Status in the U.K. in tackling CHD in relation to Overweight and Obesity

List of contents

1. Introduction

2. Definitions
2.1. Coronary Heart Disease
2.2. Obesity

3. Importance of the subject

4. The Government’s approach

5. The example of London’s borough Enfield

6. Recommendations and needed improvements

7. Critical Conclusion

References

1. Introduction

This work looks critically on current efforts to tackle the main killer Coronary Heart Disease in relation to one of its risk factors ‘obesity and overweight’. The attention of this work is especially directed to this risk factor and to what is done to draw the attention to it. Therefore some definitions of relevant expressions, a description of the importance of the subject, a description of what is currently happening in the U.K., some recommendations and urgently needed improvements and a critical conclusion will be provided.

2. Definitions

2.1. Coronary Heart Disease

First, this work should clarify the appearance of Coronary Heart Disease (CHD). CHD is the result of the reduction or complete obstruction of the blood flow through the coronary arteries by narrowing of the arteries and/or a blood clot. It is proved that if CHD is properly managed, progression of the disease can sometimes be reduced and possibly reversed. Untreated, it is progressive and will lead to death either from a heart attack or from heart failure (Department of Health 1998).

Two risk factors (and on the other side it is a stand-alone disease) are overweight and obesity to which this work refers primarily. Therefore a further definition is needed:

2.2. Obesity

To assess the condition of obesity an index was introduced, the Body Mass Index (BMI). The use of the index allows people to compare their own weight status to the general population. The only information required to calculate a person's BMI are height, weight, and the BMI formula (NHS Direct 2002a), (National Center for Chronic Disease Prevention and Health Promotion 2003a).

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Now the result can be compared with a table that gives the information if somebody is obese or not:

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for adults over 20 years

(National Center for Chronic Disease Prevention and Health Promotion 2003b)

Another possibility to assess overweight is the method of waist circumference measurement.

Obesity has dangerous long-term consequences: e.g. CHD (as mentioned), stroke, high blood pressure, breast cancer in women, arthritis, diabetes, reduced life expectancy et cetera (NHS Direct 2002b, NHS Direct 2002c).

3. Importance of the subject

Overweight and CHD are related to each other, because it is proved that overweight (respectively the consequential high cholesterol) among other risk factors causes CHD (Department of Health 2000). On the other hand, the treatment of CHD causes high costs. In 1996 it was estimated that each year CHD costs the U.K. economy a total of £10,000 million – £8,500m for production losses and £1,600m for the health care system. The percentage of medical treatment and rehabilitation during this year was about 88,3% of the total expenditure and only 1% for prevention (Coronary heart disease statistics 2003). Fortunately, the death rates from CHD have been falling in the U.K. since the late 1970s. For adults under 65 years, they have fallen by 41% in the last ten years. But, morbidity rates have risen by around a quarter since the late 1980’s (Coronary Heart Statistics 2003 edition 2003).

Furthermore, regarding the risk factors obesity and overweight it is terrifying to see the high rates: In England about 45% of men and 34% of women are overweight and additional 20% of men and 19% of women are obese. The number is still increasing and the number of people with obesity has doubled since 1980. Additionally, it is estimated that about 5% of deaths from CHD in men and 6% of such in women are due to obesity (Coronary Heart Statistics 2003 edition 2003). Obesity causes costs – in 2001 the National Audit Office (NAO) estimated the minimum economic burden to the health service i.e. not to society or the individual from obesity alone, amounted to £0.5 billion per year and around £2.5 billion including indirect costs (Obesity in Europe 2002, Prideaux, R. 2001). Now that the importance is assessed and regarded as a valuable subject the work will have a closer look on the government’s strategy.

