Download Lifestyle: Obesity and Smoking – and the Health of the Population

Public Health Norfolk
Lifestyle: Obesity and Smoking – and the Health of the
Population
Dr Abhijit Bagade
Consultant in Public Health Medicine
January 2015
1
Contents
Executive summary ................................................................................................................................. 4
Obesity .................................................................................................................................................... 7
Definitions ............................................................................................................................................... 8
Causes of obesity .................................................................................................................................... 9
Epidemiology: the size of the problem ................................................................................................. 10
Great Yarmouth and Waveney situation .............................................................................................. 13
The impact of obesity ........................................................................................................................... 18
Health impact .................................................................................................................................... 18
Obesity and mortality ....................................................................................................................... 21
Impact on Education ......................................................................................................................... 22
Impact on Social care ........................................................................................................................ 23
Economic impact ............................................................................................................................... 24
Benefits of weight loss in patients with comorbidities ......................................................................... 26
Lifestyle and behaviours ....................................................................................................................... 27
Physical activity ................................................................................................................................. 27
Nutrition............................................................................................................................................ 28
What motivates people’s decisions and choices? ................................................................................ 29
Opportunities to influence behaviour .................................................................................................. 30
Different types of policy interventions to tackle obesity ..................................................................... 32
The Policy challenge .......................................................................................................................... 32
Options for policy responses ............................................................................................................ 33
NICE guidance ....................................................................................................................................... 36
NICE Pathways ...................................................................................................................................... 42
Obesity Care Pathway ........................................................................................................................... 44
Smoking................................................................................................................................................. 46
Benefits of quitting smoking ................................................................................................................. 48
Lifestyle and cancers ............................................................................................................................. 50
Impact of lifestyle factors on surgical outcomes .................................................................................. 51
Impact of obesity on surgical outcomes ............................................................................................... 52
Obesity as a risk factor during anaesthesia ...................................................................................... 52
General Surgery ................................................................................................................................ 53
Hip and Knee replacement surgery .................................................................................................. 53
Other Orthopaedic surgery ............................................................................................................... 55
Cardiac surgery ................................................................................................................................. 56
Gastrointestinal cancer surgery ........................................................................................................ 56
Cranial surgery .................................................................................................................................. 57
2
Spinal surgery .................................................................................................................................... 57
Gynaecological surgery ..................................................................................................................... 58
Renal surgery .................................................................................................................................... 58
Impact of smoking on surgical outcomes ............................................................................................. 59
Wound-related complications .......................................................................................................... 60
Pulmonary complications ................................................................................................................. 60
Cardiovascular complications ........................................................................................................... 61
Non-union of bone fusion ................................................................................................................. 61
Need for secondary surgery .............................................................................................................. 61
Length of Stay ................................................................................................................................... 61
Duration of pre-elective smoking cessation to get benefit .................................................................. 62
Benefits of quitting before surgery ....................................................................................................... 63
Economic impact of smoking cessation before surgery ....................................................................... 64
Efficacy of smoking cessation interventions in preoperative smoking cessation................................. 65
Medical triggers and long term behaviour change ............................................................................... 67
Recommendations: ............................................................................................................................... 70
References: ........................................................................................................................................... 71
3
Executive summary
This paper attempts to present the Public Health aspects of obesity and smoking, looking at
the size of the problem, its impact on health, social care, education, economy and
sustainability of services; provides information on options to change behaviour, the NICE
recommendations and a review of the evidence of impact on obesity and smoking on
surgical outcomes. This paper goes into much more details about obesity, as the impact of
smoking on health and wider aspects is well known; only brief information on smoking is
given here.
Obesity:
The rate of increase in overweight and obesity, in children and adults, is striking.
Obesity is a consequence of abundance, convenience and underlying biology. It might also
be viewed as the perverse outcome of constantly expanding ‘choice’.
Body mass index (BMI) is routinely used to measure overweight and obesity.
The causes of obesity are complex and multifaceted, pointing to a range of different
solutions.
The proportion who were categorised as obese (BMI 30kg/m2 or over) increased from 13.2%
of men in 1993 to 26% in 2013 and from 16.4% of women in 1993 to 23.8% in 2013.
It is estimated that by 2050, 60% of adult men, 50% of adult women and 25% of children
may be obese.
The population of Great Yarmouth and Waveney is projected to increase by about 30,000 by
2035 (all ages). However, the impact of obesity on the health of the population and on the
disease profile and sustainability of the health services is going to be significantly greater
than the modest increase in population growth.
Diabetes is clearly related to high BMI, and this rate of increase is perhaps not that
surprising. However, the figures show that obesity has a major impact on almost all the long
term conditions. This is going to be a huge challenge for the sustainability of primary as well
as secondary care services in Great Yarmouth and Waveney.
4
Obesity and overweight have significant implications for health, social care, the economy
and are also associated with educational attainment. Obesity is also a good predictor of an
individual’s risk of death.
The financial consequences of obesity are not limited to direct costs to health and the NHS.
Overweight and obesity also have financial implications for the wider economy through, for
example, working days lost, increased benefit payments and social care costs.
The cost to society and the economy of people being overweight or obese was estimated at
almost £16 billion in 2007 (more than 1% of gross domestic product). It could rise to just
under £50 billion in 2050 (based on 2007 prices), if obesity rates continue to rise unchecked.
Even a relatively small amount of weight loss will decrease the chance of associated
illnesses; however, more the weight loss the greater the health benefits.
People’s attitudes and responses are key drivers of obesity trends. What motivates and
determines health-related behaviour is complex.
The evidence indicates a number of points in the life course where there may be specific
opportunities to influence behaviour.
Medical triggers have been shown to promote long-term behaviour change. A medical
trigger is for example a doctor telling a patient to lose weight and/or a family member after
an adverse event or to prevent it. It is sometimes called as the Nudge factor.
The NICE guidance recommends key priorities for implementation, and has also published
pathways to be used by clinicians.
The services commissioned for the management of overweight and obesity are categorised
form Tier 1 (universal interventions on a population basis) to Tier 4 (bariatric surgery).
Smoking:
England has made significant strides in reducing smoking, but it still remains the main cause
of preventable illness and premature death in England.
It is the primary reason for the gap in healthy life expectancy between rich and poor and is
estimated to cost the NHS £1.5 billion per year.
One in two regular smokers is killed by tobacco – half dying before the age of 70, losing an
average 21 years of life.
5
Smoking is a major risk factor for many diseases, such as lung cancer, chronic obstructive
pulmonary disease and heart disease.
Obesity and smoking are recognised as risk factors and have a substantially increased risk of
surgical complications, increasing perioperative morbidity and mortality in surgical patients.
A summary of evidence is provided in this paper.
6
Obesity
In recent years, Britain has become a nation where being overweight has become usual,
rather than unusual. The rate of increase in overweight and obesity, in children and adults,
is striking. Obesity threatens the health and well-being of individuals and will place an
intolerable burden on the Exchequer in terms of health costs, on employers through lost
productivity and on families because of the increasing burden of long-term chronic
disability.
Obesity is a consequence of abundance, convenience and underlying biology. It might also
be viewed as the perverse outcome of constantly expanding ‘choice’.
Extensive media coverage has ensured that we’re all aware that obesity is on the increase.
But popular views on the issue all too often draw on stereotypes, present simplified
descriptions of the problem, and have an unrealistic assessment of the solutions. It’s not
surprising that the median body mass index in the UK is now above that considered to be in
the ‘healthy’ range. We evolved in a world of relative food scarcity and hard physical work –
obesity is one of the penalties of the modern world, where energy-dense food is abundant
and labour-saving technologies abound.
Although personal responsibility plays a crucial part in weight gain, human biology is being
overwhelmed by the effects of today’s ‘obesogenic’ environment, with its abundance of
energy dense food, motorised transport and sedentary lifestyles. As a result, the people of
the UK are inexorably becoming heavier simply by living in the Britain of today. This process
has been coined ‘passive obesity’.1
7
Definitions
Body mass index (BMI) is routinely used to measure overweight and obesity. BMI = weight
(kg) divided by height (m2). The following figures are based on a report by the International
Obesity Task Force (IOTF) and refer to a Caucasian population.
BMI:
Underweight: <18.5
Healthy weight: 18.5–24.9
Overweight: 25.0–29.9
Obese class I: 30–34.9
Obese class II: 35–39.9
Obese class III: ≥40.0
The use of lower BMI thresholds (23 kg/m2 to indicate increased risk and 27.5 kg/m2 to
indicate high risk) to trigger action to reduce the risk of conditions such as type 2 diabetes,
has been recommended for black African, African-Caribbean and Asian (South Asian and
Chinese) groups.
8
Causes of obesity
The causes of obesity are complex and multifaceted, pointing to a range of different
solutions. At the heart of this issue lies a homeostatic biological system that struggles to
maintain an appropriate energy balance and therefore body weight. This system is not well
adapted to a changing world, where the pace of technological progress and lifestyle change
has outstripped that of human evolution. Human biology, growth and development early in
life, eating and physical activity behaviours, people's beliefs and attitudes and broader
economic and social drivers all have a role to play in determining obesity.
The scientific evidence has identified key determinants of vulnerability. These are:
•
primary appetite control in the brain
•
the force of dietary habits, keeping individuals from adopting healthier alternatives
•
the level of physical activity
•
the psychological ambivalence experienced by individuals in making lifestyle choices.
The central dynamic of the obesity system is a positive feedback cycle that locks us into a
pattern of positive energy balance as individuals and at a societal level. This ‘lock-in’ is a
powerful force that, when well-intentioned interventions are made, can give rise to
unexpected consequences both for individuals – e.g. compensatory changes in eating and
activity – and for society – e.g. the drive to make food cheaper, which may increase the
amount eaten.2
These four key determinants, combined with the lock-in to a positive feedback cycle, are
driving excess weight gain in an increasing proportion of the UK population. In addition,
many of the other determinants in the obesity system map are driven by powerful forces,
such as the need for more time or convenience, the desire to reduce stress, the availability
of greater choice, and the desire for short-term rewards or compensations.
