Public Health in local authorities – making sense of the big picture.

(A case study using obesity as an example)

Professor Malcolm Whitfield

The Health Problem

Source: Professor Vilus Grabauskas, Professor, Chancellor of Kaunus Medical University, Lithuania.

The changing nature of disease

Source: WHO Country Profiles - http://www.who.int/countries/en/

Iraq Region Poland UK USA0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

Cause of death

Communicable Non communicable Injuries

Prevention

Dealing with increased demand

Diagnosis & Treatment

Blood SugarControl

Cardio-vascularevents

Heart SurgeryCataractsAmputationsFoot ulcersEtc.

Chronic Kidney DiseaseBlindnessImmobility

Public Health

Primary Care

OutPatients

Acute / Secondary Care

Long termCare

TE TETETETE TE

AE

(Example) - Diabetes

The building burden of disease

Myocardial infarction

Stroke

Heart Failure

Kidney Failure

Diabetes

Angioplasty

Coronary bypass

DialysisAmputation

Cataracts

The policy assumptionsDemand

Time

Patient Expectations

Ageing population

New & more intensive treatments

New/Drug resistant disease

More effective treatments

Better prevention / lifestyle

More effective models of care

Greater self care

Quantifying the impact of lifestyle

Stoke Telford Liverpool Dudley Birmingham Sheffield0

2000

4000

6000

8000

10000

12000

14000

16000

18000

ActualPredicted

Estimated impact of risk reduction – Birmingham East and North

Population Estimate annual events (current risk levels)

Estimate annual events (improved risk levels)

Estimated annual events avoided

Estimated eventsavoided over the 5 year period

PCT Population (326,833)

6,095 4,898 1,197 3,590

Population Estimate annual deaths (current risk levels)

Estimate annual deaths (improved risk levels)

Estimated annual deaths avoided

Estimated deaths avoided over the 5 year period

PCT Population (326,833)

2,077 1,768 309 928

Population Estimate annual costs (current risk levels)

Estimate annual costs (improved risk levels)

Estimated annual costs avoided

Estimated costavoided over 5 year period

PCT Population (326,833)

£17,825,274 £14,451,497 £3,373,777 £10,121,330

North Karelia - Finland

Year Men Women

Smoking (%)

Serum cholesterol

(mmol/l)

Blood pressure (mmHg)

Smoking (%)

Serum cholesterol

(mmol/l)

Blood pressure (mmHg)

1972 52 6.9 149/92 10 6.8 153/92

1977 44 6.5 143/89 10 6.4 141/86

1982 36 6.3 145/87 15 6.1 141/85

1987 36 6.3 144/88 16 6.0 139/83

1992 32 5.9 142/85 17 5.6 135/80

1997 31 5.7 140/84 16 5.6 133/80

2002 33 5.7 137/83 22 5.5 132/78

2007 31 5.4 138/83 18 5.2 134/78

Main risk factors in North Karelia between 1972 and 2007 among men and women aged 30-59 years

North Karelia - Finland

Deaths Rate in

1969-1971 Rate in 2006

Change from 1969-1971 to 2006

All causes 1509 572 -62%

All cardiovascular 855 182 -79%

Coronary heart disease 672 103 -85%

All cancers 271 96 -65%

Lung cancers 147 30 -80%

Age-adjusted mortality rates of coronary heart disease in North Karelia and the whole of Finland among males aged 35–64 years from 1969 to 2006.

Understanding the complexity?

Policy

Exercise

Diet

HealthcareSurgery

Motivation

Behaviour

Environment

Lifestyle

Regulation

Education

Culture

Leisure

May 2006

Classifying Interventions

May 2006

Classifying Evidence

May 2006

Weighing the evidence

May 2006

Linking interventions/evidence

May 2006

Linking interventions/evidence

May 2006

Modeling return on investmentIntervention Level Type Budget Partcipants Age group Mean BMI Impact BMI

Mean BMI Reduction

Cost / BMI Unit

Bariatric surgery Individual Healthcare £1,350,000.00 150 Adults 45 60.00% 4050 £333.33Be Active and increased physical activity offers Environmental Physical activity £5,000,000.00 330000 Adults 27.5 3.40% 308550 £16.20Children’s healthy weight programme Group Lifestyle £25,000.00 450 Children 20 1.40% 126 £198.41Citywide obesity campaign Population Lifestyle £33,000.00 2500 Adults 27.5 0.50% 343.75 £96.00Convenience stores4life Environmental Diet £14,000.00 900 Adults 27.5 1.00% 247.5 £56.57

Financial incentives and penalties for fast food take ways to encourage promotion of healthier options Policy Diet £27,500.00 1300 Adults 27.5 0.50% 178.75 £153.85Healthier catering award scheme Environmental Diet £4,000.00 100 Adults 27.5 1.00% 27.5 £145.45Increased cycle routes Environmental Physical activity £350,000.00 4500 Adults 27.5 2.20% 2722.5 £128.56Increased use of parks Environmental Physical activity £58,000.00 1250 Adults 27.5 2.20% 756.25 £76.69Kids on track – obesity prevention for 3-4 yr olds Group Diet £87,000.00 4017 Children 20 2.00% 1606.8 £54.14Level 3 specialist adult weight management Individual Healthcare £460,391.00 331 Adults 40 3.40% 450.16 £1,022.73

Lighten UP – level 2 adult weight management programme Individual Lifestyle £369,000.00 1680 Adults 30 5.50% 2772 £133.12

Local centres and sustainability supplementary planning documents restricting growth in fast food outlets, increased use of green space, restricting mobile food vendors near schools

Policy / Environmental Lifestyle £5,500.00 1300 Adults 27.5 3.40% 1215.5 £4.52

Maternal "lighten up" obesity pathway Individual Lifestyle £53,246.00 450 Adults 30 3.00% 405 £131.47My Choice Individual Lifestyle £53,200.00 172 Adults 27.5 4.00% 189.2 £281.18

Nutrition standards in care homes, hostels, children’s homes Environmental Diet £9,450.00 340 Adults 27.5 1.00% 93.5 £101.07

Online weight management programmes – commit2Bfit and choose2Bslim Individual Lifestyle £6,000.00 1400 Adults 27.5 3.00% 1155 £5.19Primary care brief interventions Individual Lifestyle £32,000.00 250 Adults 27.5 3.00% 206.25 £155.15

Startwell - early years settings healthy living quality improvement programme Environmental Lifestyle £38,000.00 6000 Children 20 3.40% 4080 £9.31Whole school day approach to nutrition and health Environmental Lifestyle £45,000.00 400 Children 20 3.40% 272 £165.44Workplace health initiative Environmental Lifestyle £8,500.00 120 Adults 27.5 3.40% 112.2 £75.76

Thank you