Policy : College Statements : RCP response to 'Choosing Health'

OVERWEIGHT AND OBESITY

LONG TERM OBJECTIVE

To achieve a leaner, fitter and healthier nation and in this way reduce the prevalence of obesity in England/UK to less than 10% of the adult population and less than 5% of children and younger people.

MEDIUM TERM OBJECTIVE

To enable people of every age, and from every social background, to make informed choices about their eating and to become more physically activeby better information, educationand health promotion and through an environment that encourages activity.

WHAT IS THE CONTEXT OF THESE OBJECTIVES?

1.         The size of the problem

Obesity is a disorder in which excess body fat has accumulated to an extent that health may be adversely affected.

Overweight and obesity are now so common among the world’s population that they are beginning to replace under-nutrition and infectious diseases as the most significant contributors to ill health. The National Audit Office estimated for England that each year 30,000 excess deaths result from obesity, constituting 6% of all deaths.  Moreover, many of these people die prematurely (National Audit Office Tackling obesity in England, 2001). However, despite the compelling evidence, many people, including doctors, continue to consider obesity as a self-inflicted condition of little medical significance.

There has been a rapid increase in the prevalence of overweight and obesity in all age groups across the UK over the last 20 years. For example, according to the latest Health Survey for England ( Joint Health Surveys Unit, 2002), between 1993 and 2002 the proportion of overweight and obese adults rose from 62% to 70% among men, and from 56% to 63% among women. So, over two-thirds of men and nearly two-thirds of women were either overweight or obese in 2002. The proportion who were categorised as obese increased from 13% of men in 1993 to 22% in 2002, and from 16% of women in 1993 to 23% in 2002. Obesity now affects over one in five adults in the UK.

Overweight young people have a 50% chance of being overweight adults, and children of overweight parents have twice the risk of being overweight compared to those with healthy weight parents. Obese 10- to 14-year-olds with at least one obese parent have a 79% chance of becoming obese adults (Whitaker et al Predicting obesity in young adulthood from childhood and parental obesity,  New England Journal of Medicine, 1997).  Furthermore, parental obesity more than doubles the risk of adult obesity in obese and non-obese children under 10 years.

If current trends continue, at least one-third of adults, one-fifth of boys and one-third of girls will be obese by 2020.  These forward projections from existing data are conservative. If the rapid acceleration in childhood obesity in the last decade is taken into account, the predicted prevalence in children for 2020 will be in excess of 50%.

2.         Health consequences

The health consequences of overweight and obesity are wide-ranging and serious, from type 2 diabetes, to the risk of coronary heart disease.  At present, overweight and obesity may be more common in older age groups but the increase in the proportion of overweight and obese children is of major medical concern. The medical complications from overweight and obesity may become evident throughout life but are likely to occur much earlier because of the increasing fatness of children and young people. As well as exacerbating many health problems, increasing degrees of fatness shorten life.  

3.         Implications for health policy

To prevent obesity, the nation has to consume less energy and be more physically active. Most people, especially those prone to overweight, are well aware of these basic principles but, for various reasons, find it difficult to follow them. The challenge, in tipping the balance towards a trimmer and slimmer nation, is to help people overcome the many barriers to a healthier lifestyle.

4.         Target groups

Although everyone needs to watch their weight, the national programme to tackle obesity is likely to be more effective if initiatives are targeted at those individuals, families and communities most prone to overweight, or for whom being overweight poses a higher risk to health. National and local initiatives should therefore target the following three priority groups, with particular attention to individuals, families and communities who may be disadvantaged in terms of age, gender, income, language, culture, ethnicity, ability/disability, or geographical location:

• All children and young people: healthy eating and an active lifestyle should be promoted to prevent the onset of overweight and to develop healthy habits for life.
• Children and young people who are overweight or obese: weight control should be promoted and the risks associated with overweight and obesity reduced. Priority should be given to those for whom obesity would confer extra risk of ill health (eg children with diabetes, or musculoskeletal problems), and to those suffering adverse consequences (eg bullying and low self-esteem).
• Adults with a tendency to become overweight or obese: weight control should be promoted and the risks associated with over weight and obesity reduced. Priority should be given to those at particular risk of obesity (eg through a family predisposition, pregnant women), or for whom obesity would confer extra risk of ill health (eg people with high blood pressure, diabetes, depression, musculoskeletal problems).