9
Epidemiology: the size of the problem
The prevalence of obesity among adults has increased sharply during the 1990s and early
2000s. The proportion who were categorised as obese (BMI 30kg/m2 or over) increased
from 13.2% of men in 1993 to 26% in 2013 and from 16.4% of women in 1993 to 23.8% in
2013. In 2012, around a quarter of adults in England (24% of men and 25% of women aged
16 or older) were classified as obese (body mass index [BMI] 30 kg/m2 or more). A further
42% of men and 32% of women were overweight (BMI 25 to 30 kg/m2).3
In addition 9.9% of boys and 9.0% of girls (all children 9.5%) in Reception year (aged 4-5
years) and 20.8% of boys and 17.3% of girls (all children 19.1%) in Year 6 (aged 10-11 years)
are also classified as obese according to the British 1990 population monitoring definition of
obesity (≥95th centile) (National Child Measurement Programme 2013/14).
The obesity crisis is a major social, economic, health and financial issue and it continues to
escalate. It is estimated that by 2050, 60% of adult men, 50% of adult women and 25% of
children may be obese.4
Figure 1: Trend in obesity (BMI ≥ 30kg/m2) prevalence among adults (aged 16+): 1993-2012
(3-year average)
30%
Women
Men
Prevalence of obesity
25%
20%
15%
10%
5%
0%
Health Survey for England 1993-2012; http://www.hscic.gov.uk/catalogue/PUB13219
10
The graph above shows the trend in obesity prevalence from 1993-2012. It shows that
obesity prevalence remains higher for women, but the gap between men and women
appears to have narrowed over time.
The trend in severe obesity (BMI ≥ 40) shows that severe obesity prevalence is much higher
for women than men.
Figure 2: Trend in severe obesity (BMI ≥ 40kg/m2) prevalence among adults (aged 16+):
1993-2012 (3-year average)
4.0%
Women
3.5%
Men
Prevalence of severe obesity
3.0%
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
Health Survey for England 1993-2012; http://www.hscic.gov.uk/catalogue/PUB13219
The prevalence of obesity has an almost linear correlation – increase in deprivation leads to
increase in the prevalence of obesity.
Figure 3: Adult obesity prevalence by deprivation
40%
Men
Women
35%
Obesity prevalence
30%
31.5%
30.1%
25%
26.2%
20%
23.7%
21.2%
25.3%
26.0%
26.6%
25.5%
22.6%
15%
10%
5%
0%
Least deprived
Index of Multiple Deprivation 2007 quintile
Most deprived
Health Survey for England 2007-2011.
11
The maps below show how the levels of obesity have changed throughout the country.
Figure 4: Trends in levels of obesity (%) in males and females from 1994 to 2002 in England
and Scotland5
12
Great Yarmouth and Waveney situation
The population of Great Yarmouth and Waveney is projected to increase by about 30,000 by
2035 (all ages). However, the impact of obesity on the health of the population and on the
disease profile and sustainability of the health services is going to be significantly greater
than the modest increase in population growth (see Figures below).
The data below is adapted from the analysis and modelling done by Tim Winters and
colleagues from the Public Health Norfolk Information Team and their report ‘Estimating the
impact of long term conditions and obesity in NHS Great Yarmouth and Waveney’.
Figure 1 below shows the change in population for all ages to 2035. Figure 2 shows
estimates of obesity in all age groups.
Figure 5: Change in age profile for NHS Great Yarmouth and Waveney
Figure 6: Estimated change in total obese population
13
From Figure 3 onwards, the graphs focus on ages above 60 years, as long term conditions
have a relatively greater impact in the older age groups.
Figure 7: Estimated change in age profile for people aged 60+ NHS Great Yarmouth and
Waveney
Figure 8: Estimated change in numbers of people aged 60 and over who are obese
14
The modelling below clearly shows the disproportionate increase in long term conditions in
the obese group as compared to those of normal weight.
Figure 9: Estimated change in numbers of people aged 60 and over with CHD
Figure 10: Estimated change in numbers of people aged 60 and over with Stroke
15
Figure 11: Estimated change in numbers of people aged 60 and over with Hypertension
Figure 12 Estimated change in numbers of people aged 60 and over with COPD
16
Figure 13: Estimated change in numbers of people aged 60 and over with Diabetes
Diabetes is clearly related to high BMI, and this rate of increase is perhaps not that
surprising. However, the figures show that obesity has a major impact on almost all the long
term conditions. This is going to be a huge challenge for the sustainability of primary as well
as secondary care services in Great Yarmouth and Waveney.
17
The impact of obesity
Obesity and overweight have significant implications for health, social care, the economy
and are also associated with educational attainment.
Being obese or overweight increases the risk of developing a range of serious diseases,
including heart disease and cancers. The impact of obesity on the health of adults has long
been established, but rising levels of childhood obesity has consequences for the health of
children and young people in both the short and the longer term.
Obesity is also linked with:
•
Educational attainment - there is a general trend of rising obesity prevalence with
decreasing level of education.
•
Social care - obesity is associated with the development of long-term health conditions,
placing demands on social care services.
Overweight and obesity and their associated health problems have a significant economic
impact on the NHS. In addition to these direct health care costs, obesity has financial
implications for the wider economy through, for example, loss of productivity and benefit
payments.
Health impact
Being overweight or obese increases the risk of a wide range of chronic diseases, principally
type 2 diabetes, hypertension, cardiovascular disease including stroke, as well as cancer. It
can also impair a person’s well-being, quality of life and ability to earn. The risk for individual
diseases is given below.6
Type 2 diabetes
90% of Type 2 diabetics have a body mass index (BMI) of >23 kg/m2
Hypertension
5 fold risk in obesity
66% of hypertension is linked to excess weight
85% of hypertension is associated with a BMI >25 kg/m2
18
Dyslipidaemia progressively develops as BMI increases from 21 kg/m2 with rise in small
particle low-density lipoprotein (LDL)
Coronary artery disease (CAD) and stroke
2.4 fold in obese women and two-fold in obese men under the age of 50 years
70% of obese women with hypertension have left ventricular hypertrophy
Obesity is a contributing factor to cardiac failure in >10% of patients
Overweight/obesity plus hypertension is associated with increased risk of ischaemic stroke
Respiratory effects
Neck circumference of >43 cm in men and >40.5 cm in women is associated with obstructive
sleep apnoea, daytime somnolence and development of pulmonary hypertension
Cancers
10% of all cancer deaths among non-smokers are related to obesity (30% of endometrial
cancers)
Reproductive function
6% of primary infertility in women is attributable to obesity
Impotency and infertility are frequently associated with obesity in men
Osteoarthritis (OA)
Frequent association in the elderly with increasing body weight – risk of disability
attributable to OA equal to heart disease and greater than any other medical disorder of the
elderly
Liver and gall bladder disease
Overweight and obesity associated with non-alcoholic fatty liver disease and non-alcoholic
steatohepatitis (NASH). 40% of NASH patients are obese; 20% have dyslipidaemia
3 fold risk of gall bladder disease in women with a BMI of >32 kg/m2; 7 x risk if BMI of >45
kg/m2
19
Risk factors for some conditions start to increase at relatively low BMIs (e.g. hypertension
and type 2 diabetes). Eighty-five per cent of patients with hypertension have a BMI of
>25kg/m2 and 90% of those with type 2 diabetes have a BMI >23kg/m2.
The risk of developing type 2 diabetes is about 20 times more likely for people who are
obese compared to lean people.
Abdominal obesity is a particular risk for the cluster of diseases that have become known as
the metabolic syndrome – type 2 diabetes, hypertension, and dyslipidaemia – and is
strongly linked to an increased risk of cardiovascular disease.
Thirty per cent of middle-aged people in developed countries have features of the metabolic
syndrome. Its association with abdominal fat suggests that specific measures of excess
weight distribution in the body may be more accurate predictors of disease among some
groups than measures such as BMI. However, these are harder to establish and so are less
commonly recorded and reported than BMI.
The analysis indicates that the greatest increase in the incidence of disease would be for
type 2 diabetes (a >70% increase by 2050) with increases of 30% for stroke and 20% for
coronary heart disease over the same period.7
Women who are obese are estimated to be around 13 times more likely to develop type 2
diabetes and 4 times more likely to develop hypertension than women who are not obese.
Men who are obese are estimated to be around 5 times more likely to develop type 2
diabetes and 2.5 times more likely to develop hypertension than men who are not
obese3,8,9.
People who are obese may also experience mental health problems as a result of stigma and
bullying or discrimination in the workplace10.
20
Measurement of BMI and waist circumference gives an estimate of health risk to a person
as seen below:
Low
Men: <94cm
Women: <80cm
Waist circumference
High
Men: 94-102cm
Women: 80-88cm
Very high
Men: >102cm
Women: >88cm
Underweight
(Not Applicable)
Underweight
(Not Applicable)
Underweight
(Not Applicable)
No increased risk
No increased risk
Increased risk
2
No increased risk
Increased risk
High risk
2
Increased risk
High risk
Very high risk
Very high risk
Very high risk
Very high risk
BMI
Underweight
2
(<18.5kg/m )
Healthy weight
2
(18.5-24.9kg/m )
Overweight
(25-29.9kg/m )
Obese
(30-34.9kg/m )
Very obese
2
(≥40kg/m )
Obesity and mortality
There is a great deal of evidence which demonstrates that obesity measured either by BMI
or waist circumference (as a measure of central adiposity), is a good predictor of an
individual’s risk of death. A number of large scale prospective studies have demonstrated a
‘J-shaped’ association between BMI and risk of death, with higher risks of death observed in
the lower and upper BMI categories than in the middle categories.
Figure 14: Schematic illustration of the association between mortality and BMI for adults
21
A comprehensive review of 57 international prospective studies found that Body Mass Index
(BMI) is a strong predictor of mortality among adults. Moderate obesity (BMI 30-35) has
been found to reduce life expectancy by an average of three years, while severe obesity
(BMI 40-50) reduces life expectancy by eight to ten years.11 This 8-10 year loss of life is
equivalent to the effects of lifelong smoking. Around 8% of annual deaths in Europe (at least
one in 13) have been attributed to overweight and obesity.
