Healthy Weight Strategy for Portsmouth
2014– 2024
Contents
1. Forward by Councillor Jonas
2. Introduction
3. Strategic overview
4. Context
5. Strategic fit
6. Portsmouth’s vision and city’s priorities in action
7. Care pathway
8. Building change and moving forward
9. References
10. Appendix 1 - Foresight Map
11. Appendix 2 - Detailed costings
12. Appendix 3 - Healthy Weight Care Pathway
2
Page
3
4
5-6
6 - 13
13-14
14-17
17
19 - 19
20 - 21
22
23 - 24
25
Forward from Councillor Jonas
Obesity has been described as an epidemic affecting our population as a whole and
a larger percentage of Portsmouth residents both adults and children sit outside the
healthy weight category. The increasing challenges associated with obesity for the
individual, their family, our communities, society and economy are ever increasing.
Therefore we are committed to working together to achieve our vision:
“Portsmouth becomes a healthy city that empowers and supports individuals,
families and communities to achieve and maintain a healthy weight”.
Maintaining a healthy weight is challenging in today’s society due to the vast range
of factors which influence the food we consume and the activity we do both in our
working live and in our free time. Our weight is not solely influenced by the personal
choices we make (although they are key) but the environments in which we live,
work and socialise can also impact on the individual’s ability to achieve and maintain
a healthy weight. Therefore two key stands in helping our residents achieve and
maintain a healthy weight are around educating and supporting individuals, families
and communities to make healthy informed choices and also working with partners
from all sectors to address the wider determinants of health that can impact e.g.
poverty, housing, transport routes, regeneration, planning.
There is no simple solution to tackling excess weight, but residents, communities,
statutory, business and voluntary sectors all have a role to play, Utilising their
knowledge, skills and influence and working together is the only way we are going to
successful ensure we met our vision. By taking a holistic approach we can build on
good practice that already exists, whilst developing new and creative approaches
and/or interventions that can positively impact on the weight of our residents.
There’s not one simple, quick fix solution to the challenge of healthy weight but this
strategy is a start. It sets out what we are trying to achieve and the direction of travel
over the next 10 years. We all, as residents of Portsmouth have a role to play in
supporting this strategy and helping wherever we can to contribute towards
achieving the vision, after all the health and quality of life of our residents is at the
heart of what we are trying to achieve.
3
2. Introduction
Health is affected by a complex range of factors including weight. Due to the scale
of the problem and its subsequent negative consequences, the focus in recent years
has been on obesity. However, it is important to remember the healthy weight
agenda also encompasses individuals who are underweight, those who are
overweight and those trying to maintain a healthy weight. Therefore, in its widest
sense, healthy weight affects each and every resident of our city.
Portsmouth, like the rest of England, has significant numbers of people overweight or
obese. The adverse health consequences of being overweight include diabetes,
heart disease, cancer as well as adverse impacts on self-esteem and mental
wellbeing1. This affects individuals, their families and local communities as well as
being a significant financial cost to society.
Weight is affected by a number of factors such as nutrition, physically activity and
mental wellbeing. These are not only influenced by individual choices and
behaviours but also by the socio-environmental conditions in which people live, work
and play.
Portsmouth is part of the UK Healthy Cities Network, which supports cities to tackle
health inequalities and place health improvement and health equity at the heart of all
policies. Two of the key themes in the current Healthy Cities programme are:
investing in health through a life course approach and empowering people, and
creating resilient communities and supportive environments.
These themes
underpin this healthy weight strategy.
Prevention means:
Stopping overweight/underweight occurring in the first place (primary prevention)
Diverting those with excess weight from moving upwards within the weight categories (secondary
prevention
Empowering individuals preventing unhealthy weight gain/weight loss and
intervening early to adopt positive lifestyle behaviours is the focus for healthy weight,
with families and communities fundamental at every stage. The utilisation of
community assets including community members themselves, facilities, networks
etc. and maximising pooled resources from the various multi-agency partners is
crucial in helping shape the future infrastructure; support and interventions. As a city
we can work together so that being a healthy weight the norm
1
DH, 2013
4
3. Strategic overview
3.1 Our vision:
Portsmouth becomes a healthy city that empowers and supports individuals,
families and communities to achieve and maintain a healthy weight
3.2 Aim:
To increase the proportion of Portsmouth's children and adults who are a
healthy weight
3.3 Strategic objectives:

Make healthy weight a priority for all: Ensure all partners at all levels view
healthy weight as a priority and are actively engaged in supporting and
contributing to increasing our healthy weight population

Tackle the obesogenic environment: Create environments that enable and
support residents to make healthy food and physical activity choices

Invest in prevention: Ensure healthy food and physical activity are the
easiest and preferred option for individuals, families and communities

Capitalise on early intervention and treatment: Support those outside the
healthy weight category to become and maintain a healthy weight through a
range of evidence-based interventions

