1. Obesity reduction Angela Jones Consultant in Public Health
Cwm Taf Public Health Team 24 April 2013

2. Evolution of obesity... Male Female 1960 (% obese) 1% Obese 2% Obese
Good data on physical activity levels were not collated until 1980s. Howevere trends suggested even in WW1 that physical fitness levesl were not as good in USA and UK as other european countries.
By 2050 the prevalence of obesity is predicted to affect 60% of adult men, 50% of adult women and 25% of children (Foresight 2007).
Male
Female
1960 (% obese)
1% Obese
2% Obese
2010 (% obese)
25% Obese
27% Obese
2050* (% obese)
60% Obese
50% Obese
* Foresight Report, 2007

3. Health risks of obesity
Risk factor for chronic diseases – osteoarthritis, type II diabetes, heart disease
Risk factor for many cancers
Complications of pregnancy
Infertility
Social and psychological consequences – stigma, depression, low self esteem
Economic impact – greater than smoking
Obesity gives rise to two main problems:
Health consequences
The greatest consequences of obesity relate to the health of affected individuals. There is good evidence that obesity is a risk factor for many chronic diseases and is overtaking smoking as a preventable cause of disease and premature death. These include: type II diabetes, high blood pressure, breathlessness, restricted breathing during sleep (sleep apnoea), gall bladder disease, coronary heart disease or heart failure, osteoarthritis of the knees, gout, complications of pregnancy, cancer, impaired fertility, lower back pain, increased risk during anaesthesia and fetal defects arising from maternal obesity (Haslam D et al, 2006).
These are mainly disease of adults, but conditions such as. type II diabetes, coronary heart disease, cancers, osteoarthritis and back pain also affect children. There are also social and psychological consequences of obesity such as stigmatisation, discrimination, prejudice, poor self image, low self confidence and depression (Parliamentary Office of Science and Technology, 2003).
Economic impact
The impact of obesity on the economy is significant. A study in Denmark (van Ball et al, 2008) estimated that obesity associated healthcare costs for people aged 20 to 56 years were higher than comparable costs for smokers or for healthy individuals This suggests potential for reduced health care costs for these age groups if obesity prevalence is reduced. However the study also noted that the greatest lifetime expenditure was for healthy individuals due to longer life expectancy and consequent development of other conditions in later life.

4. Maternal obesity Risks for mother Risks for foetus/child
Maternal death or severe morbidity
Cardiac disease
Miscarriage
Pre-eclampsia
Gestational diabetes
Thromboembolism
Increased Caesareans
Anaesthetic challenges
Infection from other causes/sites
Post partum heamorrhage
Stillbirth
Neonatal death
Congenital anomalies
Prematurity
Macrosomia (high birth weight 4000g+)
Lower breastfeeding rates
Increased risk of obesity and metabolic disorders in childhood
More likely to need neonatal intensive care (3.5 fold increase)

5. Body weight Balance Bodyweight Energy Intake = Diet Energy Expenditure
= Physical activity
Bodyweight

6. Risks of inactivity
Coronary Heart Disease (20-35%)
Diabetes (30-40%)
Musculoskeletal problems (30%)
Mental illness (20-30% depression, dementia, distress)
Cancer (20% breast, 30% colon)
Infection
Costs:
£5.5 billion in sickness absence
£1 billion premature death of working age
£1.6 billion to NHS in UK

7. Causes of Obesity Biology Adapted from Foresight systems map, 2007
Activity: environment and physical
Food environment and consumption
Societal influences and individual psychology
On a simple level obesity develops as a result of intake of more energy in the form of food and drink than the body uses. The Foresight Programme – Tackling Obesity: Future Choices is a research programme of the UK Government Office for Science. The Foresight Programme was asked to consider how society might deliver a sustainable response to obesity over the next 40 years. Foresight (2007) has produced a map of the obesity system, identifying a multitude of influences on the energy balance:
Biology e.g. genetic factors, appetite control mechanisms
Impact of early life and growth patterns e.g. mother’s diet while pregnant, breastfeeding, weaning practices and early dietary habits
Behaviour, in particular:
Eating - motivation and health related behaviour is complex e.g. the conflict between what people want e.g. fatty, sweet foods and the desire to eat healthily and be slim
Physical activity - this is influenced by social and cultural factors. Physical activity has declined with less manual jobs, increased car ownership and labour saving devices and sedentary behaviours such as television viewing. Other behaviours such as parental fears about unsupervised play and travel to school may also play a role.
Wider cultural and social context e.g. organisational cultures, social processes and the media influence individual behaviours. There is evidence that lower educational attainment and socio-economic status and mental illness are associated with obesity and that the obese face considerable discrimination.
Additional psychological factors e.g. habits, beliefs, translating intention into action, moral climate.
The living environment, that is those environmental factors that impact on energy intake and expenditure. These include:
Technologies, particularly advances that engineer out physical activities e.g. computer games, online shopping, home appliances.
Opportunities for physical activities – this is influenced by how we perceive our environment in terms of commuting distances, safety, availability and access, convenience, local knowledge and satisfaction, urban form, aesthetics and supportiveness of environments.
Food and drink access and availability e.g. supermarkets, takeaways, restaurants.
Economic drivers include:
Price of food and drink as a proportion of household expenditure, this has generally dropped in the UK to an average of 10%, but can be as high as 23% for lower-income households.
Food marketing, including, pricing, branding, positioning e.g. for impulse buying at checkouts, presentation, advertising, sponsorship, accessibility and market segmentation.
Purchasing capacity and the impact on eating habits. As income increases people tend to eat out more frequently.
Working practices appear to play a role with evidence of greater obesity in those who work longer hours.
Adapted from Foresight systems map, 2007