Impact on Education
Obesity is associated with educational attainment. Men and women who have fewer
qualifications are more likely to be obese. Around a third of adults who leave school with no
qualifications are obese, compared with less than a fifth of adults with degree level
qualifications. Part of the reason for this is that levels of educational attainment are linked
to levels of inequality and deprivation. People who are socioeconomically deprived tend to
have poorer health and lower levels of education. In addition, low achievement at school
among obese children may be due to a variety of factors such as poor psychological health,
teasing, bullying and discrimination, low self-esteem, disturbed sleep, absenteeism and less
time spent with friends or being physically active.
Figure 15: Adult obesity prevalence by highest level of education (2006-2010)
Health Survey for England. Adult obesity: BMI ≥30kg/m
2
22
Impact on Social care
There is an important link between obesity and social care. Obesity is a contributory factor
to the development long term conditions such as diabetes and cardiovascular disease. In
addition, severe obesity can result in physical and social difficulties which impact on social
care. Increasing obesity prevalence along with the growing needs of an ageing population,
the rise in non-communicable diseases associated with obesity, and rising public
expectations for service intervention and treatment present significant challenges and cost
implications to both the health and social care systems.
Obesity and long term conditions:
Obesity is associated with a number of long term conditions that place a significant burden
on the social care system.12 These include mental health problems, liver disease, type 2
diabetes, cardiovascular disease, muscular skeletal disease, some cancers, and respiratory
disease.13,14,15 While life expectancy has improved over time, the length of time people
spend in ill health towards the end of life has increased.12 In England more than 15 million
people have a long term condition and the care of people with long term conditions
accounts for 70% of total health and social care spend.16
Individuals with severe obesity:
Adults with severe obesity may have physical difficulties which inhibit activities of daily
living. This can have resource implications for social care services including:
•
housing adaptations such as specialist mattresses, doors, toilet frames, hoists and stair
lifts
•
specialist carers (trained in manual handling of severely obese people) for people who
are house bound and have difficulties caring for themselves
•
provision of appropriate transport and facilities (such as bariatric patient transport and
specialist leisure services).
23
Economic impact
The increasing prevalence of obesity is a major public health challenge both nationally and
internationally. The financial consequences of obesity however are not limited to direct
costs to health and the NHS. Overweight and obesity also have financial implications for the
wider economy through, for example, working days lost, increased benefit payments and
social care costs.
Foresight, in his report gave some projections of the cost pressures due to the impact of
obesity on various long term conditions and the resultant costs to the NHS (see Table 1).Error!
Bookmark not defined.
Table 1: Calculating future costs of elevated BMI (£ billion/year)Error! Bookmark not defined.
NHS Costs
Total NHS costs of diabetes
Total NHS costs of coronary heart disease
Total NHS costs of stroke
Total NHS costs of other related diseases
Total costs (all related diseases)
NHS cost increase above current, due to elevated BMI
(overweight and obesity)
NHS costs attributable to elevated BMI (overweight
and obesity)
NHS costs attributable to obesity alone
Wider total costs of overweight and obesity, taken at
7x direct costs
Projected % of NHS costs @ 70 billion
2007
2.0
3.9
4.7
6.8
17.4
2015
2.2
4.7
5.2
7.4
19.5
2025
2.6
5.5
5.6
7.8
21.5
2050
3.5
6.1
5.5
7.8
22.9
-
2.1
4.1
5.5
4.2
6.3
8.3
9.7
2.3
3.9
5.3
7.1
15.8
27
37.2
49.9
6.0%
9.1%
11.9%
13.9%
The cost to society and the economy of people being overweight or obese was estimated at
almost £16 billion in 2007 (more than 1% of gross domestic product). It could rise to just
under £50 billion in 2050 (based on 2007 prices), if obesity rates continue to rise
unchecked.Error! Bookmark not defined.,8 It is estimated that overweight and obesity now costs the
NHS £5.1 billion per year. However, if current trends continue, these costs will increase by
an additional £1.9 billion per year by 203017.
24
In 2007 estimates of the direct NHS costs of treating overweight and obesity, and related
morbidity in England were £4.2 billion and estimated to be £6.3 billion in 2015. Modelled
projections suggest that indirect costs of obesity could be as much as £27 billion by 2015. It
is estimated that by 2050 the NHS cost attributable to obesity and overweight would be
£9.7 billion and the total costs would be £49.9 billion (at 2007 prices).
The social care costs to local authorities for the care of house-bound residents suffering
from obesity related illnesses, including arthritis, heart disease and diabetes and those
requiring help towards walking aids and home adaptations may be considerable – and likely
to increase in line with national predictions for obesity prevalence.
25
Benefits of weight loss in patients with comorbidities
Even a relatively small amount of weight loss will decrease the chance of associated
illnesses; however, the more weight lost the greater are the health benefits.8
Treating obesity has good health consequences, including decreased risk of premature
death and of chronic conditions which reduce quality of life.18 The aim should be to reduce
weight and to maintain that reduction. As weight is lost, the risk of other associated illness
decreases. Targets for weight loss should be agreed with each patient, however often a goal
of 10% weight loss after six months is suitable. The table shows the health benefit of weight
loss in obese patients.
Benefits of a 10% weight loss in patients with co-morbidities18
Mortality
20-25% fall in total mortality
30-40% in diabetes-related deaths
40-50-% fall in obesity-related cancer deaths
Blood pressure
Fall of approximately 10mmHG in both systolic and diastolic values
Diabetes
Reduces risk of developing diabetes by > 50%
Fall of 30 – 50% in fasting glucose
Fall of 15% in HbA1c
Lipids
Fall of 10% in total cholesterol
Fall of 15% in LDL
Fall of 30% in triglycerides
Increase of 8% in HDL
26
Lifestyle and behaviours
Lifestyle and behaviour choices are important factors in influencing weight status.
Unhealthy diets and physical inactivity are major risk factors for overweight and obesity as
well as a number of chronic health conditions including cardiovascular disease, diabetes,
some cancers and high blood pressure.
Physical activity
Physical activity includes all forms of activity, such as walking or cycling for everyday
journeys, active play, work-related activity, active recreation (such as working out in a gym),
dancing, swimming, gardening or playing games as well as competitive and non-competitive
sport.
Physical activity is a key determinant of energy expenditure and a fundamental part of
energy balance and weight control. Regular physical activity can reduce the risk of obesity,
as well as many chronic conditions including coronary heart disease, stroke, type 2 diabetes,
cancer, mental health problems and musculoskeletal conditions.19
The Department of Health recommends that adults accumulate at least 150 minutes (2.5
hours) of moderate-intensity aerobic activity (i.e. cycling or fast walking) every week and
children over five should engage in at least 60 minutes (1 hour) of moderate to vigorous
intensity physical activity every day.20 Physical activity that can be incorporated into
everyday life, for example brisk walking and cycling has been found to be as effective for
weight loss as supervised exercise programmes.
Sedentary behaviour is also linked to overweight and obesity and likely to be independently
associated with all-cause mortality, type 2 diabetes, some types of cancer and metabolic
dysfunction. Sedentary behaviours in adults are impacted by age, gender, socio-economic
conditions, occupation, weight status and some characteristics of the physical environment.
These relationships are independent of the level of overall physical activity. For example,
27
spending large amounts of time being sedentary may increase the risk of some health
outcomes, even among people who are active at the recommended levels.
Nutrition
Consumption of excess calories is often due to over consumption of high energy foods and
drinks such as processed or fast food, sweetened and alcoholic drinks, or large portion sizes.
There is also evidence that eating habits are perpetuated through families and cultures, and
are often maintained from child through to adulthood.
Adults are more likely to maintain a healthy weight if they reduce consumption of high
energy-dense foods and drinks and consume a lower-fat, high fibre diet, consisting of fruit,
whole grains, vegetables, lean meat and fish.
Healthy eating is associated with decreased risk of overweight and obesity and chronic
diseases, including type 2 diabetes, hypertension, and certain cancers. However, there is a
large gap between nutrition recommendations and what the data shows we actually eat.
For example, in England, the Health Survey for England reports that less than a third of
adults currently meet the ‘five a day’ target for fruit and vegetables.
28
What motivates people’s decisions and choices?
Our attitudes and responses are also key drivers of obesity trends. Ambivalence emerges as
a key driver of obesity. 2,21,22,23,24,25,26,27 Research in social psychology tells us a great deal
about how people make their decisions. What motivates and determines health-related
behaviour is complex, but in modern societies, there is a psychological conflict between
what people want (e.g. fatty, sweet foods) and their desire to be healthy and/or slim. Mixed
feelings and beliefs about healthy lifestyle choices complicate individual choices. For
instance, most people know that eating fatty foods in excess is generally bad for them while
taking exercise is generally beneficial. Yet they tend to enjoy eating foods that are high in
calories or excessive salt and find it difficult to find the time to exercise. No one escapes this
psychological conflict or ‘ambivalence’.28 People who are highly ambivalent will carefully
scrutinise any relevant information before making a decision. They take note if messages
are overly simplistic and identify flaws more readily. They may then form more negative
attitudes towards recommended behaviours – evidence shows examples of messages failing
accordingly. Ambivalent people tend to respond to messages in a polarised fashion –
extremely positively or negatively.23,25,28 In addition, many people do not perceive obesity as
an issue that affects them personally and consequently public demand for significant action
is relatively weak.23,25 This reinforces the importance of designing options for healthy
behaviour or ‘cues’ for behavioural change that can become usual practice and which will
influence those not yet ready to make active choices.
People often find it difficult to translate into action good intentions based on a long-term
goal and benefit. There is a risk of failing to start or failing later on if there is an actual or
perceived lack of time, forgetfulness and initial reluctance as short-term costs loom large.