Utilise the wider workforce: Ensure professionals across disciplines are
competent and confident in initiating conversations and discussing weight
within their role/setting
3.4 Outcomes for Portsmouth:
Portsmouth City Council (PCC) and other key stakeholders (notably the National
Health Service (NHS) and Clinical Commissioning Group [CCG] are responsible for
achieving the health outcomes set out in the Public Health Outcomes Framework.
Healthy Weight Outcomes
Direct measures
Excess weight in 4-5 and
10-11 year olds
Excess weight in adults
Influencing Factors
Diet
Proportion of physically
active/inactive adults
Utilisation of green
spaces for
exercise/health
Breastfeeding
Healthy weight links to other PH outcomes e.g.
Life expectancy (mortality), morbidity, tooth decay, cancer, diabetes, sickness
absence, low birth weight babies, self-reported well-being, dementia,
preventable sight loss etc.
5
The outcomes are categorised under four domains: improving the wider
determinants of health, health improvement, health protection and health care public
health and preventing premature mortality. As illustrated in the diagram these
include direct links to healthy weight, plus indirect links to nutrition and physical
activity and their impact on wider health and well-being.
3.5 Guiding principles
The underpinning action plan for delivering the strategic objectives will be based on
these guiding principles.

Make healthy weight the norm at a population level , through maximising return on
investment and creating cultural change by pooling of resources; using creative
and innovative approaches and utilising community assets

Using population insight and evidence based approaches in the decision making
process, embedding good practice and where necessary create emerging
evidence through robust evaluation of practice

A holistic approach, working in partnership to reduce insular working and joining
agendas, maximising outcomes, underpinned by long-term sustainability

Strong leadership and shared responsibility with effective communication at all
levels