8. Increasing physical activity
Areas of Influence
Schools
Increasing physical activity – especially girls
Curriculum – nutrition and cooking skills
Health Schools Scheme
Communities
Programmes and strategies
Planning – S.106
Share successful initiatives
Role of leaders/role models
The group discussed some of the current limitations and areas of influence, along with the close link to nutrition, as follows
Increasing habitual physical activity
Areas of Influence
Collaboration to influence physical activity levels in school and attainment. This is linked to the work of Sport Wales. Opportunities to influence strategically through town planning processes and partnerships; and operationally with the curriculum and Healthy Schools Scheme.
Influencing the curriculum to improve, nutrition and cooking skills teaching in schools & development of School Nutrition Action Groups (SNAGS)Links to Appetite4life and extracurricular activities around food
Focus on maximising opportunities for physical activity by influencing existing programmes/strategies:
Flying Start
Families First
Parenting Programmes
Healthy Schools Schemes
Planning (Section 106 agreements)
Consider in the context of the cost of obesity as a lever for action, e.g.
Question role of paramedics in collecting data – issues associated with emergency transport of obese patients
Cost of bariatric appliances
Healthcare
Fire services
Learn from successful physical activity initiatives e.g. Public Health Wales Good Practice Schemes, mountain bike trails – Margam, Coed-y-Brenin
Role of health care professionals in promoting physical activity and nutrition and other professionals (teachers), including referral to National Exercise Referral Schemes (NERS).
Role of leaders in society in promoting healthy lifestyle through example e.g. prominent politicians.
Explore opportunities for targeting nutrition education with
Sport Wales
Welsh Rugby Union
Football Association Wales
Limitations
Current data does not differentiate between sedentary, moderate and intensive activity. Also it groups into children or adults. It would be helpful to obtain objective data on types of physical activity in Wales and greater stratification by age bands.
Low physical activity levels in young females – how do we increase levels? What evidence is there to focus action?
Look for evidence for Work Boost Wales

9. Food and the Environment
Strategic action plan for nutrition in Wales
Exploit “Grow your own”
Healthy Options Award – Local Authority leadership
Fast foods near schools
EHO role in promoting healthy choices
Research around food labelling changes
Franchising contracts for public events
Healthy Cities – Swansea + Cardiff
Planning legislation
Food and the Environment
The group considered a number of areas where joint work could promote an improved food environment. They included:
Strategic action plan for nutrition in Wales
Exploiting opportunities to “Grow your own”
Allotments
Garden sharing
Audit of green spaces (Countryside Commission for Wales)
Encouraging use of land of registered social landlords and other publicly owned land
Link to corporate health standard via link to community
Look at impact of healthy options awards and opportunities to expand it. Local Authorities and Health Boards could sign all their catering facilities up to it and lead by example.
Influence planning legislation regarding the density of fast food premises and access to fresh fruit and vegetables. Incentives for fruit and vegetable shops on High Street. Also consider the provision of fast food outlets (permanent and mobile) in the vicinity of schools and colleges.
More people die from obesity that from food poisoning
Environmental Health Officers and Trading Standards Officers to promote healthy choices during visits for food premises. This could be linked to the healthy options awards and there may be a need for training support.
Approach large companies – has food labelling changed behaviour (having regard to inconsistency of approach my large retailers)? Opportunity for research.
Influencing specifications for franchising contracts to improve food provision at public events
Shared learning opportunities with Healthy Cities
Cardiff
Swansea
Farm to fork approach
Utilise experience from developing local food charters e.g. Cardiff and Vale