WHAT POLICIES ARE AVAILABLE?

In our report ‘Storing up problems: the medical case for a slimmer nation’ (Royal College of Physicians, 2004), the College made the following policy recommendations: 

• A cross-governmental task force should be established at Cabinet level to develop national strategies for tackling the threat from overweight and obesity, and to oversee the implementation of these strategies.
• Government should mount a sustained public education campaign to improve people’s understanding of the benefits of healthy-eating and active living, and to motivate people to eat a healthier diet and adopt a more active lifestyle.
• New standards in nutritional content, food labeling and food marketing and promotion should be agreed jointly by the food industry and the Food Standards Agency.  Incentives to encourage the production, promotion and sale of healthier foods should be introduced. 
• Population-wide initiatives should be implemented at local level to tackle obesity.  Public services should take the lead by promoting healthy eating and increased physical activity in public places and institutions, such as schools and hospitals.
• The prevention and management of overweight and obesity should be included in all NHS policies and clinical care strategies.  Appropriate training programmes for doctors, nurses and other health professionals should be established.

· There should be further funded research to improve understanding of the societal and cultural factors behind the epidemic of overweight and obesity, and the development and implementation of effective prevention and treatments.

WHAT SHOULD UK POLICY BE ON OBESITY?

1.         National level co-ordination

There is evidence from around the world that centrally coordinated, multi-agency, strategic approaches to tackling obesity are more likely to achieve substantial and sustained results. Such approaches are often contained within broader health improvement strategies.

In England, the Government White Paper on health improvement, ‘Saving lives: our healthier nation’ (1999), sets targets for reducing the impact of such major killers as coronary heart disease (CHD), strokes and cancers. Saving lives proposes action at three levels: individual, community and government (national).

RCP Patient and Carer Network Central and local government should take a more active role in making it easier for people to access better community spaces, gyms, exercise activities, local authorities, town and country planners etc, could support small corner shops, rural businesses, to stay open to provide employment, accessibility etc. They could be encouraged by being given incentives to sell fresh fruit and vegetables, healthy foods and snacks, therefore families would be given the opportunity to walk to shops/or cycle instead of using cars, buses etc to shop further from their homes.

Government has also developed diseased-focused plans to prevent and treat major diseases such as CHD, stroke, diabetes and cancer.  For example, there are national service frameworks (NSFs) to tackle cancers, mental health, CHD, diabetes, health problems in older people (including stroke and falls), and children’s health. Each of these will have a major impact on overweight/obesity in various ways, and the CHD NSF specifies reducing obesity as a designated priority with stated objectives and milestones.

And there are specific plans to improve the national diet or increase physical activity and sport such as England’s ‘Game plan’ and its recent physical activity strategy and food and health action plan. The UK-wide Food Standards Agency (FSA) is also doing much to promote healthy eating by encouraging the food industry to improve the nutritional quality of processed and convenience foods, to promote healthier alternatives and to develop simple nutritional labeling

To succeed in tackling the time bomb of obesity the Government needs a cross-governmental, ‘joined-up’, high-level strategy which gathers together all these elements and welds them into a coherent, whole-system approach to the prevention and treatment of overweight and obesity.

2.         Public education and social marketing

In the developed world, there are a number of national public education campaigns that have succeeded in raising awareness of the issues and promoting healthier eating and more active living, the most notable example being Finland’s North Karelia Project.  Multimedia public education approaches have proved effective in reducing weight gain in two large-scale community-based programmes in the USA. 

As part of its strategy, central government should mount a promotional campaign to motivate the public to eat a healthy, balanced diet and adopt a more active lifestyle. The campaign should be directed at everyone, whatever their background, but should particularly aim to engage children, young people, and people who are disadvantaged

or from those ethnic groups at greatest risk from increasing fatness.

People’s choice of food and drink depends greatly on such factors as price and availability, as well as flavour, quality, convenience and nutritional value. The food industry, from farm gate to consumer’s plate, has a key role to play in determining what foods are consumed and in what quantity or balance.

The dominant force in this chain is likely to be the supermarkets, which can strongly influence primary producers as well as consumers. Ideally, consumers should be presented with a wide choice of foods from which they can select a healthy balance for the family table at prices the poorest can afford. Theoretically, the contents of the family shopping trolley should correspond to nationally recommended dietary intakes.