Active community participation in making decisions that impact on the
environment, opportunities, support and services relating to individual and their
communities
4. Context
4.1.
What do we mean by healthy weight?
'Healthy weight' is the term used to describe an individual whose height and weight
is proportional and falls within defined parameters where the risk of ill-health (due to
weight) is at its lowest. Those individuals above (overweight or obese) or below
(underweight) a healthy weight are at increased risk of adverse effects on their
health and wellbeing during childhood, adulthood and later life.
4.2.
Factors affecting weight
In simple terms the balance between the food we consume (calories) and energy we
use through our metabolism and physical activity (metabolic equivalent) is known as
the ‘energy balance’. An imbalance in this equation can cause weight gain or weight
loss and if balanced, weight maintenance.
6
Under-nutrition and obesity existing side-by-side within the same country, community
and household is not uncommon1, thus highlighting how extreme the challenges
surrounding healthy weight can be within families, communities and society.
Maintaining a healthy weight in isolation is not enough for overall health and
wellbeing. A varied diet is essential for people to get all the nutrients their bodies
need to function effectively, combined with being physically active in order to
maintain good overall health. Food consumed and physical activity is both affected
by, and influences, our mental wellbeing and it's the complexity of the interlinking
lifestyle behaviours that make tackling weight such a challenge. However, it’s not
just lifestyle behaviours that are influential: the physical, policy and political
environments also affect lifestyle choices, as does social and economic development
e.g. urban planning, education, marketing, food processing, and increasingly these
influences are promoting unhealthy weight gain2. There is no single influence but
rather multifaceted systems of determinants3 which impact on an individual’s ability
to achieve and maintain a healthy weight (this is illustrated in Appendix 1).
Inequalities in conditions in which people are born, grow, live, work and age mean
many people in England are dying prematurely. There are strong links between
obesity and both deprivation and ethnicity (particular Black Minority Ethnic [BME]
groups) and this can increase health and social care inequalities and result in
adverse social impacts e.g. discrimination, social exclusion and reduced earnings 4.
Reducing inequalities is a matter of fairness and social justice5.
4.3.
Classification of healthy weight
The most commonly used measure and classification of weight status is Body
Mass Index (BMI) calculated by dividing body mass in kilograms by height in
meters squared.
In isolation BMI may not be the best measurement for adults as some variables are
not accounted for e.g. ethnicity or muscle mass in, for instance, athletes. However, it
is simple to calculate and gives a quick indication of weight status, making it the
most frequent and accepted form of weight classification. Measuring children’s
weight is more complex because they are growing and growth patterns for boys and
girls are different, meaning BMI is subject to variations by age, height, and gender6.
Unlike adults (where fixed thresholds are used to calculate weight status) scaled
reference charts (based on centiles) are used with children.
2
WHO, 2013
Foresight, 2007
4
PHE, 2013a (cited)
5
Marmot, 2010
6
NICE, 2006
3
7
Children’s
classification
Description
Adult’s
classification
BMI
(kg/m2)
categories
Underweight
2nd centile for population monitoring
and clinical assessment
2nd centile – 84.9th centile
85th centile for population monitoring
91st centile for clinical assessment
95th centile for population monitoring
98th centile for clinical assessment
Underweight
Less than 18.5
Healthy weight
Overweight
18.5 – 24.99
25 – 29.99
Obese I
30 – 34.99
Obese II
Obese III (morbidly)
35 – 39.99
40 or above
Healthy weight
Overweight
Obese
Source: WHO, 2004
4.4
The scale of the challenge
As a nation each generation is becoming heavier (passive obesity), with weight
creeping up without us consciously realising it so that obesity is now a global
epidemic3. Reducing obesity is a national aim7 and a local priority. However there
needs to be a shift in focus to healthy weight in its widest sense and not solely
obesity treatment, which is a symptom of the underlying factors that need addressing
i.e. poor nutrition and physical inactivity.
4.4.1 Overweight/obesity
England is one of the most obese countries in the world with one quarter of adults
obese and another third classed as overweight8. There is a strong correlation
between childhood and adult obesity, with obesity prevalence increasing with age.
The height and weight of all children in Reception year and in Year 6 or primary
school is measured each year (National Child Measurement Programme [NCMP]).
The table below highlights the most recent NCMP data around weight status of
children in Portsmouth.
Year R
Under
weight
Healthy Over
weight weight
Obese Comments
Portsmouth
Southampton
(stat. neighbour)
England
0.59
75.48
14.42
9.51
1.15
76.66
12.66
9.54
0.88
76.89
12.96
9.27
Year 6
Under
weight
Healthy Over
weight weight
Obese
Portsmouth
Southampton
(stat. neighbour)
England
1.13
63.59
14.42
20.86
1.96
64.83
13.87
20.33
65.35
1.33
Source: NCMP 2012/13 data set
14.40
18.92
7
DH, 2011
LGA, 2013
9
HSCIC, 2013
8
8
Portsmouth child residents at local
authority schools have the lowest
rates of healthy weight in both Year R
and Year 6 and have the highest
levels of overweight and obesity in
both Year R and Year 6.
23.9%
of
Portsmouth
resident
children were overweight/obese on
joining primary school compared to
22.2% nationally, and this increased
to 35.28% on leaving primary school
9
compared to 33.3% nationally .
The charts show children attending local authority schools in Portsmouth are heavier
than children in our comparator city (Southampton), regionally and nationally and this
has been consistently the case since the NCMP data set was first collected in 2006.
Percentage of Year R (Reception) residents overweight or obese
Portsmouth City UA and comparators, 2010/11 to 2012/13
England
GOSE
Portsmouth City UA
Southampton City UA
40
% of Yr 6 pupils
30
20
10
0
2010/11
2011/12
2012/13
Source: National Child Measurement Programme, Health and Social Care Information Centre. © Crown Copyright
Percentage of Year 6 resident pupils overweight or obese
Portsmouth City UA and comparators, 2010/11 to 2012/13
England
GOSE
Portsmouth City UA
Southampton City UA
40
% of Yr 6 pupils
30
20
10
0
2010/11
2011/12
2012/13
Source: National Child Measurement Programme, Health and Social Care Information Centre. © Crown Copyright
In Portsmouth, boys are more likely to be overweight/obese than girls, the latest data
by gender shows that between 2010/11 and 2011/12, the proportion of Portsmouth
girls at reception and Year 6 being overweight/obese decreased and for boys the
proportion increased10.
10
Portsmouth JSNA, 2014
9
