Monthly Archives: December 2020

Since the pandemic began, clinical studies have reported that many of the sickest COVID-19 patients have been people with obesity. Large population studies are being published in academic journals cementing this association. An analysis of 75 studies (some 399,000 patients) published in Obesity Reviews, for example, found people with obesity who contracted COVID-19 were 113% more likely than people of healthy weight to end up in hospital, 74% more likely to be admitted to an intensive care unit, and 48% more likely to die. In the UK, a study found of all the people admitted to intensive care, 73% were overweight or obese; with another study revealing that people who are obese to be some 33% more likely to die with COVID-19. These figures come against a backdrop of a growing recognition of the problems associated with weight gain dating back to the 1980s. How many of us are overweight or living with obesity, and what can we do about it in rural areas? Jessica Sellick investigates. 

………………………………………………………………………………………………..

What is obesity? According to the NHS, the term obese “describes a person who’s very overweight with a lot of body fat”. A common method of identifying obesity is calculating a person’s Body Mass Index (BMI). This considers your height, weight, age, sex, ethnic group (optional) and activity level to give you a BMI score: 

• Below 18.5 – you are in the underweight range. 
• Between 18.5 and 24.0 – you are in the healthy weight range. 
• Between 25 and 29.9 – you are in the overweight range. 
• Between 30 and 39.9 – you are in the obese range. 

BMI was first developed more than 160 years ago by a Belgian astronomer, mathematician, statistician and sociologist called Lambert Adolphe Jacques Quetelet. Originally called the Quetelet Index, he developed the basis of BMI between 1830 and 1850 as part of his work on social physics. The National Institute for Clinical and Healthcare Excellence (NICE) recommends using BMI as ‘a practical estimate of adiposity in adults’ and to ‘think about waist circumference in addition to BMI, in people with a BMI of less than 35 kg/m2’. BMI provides a useful tool for researchers to measure and monitor weight across large populations; and also offers a simple means for members of the general public to calculate theirs. 

However, NICE and other clinical bodies acknowledge that there are some limitations in using BMI. For example:  

• BMI does not reflect the location or amount of body fat, and these factors can impact health. For example, people who have fat around their waist and abdominal organs are more at risk of health problems than those with fat in other areas.  
• BMI does not reveal how much muscle you have; and the more you have, the higher your BMI will be, even though you may be healthy. 
• BMI does not consider frame size. People with a bigger frame will have a higher BMI even though they may still be healthy. 

BMI is not used with pregnant women or people over the age of 60 years (who lose muscle as part of the ageing process). 

While BMI remains the most widely used method for assessing whether someone is overweight or underweight in the general population; scientists are developing alternatives. These include: waist circumference, waist-to-hip-ratio, skinfold thickness, bioelectrical impedance, hydrostatic testing, air displacement plethysmography, the dilution method (hydrometry), dual-energy X-ray absorptiometry, magnetic resonance imaging (MRI), and the relative fat mass index (RFM).  

How many of us are overweight or living with obesity? The Health Survey for England monitors trends in the nation’s health and care. It provides information about children and adults living in England, including estimates of obesity levels. The 2018 survey, published in December 2019, found 27.7% of adults were obese, and a further 35.5% were overweight. 1 in 8 of obese adults were morbidly obese (i.e., they had a BMI of 40+). Men were more likely than women to be overweight or obese – 66.9% male compared to 59.7% female. The survey identifies trends in obesity and in overweight between 1993 and 2018 (see figure 4, table 6 on page 16). This shows between 2006 and 2016 the proportion of adults who were either overweight or obese changed little. In 2017, however, the survey returned the highest recorded level of obesity at 28.7%. In 2018 this figure reduced slightly to 27.7%. The prevalence of adult obesity in England has increased from 15% in 1993 to 28% in 2018. The age group most likely to be overweight or obese is aged 65-74 years and the least likely to be obese 16-24 years.  

The National Child Measurement Programme (NCMP) measures the height and weight of children in reception (aged 4-5 years) and year 6 (aged 10-11 years). The data shows that 9.7% of reception age children were obese in 2018-2019, and a further 12.9% overweight. Amongst year 6 children, 20.2% were obese and 14.1% overweight. Boys were found to be slightly more likely than girls to be obese.    

According to Public Health England (PHE), being overweight or obese is linked to a wide range of diseases, including type 2 diabetes, hypertension, some cancers, heart disease, stroke and liver disease. Obesity is also associated with poor psychological and emotional health – with obese adults more likely to suffer from stigma which may impact on their self-esteem. Obesity is also associated with reduced life expectancy. PHE estimated that treatment of obesity-related conditions in England cost the NHS £6.1 billion in 2014-2015, and that failing to address the challenge posed by the obesity epidemic will place an even greater burden on health and care resources. 

