Health services responses to the obesity epidemic: Wicked solutions need systems thinking

Boyd Swinburn

Professor of Population Nutrition and Global Health

University of Auckland

and

Co-Director, WHO Collaborating Centre for Obesity Prevention

Deakin University

Queensland Clinical Senate,

Brisbane, July 2015

Outline

• Global and Australian context – WHO: Global Action Plan on NCDs and Commission on

ending childhood obesity

– Australia: Post COAG prevention efforts

• Short, medium, long term options: – Services (primary care)

– Programs (prevention, treatment)

– Specific policies (food)

– Capacity building (whole of communities)

– High-level Policy (targets, accountability)

– Systems approaches (state level)

Agreed global target: Halt the rise in obesity and diabetes

WHO Commission for Ending Childhood Obesity

• Reporting end 2015

– Possible leadership on marketing to children

– Other policies: fiscal policies, school food, social marketing, food and PA environments

– ?step up from previous recommendations

Australian context

• 20y of multiple reports – patchy policy uptake

• COAG Prevention Policy

– ~$900m over 8 years = massive natural experiment in prevention cut short by short sightedness

• Many lessons learnt

– The value of systems-based approaches

– The perils of single-source $$ dependency

– The value of collective ‘bootstrap’ action

– The perils of not evaluating well

• Post COAG prevention era

The Full Prevention House

• Leadership & governance

• Information & intelligence

• Finances & resources

• Networks & partnerships

• Workforce development

• Health in all policies

Service

delivery,

programs,

policies

High Level Policies

Political commitment

Specific actions

– people and

food & PA envs

System & capacity building blocks

Systems dynamics

Apply arrows everywhere

Services (primary care)

• Strengths

– eg core funding, contact with high risk individuals, engaged in communities, PHN structures & mandates

• Weaknesses

– eg funding models constrain interactions, links with public health & information systems, restructuring

• Short interventions

• Referral for weight loss

• Monitoring and feedback

Short interventions

• Fit within the existing systems and paradigms

• Successful experiences of smoking, alcohol, PA

• Unsuccessful experiences with obesity

– Active Scripts + diet

• Potential for linking in with a monitoring and social marketing campaign ‘Extra K not OK’

– Growth monitoring in children

– 2/3 adults overweight or obese

– Mass weight loss program unlikely

– No age-related weight gain

– Will reduce obesity prevalence and diabetes

Referral systems

• Weight Watchers (vs GP management)

– 5kg vs 2.3kg weight loss over 1 year (Jebb Lancet 2012)

– Regain to baseline over 5y (vs 4y) (Holzapfel IJO 2014)

– Cost-effectiveness models: 50 LY saved/1000 patients, diabetes delayed 10 months, cost-saving (Fuller IJO 2014)

• Diabetes prevention programs – 4 large trials showing ~50% ↓ in diabetes conversion

– CDC guide (3 papers in Ann Int Med July 2015)

• Meta-analysis of 53 (efficacy) studies

• Cost effectiveness $13k/QALY gained

• Real world effectiveness: experience in Montana, YMCA, HMOs

Added value of monitoring

• Routine nature (awareness, ownership)

– Accepted normal practice

– Talking point

– Self-care paradigm

• Individual feedback (clinical intervention)

– Reality check (50% of parents of obese children think they are normal weight)

– Self-monitoring

• Local data feedback (community intervention)

• National data systems (‘white spots’, ‘black spots’)

Overweight & obesity prevalence

%

England’s National Child Measurement Program

0%

2%

4%

6%

8%

10%

12%

14%

Least

deprived

Most

deprived

Ob

esi

ty p

reva

len

ce

Index of Multiple Deprivation (IMD 2010) decile

2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13

0%

5%

10%

15%

20%

25%

30%

Least deprived

Most deprived

Ob

esit

y p

reva

len

ce

Index of Multiple Deprivation (IMD 2010) decile

2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13

4-5 year olds

By year &

deprivation

decile

10-11 year olds

By year &

deprivation

decile

England

child

monitoring

data

Programs

• Issues of evidence, scale, sustainability of effects, sustainability of programs, costs etc

• MEND program for children

– 2.4y F/U: improvements in all outcomes except BMIz (Kolotourou Childhood Obesity July 2015)

• Positive Parenting Program (PPP)

– Family-based intervention for children with obesity

– Significant BMIz effects over 12 months (West, Behav

Res Ther 2010)

• Others eg PEACH, Indigenous programs

Specific policies

• Healthy food service policies

– Schools and ECEs

– Government departments (led by Health)

– Other govt-related settings (eg hospitals, recreation centres, sporting venues)

– Supporting private sector action

• kJ labelling on fast food outlets

• Health-in-all policies (eg SA)

• Advocacy for national policies

– Restrict food marketing to children

– SSB taxes

– Uptake of Health Star Rating system

Sustainability of effects

Treatment

in adults

Prevention

in children - Community

- ?Individual

Swinburn Psych Clin N Am 2008

Barwon-South Western region

Geelong

Regional

population

~300,000

Geelong

population

~200,000

What is the intervention in CBIs?

• Community capacity building approach

– Leadership and commitment

– Funding and resources

– Organisational relationships and structures

– Knowledge and skills

• Multiple settings and participatory process

– The approach and process need to be robust

– Content is determined and specified by the community players

– Well evaluated

Bell et al Health Prom Int 2008

(Geelong) <5s 1

2004-‘08

1.8% (2y/o) & 2.7 %(3.5y/o)

over 3 y

$100k for 12,000 children

Δ behaviours and environments

Δ state prevalence (de Silva-Sanigorski Am J Clin Nutr 2010)

(Colac) 4-12 2

2002-’06

~1kg, 3cm waist over 3y

Greater effect in lower SES

children

No Δ ‘safety measures’

Sustained & ?spreading

influence (Sanigorski et al Int J Obesity 2008)

(E Geelong) 13-18

2004-‘08

5.8 % prevalence over 3 y

Δ community capacity

Δ in school environments

No Δ behaviours (Millar et al Obes Rev 2011)

Healthy Together Victoria

• Investment in a systems-based approach through local government

• Injection of capacity into 12 sites (~120 FTE)

• 2 years planning, 3 years intervention, change in govt, prevention defunded

• ‘Prevention virus’ was starting to spread after 3 years

• Non-HTV sites stimulated by HTV activity started their own processes

Big ‘P’ policy approach

• Greatest potential

• Needs political commitment

• Targets – include ↓ inequalities

• Risk of start/stop

• Accountability more explicit

Accountability framework

Summary

• Services: opportunities for ‘monitoring+’ approach

• Programs: need to be scalable & sustainable

• Policies: patchy implementation of agreed policies

• Community-based interventions: proof of principle for white populations

• Equity: Lack of evidence on effective approaches for high risk populations

• Systems approaches: ideal, prevention ‘virus’ spreads through networks, ‘bootstraps’ approach

• Big ‘P’ policy: start/stop funding, accountability