Teenage girls in Portsmouth are less happy with how they look and considerably
more anxious about their appearance than the national average11.
Nationally it’s estimated that 64% of the adult population (16+) is above normal
weight (36.9% overweight; 24.8% obese and 2.5% morbidly obese), with a further
1.8% underweight, meaning only 36.5% of the population falls within the healthy
weight range12.
An estimated 97,868 residents out of a total over 16 years
population of 168,923 in Portsmouth are above normal weight, as highlighted in the
table below.
2012
% by weight
category
Underweight
Healthy weight
Overweight
Obese
2.5
39.6
32.9
25.1
Estimated Portsmouth
residents aged over 16 years,
by weight category
4,127
66,896
55,547
42,322
Source: Prevalence from Active People's Survey via National Obesity Observatory, Public
Health England applied to 2012-based Subnational Population Projections (ONS)
Between two to 10 years of life are lost to obesity depending on severity 13 about
45,650 of Portsmouth’s adult population will have reduced life expectancy due to
excess weight.
The most significant predictor of childhood obesity is parental obesity and despite
the multitude of factors impacting on it, breaking the pattern of lifestyle behaviours
that reinforce weight gain is crucial4 as once established, it is notoriously difficult to
treat. The focus needs to be on prevention and early intervention14 within families if
a reversal of the rising tide of obesity is to be achieved.
In Portsmouth, the prevalence of childhood obesity is higher in the most deprived
areas compared to the least deprived areas, which follows the links between
childhood obesity and deprivation often seen nationally15. A similar association
between deprivation and adult obesity is apparent, with the most deprived ward
having the highest levels of obesity and the wards with lower deprivation having
lower rates of obesity2. We need to create a culture where healthy eating and
physical activity become the norm, through developing supportive environments,
ensuring healthy options are easy and readily affordable, accessible and the right
support, at the right time is available to help individuals achieve a healthy weight.
4.4.2 Healthy eating/nutrition
Healthy eating is associated with decreased risk of overweight/obesity and chronic
diseases, including type 2 diabetes, hypertension, and certain cancers. However,
11
Children's Society, 2014
HSCIC, 2012a
13
NOO, 2010
14
PHE, 2013b
15
PHE, 2014
12
10
there is a large gap between nutrition recommendations and what we actually eat
e.g. the Health Survey for England reports that less than one third of adults currently
meet the ‘five a day’ target for fruit and vegetables12.
Early life interventions such as appropriate maternal nutrition, breastfeeding and
healthy introduction of solid foods for babies have all been linked to reduced obesity
later in life4. In Portsmouth our rates of breastfeeding babies at six to eight weeks
are lower than the England and regional averages and slightly lower than
Southampton our statistical neighbour as the chart below illustrates.
4.4.3 Physical activity
Nationally it is estimated that seven out of 10 men and eight out of 10 women are not
taking the amount of physical activity appropriate for their age group 16 and in
Portsmouth only three out of 10 adults are active for 30mins at least once a week.
The national recommendation for adults is to take physical activity for 150minutes
each week, so we can assume that only a small percentage of residents are
achieving that.
Adults
Portsmouth
Southampton
(stat. neighbour)
England
% participating in at least 30mins sport
(moderate intensity) at least once a week
30.61
41.51
35.18
Source: Active people survey, 2012
16
HSCIC, 2012b
11
As the chart above illustrates physical activity levels of adults in Portsmouth are
currently lower than the national average and Southampton (statistical neighbour)
with drop-off in participation seen over the past three consecutive years.
Physical activity levels are not routinely collected and reported for children and
statistics on childhood activity within Portsmouth are not available. However,
national data shows boys are more active than girls, with children of active parents
more likely to be active (particularly boys) and participation rates decline as age
increases and some evidence exists that independent of physical activity levels high
rates of sedentary behaviour is linked to obesity17.
4.5 The costs of excess weight and inactivity
The impact of excess weight to individuals, families and wider society (employers,
NHS etc.) is significant. Most evidence about the impact of weight relates to obesity
as awareness has increased about its increasing scale, severity and adverse impact,
but being physically inactive also contributes to cost. Some of the headline costs are
listed in the table below but more detail can be found in appendix 2.
Reduced life expectancy:
Moderate obesity (BMI 30-35) reduces life
expectancy by 2-4 years, while morbid obesity
(BMI 40-50) reduces life expectancy by 8-10
years, equivalent to the effects of lifelong
smoking13.
Increased risk of associated health problems:
These include: cardiovascular diseases, diabetes,
17
NOO, 2012
12
Increased morbidity:
Overall 29% of men and 36% of women
classed as obese have a life-limiting
illness, double the rates in the healthyweight population10.
Long-term conditions:
More than 15 million people in England
musculoskeletal disorders and some cancers5
have a long-term condition and a number
are associated with obesity and longSometimes the increased risk is stark e.g. an term conditions account for 70% of
obese woman is 13 times more likely to the total social care budget18.
develop type 2 diabetes than a healthy weight
woman10
Inequalities:
Poor mental well-being:
People with disabilities are more likely to be obese Severely obese children and young
and less physical active than the general people rated their quality of life as low
population, with both underweight and obesity a as children and young people having
particular issue for people with learning chemotherapy for cancer7.
disabilities19.
Economy:
Economy:
Treating obesity alone is estimated to cost the Inactivity costs are estimated at
NHS £5bn per year and the wider economy £8.2bn per year, and in addition, the
approx. £20bn per year e.g. lost productivity contribution of inactivity to obesity is
and sick days. By 2050 this is forecast to rise to estimated to cost a further £2.5bn
£10bn per year NHS costs and £49.9bn per year annually20.
(at 2007 prices) wider societal and business
costs4. It’s estimated that 18million sick days per
year can be attributed to obesity10.
Table 1. Some consequences/impact of excess weight
5
Strategic fit
5.1 Responsibility for health weight
The city council is responsible for achieving the outcomes set out in the Public
Health Outcomes Framework. Factors associated with healthy weight are covered
under a number of outcomes within the framework. However, like many health and
wellbeing issues, a collaborative approach between key stakeholders (NHS