In May 2020 NHS Digital published figures on obesity-related hospital admissions. ‘Statistics on Obesity, Physical Activity and Diet, England (2020)’ is an annual compendium of information on hospital admissions and prescription items. The latest statistical release reveals 11,117 hospital admissions were directly attributable to obesity (an increase of 4% on 2017-2018) and there were a further 876,000 hospital admissions where obesity was a factor (an increase of 23% on 2017-2018). The majority of adults are overweight or obese: 67% of men and 60% of women. Of the 20.2% of children in year 6 classified as obese, the prevalence of obesity was found to be twice as high in the most deprived areas compared to the least deprived areas. 

According to the COVID Symptom Study app, 29% of those surveyed have gained weight since March 2020. The weight gain varied from 1.6 pounds to 6.5 pounds and was caused by increased snacking (35%), decreased levels of physical activity (34%), increased alcohol consumption (27%), and/or a less healthy diet (19%). People who reported increased snacking gained the most weight (6.5 pounds). The research found regional differences in weight gain – with residents in Scotland, Northern England and Wales gaining twice as much weight as residents in the south of England. 

The Government has described tackling obesity as one of the greatest long-term challenges the country faces. With COVID-19 obesity has become a more immediate concern for health and care services.  

What causes obesity? A number of complex and multifaceted issues are thought to cause or worsen obesity. These include: 

• An unhealthy diet where people consume more energy than they need [known as positive energy balance]. While there is no single food or nutrient that causes obesity, if you consume high amounts of energy – particularly fats and sugars – and do not burn the energy off through physical activity, the surplus energy is stored as fat. 
• Lack of physical activity – people who are less active reduce their opportunity to use up the energy they consume through food. 
• Using the English Indices of Multiple Deprivation (IMD), the most deprived areas have the highest mean BMI and the highest prevalence of obesity. Low socioeconomic groups appear to be two-times more likely to become obese. 
• In some cases, medications or medical conditions may contribute to weight gain (e.g. underactive thyroid, Cushing’s syndrome) or genetics (e.g. Prader-Willi syndrome) but if they are properly diagnosed, monitored and treated they should pose less of a barrier to weight loss.  

What are the trends in rural areas? Research led by Imperial College London analysed the height and weight of 112 million adults across urban and rural areas in 200 countries between 1985 and 2017. The study, involving a network of more than 1,000 researchers, found that between this time period BMI rose by an average of 2.0 kg/m2 in women and 2.2 kg/m2 in men: equivalent to each person becoming 5-6 kg heavier. More than half of the global rise over the 33 years was due to increases in BMI in rural areas. In some low- and middle-income countries, rural areas were responsible for more than 80% of the increase. Researchers found that since 1985, average BMI in rural areas has increased by 2.1 kg/m2 in both women and men. But in cities, the increase was 1.3 kg/m2 in women and 1.6 kg/m2 in men. 

A Centers for Disease Control and Prevention (CDC) analysis of 2016 data for the United States found a higher obesity prevalence among adults in nonmetropolitan (rural) counties than those living in metropolitan (urban) counties: 34.2% of adults residing in nonmetropolitan areas self-reported as obese compared to 28.7% of adults residing in metropolitan areas. 

In England, the Active Life Survey allows for an estimate variation in the proportion of adults that are overweight or obese by Local Authority area. For the period 2017-2018, areas with a high percentage of overweight or obese adults included Hyndburn (Lancashire), Wellingborough (Northamptonshire) and Redditch (Worcestershire). Areas with a low percentage of overweight or obese adults included Cambridge, the City of London and Camden. Geographical variation is not currently analysed using the Rural Urban Classification.  

The Rural Health Information Hub (RHI Hub) draws together a range of studies to understand the causes of higher obesity prevalence rates in rural areas. Contributors are thought to include: poverty, limited access to healthy and affordable food, higher calorie consumption, lack of nutritional education and services, limited access to prevention programmes and weight management services, fewer opportunities for children to be physically active after school, scarcity of recreational areas to promote physical activity, and a reliance on the car to meet transport needs rather than being able to walk or bike.  

What treatment, prevention and support services are available? Clinical guidelines published by NICE recommends that health practitioners should: (1) assess lifestyle, comorbidities and willingness to change; (2) consider lifestyle changes such as diet and physical activity; (3) consider pharmacological interventions, only after behavioural approaches have been started and evaluated; and (4) consider bariatric surgery, subject to meeting a number of criteria. The NHS website suggests if you are obese you speak to your GP about losing weight safely, noting that they can advise you on eating a healthy, balanced diet and taking regular physical activity. GP practices are also able to provide patients with access to other services which may include (but are not limited to): local weight loss groups, exercise on prescription and social prescribing.    