Evidence suggests that prior planning and thinking through possible distractions can help
overcome these risks of failing as people become ‘perceptually ready’ to respond when
temptation occurs. Distractions, stress and environmental influences are critical at this stage
and can help or hinder maintenance of new behaviours.
29
Opportunities to influence behaviour
The evidence to date indicates a number of points in the life course where there may be
specific opportunities to influence behaviour. These relate to critical periods of metabolic
plasticity (e.g. early life, pregnancy, menopause), times linked to spontaneous changes in
behaviour (e.g. leaving home, becoming a parent), or periods of significant shifts in attitudes
(e.g. peer group influences, diagnosis of ill health).
Critical opportunities for intervention during an individual’s life courseError! Bookmark not defined.:
It is important to note that there is no one point in the life course where intervention is
particularly successful but that progress through life offers a number of naturally occurring
opportunities such as metabolic plasticity or behaviour change.
Breast-feeding and early growth patterns provide the only period in which there is clear
evidence to support the concept of a critical period of development associated with longterm consequences.29,30 Other stages of life, however, may offer good opportunities to
30
modify behaviour. For example, there is some limited evidence that behaviours, such as
liking fruit and vegetables, can be established in early childhood31, and it is important to
note that the most significant predictor of child obesity is parental obesity (obesity in a
parent increases the risk of childhood obesity by 10%)32. Meanwhile, in older adults,
effective interventions associated with modest weight loss have been shown to reduce the
healthcare costs arising from associated chronic diseases such as diabetes.33,34
Interventions based on improved nutrition and increased physical activity can be effective
for individuals. But shifting the population distribution of obesity will require interventions
that target elements of the obesogenic environment as well.
Opportunities in the built environment35:
Provision of facilities for sport and formal exercise is an important part of a strategy to
counter obesity. However, their lower usage by people of lower socioeconomic status,
combined with the need to increase total activity levels across society, not merely among
those motivated to engage in sports, suggests additional action needs to be taken.36 There
are other ways to increase physical activity through designing opportunities for health and
activity into architecture and urban design.
Solutions to address the obesogenic environment such as changes in transport
infrastructure and urban design can be more difficult and costly than targeting intervention
at the group, family or individual.
It is unlikely that our biological predisposition to gain weight in a modern society can itself
be modified significantly in the medium term. Nevertheless, it is possible to ensure that
physiological development is optimal to reduce our vulnerability to the ‘obesogenic
environment’ and the risk of obesity and associated chronic disease. Early life interventions
such as breast-feeding, healthy weaning practices and appropriate maternal nutrition have
all been linked to reduced obesity later in life.
31
Different types of policy interventions to tackle obesity
The Policy challenge
The prevalence of obesity is a major challenge, not just for medicine and public health but
for governance and decision making. The deceptively simple issue of encouraging physical
activity and modifying dietary habits, in reality, raises complex social and economic
questions about the need to reshape public policy in food production, food manufacturing,
healthcare, retail, education, culture and trade. In some respects, the objectives of previous
eras, for example, improvements in food availability or opportunities for personal travel,
now need reassessment in a time when energy-dense food is ubiquitous and transport
choices restrict walking or cycling.
Evidence shows that a substantial degree of intervention is required to affect an impact on
the rising trend in obesity. A systemic or paradigm shift is needed to disrupt the cycle of
accumulation of fat and to restore balance.
32
Achieving this would inevitably require some fundamental choices to be made, raising a
range of ethical issues. Developing a mandate for such a shift is a formidable challenge.
However, much progress could be made by creating a new framework for delivering an
integrated strategy of prevention.
The main challenge of obesity is that as the prevalence of obesity rises, it will become
normal to be obese, which may dilute calls to action.
A higher priority for the prevention of health problems is needed, with clearer leadership,
accountability, strategy, resource and management structures. To succeed in tackling
obesity, it is critical that the health of the population is seen as a priority.
Tackling obesity is fundamentally an issue about healthy and sustainable living for current
and future generations. There is therefore an urgent need for leadership, vision and above
all, sustained commitment. This is crucial if the prospect of 60% of the UK population being
obese in less than 50 years, with its attendant costs, is to be prevented from becoming
reality.
Options for policy responses
ForesightError! Bookmark not defined. considered the following options for policy responses:
The built environment and transport
1 Introduce health as a significant criterion in all planning procedures (including new build
and upgrading of the current infrastructure)
2 Improve the perceptions of safety from the points of view of traffic and crime
3 Increase the ‘walkability’ and ‘cyclability’ of the built environment (urban and rural)
Health
4 Focus on targeted interventions, such as when children are young, and targeting those
most ‘at risk’
5 Implement population-wide interventions i.e. focus on improving the health and wellbeing of the population as a whole
6 Focus on the health consequences of obesity, such as diabetes, rather than obesity itself
33
Research
7 Invest in the search for a highly effective post-hoc solution to obesity – a ‘magic pill’
8 Introduce toolkits to evaluate the success of obesity interventions and policies throughout
the whole of the delivery chain
Fiscal incentives
9 Introduce a tax on obesity-promoting foods
10 Use fiscal levers to make all organisations/institutions take some responsibility for the
health of their employees (public and private sectors)
11 Use individually targeted fiscal measures to promote healthier living
Education
12 Introduce programmes to increase food literacy and food skills
Regulation
13 Control availability of and exposure to obesogenic foods and drinks
Social structure
14 Take a directive approach to changing cultural norms in order to establish healthy living
as the default within UK society
15 Invest in technology to support informed individual choice, including devices to help
monitor diet and activity
Family
16 Promote/implement a programme of early interventions at birth or infant stages
17 Penalise parents for the unhealthy lifestyles of their children
The top five policy responses assessed by Foresight as having the greatest average impact
on levels of obesity across the scenarios were:
•
increasing walkability/cyclability of the built environment
•
targeting health interventions for those at increased risk (dependent on ability to
identify these groups and only if reinforced by public health interventions at the
population level)
•
controlling the availability of/exposure to obesogenic foods and drinks
•
increasing the responsibility of organisations for the health of their employees
•
early life interventions at birth or in infancy.
34
The government's obesity strategy 'Healthy lives: a call to action on obesity in England'
aimed to reduce, 'the level of excess weight averaged across all adults by 2020'. It
advocated a range of local interventions that both prevent obesity and treat those who are
already obese or overweight.8
35
NICE guidance
The National Institute for Health and Care Excellence has produced various guidelines to
plan and manage the impact of public health issues like obesity, physical activity and
smoking. The summary below covers the guidance and pathways on obesity.
The NICE guidance37,38 aims to:
•
stem the rising prevalence of obesity and diseases associated with it
•
increase the effectiveness of interventions to prevent overweight and obesity
•
improve the care provided to adults and children with obesity, particularly in primary
care.
Rationale for integrated clinical and public health guidance
Public health and clinical audiences share the same need for evidence-based, cost-effective
solutions to the challenges in their day-to-day practice, as well as to inform policies and
strategies to improve health. Complementary clinical and public health guidance are
essential to address the hazy divisions between prevention and management of obesity.
The 2004 Wanless report 'Securing good health for the whole population' stressed that a
substantial change will be needed to produce the reductions in preventable diseases such as
obesity that will lead to the greatest reductions in future healthcare costs. In addition to
recommending a more effective delivery framework for health services providers, the report
proposed an enhanced role for schools, local authorities and other public sector agencies,
employers, and private and voluntary sector providers in developing opportunities for
people to secure better health.
NICE Key priorities for implementation – for Public Health and Clinical Care:
The prevention and management of obesity should be a priority for all, because of the
considerable health benefits of maintaining a healthy weight and the health risks associated
with overweight and obesity.
36
Public health
People
Everyone should aim to maintain or achieve a healthy weight, to improve their health and
reduce the risk of diseases associated with overweight and obesity, such as coronary heart
disease, type 2 diabetes, osteoarthritis and some cancers. People should follow the
strategies, which may make it easier to maintain a healthy weight by balancing 'calories in'
(from food and drink) and 'calories out' (from being physically active).
NHS
Managers and health professionals in all primary care settings should ensure that
preventing and managing obesity is a priority, at both strategic and delivery levels.
Dedicated resources should be allocated for action.
NHS organisations should set an example –
•
on-site catering should promote healthy food and drink choices (for example by signs,
posters, pricing and positioning of products)
•
there should be policies, facilities and information that promote physical activity, for
example, through travel plans, by providing showers and secure cycle parking and by
using signposting and improved décor to encourage stair use.
All primary care settings should address the training needs of staff involved in preventing
and managing obesity.
Local authorities and partners
Local authorities should work with local partners, such as industry and voluntary
organisations, to create and manage more safe spaces for incidental and planned physical
activity, addressing as a priority any concerns about safety, crime and inclusion, by:
•
providing facilities and schemes such as cycling and walking routes, cycle parking, area
maps and safe play areas
37
•
making streets cleaner and safer, through measures such as traffic calming, congestion
charging, pedestrian crossings, cycle routes, lighting and walking schemes
•
ensuring buildings and spaces are designed to encourage people to be more physically
active (for example, through positioning and signing of stairs, entrances and walkways)
•
considering in particular people who require tailored information and support,
especially inactive, vulnerable groups.
Early years settings
Nurseries and other childcare facilities should:
•
minimise sedentary activities during play time, and provide regular opportunities for
enjoyable active play and structured physical activity sessions
•
implement Department for Education and Skills, Food Standards Agency and Caroline
Walker Trust guidance on food procurement and healthy catering.
Schools
Head teachers and chairs of governors, in collaboration with parents and pupils, should
assess the whole school environment and ensure that the ethos of all school policies helps
children and young people to maintain a healthy weight, eat a healthy diet and be physically
active, in line with existing standards and guidance.
This includes policies relating to building layout and recreational spaces, catering (including
vending machines) and the food and drink children bring into school, the taught curriculum
(including PE), school travel plans and provision for cycling, and policies relating to the
National Healthy Schools Programme and extended schools.
