Obesity: working with local communities

For the purpose of this guidance, 'local community' refers to a group of people from the same geographic location that is not necessarily related to any official, administrative boundary. The community may be located in a ward, borough, region or city. The PDG recognised that 'community' can also refer to groups with an interest, background or issue in common (such as low income and black and minority ethnic groups – see NICE's guideline on type 2 diabetes prevention: population and community interventions). However, while communities of interest are not excluded from this guidance, the primary focus is on those located in specific geographic areas.

The Group noted that aiming for a 'healthier weight', rather than focusing on preventing or combating obesity, may be a more acceptable and achievable goal for many people. Members also felt this goal could be accommodated within a general health and wellbeing agenda. The PDG heard that the term 'obesity' may be unhelpful among some communities – while some people may like to 'hear it like it is', others may consider it derogatory. Bearing these differing views in mind, the PDG acknowledged the need to choose the most appropriate language for any given community or situation.

The scope for this guidance was revised during its development. Originally the aim was to look at a whole-system approach to obesity. Following the revision, the PDG focused more on local, community-wide best practice. Consultation with stakeholders confirmed that the evidence previously considered was still relevant and features of an effective whole-systems approach have been incorporated in the recommendations.

There is a lack of evidence on effective community-wide approaches to obesity. The most advanced studies have only started to publish early findings. These include: EPODE in France ('Ensemble prevenons l'obesite des enfants' ['Together let's prevent childhood obesity']) or CO-OPS Collaboration in Australia (the 'Collaboration of community-based obesity prevention sites'). No UK-based studies were identified. The PDG had hoped to gain insight from community-wide approaches to tobacco control, but again there was little UK-based evidence. As a result, the recommendations draw heavily on the experience of local practitioners in England (via expert testimony and commissioned research). They also draw on early learning from ongoing initiatives (such as Healthy Towns, Cycling Demonstration Towns and the work of the Department of Health Child Obesity National Support Team).

In recent years, there has been a proliferation of community-based interventions aimed at preventing and managing obesity. These have tended to be one-off, highly controlled explanatory studies, developed and delivered by academic centres. While some studies have been evaluated using the approaches set out in the MRC Framework on complex interventions, system-wide interventions are still being evaluated using randomised trials. The PDG considered that there is a need to develop appropriate methodological models for evaluating system-wide, community-led approaches to obesity prevention and management.

Evaluation of local action on obesity is not straightforward, as the full impact may not be seen for a number of years. In particular, there is a lack of evaluation that considers process and economics, as well as health outcomes, over the short, medium and long term. The PDG noted that the recommendations on monitoring and evaluation in NICE's guideline on cardiovascular disease prevention are of relevance.

The recommendations synthesise learning from the available evidence and indicate promising areas for future innovation in a culture of ongoing evaluation and action. The evidence does not demonstrate that a particular approach (or established package of interventions) holds the key to tackling obesity in any given community. However, it does provide useful pointers to approaches that may be worth putting into practice and evaluating.

There is enormous variation in current practice, both in terms of the types of action taken, local capacity and assets. The PDG recognised that different areas are at different 'starting points'. The recommendations aim to bring all areas up to the standard of the most advanced and to encourage future innovation.

Context is vital – and what works in one locality may not always work in another. The PDG considered techniques that could be used to tailor interventions for particular contexts. These included, for example, community engagement techniques and development and good practice in relation to partnerships and commissioning.

Ongoing structural changes to the public sector, particularly local authorities and the NHS, have influenced the direction and tone of the PDG's recommendations. The Group was aware that the timing of the guidance offered an opportunity to stress the importance of a systemic approach to obesity that is integrated with other local agendas.

Many of the recommendations are aimed at local authorities and new bodies, particularly health and wellbeing boards. The PDG believes the latter will provide a crucial forum for the NHS, public health and local authority representatives. This includes playing a critical role in developing a long-term obesity strategy.

In two-tier areas the involvement of district councils and other tiers of local government in the development and implementation of a long-term obesity strategy will be critical to success. The PDG acknowledges that individual health and wellbeing boards will manage this local engagement differently but advocates that key contributors to obesity prevention such as planning, transport, parks and leisure services must be included in the strategy and are integral to action to prevent obesity.

The PDG recognised the importance of informing elected members of the personal, community and wider economic and social costs that will accrue if the prevalence of obesity continues to rise. It also noted the need to provide elected members with tools to take effective action.

The PDG acknowledged that national policy can act as a facilitator or barrier to local action on obesity. Analogies were drawn with action on tobacco control and smoking cessation. Here evidence points to the importance of supportive national policies. It also points to the need to 'de-normalise' behaviours that increase the risk of obesity via strong advocacy and market regulation (in this analogy, in relation to tobacco products).