The Health and Social Care Act 2012 transferred responsibility for anti-obesity provision from the NHS to Local Authorities. Since April 2013 upper tier and unitary Local Authorities have had responsibilities to improve the health of their populations. While the increasing costs, funding shortfalls and pressures on social care are recognised by many readers; against this backdrop – and amid the impact of COVID-19, the Local Government Association (LGA) has published a report on the obesity related costs and pressures. The authors calculate (using the average cost of a care worker of £24/hour [2014 prices]), that the yearly cost of council funded community-based social care for an individual with severe obesity and a BMI of 40, would be £1,086 – nearly double the cost for a person with a BMI of 23. This equates to an annual excess social care cost for a typical council of £423,000 [2014 prices]. Note that due to limitations of the data, the report relates only to those aged 65 years or over and not living in care homes. Therefore, the true cost of the effect of BMI on the need for social care may be higher. In May 2020 the LGA published a set of case studies highlighting how Councils are supporting adults to lose weight. This includes examples from North Yorkshire and West Sussex. PHE’s guide to supporting local approaches to promoting a healthy weight calls for a ‘whole system approach’ which engages stakeholders across the wider system to develop a shared vision and actions that tackle the more upstream drivers of obesity. 

The NHS Long Term Plan (published in January 2019) sets out, in chapter 2, the actions the NHS will take to strengthen its contribution to reducing obesity. This includes providing a targeted support offer and access to weight management services in primary care for patients with a diagnosis of type 2 diabetes or hypertension with a BMI of 30+; doubling the diabetes prevention programme – including having a digital option; providing healthy food for staff and patients on NHS premises; and ensuring nutrition has a greater place in the education and training of healthcare professionals. The plan calls for a focus on prevention (e.g. working with partners to embed physical activity and healthy eating in existing social care pathways); move towards integration between health and social care services; taking a whole systems approach rather than single or separate interventions; including data on obesity as part of the basis for service provision; providing specific training or social care staff; and investing in reablement.  

In July 2020 PHE launched a Better Health Campaign  aimed at encouraging adults to introduce changes that will help them work towards a healthier weight. The campaign forms part of the Government’s emerging obesity strategy which began with the publication of a policy paper on tackling obesity. This sets out a range of measures aimed at getting the nation fit and healthy, protecting themselves against COVID-19 and protecting the NHS. These range from banning unhealthy food advertisements and ending some ‘buy one get one free’ food promotions, through to improving labelling and expanding NHS weight management services. 

Back in 2016 Government published its childhood obesity plan, setting out proposals to reduce England’s rate of childhood obesity within 10-years by encouraging industry to cut the amount of sugar in food and drinks; and helping primary school children to eat more healthily and stay active. PHE oversees the Government’s reduction and reformulation programme which aims to reduce sugar, calories and salt in food and beverages. The Soft Drinks Industry Levy (SDIL) was introduced in April 2018 and applies to the packaging and importation of soft drinks containing added sugar. Government is encouraging the food industry to support PHE’s voluntary calories reduction guidelines to make it easier for people to choose healthier options in everyday meals and foods. 

In July 2018 Ofsted undertook a thematic review to understand what schools contribution can be to reducing child obesity. The review highlighted the importance of the behaviour and attitudes of schools, parents and children in school meal uptake/packed lunch content, and the importance of extra-curricular physical activity. In July 2019 the Department for Education (DfE) published its healthy schools rating scheme; a voluntary scheme for schools to determine how well they are promoting healthy eating and physical activity. 

In September 2020, the National Audit Office (NAO) published its report examining the effectiveness of the Government’s approach to reducing childhood obesity by considering progress so far. The report highlights how successive Governments have been grappling with childhood obesity since the 2000s, all with limited success. The NAO estimates that 1.4 million children aged from 2 to 15 years old were obese in 2018. They also found obesity to be increasing amongst 10-11 year olds and increasing even faster for children in deprived areas. While the DfE’s programme aims to tackle this issue, the NAO concludes that it is not yet clear that the actions within the programme are the right ones to make the step-change needed in the timescale available. The NAO recommends that the Government acts with greater urgency, commitment, co-ordination and cohesion.  