Portsmouth Clinical Commissioning Group, NHS providers, the voluntary and
community sector and private sector is essential to ensure we successfully achieve
the city’s healthy weight vision.
5.2 Governance
The Health and Wellbeing Board has responsibility for overseeing the health of
Portsmouth residents and ultimately the healthy weight strategy21. However the
operational implementation will be overseen by the strategic steering group. The
strategy also contributes to other multi-agency boards and their objectives e.g.
Children’s Trust, Pre-birth to 5, 6-13 and 14-19 boards. It is vital the relationships
between local agendas are exploited to achieve maximum benefit for all partners
against the range of outcomes, achieving best value for money and providing a
holistic approach across the life course. This will ensure residents receive the
18
PHE, 2013c
PHE, 2013d
20
PHE, 2013e
21
NICE, 2012
19
13
highest quality services and have the necessary resilience and support to achieve
positive health outcomes.
5.3 Policy context
Healthy weight, including obesity and physical activity is a priority area for National
Institute of Clinical Excellence (NICE), Department of Health (DH), and now Public
Health England (PHE). For over a decade many policy and guidance documents
have both directly and indirectly linked to healthy weight.
The main policies
nationally, regionally and locally affecting healthy weight are not only topic specific
(obesity etc.) but also include those around the built environment (planning,
regeneration, transport, housing etc.), society (health inequalities, communities etc.),
physical activity (active travel, green spaces) and food industry (planning, production
etc.). Other strategies could potentially indirectly impact on healthy weight e.g. antipoverty, parenting, and the workforce.
Fundamentally there is a need for achieving a balance between agendas, as often
they are competing. However, due to the colossal impact of poor health not only for
the individual but wider society, health considerations (including healthy weight)
needs to be a focal point of all policy development and participatory decision making
within Portsmouth’s strategic operating boards. Health Impact Assessments are a
tool that should be adopted to ensure this routinely happens, plus Portsmouth’s Joint
Strategic Needs Assessment (JSNA), which provides intelligence around health and
well-being when making decisions and developing local strategies/policies and
guidance documents. Strong leadership overseeing the decision making and
implementation of strategic plans, collaborative working between partner agencies
and healthy, engaged communities are all necessary, and when combined will help
Portsmouth prosper and become a great waterfront city.
6
Portsmouth's vision and the city's priorities in action
"Portsmouth becomes a healthy city that empowers and supports individuals,
families and communities to achieve and maintain a healthy weight"
6.1 Target population groups
The focus in Portsmouth is to tackle cultural norms and shift the momentum towards
healthy weight. The challenge is balancing the need to invest in the entire
population versus those most in need. Socioeconomic inequalities have led to wider
inequalities in both child and adult obesity, with rates increasing fastest among those
from poorer backgrounds22. Achieving a cultural shift requires universal action;
however with higher prevalence of adult obesity within the most deprived wards of
Portsmouth and this being a significant indicator of childhood obesity, these areas of
the city will require additional support.
22
PHE, 2013 (cited)
14
Eating and physical activity habits are perpetuated through families and cultures, and
are often established in childhood and maintained into adulthood. There is also the
need to shift focus onto prevention and early intervention as once ingrained obesity
is difficult to treat. Therefore establishing positive behaviours in early childhood will
help create and instill positive lifestyle choices for future generations. Families with
children are a key target group, particularly those on low incomes and where one or
more parent is overweight.
There is the need for comprehensive universal action at all levels including
individual, families, communities and wider environment, plus using intelligence to
target those at higher risk or already burdened with obesity and ensure they receive
the most appropriate support (universal, targeted, specialist - see definitions below)
to meet their needs. However to break the pattern of ‘passive obesity’ (each
generation getting bigger) and ensure Portsmouth as a healthy city has a healthy
weight population as the norm, the focus is firmly on prevention and early
intervention.
Universal: Whole population prevention activities/initiatives (Tier 1)
Creating environments that promote and encourage healthy weight e.g. built
environment, green spaces, access to healthy food etc. plus interventions that are
available to all e.g. healthy child programme, workplace health, healthy schools,
children centre programmes, general health advice, healthy walks etc.
Targeted: Community based lifestyle interventions (Tier 2)
Interventions or services that support individuals/families with weight issues e.g. 1-21 or group based weight management programmes etc.
Specialist: Specific services/programmes for high need clients (Tiers 3/4)
Specific services/programmes for clients with complex medical needs around weight,
e.g. specialist clinicians, bariatric surgery etc.
6.2 Strategic objectives in practice
6.2.1 Make healthy weight a priority for all:
Ensuring health including all aspects of healthy weight (nutrition, physical activity,
mental well-being, obesity etc.) is a strategic priority for the city. Embedding the
guidance principles (section 3.5) as a way of working, is fundamental to ensuring
everyone at all levels, from individual and local communities to private, voluntary and
public sector organisations play their part in helping Portsmouth become a healthy
city to live, work and visit.
6.2.2 Tackle the obesogenic environment:
The modern environment has been labeled ‘obesogenic’ or ‘obesity-causing’, making
it difficult for people to maintain a healthy weight e.g. energy dense food and drink
15
are increasingly available and accessible; sedentary leisure activities and travel by
car are now the societal norm14. It is vital that we make our environments more
conducive to supporting activity (e.g. leisure time opportunities, active travel) and
healthy food options are more affordable, accessible within communities, schools,
workplaces etc. Ultimately our infrastructure, facilities and policies need to work
together, with health considerations as part of joined-up decision making.
6.2.3 Invest in prevention:
Use the best available evidence or create local emerging evidence (if necessary) to
inform decision making around enabling and empowering individuals and
communities to make healthy informed choices. This includes easy access to
universal services and key healthy weight messages. These opportunities could
involve:

Providing training/workshops for wider public health professionals so they can
Make Every Contact Count (MECC), community sessions delivering general
messages on healthy eating, breastfeeding, exercise, food and mood etc.

Self-help advice and guidance via websites and resources

Utilising community assets e.g. schools, workplaces, children centres, cafés,
breastfeeding friendly venues, community centres

Involve partners from both the public, private and voluntary sectors to ensure
their practices are supportive of healthy weight, whether that be in relation to
food or physical activity
The key is the versatility and range of provision necessary within the prevention
agenda to ensure needs of the whole population are met and residents have the
knowledge, skills, confidence and motivation to make informed, healthy choices.
6.2.4 Capitalise on early intervention and treatment:
Using the best available evidence and most up-to-date guidelines on weight
management to design a range of services/programmes around behaviour change
and goal setting for those wanting to lose weight, with specific support from
professionals based on the level of need, age of client and complexity of obesity and
associated health problems, to maximise achievable outcomes.
6.2.5 Utilise the wider workforce:
A competent and confident workforce who can raise and discuss the issue of weight
with residents of all ages is vital if healthy weight is to become the norm. Historically
weight has been a taboo subject, due to the sensitivity around it, but all professionals
working with children/adults have a duty of care to ensure their needs are being met
including health needs and healthy weight. Making Every Contact Counts (MECC)
aims to engage individuals in discussions about their health and wellbeing at
appropriate opportunistic times.
16
Professionals across several disciplines i.e. wider workforce including: teachers,
youth workers, social workers, housing officers etc. not just health professionals
have a role to play in MECC whether that be providing advice/guidance or
signposting/referring into other services. Therefore up-skilling the wider workforce is
crucial in ensuring healthy weight becomes an everyday topic of conversation,
starting within maternity (pre-natal/antenatal) and continuing into early years, school
age and adulthood. By discussing weight across the life course it will become
normalised and solutions to the problem will come from the residents themselves.
Local community advocates are vital to ensuring healthy weight is a normal topic of
conversation and messages are successfully cascaded and positive behaviours
embedded within their communities. The insight gained from communities and the
wider workforce within them will help to shape future prevention and early
interventions in Portsmouth as we move forward.
7. Care pathway
The care pathway used to focus solely on obesity treatment but the new focus is on
a much more holistic healthy weight care pathway, from prevention through to
treatment, covering the life course.
This is a radical shift in thinking and the
pathway will develop over time, a summary to help start to conceptualise the new
approach can be seen in Appendix 3.
8. Building change and moving forward
We need to change our thinking, planning and as individuals, families, communities
and organisations to ensure that Portsmouth becomes a healthy city.
8.1 Shifting the focus
A strategic shift in thinking is required moving from the obesity driven focus of
previous decades towards a more holistic approach, this includes focusing on
nutrition (healthy eating) and both physical and mental health in addition to excess
weight, as all are intrinsically linked. In addition, the focus is not about tackling
healthy weight in isolation, but rather as a component of holistic health and wellbeing
and addressing the underlying multi-factorial issues that affect weight including key
lifestyle behaviours and the wider determinates of health. People, policies and
performance need to come together and complement each other, because tackling
healthy weight is a shared responsibility. A multi-component approach across levels
and areas of influence is required to support Portsmouth's population to achieve and
maintain a healthy weight.
A move from treatment to substantial investment in prevention and early intervention,
particularly within the younger/future generations is critical and combined with
ensuring healthy eating and physical activity are part of everyday life from an early
age, will aid supporting the cultural shift necessary to normalise healthy weight.
17
8.2 Leadership and partnerships
The scale of the challenge and its complexity means one organisation alone cannot
solve the issue of excess weight within our population, therefore multi-faceted, multicomponent approaches on a large scale are necessary to tackle the associated
problems. The key is partnership working at both strategic and operational level,
bringing together a range of agendas and operating through shared policies and
maximising the limited resources available. A clear strategic direction, long-term
vision and strong leadership are essential to ensuring the shared objectives and
health outcomes are achieved.
8.3 Engagement with communities
Communities have numerous assets (people, places, insight etc.) that are crucial
when addressing health inequalities and improving health. Successful engagement
and empowerment of communities will ensure that the resources within them are
understood and utilised, achieving maximum benefit and successes that a top down
approach to tackling healthy weight would not achieve.
8.4 Sustainability, evidence and innovation
It has taken decades of escalation for obesity to reach its current epidemic status
and a quick fix solution does not exist. It will take sustainable, long-term, large scale
approaches to successfully tackle it. There is a paucity of information on
successfully turning the tide on obesity, however the evidence base is emerging and
using best practice at all levels will ensure value for money and potential health
outcomes are achieved. Where evidence is not available then creative and
innovative approaches/interventions are necessary and with a robust evaluation,
they can contribute to the emerging evidence base.
8.5 Priorities and planning
An underpinning action plan will be used as the operating framework for the healthy
weight strategy. This will be developed by key stakeholders using intelligence from
the JSNA, professionals, local residents, NICE guidance, other published evidence
and informed by local/national best practice. The action plan will act as the
implementation plan, providing specific details on how the various outcomes will be
achieved. It will also be used as a monitoring tool, holding to account the
performance of the various stakeholders signed-up to improving healthy weight