4. The Government’s approach

Tackling the problem ‘obesity’ is a very difficult challenge and the government doesn’t regard obesity as a stand-alone disease. The government’s strategy ‘Saving Lives: Our Healthier Nation’ is looking to nation’s main killers like: CHD and stroke, mental illness, accidents and Cancer. In this context anti-obesity and –overweight strategies can only be found in different National Service Frameworks (NSF), created from the Department of Health. These frameworks contain standards and different service models for special diseases. The NSFs have to be translated by local health communities and have to be implemented into local Health Improvement Programmes (HImPs). These HImPs clearly point out how the local health communities want to make the NSF’s demands happen. Regarding obesity and overweight, the NSF for CHD also makes clear that policies against overweight and obesity have to be implemented in local health delivery plans in cooperation – this should be realised through partnerships between health authorities, local authorities, primary care groups/primary care trusts, and NHS trusts. But there’s a problem: “The government believes, however, that prevention is important.” (National Audit Office 2001). That means that in relation to obesity and overweight the government directs its attention to primary prevention and doesn’t really know how to tackle the problem of already established obesity and overweight (Treatment and Prevention 1997). There is a lot of cross-Government work in the areas of physical activity and diet, which are central to preventing obesity and they often target people where the problem potentially arises: e.g. school children. But ideas are missing how to manage obesity and overweight on the second and third level of prevention (Health Promotion: Models of Health Promotion 2002, Naidoo J. & Wills, J. 2002, p. 79-80)

The problem also needs more attention in health education in spite of the fact that education concerning obesity is discussed controversially: knowledge about the risks of obesity (e.g. CHD) and about what can be done to change attitudes and to alter behaviour, empowerment of affected people is needed and good health promotion is needed locally with good and specialised programmes to help people with overweight and to reduce the risk of getting CHD. But also general practitioners need more information about what they can do. A research from the National Audit Office found out that there is “wide variation in the way general practices manage overweight and obese patients, and uncertainty about which treatment and referral options are the most effective.” (National Audit Office 2003).

Concerning health protection the government could also do more: but all this points will be provided later in the part “Recommendations and needed improvements”.

Coming back to the NSFs, the NSF for CHD doesn’t give clear advice what should be done to reduce the risk factors overweight and obesity. But in April 2001 all NHS bodies and local authorities agreed to implement effective policies into their local delivery plans to reduce overweight and obesity. “Local strategies to address obesity had been developed in some areas, but not in the majority.” (National Audit Office 2001). Therefore this work will now look at London’s borough Enfield, to see what is happening there.

5. The example of London’s borough Enfield

Looking at the Health Improvement and Modernisation Plan of Enfield it can be noticed that nothing is said in relation to obesity and overweight, but the Health Improvement Action Plan (HIAP) of Enfield does: in relation to diabetes (a NSF for diabetes exists) the HIAP wants to reduce the number of obese people, making actions to improve diet, nutrition and physical activity and helping people to maintain weight loss. For example, healthy eating sessions as part of the Enfield Healthy Living Centre Network were introduced, but the problem here is that these improvements have just started. They were initiated by the Enfield Food Nutrition Strategy Implementation Group in April 2003. Nothing can be said about the effectiveness. Concerning CHD prevention a number of ‘Fit for Life’ projects with exercise classes and presentations about diet and lifestyle was started, especially focusing on obese schoolgirls, and a lot of other activities were initiated to increase physical activities and to improve healthy eating, not only but very focused on pupils. In addition to that, Enfield has a Sports Strategy that also intends to increase physical activity, especially amongst those people identified as at risk from CHD (Barnet, Enfield & Haringey Health Authority & the Health Informatics Service 2003a and 2003b).

Some signals are cognizable and Enfield has started to do something, but much more improvements are needed to tackle the problem of established obesity and therefore to prevent CHD.

6. Recommendations and needed improvements

First of all, most authors of the different texts agree that much more actions and research on obesity is needed urgently and should be funded by national governments to prevent or to treat obesity and to built cost-effective strategies.