In October 2020 PHE published data highlighting the success of the SDIL, with average sugar levels in drinks subject to the levy falling by 44% between 2015 and 2019. Overall, sugar consumed through these products has fallen even as sales have increased. However, the report shows mixed progress across other food categories and sectors; with branded breakfast cereals and yoghurts seeing some of the biggest falls in sales weighted average sugar (13%) and sugar levels in chocolate and sweet confectionery have remain unchanged as product sales have increased.

In November 2020 the Government launched a consultation on proposals for a total online advertising restriction for HFSS products [High in Fat, Salt and/or Sugar] to reduce the amount of HFSS advertising children are exposed to online. The consultation closes on 22 December 2020.  

How can we reduce obesity and overweight in rural areas? In the United States, the RHI hub has produced a rural obesity toolkit. This contains seven modules that practitioners and communities can use to develop programmes for their local area in school, community and/or clinical settings. From taking your first steps in creating a programme through to using evidence-based interventions and evaluating your programme, the toolkit is designed to provide better access to weight management services in rural areas.   

The Bridge-Building Toolkit, developed by the Rural Practice-based Research Network in Oregon, provides tools that have been developed with six primary care practices. The toolkit moves patients from an individual practice-based “rope bridge” to a modern day “suspension bridge” that supports patients to access a wider range of community services.  

Win with Wellness is a community-wide effort to promote wellness through health eating and physical activity in rural Illinois. Two programmes have been implemented to help residents reduce their risk of chronic disease. Firstly, TOPS® (Take Off Pounds Sensibly®) groups – these provide a safe place for adults to learn how to eat healthy and move more. Secondly, Heart-to-Heart, a programme for adults who live or work in Stephenson or Carroll County to improve eating habits and increase daily physical activity by using interactive health education modules on a variety of topics.

The Healthy Early Learning Project (HELP) in Kansas provided 9 school sites and 4 teacher-parent programmes with physical movement activities, book-in-a-bag to encourage children’s interests in healthy foods, encouraged the consumption of fruits and vegetables, and helped children to make healthy eating choices. By the end of year 3 of the project, the number of schools offering fruit and vegetables as a daily snack increased from 52% to 100%; the number of children undertaking 60 minutes of physical activity a day increased from 31% to 98%; and all 9 sites had developed 5-year strategic plans. 

In Australia researchers have developed a community readiness to change tool. Yarriambiack experienced adult prevalence of overweight and obesity 13.6% above the Victorian average and had the highest per capita intake of sugar-sweetened beverages of all Victorian local governments. The tool was used to support the community and local stakeholders to develop healthier food and physical activity environments – with the readiness of community members to engage measured before the intervention in 2016 and at the end in 2018. 

Notwithstanding these examples there is much discussion in the literature about why some people regain weight after they have worked so hard to lose it. According to the NHS website, as you lose weight your body needs less food (calories) and if you return to your previous calorie intake once you have lost weight, it is likely you will put the weight back on. The NHS website suggests continuing to watch what you eat and increasing physical activity to up to 60 minutes a day. However, some studies estimate that 80% of people who lose at least 10% of their body weight not only end up regaining it, but often put on even more pounds. Nonetheless researchers at the University of Warwick studied patients attending a hospital based obesity service. They found patients aged over 60 years lost an equivalent amount of weight to younger patients. While we are more likely to develop weight related comorbidities in later life, the study shows that age should not be seen as a barrier to losing weight. 

For many of us Christmas is often a time for indulging in food and drink. According to the British Dietetic  Association (BDA), some of us may consume 6,000 calories on Christmas Day, three-times the recommended daily limit. And because weight tends to not always be lost after the festive period, over time this could contribute towards obesity. 

For me what remains missing in much of the literature is that it is one of the biggest steps for a person to take in life to admit they are overweight, whether it’s just a few pounds or several stones, and to actually take steps to deal with it. As we approach the end of this very difficult year and look ahead to the festive season, for those of us looking to lose weight, or maintain our losses, may our determination see us through – we can do it. And as we turn to 2021, what will the Government’s focus on weight management services, diabetes prevention [with digital option], and more nutritional training for practitioners mean for rural communities? Watch this space.

…………………………………………………………………………………………………

Jessica is a researcher/project manager at Rose Regeneration and a senior research fellow at The National Centre for Rural Health and Care (NCRHC). Her current work includes supporting health commissioners and providers to measure their response to COVID-19 and with future planning; and evaluating two employability programmes helping people furthest from the labour market. Jessica also sits on the board of a Housing Association that supports older and vulnerable people. 

She can be contacted by email jessica.sellick@roseregeneration.co.uk. 

Website: http://roseregeneration.co.uk/https://www.ncrhc.org/ 

Blog: http://ruralwords.co.uk/ 

Twitter: @RoseRegen