against the agreed targets/outcomes.
8.6 Performance monitoring
The Health and Wellbeing Board will ensure the outcomes are achieved, with the
strategic steering group overseeing the development of the action plan and
monitoring the delivery against the set targets and outcomes. Key stakeholders will
also monitor their areas to ensure their practices, service, policies, initiatives,
programmes etc. are achieving as they should against the wider determinants of
health and having the desired effect on tackling issues around the achievement of
18
healthy weight for all. The action plan will be reviewed bi-annually with the flexibility
to alter interventions and develop approaches as new evidence emerges or
influential changes come into force.
8.7 Investment
Portsmouth will continue to invest in improving the health of its population including
through healthy weight initiatives However, the reality of the current financial
pressures mean investment will not always be monetary, with shared responsibility
comes shared resources, which if pooled can be beneficial to all. Maximising
community assets and facilities will be key, using community advocates and
adopting a community development approach is essential to reaching those who
need it most and ensure behaviour changes (if necessary) are supported.
A significant investment in our wider public health workforce, who can cascade
messages within the scope of their day job and routine contacts with local residents,
is fundamental. MECC is a valuable resource that can significantly contribute to the
achievement of the vision. A frontline workforce (public, private and voluntary) which
is confident and competent in both raising the issue of weight and supporting
individuals either directly or via others to achieve a healthy weight is fundamental to
the success of this strategy, particularly those working with the target audiences
identified at higher risk. Prevention (primary and secondary) and early intervention
across the life course is essential in achieving our vision:
"Portsmouth becomes a healthy city that empowers and supports individuals,
families and communities to achieve and maintain a healthy weight"
19
References
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Available from: https://www.gov.uk/government/policies/reducing-obesity-andimproving-diet [Accessed 2nd Sept 2013].
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2013]
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30th July 2013].
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http://www.noo.org.uk/LA/impact [Accessed 31st July 2013].
5. Marmot. (2010) Fair Society, Healthy Lives. [Online] Available from:
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6. National Institute of Clinical Excellence. (2006) Obesity guidance on the prevention,
identification, assessment and management of overweight and obesity in adults and
children. [Online] Available from:
http://www.nice.org.uk/nicemedia/live/11000/30365/30365.pdf [Accessed 31st July
2013].
7. Department of Health. (2011) ‘Healthy Lives, Healthy People: A call to action on
obesity in England’. [Online] Available from:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213720/
dh_130487.pdf [Accessed 31st July 2013].
8. Local Government Association. (2013) Tackling obesity - Local government’s new
public health role. [Online] Available from:
http://www.local.gov.uk/c/document_library/get_file?uuid=440a1dfa-5920-4757-a185af6a3e8b8026&groupId=10171 [Accessed 30th July 2013].
9. Health and Social Care Information Centre. (2013) National Child Measurement
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hild+measurement+programme%22&sort=Relevance&size=10&page=1#top
[Accessed 31st July 2013].
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[Online] Available from:
http://www.hants.gov.uk/pccjsna/API_STR_JSNA_LIF_WGT_ReceptionYr6Male
Female.xls [Accessed 31st July 2013].
20
11. Children's Society. (2014) Portsmouth survey of children and young people
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2013].
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[Accessed 30th July 2013]
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[Accessed 3rd July 2014].
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activity and diet: England, 2012. [Online] Available from: http://www.aso.org.uk/wpcontent/uploads/downloads/2012/03/2012-Statistics-on-Obesity-Physical-Activity-andDiet-England.pdf [Accessed 31st July 2013]
17. National Obesity Observatory. (2012) TV viewing and obesity in children and young
people. [Online] Available from:
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2013]
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2013].
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[Accessed 31st July
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21
Appendix 1
Foresight's full obesity system map with thematic clusters
(http://weightandwellbeing.co.uk/wp-content/uploads/2012/01/obesity-systems-map.jpg)
Appendix 2
Detailed costings
Reduced life expectancy:
Morbid obesity (BMI 40-50) reduces life expectancy by 8-10 years, equivalent to the
effects of lifelong smoking, while moderate obesity (BMI 30-35) reduces life
expectancy by 2-4 years13. In Portsmouth, the life expectancy of about 45,650 adults
is reduced because of their weight.
Increased morbidity:
Overall 29% of men and 36% of women classed as obese have a life-limiting illness double the rates in the healthy-weight population10.
Poor mental wellbeing:
Emotional and psychological effects of overweight/obesity include: teasing by peers;
low self-esteem; anxiety, depression, disturbed sleep, fatigue, poor body image,
maladaptive eating behaviours, exercise avoidance and social difficulties e.g.
isolation, discrimination etc.7,10,19. Severely obese children and young people rated
their quality of life as low as children and young people having chemotherapy for
cancer7.
Increased risk of associated health problems:
 Cardiovascular diseases (mainly heart disease and stroke)
 Diabetes
 Musculoskeletal disorders (especially osteoarthritis)
 Some cancers (endometrial, breast, and colon)5
In some cases the increased risk is stark e.g. an obese women is 13 times more
likely to develop type 2 diabetes than a healthy weight women 10
Long-term conditions:
More than 15 million people in England have a long-term condition and a number are
associated with obesity e.g. type 2 diabetes, mental health problems; liver;
respiratory; cardiovascular; muscular skeletal diseases and these place a significant
burden on the social care system, with care associated with long-term conditions
accounting for 70% of the total social care budget. This includes resource
implications for:
 housing adaptations (specialist mattresses, hoists, stair lifts etc.)
 specialist carers trained in manual handling of severely obese people