The PDG considered that if the findings from recommended local action on monitoring and evaluation were fed back to national or supra-regional policy teams and practitioners, it may foster a wider culture of action learning and aid the development of supportive national policies.

The PDG strongly emphasised the need to take systemic, sustainable action that encompasses the wider determinants of health. Obesity may be the long-term consequence of a passive response to decisions taken elsewhere (for example, in relation to planning, policing or traffic law enforcement). The Group believes single, one-off interventions are likely to have a limited impact – and that multi-sector action is needed across the local system if there are to be appreciable changes in the prevalence of obesity.

The recommendations focus on sustained community engagement and the development of effective partnerships involving a broad range of groups. The PDG believes the public health team's role in this is to build an area-wide partnership across sectors to help tackle the wider social, economic and environmental determinants of obesity.

The PDG recognised that change will take a long time unless a simultaneous top-down, bottom-up and partnerships (co-production) approach is adopted. This includes action across all local organisations and networks supported by effective policies and delivery systems.

The effectiveness of individual interventions was outside the scope of this guidance. However, the PDG recognised that a range of existing NICE guidance provides details on the types of interventions that are likely to be effective. The exact package commissioned will depend on the needs of the local area. However, the PDG felt that it was very important to take a long-term, coherent approach to commissioning – for both obesity prevention and treatment among children and adults.

The PDG noted that activities focused on obesity prevention receive greater support, especially among practitioners, when there are clear opportunities for referral into local treatment services. This is also the case when actions to prevent and treat obesity are closely integrated.

Evidence considered by the PDG suggests managing weight is difficult for many people and health professionals may avoid raising this issue. Moreover, just as someone who smokes may attempt to quit many times before they finally succeed, so it may take many conversations (and attempts) before someone is able to change their behaviour to control their weight. The PDG heard that many public health workers lack confidence in raising the issue of obesity with clients. The Group felt that this was a fundamental issue for local authority and NHS staff. It considered it vital that all staff, but particularly those on the 'frontline', have the skills and confidence to provide basic information about local obesity services.

The PDG recognised that success in preventing and managing obesity in local areas can sometimes depend on one or two highly motivated people. While passionate individuals can be a catalyst for change, it leaves sustained action vulnerable to any change in personnel. Accordingly, the PDG has advocated action that is embedded in organisational processes and skill sets.

Volunteers have a vital role in driving community-wide action on obesity – from championing community needs and assets to providing peer support. While there may be a high turnover in volunteers, the PDG acknowledged that they free up other resources and provide an essential supporting role. However, members were concerned to ensure volunteers' training needs and other related costs are not ignored.

Relevant NICE guidance (such as the NICE guidelines on obesity prevention and type 2 diabetes prevention: population and community intervention) demonstrates that individual interventions to prevent or reduce the prevalence of obesity in a particular setting or environment are known to be cost effective. While some interventions or programmes may result in short-term financial benefits, most benefits will be health benefits that will take place over the medium to long term.

It is very difficult, if not impossible, to apply the standard techniques of health-economic evaluation to local system-wide approaches to obesity. Economic evaluation of system-wide approaches reduces to determining the cost effectiveness of partnership working. Partnerships are formed in many different ways and circumstances, and this makes economic evaluation very difficult. The depth of involvement of the partners can vary enormously, as can the number of partners. The decision to become involved as a partner will also depend on how long a project will be funded, how assured the funding is, and whether all potential partners have the same assurances on project funding.

At low levels of engagement, potential partners may simply wish to share information. Such 'partnerships' are virtually costless and may generate relatively large benefits. They will therefore almost certainly be cost effective when viewed from a societal perspective. Further engagement that is likely to cost little to achieve but which is expected to yield relatively large future health benefits should also be cost effective. The greater the number of partners or the more the level of engagement is increased, the more difficult it will become to decide whether further engagement would be cost effective. There will usually come a time when the addition of more partners or the further increase in the level of engagement will no longer be worth the additional effort. However, in practice it will not be easy to determine when such points are reached, particularly when arrangements are already complex.

This guidance concludes that it is more informative to consider the cost effectiveness of each intervention or set of interventions within a complex programme rather than try to consider the cost effectiveness of the programme as a whole. It will be important for potential partners to consider:

• whether it would be better to work together than to work alone

• whether to increase the existing level of engagement.

Modelling shows that projects with long-term funding are more likely to be cost effective, compared with projects funded on an annual basis.