1. Public Health in local authorities – making sense of the big picture. (A case study using obesity as an example) Professor Malcolm Whitfield

2. The Health Problem Source: Professor Vilus Grabauskas, Professor, Chancellor of Kaunus Medical University, Lithuania.

3. The changing nature of disease Source: WHO Country Profiles - http://www.who.int/countries/en/

4. Prevention Dealing with increased demand Diagnosis & Treatment Blood Sugar Control Cardio- vascular events Heart Surgery Cataracts Amputations Foot ulcers Etc. Chronic Kidney Disease Blindness Immobility Public Health Primary Care Out Patients Acute / Secondary Care Long term Care TE AE (Example) - Diabetes

5. The building burden of disease Myocardial infarction Stroke Heart Failure Kidney Failure Diabetes Angioplasty Coronary bypass Dialysis Amputation Cataracts

6. The policy assumptions Demand 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

7. Quantifying the impact of lifestyle

8. Estimated impact of risk reduction – Birmingham East and North PopulationEstimate annual events (current risk levels) Estimate annual events (improved risk levels) Estimated annual events avoided Estimated events avoided over the 5 year period PCT Population (326,833) 6,0954,8981,1973,590 PopulationEstimate 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) 2,0771,768309928 PopulationEstimate annual costs (current risk levels) Estimate annual costs (improved risk levels) Estimated annual costs avoided Estimated cost avoided over 5 year period PCT Population (326,833) £17,825,274£14,451,497£3,373,777£10,121,330

9. North Karelia - Finland YearMen Women Smoking (%) Serum cholesterol (mmol/l) Blood pressure (mmHg) Smoking (%) Serum cholesterol (mmol/l) Blood pressure (mmHg) 1972526.9149/92106.8153/92 1977446.5143/89106.4141/86 1982366.3145/87156.1141/85 1987366.3144/88166.0139/83 1992325.9142/85175.6135/80 1997315.7140/84165.6133/80 2002335.7137/83225.5132/78 2007315.4138/83185.2134/78 Main risk factors in North Karelia between 1972 and 2007 among men and women aged 30-59 years

10. North Karelia - Finland Deaths Rate in 1969-1971 Rate in 2006 Change from 1969-1971 to 2006 All causes1509572-62% All cardiovascular855182-79% Coronary heart disease672103-85% All cancers27196-65% Lung cancers14730-80% 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.

11. Understanding the complexity? Policy Exercise Diet Healthcare Surgery Motivation Behaviour Environment Lifestyle Regulation Education Culture Leisure

12. May 2006 Classifying Interventions

13. May 2006 Classifying Evidence

14. May 2006 Weighing the evidence

15. May 2006 Linking interventions/evidence

16. May 2006 Linking interventions/evidence

17. May 2006 Modeling return on investment InterventionLevelTypeBudgetPartcipantsAge groupMean BMIImpact BMI Mean BMI Reduction Cost / BMI Unit Bariatric surgeryIndividualHealthcare£1,350,000.00150Adults4560.00%4050£333.33 Be Active and increased physical activity offersEnvironmentalPhysical activity£5,000,000.00330000Adults27.53.40%308550£16.20 Children’s healthy weight programmeGroup Lifestyle£25,000.00450Children201.40%126£198.41 Citywide obesity campaignPopulation Lifestyle£33,000.002500Adults27.50.50%343.75£96.00 Convenience stores4lifeEnvironmentalDiet£14,000.00900Adults27.51.00%247.5£56.57 Financial incentives and penalties for fast food take ways to encourage promotion of healthier optionsPolicyDiet£27,500.001300Adults27.50.50%178.75£153.85 Healthier catering award schemeEnvironmentalDiet£4,000.00100Adults27.51.00%27.5£145.45 Increased cycle routesEnvironmentalPhysical activity£350,000.004500Adults27.52.20%2722.5£128.56 Increased use of parksEnvironmentalPhysical activity£58,000.001250Adults27.52.20%756.25£76.69 Kids on track – obesity prevention for 3-4 yr oldsGroupDiet£87,000.004017Children202.00%1606.8£54.14 Level 3 specialist adult weight managementIndividualHealthcare£460,391.00331Adults403.40%450.16£1,022.73 Lighten UP – level 2 adult weight management programmeIndividual Lifestyle£369,000.001680Adults305.50%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£5,500.001300Adults27.53.40%1215.5£4.52 Maternal "lighten up" obesity pathwayIndividual Lifestyle£53,246.00450Adults303.00%405£131.47 My ChoiceIndividual Lifestyle£53,200.00172Adults27.54.00%189.2£281.18 Nutrition standards in care homes, hostels, children’s homesEnvironmentalDiet£9,450.00340Adults27.51.00%93.5£101.07 Online weight management programmes – commit2Bfit and choose2BslimIndividual Lifestyle£6,000.001400Adults27.53.00%1155£5.19 Primary care brief interventionsIndividual Lifestyle£32,000.00250Adults27.53.00%206.25£155.15 Startwell - early years settings healthy living quality improvement programmeEnvironmental Lifestyle£38,000.006000Children203.40%4080£9.31 Whole school day approach to nutrition and healthEnvironmental Lifestyle£45,000.00400Children203.40%272£165.44 Workplace health initiativeEnvironmental Lifestyle£8,500.00120Adults27.53.40%112.2£75.76

18. Thank you