Much work is currently being undertaken in partnership with the food industry to try to shift consumer demand away from high fat, high sugar, high-calorie products, towards healthier alternatives. However, greater effort is needed to achieve a healthier national diet and, in particular, to increase consumption of fresh fruit and vegetables. This should go beyond simply engaging the food industry in initiatives, and should instead aim for joint working towards good practice as part of the food and advertising industries’ corporate social responsibility.

As people become more aware of the health consequences of what they eat and drink, so it becomes increasingly important for them to have useful nutritional information about each food item. This should include guidance on calorie content. However, it is essential that this is given in an easily understandable form, such as simple symbols indicating ‘high’, ‘medium’ and ‘low’ calorie content. As far as possible, this should be in accordance with the latest European Union nutritional labeling proposals.

3.         Promoting ‘active transport’

Any national strategy must contain a strong element promoting ‘active transport’, ie discouraging the unnecessary use of cars, and encouraging walking and cycling. This might involve initiatives regarding town planning, building specifications, road taxation, VAT on bikes, etc. Safety of walkers and cyclists is a key issue. The need for policies, which promote and support active transport has already been recognised by the Government.

4.         Promoting leisure-time physical activity

Much is already being done to promote leisure-time physical activity and sport. All four UK countries have well-funded non-governmental organisations (NGOs) which promote such sport and leisure activities. All four have comprehensive strategies in place, with clearly identified priority target groups. However, there is still much to be done, particularly in terms of joining up with local strategic partnerships for health and well-being. A key gap is the lack of strong and effective links between the leisure and health sectors.

RCP Patient and Carer Network Having shorter journeys to work More time should be allotted in school to health and home Free supplies of fruit for all school-aged children to support the 5 a day campaign. Support for workplaces to provide sporting facilities, reduced entrance costs to sports clubs, teams etc Provide greatly-reduced entrance costs to sports clubs etc. for unwaged members of the public Encourage canteens in schools, colleges, universities, workplaces, all public places to provide healthychoices on their menus. Access to fresh food - out of town supermarkets may deprive the poor and elderly access and generate traffic/transport issues and mean fewer people walking to shops (same for argument for locating pharmacies in supermarkets, restricts choice for those without access) Supporting services in rural areas i.e. sports clubs, aimed at different ages groups, regular bus services providing regular access to these venues in nearby towns to help alleviate social isolation, causing ill health etc. Encourage workplaces to introduce flexible working times-to allow parents to walk their children to school before commencing work. Central government to support and encourage more 'walk to school' initiatives, Safer cycling routes etc.

5.         Promoting healthy schools

There is evidence to support a multifaceted approach to promoting healthy eating and physical activity in the schools setting, including: curricular and non-curricular education; healthy food and drink choices in school meals, tuckshops and vending machines; and sport, active pursuits and active travel to and from school.

For many years, school catering suffered from inadequate budgets and an absence of statutory nutritional standards. In 2001, national nutritional standards were re-introduced and catering budgets were made the responsibility of school governors. Hopefully, these changes will result in healthier choices for all schoolchildren. Inparticular, thereshould always be an attractive choice of fresh fruit on offer in school dining rooms.

In England, the National School Fruit Scheme, offering every child in England aged four to six a free piece of fruit each school day, has been successfully piloted and will be fully operational nationwide from 2004. The Government has also recently launched its ‘Food in schools’ programme, jointly run by the Department of Health and Department for Education and Skills, which will involve over 500 schools in eight pilot projects around the country, looking at a range of initiatives from breakfast clubs and lunchboxes to healthier vending machines, fruit tuckshops, and after-school cookery classes.

Pressure on the school curriculum has been blamed for the gradual erosion of teaching time devoted to sports, active games and physical education. There has also been a trend toward selling off school playing fields in order to help balance hard-pressed education budgets. These issues are being actively addressed and the trends reversed. There is now a minimum standard of two hours of moderate physical activity in school time per week. Very large capital sums, from such sources as the New Opportunities Fund, are being invested in schools’ sport and physical education facilities and equipment, focusing on the more deprived areas of the country.