Workplaces
Workplaces should provide opportunities for staff to eat a healthy diet and be physically
active, through:
•
active and continuous promotion of healthy choices in restaurants, hospitality, vending
machines and shops for staff and clients, in line with existing Food Standards Agency
guidance
38
•
working practices and policies, such as active travel policies for staff and visitors
•
a supportive physical environment, such as improvements to stairwells and providing
showers and secure cycle parking
•
recreational opportunities, such as supporting out-of-hours social activities, lunchtime
walks and use of local leisure facilities.
Self-help, commercial and community settings
Primary care organisations and local authorities should recommend to patients, or consider
endorsing, self-help, commercial and community weight management programmes only if
they follow best practice according to NICE guidance.
Clinical care
Children and adults
Multicomponent interventions are the treatment of choice. Weight management
programmes should include behaviour change strategies to increase people's physical
activity levels or decrease inactivity, improve eating behaviour and the quality of the
person's diet and reduce energy intake.
Children
•
Interventions for childhood overweight and obesity should address lifestyle within the
family and in social settings.
•
Body mass index (BMI) (adjusted for age and gender) is recommended as a practical
estimate of overweight in children and young people, but needs to be interpreted with
caution because it is not a direct measure of adiposity.
•
Referral to an appropriate specialist should be considered for children who are
overweight or obese and have significant comorbidity or complex needs (for example,
learning or educational difficulties).
39
Adults
•
The decision to start drug treatment, and the choice of drug, should be made after
discussing with the patient the potential benefits and limitations, including the mode of
action, adverse effects and monitoring requirements and their potential impact on the
patient's motivation. When drug treatment is prescribed, arrangements should be
made for appropriate health professionals to offer information, support and counselling
on additional diet, physical activity and behavioural strategies. Information about
patient support programmes should also be provided.
•
Bariatric surgery is recommended as a treatment option for adults with obesity if the
NICE guidance criteria are fulfilled.
•
The level of intervention to discuss with the patient initially should be based as follows:
Waist circumference
BMI
Low (cm)
High (cm)
Very high (cm) Comorbidities
classification
Men: < 94
Men: 94-102
Men: > 102
Women: < 80
Women: 80-88
Women: > 88
present
Overweight
1
2
2
3
Obesity I
2
2
2
3
Obesity II
3
3
3
4
Obesity III
4
4
4
4
1 = General advice on healthy weight and lifestyle
2 = Diet and physical activity
3 = Diet and physical activity; consider drugs
4 = Diet and physical activity; consider drugs; consider surgery
Interventions to increase physical activity should focus on activities that fit easily into
people's everyday life (such as walking), should be tailored to people's individual
preferences and circumstances and should aim to improve people's belief in their ability to
change (for example, by verbal persuasion, modelling exercise behaviour and discussing
positive effects). Ongoing support (including appropriate written materials) should be given
in person or by phone, mail or internet.
40
Interventions to improve diet (and reduce energy intake) should be multicomponent (for
example, including dietary modification, targeted advice, family involvement and goal
setting), be tailored to the individual and provide ongoing support.
NICE guidance on managing overweight and obesity in the community39 makes a number of
recommendations, some of which are:
• A coherent, community-wide, multi-agency approach should be in place to address
obesity prevention and management.
• Adopt an integrated approach to preventing and managing obesity
• The Health and Wellbeing Board ensure that tackling obesity is one of the strategic
priorities of the joint health and wellbeing strategy, based on needs identified in the
JSNAs. (This is a strategic priority in the local HWB strategy).
• Local authorities and the NHS should be exemplars of good practice: e.g. develop internal
policies to help staff, service users and the wider community achieve and maintain a
healthy weight; and promote healthier food and drink choices (and discourage less
healthy choices) in all onsite restaurants, hospitality suites, vending machines, outreach
services and shops.
• Identify 'champions' who have a particular interest or role in preventing obesity in local
authority and NHS strategy groups and public, private, community and voluntary sector
bodies. This includes, for example, those involved in planning, transport, education and
regeneration.
• Ensure the local adult population is aware of the health benefits for adults who are
overweight or obese of losing even a relatively small amount of weight and keeping it off
in the long term (or avoiding any further weight gain).
• Professionals and the people should be made aware of national sources of accurate
information and advice such as NHS Choices and Change4life.
41
NICE Pathways
NICE has developed a number of pathways40,41,42 to bring together all NICE guidance, quality
standards and materials on overweight and obesity. The pathways are interactive and
designed to be used online. The single pathway diagrams below show various pathways.
Obesity overview
Managing weight through lifestyle change in adults
42
Overweight and obese adults
43
Obesity Care Pathway
The services commissioned for the management of overweight and obesity have been
defined by the Department of Health43 and are shown in the diagram below.
Tier 1: Behavioural: Universal interventions
• Universal interventions (prevention and reinforcement of healthy eating and physical
activity messages, cook and eat sessions, walking for health, cycling highways and
Change4Life).
• Includes public health and national campaigns.
• Brief advice.
Tier 2: Weight management services: Lifestyle interventions
• Lifestyle multi-component weight management services that support people to lose
weight and learn how to maintain a healthier weight. Multi-component = they address
dietary intake, physical activity levels and behaviour change. The services are developed
by a multi-disciplinary team, including a registered dietician, registered practitioner
psychologist and a qualified physical activity instructor.
• The programmes should include behaviour change strategies to increase people's
physical activity levels or decrease inactivity, improve eating behaviour and the quality of
the person's diet and reduce energy intake.
44
Tier 3: Clinician led multi-disciplinary team (MDT): Specialist Services
A MDT clinically led team approach, potentially including physician (including consultant or
GP with a special interest), specialist nurse, specialist dietician, psychologist, psychiatrist,
and physiotherapist.
Tier 4: Surgical interventions
• Bariatric Surgery
• Supported by MDT pre and post op.
In many areas, public, private or voluntary organisations are commissioned to provide
individual or group lifestyle weight management services. People can also self-refer to
commercial or voluntary programmes, for example, by attending a local class or 'club' or
joining an online programme.
People need to be supported to lose weight. Many will use their own motivation with
support from family and primary/community care to lose weight. Others will need access to
weight management programmes, either commercial or provided by the public sector to
help them lose weight. However, personal motivation and responsibility is of paramount
importance, and determines the success or failure in their weight management endeavours.
Some services commissioned for people in Great Yarmouth and Waveney are given below:
Tier 1:
Live Well Suffolk
Mytime Active Health Trainer Service
BHF Hearty Lives Great Yarmouth
Community activity Support Grant
Exercise Referral Scheme
Fun & Fit
GP Brief Intervention
Healthy Living Pharmacy Intervention
Joy of Food
Mobile Food Store
Parkrun
Physical Activity Forum
Workplace Health ECCH
Tier 2:
Live Well Suffolk
Mytime Active Health Trainer Service
Tier 3:
Luton and Dunstable Hospital weight
management service
Tier 4:
Luton and Dunstable Hospital
45
Smoking
The effects of smoking on health and wider aspects are well known; hence a detailed review on
smoking is not given here.
There has been a dramatic decrease in smoking since the early 1970s when 70% of men and 50% of
women smoked. This had decreased to 36% of men and 28% of women by the late 1990’s and in
2010 20% of men and 19% of women smoked.44 England has made significant strides in reducing
smoking, but it still remains the main cause of preventable illness and premature death in
England. It is the primary reason for the gap in healthy life expectancy between rich and
poor.45,46
The health problems associated with smoking have been estimated to cost the NHS around
£2.7 billion every year while other estimates have put the cost as high as £5.2 billion.47,48
This does not include the cost of work days lost, sickness benefits and other indirect costs.
One in two regular smokers is killed by tobacco – half dying before the age of 70, losing an
average 21 years of life. Smoking is a major risk factor for many diseases, such as lung
cancer, chronic obstructive pulmonary disease and heart disease. It is also associated with
cancers in other organs, including lip, mouth, throat, bladder, kidney, stomach, liver and
cervix.46
Smokers have a substantially increased risk of post-operative complications97 and the British
Thoracic Society (BTS) recommends that smoking cessation should be considered as preoperative treatment in patients who smoke.137 The National Institute for Health and Care
Excellence (NICE) first released guidance on commissioning smoking cessation services for
people undergoing elective surgery back in 2009, stating commissioners should ensure all
people who smoke and who are undergoing elective surgery are asked how interested they
are in quitting and, even those patients who choose not to make a quit attempt, but who
will be subject to enforced abstinence during their inpatient stay, should be considered.49
46
Elective surgery and hospital admission provides an excellent opportunity for health
professionals to offer people advice, support and referral to NHS Stop Smoking Services.
NICE guidelines on behaviour change (PH6) state that significant events of transition points
in people’s lives present an important opportunity for intervening, because it is then that
people often review their own behaviour and contact services. A hospital admission may
boost a person’s receptivity to smoking cessation interventions and increase their
motivation to stop smoking.136
Most smokers smoke because of addiction to nicotine and not out of choice and, moreover,
most smokers would like to quit, but the majority will not be able to do so without help.50
Indeed, more than two thirds (67%) of adult smokers (aged 16 and over) who were surveyed
in Great Britain in 2008/09 said they wanted to give up smoking and estimates suggest that,
in 2008/09, more than a quarter (26%) of adult smokers in Great Britain attempted to give
up smoking in the previous year.51
Healthy Lives, Healthy People: a Tobacco Control Plan for England51 has set three healthoutcome related national ambitions to reduce:
•
Adult smoking prevalence from 21.2% to 18.5% by end of 2015.
•
Regular smoking in 15 year olds from 15% to 12% by end of 2015.
•
Reduce smoking in pregnancy from 14% to 11% by end of 2015.
The Cardiovascular Disease Outcomes Strategy52 has a target to reduce smoking prevalence
rate by 0.5% year over 3 years to 18.5%.
Living well for Longer53 – a call to action contrasts smoking rate in England other European
countries calling for more action.
47
Benefits of quitting smoking
The health benefits of quitting smoking start immediately, and have profound effects on
mortality and morbidity as demonstrated in the table below taken from the British Thoracic
Society’s ‘Case for Change’:
Benefits of Stopping Smoking131
20 mins
Reduction in BP, pulse rate, and normalisation of temperature of hands and feet
8 hrs
Serum nicotine falls to 90% of normal peak levels.