10. Mapping food outlets Map food outlets throughout Wales
Food premises need to be registered
Take away
Fruit and vegetables
Healthy options
Mapping could be explored for correlation with
Deprivation
Obesity
Proximity and density near schools.
Mapping food outlets and deprivation
Map food outlets throughout Wales – (Local Authorities and Public Health Observatory). All food premises need to be registered and registration includes details of takeway food and availability of fresh fruit and vegetables. Mapping could be explored for correlation to deprivation and obesity, for example, and also the proximity and density near schools.
Take away
Fruit and vegetables
Healthy options

11. Active Transport Model of healthy school e.g. Pontypridd High School
Maximise opportunities for active travel through the use of Section 106 agreements with Local Planning Authorities
Increase level of active transportation and links to public transport e.g. safe bike parks at train and bus stations.
Increase road safety awareness
Targeted approach to those in greatest need
Role of workplaces: promotion, shower facilities
Active Transport
The group discussed the following areas that could be further researched and where there were opportunities for sharing good practice across Wales.
Evidence suggests that 12% of people cycle but it needs to be increased to 30% to have safety benefits.
Model of healthy school e.g. Pontypridd High School
Cycle lane to school
Supervised walk/cycle to school routes
Recycle bikes
Bike maintenance training opportunities
Safe cycling training
Target to increase active transport to school by 20% this school year.
Maximise opportunities for active travel through the use of Section 106 agreements with Local Planning Authorities
Need to increase level of active transportation and links to public transport e.g. safe bike parks at train and bus stations. Currently no requirement for new developments to have cycle parks/stores
Increase road safety awareness
Targeted approach to those in greatest need
Involve other partners e.g. Sustran, Planet Health Cymru
Needs to be considered in the context of shower facilities in work places to encourage use.

12. Role of Local Authority Planning
Opportunities to influence – policies & guidance
Health Impact Training for planners, members
Health improvement through the use of S.106
Gloucestershire Active Planning Toolkit
Include in regeneration schemes.
Link in health with Highways Authorities – transport survey
Targeting schemes in areas of greatest deprivation and around schools
Domestic dwelling design
National Guidance on protecting “Green Space”
Tension between people/environment.
Tension between economic recovery/burden legislation.
Role of Local Authority Planning
The Group discussed the areas of opportunity to maximise impact:
Planning not currently focussing on health as there is no requirement to do so. However there were opportunities to incorporate it into
Guidance
Technical Advice Notes
Local Development Plans
Health Impact Training for key people such as planners and elected members or those that have an influencing role.
Maximise the opportunities for health improvement through the use of Section 106 agreements.
Make active transportation more attractive e.g. use the Gloucestershire Active Planning Toolkit – could be adapted to all Wales use.
Include in regeneration schemes. Aberystwyth example of regeneration areas, with designated areas that have to take account of health – showing benefits and not just harm.
Needs to link in health with Highways Authorities and Planning Authorities (Ref: ‘Crossing Bridges’ HiaP Case study report Public Health Wales did on Transport & Health).
Targeting schemes in areas of greatest deprivation and around schools. There have been successful court cases in England that have restricted fast food outlets in the vicinity of schools.
Link to the National Transport Survey of mapping how people in Wales get to work, school and shops.
Greater emphasis required on health – legislation. Opportunity with new Planning legislation on the horizon and Public Health Bill
Domestic dwelling design Stats – should include sufficient room for food storage/preparation and dining as well as bike parks/storage.
National Guidance on protecting “Green Space” around developments/existing housing
A tension was recognised between people and the environment e.g. unlit paths/cycle routes deter use but are considered beneficial to bats.
Also a tension recognised between economic recovery and the burden of new legislation.

13. Legislation
Welsh Government support would be needed to enable local authorities to implement change
Look at policy and legislation in other countries that has impacted on lifestyle changes
Significant opportunities to legislate with the Public Health Bill and the New Planning legislation.
Legislation
The group considered there would be merit in collaborative work to maximise the influence in the following areas.
Welsh Government support would be needed to enable local authorities to implement change
Look at policy and legislation in other countries that has impacted on lifestyle changes
Significant opportunities to legislate with the Public Health Bill and the New Planning legislation.

14. Workshop Map food outlets Correlation Take away Fruit and vegetables
Healthy options
Correlation
Deprivation
Obesity
Proximity/density near schools.

15. Workshop Will Local Authority databases hold the data?
What data on obesity could be used?
At what geographical level could it be used?
How could the data be used in LAs to promote change?
What would be needed from others to support this?
Health Boards
Public Health
Welsh Government