In England, the National Healthy School Standard aims to encourage schools to develop a ‘whole school’ approach to health and to consider diet and physical activity (along with sex and relationships, drugs and alcohol, tobacco and citizenship) in all aspects of school life. It is part of the Healthy Schools Programme, led jointly by the Department for Education and Skills and the Department of Health. Similar initiatives exist in other UK countries.

However, it is up to the individual school to decide its Healthy School priorities, and in many cases education in sex and relationships, drugs and alcohol takes precedence over attention to diet and physical activity.

One aspect of the whole school approach is to ensure that healthy eating messages are consistent across the classroom, dining room, tuckshop and vending machine. The tuckshop and vending machine, in particular, should not promote sugary or fatty snacks or sugared drinks. School governors should consider banning these items from the tuckshop or vending machine. At the same time, they should ensure the easy availability of plain drinking water. In Scotland, the provision of water and fruit juice in school vending machines is now mandatory and advertisements on the front

of the machines promoting sugar-sweetened drinks and fatty or sugary snacks are banned. It is important that these school-based initiatives are sustained and built upon, involving parents and local communities.

6.         NHS priorities, planning and performance

Recent NHS priorities and planning guidance continues to focus on health services and pays scant attention to tackling obesity or promoting healthy eating and active living. Any references to these aspects tend to be inferred in longer-term targets concerning CHD and cancer, with an emphasis on adults. The urgency of the problem among children and young people is barely acknowledged. It is most important that the prevention and management of overweight and obesity, prioritising children and young people, be given greater prominence in future priority-setting and planning for the NHS and social care.

With regard to adults, an important opportunity now exists with the implementation of the new General Medical Services (GMS) contract. The contract’s Quality and Outcomes Framework is designed to raise organisational and clinical standards in primary care, with an emphasis on teamworking and nurse-led chronic disease management. Within it is a requirement to record accurate data in a standardised electronic format. This should greatly improve risk management of CHD, stroke, hypertension and diabetes, including the risks associated with overweight and obesity. Along with other initiatives such as the Expert Patients Programme and the Electronic Patient Record, this is expected to contribute greatly to an improved service for managing overweight/obesity, and for monitoring the implementation and effectiveness of programmes to prevent and treat obesity.

However, there remains a lack of coordination in terms of workforce planning. As more and more overweight patients are assessed as being at risk of cardiovascular disease or diabetes, so this will put a greater strain on local community dietitians and exercise referral services. It is essential that workforce planners factor these trends into their calculations, and provide for extra community dietitians and physical activity coordinators as necessary.  All NHS trusts should ensure that the management of overweight and obesity is integrated into all relevant clinical programmes.

RCP Patient and Carer Network The NHS Expert Patient’s Programme should be extended to include sessions for children and young people with a more positive attitude to good health and prevention.  This would make a contribution to reducing the number of obese and overweight children and young people.

7.         Prevention programmes at local level

Sustained change can only be brought about by working in a ‘whole system’ way across the various sectors locally. Local strategic partnerships (or local community planning partnerships or equivalent) should be urged to develop local action plans to tackle obesity as a priority within their community strategy to promote well-being in their population. In England, a requirement along these lines is included in the Coronary Heart Disease NSF.  The Faculty of Public Health has also published a toolkit to help local teams develop and implement action plans to tackle obesity.

Action to prevent obesity at local level will require a coordinated approach involving a range of partner organisations, notably: 

• Community services, such as health visiting and community child health services, eg school nursing
• Schools and local education authorities
• Leisure services
• Local authority planning departments and parks departments
• Police and community safety partnerships
• Primary care organisations and general practices
• Hospitals and community health services
• Community groups and voluntary bodies
• Local food retailers and caterers
• Local employers
• Local media.

A practical framework for local programmes could be that offered by the so-called ‘healthy settings’ approach, which focuses interventions in a number of key settings to develop a coordinated programme for obesity prevention. There are many possible settings to develop: from home to hospital, from park to prison, and from community group to club or pub. Each provides a particular opportunity to influence people’s eating, drinking and physical activity habits. A simple range of settings for preventing obesity might include:

• Home and pre-school
• School
• Workplace
• Community group
• Leisure facility
• Retail outlet
• Media
• GP surgery, health centre or clinic
• Wider population.

RCP Patient and Carer Network ‘There exists a large evidence base on major inequalities…The major gap is the inability of agencies and areas to work together for the benefit of individuals and their families.’

 

This page last updated on September 13, 2006