12-24 hrs
Normalisation of oximetry (12hrs); carbon monoxide levels (24 hrs).
48 hrs
Sense of smell and taste noticeably improved.
72 hrs
90% of nicotine metabolites excreted. Improvement in breathing.
2 weeks to 3 Risk of MI begins to fall and lungs begin to improve.
months
Decrease in respiratory symptoms (cough and breathlessness)
1 year
Excess risk of MI and stroke less than half that of a smoker.
5 to 15 years CVA risk has declined to that of a non-smoker
10 years
Risk of lung cancer decreases to 30%-50%. Risk of pancreatic cancer has declined to a
non-smoker. Risk of cancer of mouth, throat and oesophagus has declined.
13 years
Risk of diabetes and tooth loss declined to never smoker.
15 years
Risk of coronary heart disease reduced to never smoked.
20 years
Female excess risk of death all smoking related causes reduced to never smoker.
This is in addition to the long-term benefits of quitting smoking such as reduced risk of lung
cancer and heart disease.
Furthermore, stopping smoking, at any age, gives extra years to life. The study on ‘Benefits
of Smoking Cessation for Longevity’132 shows the extra years of life gained by smokers who
are able to stop and is given in the table below.
48
Benefits of Smoking Cessation for Longevity132
132
Men
Women
Extra years
Life expectancy
compared to
Extra years
Life expectancy
smokers
compared to
smokers
Smoked until death
69.3
73.8
Never smoked
78.2
8.9
81.2
7.4
Quit age 35
76.2
6.9
79.9
6.1
Quit age 45
74.9
5.6
79.4
5.6
Quit age 55
72.7
3.4
78.0
4.2
Quit age 65
70.7
1.4
76.5
2.7
49
Lifestyle and cancers
Obesity and smoking are linked with most of the long term conditions – the example of
cancer given in the diagram below from Cancer Research UK54 is illustrative of that.
50
Impact of lifestyle factors on surgical outcomes
Smoking and obesity are known to have an adverse impact on patients undergoing surgery.
The following sections provide a summary of a non-systematic review of literature, starting
with obesity, its impact on various other surgical sites; and then looking at smoking and how
it affects wound healing, lung complications and length of stay in patients undergoing
elective surgery.
Policies have been in place for a number of years in various parts of the country to restrict
access to elective surgery for patients with high BMI and those who smoke. Commonly
these restrictions have been applied to hip and knee replacement surgeries. A few health
economies have also restricted or attempted to restrict access to a wider range of elective
procedures.
It is important to understand the evidence base for increased perioperative morbidity and
mortality in surgical patients due to high BMI and smoking.
51
Impact of obesity on surgical outcomes
Obesity is recognised as a risk factor for increased perioperative morbidity and mortality in
surgical patients.
Emerging concepts position central/visceral adipose tissue as potentially key to the
pathogenesis of the comorbidities associated with obesity, and BMI is commonly used as it
is much easier to measure than body composition analysis. It is hypothesized that the state
of chronic inflammation and dys-metabolism observed in visceral obese patients negatively
influences post-operative outcomes and represents a potential target for pharmaconutrition55.
It is important to note that the NHS England policy on Knee Replacement Surgery has
criteria of BMI < 3056.
Summary of evidence:
Obesity as a risk factor during anaesthesia
The Royal College of Anaesthetists published a major UK study based on the 4th National
Audit Project of the Royal College of Anaesthetists (NAP4) to address the issue of
anaesthetic risks in obese patients. This showed that obese patients were twice likely to
develop serious airway problems during a general anaesthetic than non-obese and severely
obese patients were four times more likely to develop such problems57. Particular
complications in obese patient included an increased frequency of aspiration and other
complications during the use of supraglottic airway devices, difficulty at tracheal intubation
and airway obstruction during emergence or recovery. When rescue techniques were
necessary in obese patient they failed more often than in the non-obese.
A literature review by Lloret-Linares et al found that the physiological differences between
obese and normal-weight subjects may modify not only anaesthetic requirements during
52
surgery but also post-operative analgesic management, raising a number of challenges in a
critical period58.
General Surgery
A prospective study of a large cohort of patients (n-118,707) undergoing nonbariatric
general surgery examined the effect of BMI on perioperative outcomes, particularly 30-day
morbidity and mortality. The authors found that obese patients undergoing surgery are at
significantly higher risk for surgical site infection compared non-obese patients. Patients
with BMI>40 had higher rate of 30-day post-operative incidence of morbidity, return to
operation theatre, length of stay, wound occurrence, sepsis/septic shock, pulmonary
occurrence (postoperative pneumonia, ventilation >48 hours, or unplanned reintubation)
urinary tract infection, renal insufficiency, acute myocardial infarction or cardiac arrest,
transfusion, incidence of cerebro-vascular accident and coma compared to patients with
normal weight (BMI 18.6-25).59
Hip and Knee replacement surgery
A systematic review of knee replacement surgery identified 24 studies that showed that at a
mean 5-year follow-up, obese and morbidly obese patients had significantly lower implant
survivorship (88%, 95% and 97%), lower postoperative mean Knee Society objective and
function scores (75 & 90, 78 & 84 and 71 & 60 points); and the complication rates (9, 15,
and 22%, respectively), all of which were significantly different60.
Another literature review by Vincent et al identified 5 retrospective studies and 18
prospective studies looking at long-term outcomes following hip replacement surgery found
that obese patients did not attain the same level of physical function, and concluded that
uncontrolled obesity after total hip arthroplasty is related to worsening of comorbidities and
excessive health care costs over the long term61.
Kerkhoffs et al in their meta-analysis and systematic literature review found that obesity
had a negative influence on outcome after total knee arthroplasty. Deep infection requiring
surgical debridement (OR 2.38, CI 1.28 – 4.55) and revision of the total knee arthroplasty
occurred more often in obese patients (OR 1.30, CI 1.02 – 1.67)62.
53
A systematic review of medical databases by Samson et al found that all studies reporting
complications noted a greater prevalence in morbidly obese patients (10-30%). Of concern
was the significantly higher prevalence of deep prosthetic infection (3-9-times that of
controls). The morbidly obese also had a significantly higher incidence of wound
complications. They also noted that total knee replacement did not result in weight loss for
morbidly obese patients, and therefore these patients should be advised to lose weight
before surgery63.
The Workgroup of the American Association of Hip and Knee Surgeons (AAHKS) Evidence
Based Committee, in their evidence review found that despite improvements in patient
related outcome measures, all obese patients (BMI >30) undergoing total joint arthroplasty
are at increased risk for perioperative complications. The review noted that the degree of
functional improvement following total joint arthroplasty in the obese population remains
controversial. It appears that obese patients have similar satisfaction rates as the nonobese
population following total joint arthroplasty. As BMI increases (> 40), however, the
functional improvement becomes less and/or occurs more gradually and must be tempered
with the associated increased complication profile. Based on the current literature, it
appears that the morbidly obese patients, defined as a BMI ≥40, are the threshold for which
the majority of perioperative complications, including infection and revision rates appear to
increase considerably. They recommended that his needs to be discussed with every patient
prior to surgery and strong consideration should be given to reducing weight (BMI < 40) and
minimizing associated comorbidities.64
There is a clear increase in wound healing complications and deep infection in reports
examining joint replacement surgery in the obese. In a single-centre analysis of 7181
primary hip and knee arthroplasties for osteoarthritis, Jamsen & colleagues65 demonstrated
that the infection rate increased from 0.37% in patients with a normal body mass index to
4.66% in the morbidly obese group. Furthermore, Malinzak et al showed that in both hip
and knee patients a BMI greater than 50 increased the odds ratio of infection to 21.3.66
Wound healing complications and infection, particularly deep infection, are among the most
concerning complications for surgeons and patients alike. A deep infection may ultimately
54
lead to resection or removal of the prosthesis, joint fusion, or amputation, and almost
always requires reoperation.
Multiple reports identify obese patients as being at elevated risk for thromboembolic
disease (TED) in the post-operative period after the arthroplasty.67,68,69
Of the potential complications associated with total hip arthroplasty (THA), obese patients
have higher dislocation rates. Lubbeke et al studied the gender differences in outcomes of
obesity following total hip arthroplasty.70 Of the 2,186 patients that underwent primary
THA, 23.6% were in obese patients. The incidence rate of dislocation was 2.3 times higher in
the obese than non-obese and obese women were at the highest risk (rate ratio 3.0). Grant
et al evaluated 255 males undergoing primary THA and demonstrated an increased risk of
dislocation in the morbidly obese group (BMI >40) compared to the obese and non-obese
group (BMI >30).71 A pooled analysis demonstrated that dislocation was increased in obese
patients undergoing primary THA.72 Davis et al showed a 4.42 times higher dislocation rate
in THA patients with a BMI of greater than 35, compared with those with a BMI of less than
25.73
Other Orthopaedic surgery – for ambulatory knee and shoulder injuries
A systematic review by Kluczynski et al found that obesity is highly prevalent among patients
with knee and shoulder injuries and is associated with greater odds of surgical treatment for
these injuries. In their review, seven knee studies and 2 shoulder studies found increased
BMI to be associated with worse postoperative outcomes. Increased BMI was associated
with worse clinical scores and less patient satisfaction after arthroscopic meniscectomy or
debridement, and with worse clinical scores and lower activity levels after anterior cruciate
ligament reconstruction. It was also associated with worse clinical scores and a longer
hospital stay after rotator cuff repair and with longer time to return to work after
subacromial decompression74.
They also noted that there is a lack of consensus in the literature regarding the association
between BMI and ambulatory knee and shoulder surgery. Several factors may have
55
contributed to contradictory findings, including variation in measuring and classifying
anthropometry, postoperative outcomes, and follow-up time74.