The following postulated actions work at the individual, community, environmental, and policy level to manage and to treat obesity, collected with help from the following references (Hitchcock 2002, A systematic review of interventions to improve health professionals’ management of obesity 1999, Crawford, D. 2002, National Audit Office 2001 and 2003, Kelly, P. 2003, Barth, J.H., 2002, Storer, H. 2003, Grimshaw, J. 2002):

Further needed actions on behalf of the government :

- Setting of national priorities
- Tax on unhealthy foods
- Subsidies for healthy foods

Mass Media and entertainment industry:

- Promotion of healthy lifestyle and realistic body images
- Dissemination of health information

Food industry:

- Better labelling with better understandable information about the content
- Healthy food on restaurant menus
- Restrictions on misleading and confusing advertisement (to protect children)

Health Professions and the general NHS:

- Guideline development for best practice to tackle the feeling amongst GPs that they need more information on how to address weight issues
- Identification of high risk groups and individuals
- Establishment of a clinical information system, e.g. for a population based registry of overweight and obese patients or for computer generated patient calls and provider reports
- Building a delivery system design: e.g. weight management teams
- Self management support: web based help materials, individual or group education or skills training, maintenance support

Pharmaceutics and Surgery:

- NICE (National Institute for Clinical Excellence) should intensify its examinations of anti-obesity drugs – drugs as adjuncts to strategies for changing lifestyle
- Surgery on obesity should be intensified if there is every indication

Local government:

- improving environment to promote physical activity: safe walking paths and bicycle lanes, safer parks and public places, better public transport, safer playing areas, lighting in the streets

Community organisations:

- Sponsorship of local public education campaigns to promote physical activity
- Build a strong lobby
- Liaisons with other community based programmes

Workplace:

- Wellness programmes

Schools:

- Requirements for daily physical education
- Abolition of drink and snack machines
- Topics on promoting health in the curriculum
- Family involvement

7. Critical Conclusion

The National Audit Office (NAO) has found out that the trend in tackling the problem ‘obesity’ is moving to the wrong direction because the proportion of obese persons is still rising – against all intentions (National Audit Office 1996). In connection with that the British Heart Foundation has detected that there are no more overweight and obesity targets in the concept of Our Healthier Nation (Coronary Heart Statistics 2003 edition 2003). The government should face and tackle this fact.

Furthermore, it is interesting to see that some National Service Frameworks provide statements concerning obesity like the NSF for cancer, older people and diabetes - but each one from its own point of view and only concentrated on one special disease (Department of Health 2002) in spite the fact that being obese causes much more diseases than this special one. For example the NSF for older people doesn’t mention obesity explicitly and how it should be tackled, but the NSF contains elements which are also important for obesity treatment: e.g. increasing physical activity, diet and nutrition. The question is now if it is a good idea to have such a concentrated look on diseases. Many from the NSFs postulated interventions are targeting the same risk factors. Probably it would be a better idea to develop NSFs for risk factors and for health promoting factors. If all factors were targeted appropriately the running programmes wouldn’t be concentrated on special diseases any more and programmes would cover all diseases which include this risk factor. Then health professionals like GPs or nurses could choose all needed programmes for their patients which help them to do something against the risk factor and to prevent a disease or to improve a health status if the patient is already suffering from a disease. At the moment the programmes seem to be scattered all over the diseases in spite of the fact that they intend to achieve the same target.

If this doesn’t seem to be possible a wider ranged multi-disciplinary combination of approaches is needed to tackle obesity in the U.K. Probably, it would be a better idea to regard obesity as a stand-alone disease and not only as a simple risk factor of CHD or diabetes. Perhaps a further NSF for overweight and obese people is needed. It is curious that this hasn’t happened already. Reading the part of this work ‘Importance of the subject’ it is incredible that only in the last five or six years obesity has become recognised as an issue that warrants actions (Crawford 2002).

The government could perform better – it shouldn’t blame obese people saying that they are responsible for their condition. It is proven that mainly toxic environments are responsible for the condition and restricts mobility and stimulates high energy intake (Obesity in Europe – The Case For Action 2002).

Nevertheless, it is appeasing to see that there’s something happening in the country now. Beginnings are recognizable even if they aren’t working adequately but much more has to be done if the government wants to tackle obesity and overweight and consequently CHD appropriately.

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