tackle this issue.

7. Advertising for food high in fat, salt andsugar accounts for 80-90% of all foodadvertising on television. In November 2006the Office of Communications (Ofcom)announced new restrictions on the adver tisingof unhealthy foods. These include a ban onadvertisements for unhealthy foods “in andaround all programmes of par ticular appeal tochildren”. Ofcom should make arrangementswith the Departments concerned to monitorand assess the impact of the new r estrictionsand tighten the restrictions if those nowplanned are found to be inef fective.

8. In 2003-2004, 72 new playing fields werecreated against 52 lost and during the sameperiod 131 swimming pools were openedagainst the 27 that were closed. Departmentshave made progress in encouraging childr ento lead more active lifestyles, but there isscope for better targeting at children’spreferences and at localities and socialgroupings with fewer oppor tunities. TheDepartments for Education and Skills and forCulture, Media and Spor t should encouragelocal authorities, schools and other providersto develop more public facilities such as lidos,and identify and prioritise those competitiveand other sports and physical activities thatchildren are most likely to take up.


Appendix Three: (paragraph 1.6)

Test designed by Professor Jaakko Tuomilehto, Department of Public Health, University of Helsinki, and JaanaLindström, MFS, National Public Health Institute.

Appendix Four: (paragraph 2.2)Advantages and Disadvantages of PHO-Brent-ScHARR DiabetesPopulation Prevalence Model (PBS)


The PBS model of fers several advantages over theexisting methods used to forecast populationprevalence of diabetes:

• It provides a systematic approach with clearmethodology based upon the use of populationstudies and resident population counts. Themodel has been rigorously tested in England.

• As well as producing national forecasts, thePBS Model generates forecasts at sub-nationallevels.

• The model allows us to include dif ferentscenarios of BMI distribution over the period2005 – 2015.

• It provides a single methodology that can beapplied in both the Republic of Ir eland andNorthern Ireland.

• It provides estimates of population prevalencewithout making assumptions about thepercentage of cases that are undiagnosed.

However like any model there are also limitations:

• In the Republic of Ir eland, it was necessar y toassume the whole population belonged to the“White” ethnic group. Although a question onethnicity was included in the April 2006census, detailed information is not yetavailable.

• In Northern Ireland, it was necessar y to assumethat the proportion of people from ethnicgroups has remained constant since 2001 aspopulation projections are not disaggregatedby ethnicity.

• There is insufficient information on BMIavailable on the island of Ireland to estimatetrends therefore trends in BMI distribution arebased on data from the National Health Sur veyfor England.

• The reference prevalence rates for Type 2diabetes are based on the WHO 1985diagnostic cut-off points.

NIAO Reports 2007-2008


Title HC/NIA No. Date Published

2007

Internal Fraud in Ordnance Sur vey of Northern Ireland HC 187 15 March 2007

The Upgrade of the Belfast to Bangor Railway Line HC 343 22 March 2007

Absenteeism in Northern Ireland Councils 2005-06 - 30 March 2007

Outpatients: Missed Appointments and Cancelled Clinics HC 404 19 April 2007

Good Governance – Effective Relationships between HC 469 4 May 2007Departments and their Arms Length Bodies

Job Evaluation in the Education and Librar y Boards NIA 60 29 June 2007

The Exercise by Local Government Auditors of their Functions - 29 June 2007

Financial Auditing and Repor ting: 2003-04 and 2004-05 NIA 66 6 July 2007

Financial Auditing and Repor ting: 2005-06 NIA 65 6 July 2007

Northern Ireland’s Road Safety Strategy NIA 1/07-08 4 September 2007

Transfer of Surplus Land in the PFI Education NIA 21/07-08 11 September 2007Pathfinder Projects

Older People and Domiciliar y Care NIA 45/07-08 31 October 2007

2008

Social Security Benefit Fraud and Er ror NIA 73/07-08 23 January 2008

Absenteeism in Northern Ireland Councils 2006-07 – 30 January 2008

Electronic Service Delivery within NI Government Departments NIA 97/07-08 5 March 2008

Northern Ireland Tourist Board – Contract to Manage the NIA 113/07-08 28 March 2008Trading Activities of Rural Cottage Holidays Limited

Hospitality Association of Nor thern Ireland: A Case Study NIA 117/07-08 15 April 2008in Financial Management and the Public Appointment Process

Transforming Emergency Care in Nor thern Ireland NIA 126/07-08 23 April 2008

Management of Sickness Absence in the Nor thern NIA 132/07-08 22 May 2008Ireland Civil Service

The Exercise by Local Government Auditors of their Functions – 12 June 2008

Transforming Land Registers: The LandWeb Project NIA 168/07-08 18 June 2008

Warm Homes: Tackling Fuel Poverty NIA 178/07-08 23 June 2008

Financial Auditing and Repor ting: 2006-07 NIA 193/07-08 2 July 2008General Report by the Comptroller and Auditor General

NIAO Reports 2007-2008


Brangam Bagnall & Co NIA 195/07-08 4 July 2008Legal Practitioner Fraud Perpetrated against the Health & Personal Social Ser vices

Shared Services for Efficiency – A Progress Repor t NIA 206/07-08 24 July 2008

Delivering Pathology Services: NIA 9/08-09 3 September 2008The PFI Laboratory and Pharmacy Centre at Altnagelvin

Irish Sport Horse Genetic Testing Unit Ltd: NIA 10/08-09 10 September 2008Transfer and Disposal of Assets

The Performance of the Health Ser vice in NIA 18/08-09 1 October 2008Northern Ireland

Road Openings by Utilities: Follow-up to Recommendations NIA 19/08-09 15 October 2008of the Public Accounts Committee

Internal Fraud in the Spor ts Institute for Nor thern Ireland/ NIA 49/08-09 19 November 2008Development of Ballycastle and Rathlin Harbours


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