Cardiac surgery
In a systematic review and random-effects meta-analysis, Hernandez et al found that obese
patients had a higher risk of postoperative atrial fibrillation (POAF) in patients undergoing
cardiac operations (OR 1.12, CI 1.04 – 1.21). POAF was associated with a significantly higher
risk of stroke, respiratory failure, and operative death75.
Gastrointestinal cancer surgery
Various studies have looked at the correlation of obesity and complications following
surgery for gastrointestinal cancer. These included lower grade of evidence ‘case studies’ to
the highest grade ‘meta-analysis and systematic reviews’. The cancers studied included
oesophageal, gastric, colon, rectum cancers.
These studies showed that obesity was significantly associated with higher rates of overall
complications76,77, anastomotic leakage78,79,80, surgical site infections78,80,81,82, and overall
morbidity81. There is also an increase in urinary tract infections, venous thromboembolic
events, sepsis, and wound dehiscence81. Another study showed increased blood loss and
increased operating time83,84. The disease free survival was also significantly worse in those
with high BMI than that of the normal BMI85.
There is also evidence that BMI was incrementally associated with wound-related
complications, illustrating how the proliferation of obesity relates to a growing risk for
surgical complications. In a study looking at colon cancer surgery outcomes, it was shown
that for every increase of BMI (obesity) category, there was a significant increase in wound
infection and slow healing86.
Another meta-analysis showed that overweight and obese patients had significantly
increased operation times, blood loss, anastomosis leakages, and pancreatic fistulas,
whereas lymph node retrieval was decreased significantly in the overweight group. In
addition, overweight patients had poorer long-term survival87.
56
Cranial surgery
A retrospective review of patients with cranial surgery demonstrated a significant increase
in postoperative cerebrospinal fluid leak (p=0.04) and postoperative brachial plexopathy
(p=0.03) in patients with high body mass index undergoing surgery of the cerebellopontine
angle. Logistical regression analysis confirmed that body mass index is significant in
predicting both postoperative cerebrospinal fluid leak (p=0.004; OR 1.10) and brachial
plexopathy (p=0.04; OR 1.07)88.
Spinal surgery
McClendon et al looked at 189 surgeries for long-segment spinal fusions. Their case control
study found that morbidly obese patients had longer hospitalizations, worse Oswestry
Disability Index (ODI), and more complications at 1 and 2 years than ideal weight patients.
Mean complications at 2 years for the morbidly obese were 3 times more than those
underweight and 8 times more than those with ideal weight89.
The systematic review to quantify the association between increased BMI and risk of
surgical site infection (SSI) following spine surgery found that pooling of risk estimates
adjusted for diabetes and other confounders resulted in a 21 % increase in risk of spinal SSI
for every 5-unit increase in BMI90.
A cohort study based on the Swedish Spine Register found that higher BMI was associated
with greater odds of dissatisfaction after surgery and inferior results at the 2-year follow-up.
After adjusting for differences in baseline characteristics, the obese group demonstrated
inferior function and quality of life as measured by the Oswestry Disability Index (ODI) (33,
CI 31-34 v/s 25, CI 24-26) and the EuroQol Group Index (EQ-5D) (0.56, CI .054-.059 v/s 0.64,
CI 0.62-0.66) respectively91.
A meta-analysis of studies looking at spinal surgery noted that obesity was associated with
higher risk of surgical site infection (OR 2.33; CI 1.94-2.79), venous thromboembolism (OR
3.15; CI 1.92-5.17), mortality (OR 2.6; CI 1.50-4.49), revision rate (OR 1.43; CI 1.05-1.93)
operating time (OR 14.55; CI 10.03-19.07), and blood loss (MD, 28.89; CI, 14.20-43.58)92.
57
Gynaecological surgery
The literature review by Bardens et al showed that patients with increased BMI who
underwent laparoscopic hysterectomy for benign disease had increased operating times
(p=0.017) and blood loss (p=0.027). Follow-up of these patients showed that overweight
women had the highest rate of complications (p=0.008)93. Another retrospective cohort
study found that for obese women, bleeding requiring transfusion was almost 3-fold (3.1 vs.
1.1%, adjusted odds ratio [AOR] 2.93, CI 1.10-7.80) and laparotomy risk increased
approximately 2-fold (7.5 vs. 3.5%, AOR 2.35, CI 1.30-4.24)94.
Gunderson et al showed that obese women have greater surgical risk and lower risk of
metastatic disease. Hospitalization >2days, antibiotic use, wound infection, and venous
thrombophlebitis were higher with BMI >40. BMI is associated with all-cause but not
disease-specific mortality (p=0.016), emphasizing the detrimental effect of obesity in
patients with uterine cancer95.
Renal surgery
A systematic review by Nicoletto et al found that obese patients have increased risk for
delayed graft function in renal transplant patients (RR 1.41, CI 1.26-1.57)96.
58
Impact of smoking on surgical outcomes
This section looks at the evidence base on the impact of smoking on patients undergoing
elective surgery. Postoperative complications result in increased morbidity and mortality, and
extended hospital stay and convalescence and expensive for the NHS.97,98,99,100,101
There is strong evidence that smokers who undergo surgery:
•
have a higher risk of lung and heart complications102,103,104
•
have higher risk of post-operative infection105,101,106
•
have impaired wound healing107,108,106,109
•
are more likely to be admitted to an intensive care unit110
•
have an increased risk of dying in hospital111,112
•
are at higher risk of readmission113
•
remain in hospital longer.111
Reviews of large surgical databases (consisting of over 250,000 operations) confirm that
active smoking at the time of surgery independently increases post-operative risk and many
complications in all types of surgery compared with non-smoking or even ex-smoking
patients, with a clear temporal relationship and significant dose-response between amount
smoked and adverse outcomes.114
Smoking is the single most important risk factor for the development of serious postoperative complications in patients undergoing elective hip and knee replacement110 as well
as the single most important factor for the development of post-operative cardiopulmonary
and wound-related complications in elective orthopaedic surgery.102 Smoking is also an
important predictive factor for anastomotic leakage after colonic and rectal resection115 and
smokers are at significantly higher risk of complications during reconstructive breast surgery
and breast cancer surgery.116,106 There is some research which suggests that smokers who
have been smoking for longer than ten years should not undergo breast reconstructive
surgery as the risk of complications is so high.116
59
A function of anaesthesia is to reduce coughing and spasms during surgery but because
smokers are more prone to coughing during surgery they need a higher dose of anaesthesia
than non-smokers.117 Also, smokers have decreased blood oxygenation, leading to
decreased oxygen delivery to their tissues and are consequently more likely to need oxygen
therapy.118 Depriving vital organs of oxygen for even a short period of time can lead to
serious complications.119
Wound-related complications
Two randomized controlled trials found that wound infections and delayed healing were
significantly reduced in smokers who abstained from smoking to the level of never smokers
(12%-31% in smokers; 1.2% - 5% in quitters; 2% never smokers).114 In plastic surgery and
breast reconstruction the effects of smoking cessation include improved wound healing and
complications and reduced need for reoperation.114
Pulmonary complications
Pulmonary or cardiovascular complications occur in up to 10% of the cases,120 with people
who smoke having a considerably increased risk of intra- and post-operative
complications.121 In a retrospective study, smokers were found to have a three-to-six-fold
increased risk of intraoperative pulmonary complications.122,123 Smokers with chronic heart
or lung disease have a two-to-five-fold increased risk of perioperative complications.
Three large prospective studies and one retrospective study have shown that smokers and
recent smokers had significantly higher risk of developing post-operative pulmonary
complications (PPCs). Ex-smokers had a slightly higher although non-significant risk.114
A blinded prospective study of preoperative smoking cessation in coronary artery bypass
graft (CABG) patients found 33% of current smokers had PPCs compared with less than 12%
of those that had quit for more than 8 weeks. Another prospective cohort study found that
current smokers had significantly more pulmonary complications than past or never
smokers (22%, 13%, and 5% respectively).114
One study modelled the incidence of pulmonary complications compared with the duration
of the smoke-free period and found that after a 5-8 weeks smoke-free period the incidence
of PPCs gradually decreased. Another study found that smokers who had quit less than 8
60
week prior to surgery had an increased risk of pulmonary complications and that the risk
increased for the first 28 days after quitting and reduced to the same rate as smokers by 8
weeks then declines rapidly.114
Cardiovascular complications
In an RCT, although the difference was not significant, there was a trend towards more
cardiovascular complications in the group that continued smoking compared with the group
that quit (10% vs 0%, p=0.08).114
Non-union of bone fusion
With regard to spinal fusion, smokers are at an increased risk of non-union than nonsmokers and that both pre and post-operative smoking cessation were associated with
higher spinal fusion rates.114
Smoking has pronounced effects in foot and ankle surgery, resulting in higher rates of
complications, particularly non-union.124
Need for secondary surgery
Secondary surgery is further surgery undertaken to deal with the complications of the initial
surgery. One trial found that the need for secondary surgery was higher in smokers than
quitters (4% vs. 15%, p=0.07) although the difference was not significant, probably due to
small numbers.114
Length of Stay
Two RCTs looking at length of stay in orthopaedic patients found that the length of stay in
smokers was longer (13 days) compared to non-smokers (11 days) but that while this was
not significant; there was a significant difference in the number of days spent in nonorthopaedic departments. Another study noted that for those patients who had a PPC, the
average length of stay increase by 0.4 days.114
61
Duration of pre-elective smoking cessation to get benefit
Evidence about the optimum time to quit smoking prior to surgery varies, with most
research finding that two months prior to surgery provides the most benefit.113,125,126,130
The relationship between smoking cessation and the development of complications
depends upon the duration of smoking cessation prior to surgery. In one study patients
who had stopped smoking for 2 months or less had a pulmonary complication rate almost 4
times that of patients who had stopped for more than 2 months (57.1% versus 14.5%).