provision of appropriate transport and facilities e.g. bariatric patient transport and
specialist leisure services16
Inequalities:
There are strong links between obesity and both deprivation (disadvantaged
communities) and ethnicity (particular black and minority ethnic groups), this can
increase health and social care inequalities and result in adverse social impacts e.g.
discrimination, social exclusion and reduced earnings. Children with a limiting illness
are more likely to be overweight or obese and people with disabilities are more likely
to be obese and less physical active than the general population, with both
underweight and obesity a particular issue for people with learning disabilities17.
Lower educational attainment:
Factors contributing to low attainment include: poor psychological health (teasing,
bullying and discrimination), low self-esteem, disturbed sleep, absenteeism and less
time spent with friends or being physically active, with one third of adults who leave
school with no qualifications being obese. Although obesity does not cause lower
educational attainment, the identified factors have also been linked with obesity and
mental well-being. Tackling healthy weight requires a holistic approach.
Economic costs:
With the rising rates of excess weight/inactivity the costs are escalating for the NHS
(treatment/interventions) and wider economy (benefits, care, sick pay, loss
productivity etc.).
In monetary terms treating obesity alone is estimated to cost the NHS £5bn per year
and the wider economy approx. £20bn per year through factors such as lost
productivity and sick days10. By 2050 this is forecast to rise to £10bn per year NHS
costs attributed to overweight and obesity and £49.9bn per year (at 2007 prices)
wider societal and business costs4.
In England costs relating to inactivity are estimated at £8.2bn per year, including
direct costs of treatment for the major lifestyle related diseases, and the indirect
costs caused through sickness absence etc. In addition the contribution of inactivity
to obesity is estimated to cost £2.5bn annually: £0.5 bn in NHS costs and a further
£2bn across the economy as a whole. It is estimated that 18million sick days per
year can be attributed to obesity10.
Total costs for overweight/obesity = £25bn per year
= £59.9bn by 2050
Total costs for inactivity = £10.7bn per year
= £21.4bn by 2050
(doubled as an estimate like obesity)
= £35.7bn per year
= £81.3bn by 2050
These are an under representation of the problem around healthy weight as
underweight and mental wellbeing connected with weight is not necessarily captured
in these figures. Quality of life for individuals and the wider impact on their families
and communities are difficult to quantify but should also be considered. The costs
above are rough estimates but they do highlight the severity of the financial
implication of excess weight and these costs will continue to escalate year on year
unless a downward shift towards a healthy weight population is achieve.
24
Appendix 3
Healthy Weight Care Pathway
Early years
(pre-birth - 5yrs)
Children
(5-11yrs)
Young people
(11-18yrs)
Adults
Older people
65+
Open spaces (seafront, parks, green spaces etc.)
Environment
Housing (type, condition)
Urban infrastructure (safe and attractive walking/cycling routes, street lighting, transport routes etc.)
Community centres
Children centres
Adventure playgrounds
Pre-schools/nurseries
Schools
Colleges
Facilities
Youth centres
Community Allotments/growing sites
Parks, Multi Use Games Area's, outdoor sports courts
Universal
Commercial leisure providers e.g. Sports clubs, gyms
Commercial food providers e.g. Supermarkets, cafes, restaurants, take-aways.
Health - GPs, Pharmacists, Dentists, Opticians Practice nurses, community nurses etc.
Midwifery
Support
Services
Schools nursing
Voluntary sector support services
Health visiting
Nursery Nurse
Education - teachers, teaching assistants, lunchtime supervisors etc.
Social care
Planning decisions (Regeneration, housing, commercial tenancy etc.)
Political
Education decisions (Curriculum - Home economics, Physical activity etc.)
Parenting
Economic - benefits, wages etc.
Health - dietitians, occupational health, mental health etc.
Targeted
Education - SEN, NEETs,
Healthy living pharmacists
Social care - LAC, safeguarding [obesity, under nourished etc.]
Health trainers
Food bank
Specialist
Health services - bariatric surgery, weight management clinicians etc.