Patients who had stopped smoking for more than 6 months had rates similar to those who
had never smoked (11.1% and 11.9%, respectively).114
62
Benefits of quitting before surgery
There is evidence to suggest that quitting smoking before having surgery:
•
reduces the risk of post-operative complications127
•
reduces lung, heart and wound-related complications102,128
•
decreases wound healing time129
•
reduces bone fusion time after fracture repair124
•
reduces length of stay in hospital.111,130
Furlong reviewed the evidence for the effect size of smoking cessation interventions of surgical
complications. The largest effect is seen in the reduction in wound related and pulmonary
complications.122
A systematic review of mortality risk reduction associated with smoking cessation in
patients with coronary heart disease found a 36% reduction in all-cause mortality in quitters
compared with those patients that continued to smoke.131
Quitting smoking after surgery also brings significant benefits. In a twenty year follow-up
study of 1,041 people who underwent coronary artery bypass graft surgery in the 1970s,
smoking cessation after surgery was an important independent predictor of a lower risk of
death and of fewer further coronary interventions during the 20-year follow-up when
compared with patients who continued smoking .132,133
63
Economic impact of smoking cessation before surgery
Based on the knowledge of the pre-operative morbidity and mortality of smoking, and the
cost-effectiveness of smoking cessation therapy, the former London Strategic Health
Authority commissioned the London health Observatory (LHO) to model and assess the
realisable short term financial savings from instituting pre-operative smoking cessation
interventions.50
It has been estimated that, in London alone, savings of around £2,650,000 a year could be
made if between 8% and 17% of smokers quit before having surgery.50
The Welsh government has estimated that supporting smokers to quit before having surgery
smokers could save as much as £2.3 million more every year.134
These savings are derived from bed days saved and the reduced cost of treating postoperative complications.
64
Efficacy of smoking cessation interventions in preoperative smoking cessation
NICE public health guidance PH10135 on smoking cessation services states:
o Patients should be encouraged to stop smoking before elective surgery
o Smoking cessation services are highly effective and cost effective
o Following surgery, smoking contributes to lower survival rates, delayed wound
healing and postoperative respiratory complications
NICE public health guidance PH6136 on behaviour change states that ‘a hospital admission
may boost a person's receptivity to smoking cessation interventions as .. at significant events
or transition points in people's lives .. and increase their motivation to stop smoking’.
The British Thoracic Society137 advocated that:
o smoking cessation be considered a ‘treatment in sick smokers’; and
o every hospital admission provides an opportunity to help stop smoking
Evidence suggests that smoking cessation programmes aimed at assisting smokers
undergoing surgery to quit are effective at reducing post-operative complications138,139 and
intensive interventions which begin during the hospital admission are especially effective.97
There are 11 Cochrane reviews of particular relevance to commissioning specific smoking
cessation services. Studies included in the review involved preoperative smoking cessation
interventions on patients undergoing a variety of different surgery, including:
1. Hip and knee joint replacement (Moller, 2002)
2. Enteric anastomosis (Sorensen, 2003)
3. Cardiovascular, ophthalmologic, plastic and urologic surgery (Ratner, 2004)
4. Nervous, ear, nose, throat, digestive, hepatobiliary, pancreas, musculoskeletal,
connective tissue, skin, subcutaneous tissue, breast, gynaecologic systems
(Wolfenden, 2005)
5. Andrews (2006) elective surgery but procedures not specified.
6. Elective open incisional or inguinal day-case herniotomy (Sorensen, 2007)
65
7. Elective inguinal and umbilical hernia repair, laparoscopic cholecystectomy, or a hip
or knee prosthesis (Lindstrom, 2008)
8. Elective breast surgery (Thomsen, 2009)
The authors categorised smoking cessation interventions into two subgroups according to
intensity of counselling:
1. Intensive preoperative intervention: consisting of weekly counselling sessions over a
period of four to eight weeks.
2. Brief preoperative intervention: provided in relation to routine preoperative
evaluation and consisting of one face-to face and/or telephone counselling session
and/or interactive computer counselling or one letter about the risks of smoking in
relation to surgery before surgery.
Subgroup analyses showed that both intensive and brief intervention significantly increased
smoking cessation at the time of surgery; pooled RR 10.76 (CI 4.55 to 25.46) and RR 1.41 (CI
1.22 to 1.63) respectively. The RR refers to smoking cessation. Four trials evaluating the
effect on long-term smoking cessation found a significant effect; pooled RR 1.61 (CI 1.12 to
2.33). However, when pooling intensive and brief interventions separately, only intensive
intervention retained a significant effect on long-term smoking cessation; RR 2.96 (CI 1.57 to
5.55, two trials).97
Five trials examined the effect of smoking intervention on postoperative complications.
Pooled risk ratios were 0.70 (CI 0.56 to 0.88) for developing any complication; and 0.70 (CI
0.51 to 0.95) for wound complications. Exploratory subgroup analyses showed a significant
effect of intensive intervention on any complications; RR 0.42 (CI 0.27 to 0.65) and on
wound complications RR 0.31 (CI 0.16 to 0.62). For brief interventions the effect was not
statistically significant but CIs do not rule out a clinically significant effect; RR 0.96 (CI 0.74 to
1.25) for any complication, RR 0.99 (CI 0.70 to 1.40) for wound complications).97 From this
review, the author’s concluded that preoperative smoking interventions including NRT
increase short-term smoking cessation and may reduce postoperative morbidity.
66
Medical triggers and long term behaviour change
Medical triggers have been shown to promote long-term behaviour change. A medical
trigger is for example a doctor telling a patient and/or a family member to lose weight or
stop smoking after an adverse event or to prevent it.
A study by Gorin et al140 using the National Weight Control Registry of US showed that
people who had medical reasons for weight loss also had better initial weight losses and
maintenance. Medical triggers were associated with less regain over a 2 year follow-up.
These findings suggest that the period following a medical trigger may be an opportune
time to initiate weight loss to optimise both initial and long-term weight loss outcomes.
This a registry of a self-selected population of more than 4000 individuals who are age 18 or
older and have lost at least 13.6 kg (30 lb) and kept it off at least 1 year. They identified that
most registry participants reported a trigger for their weight loss (83%). Medical triggers
were the most common (23%), followed by reaching an all-time high in weight (21.3%), and
seeing a picture or reflection of themselves in the mirror (12.7%).
Participants with medical triggers reported greater initial weight loss than those with
nonmedical triggers or no trigger (p=0.01). Participants with medical triggers also gained
less weight over 2 years of follow-up than those with nonmedical triggers or no trigger
(p=0.003). Based on their work the authors concluded that “Medical triggers may produce a
teachable moment for weight control, resulting in better initial weight loss and long-term
maintenance”.140
Another research from the US shows that approximately 20% of these overweight
individuals are successful at long-term weight loss when defined as losing at least 10% of
initial body weight and maintaining the loss for at least 1 year.141
A Cochrane review looking at interventions for smoking cessation in hospitalised patients
found that a hospital admission may boost a person’s receptivity to smoking cessation
interventions and increase their motivation to stop smoking.142
67
The National Institute for Health and Care Excellence (NICE) recommends that patients
referred for elective surgery should be encouraged to stop smoking before an operation and
that services should be developed to assist them.143,135
Elective surgery and hospital admission provides an excellent opportunity for health
professionals to offer people advice and support to stop smoking and reduce weight. NICE
guidelines on behaviour change (PH6) state that significant events of transition points in
people’s lives present an important opportunity for intervening, because it is then that
people often review their own behaviour and contact services. A hospital admission may
boost a person’s receptivity to smoking cessation interventions and increase their
motivation to stop smoking.136
However, many clinicians do not discuss life style issues with their patients. Research in the
USA found that many surgeons and most anaesthetists do not routinely counsel prospective
patients to quit smoking prior to surgery, 42% and 70% respectively.144
The department of Health initiative MECC (Making Every Contact Count) is about ‘Using
every opportunity to achieve health and wellbeing’. NHS Future Forum145 made the
recommendation that every healthcare organisation should deliver MECC and ‘build the
prevention of poor health and promotion of healthy living into their day-to-day business.’
The Nudge factor:
In a book146 written by University of Chicago economist Richard H. Thaler and Harvard Law
School Professor Cass R. Sunstein, a case is made for the Nudge factor, by drawing on
research in psychology and behavioural economics to defend libertarian paternalism and
active engineering of choice architecture. They note that people make decisions every day
on topics ranging from personal investments to schools for children to the meals they eat to
the causes they champion and unfortunately they often choose poorly. They show that by
knowing how people think, we can design choice environments that make it easier for
people to choose what is best for themselves, their families, and their society. Sunstein and
Thaler state that "the libertarian aspect of our strategies lies in the straightforward
68
insistence that, in general, people should be free to do what they like-and to opt out of
undesirable arrangements if they want to do so". The paternalistic portion of the term "lies
in the claim that it is legitimate for choice architects to try to influence people's behaviour in
order to make their lives longer, healthier, and better".
Many commissioning bodies have policies where clinicians are asked to discuss weight
reduction strategies with their patients who are obese before adding them to the operating
list. For many patients who have been contemplating weight reduction, this nudge does
prove to be an important impetus to change.
Of recent salience is the NHS England’s Five Year Forward View147 authored by NHS England
Chief Executive Simon Stevens. The Forward View calls for a radical upgrade in prevention
and public health and cites Derek Wanless’s report, Securing Our Future Health: Taking a
Long-Term View, stating: Twelve years ago Derek Wanless warned that unless the country
took prevention seriously we would be faced with a sharply rising burden of avoidable
illness. That warning has not been heeded – and the NHS is on the hook for the
consequences.
Commissioners and providers should work together and consider developing policies on
access to elective surgery for smokers and those with high BMI, as the evidence is clear on
the impact of smoking and obesity on surgical outcomes.
However it is necessary that an equality impact assessment is done prior to developing such
a policy, so that inequalities do not inadvertently increase as a result of implementing such
policies.
69
Recommendations:
A joined up approach is necessary to reduce the rising prevalence of obesity, and reducing
inequalities due to smoking.
The Health and Wellbeing Boards should include tackling life style factors as their strategic
priorities.
• The Norfolk Health and Wellbeing Board has tackling obesity as one of the strategic
priorities of the joint health and wellbeing strategy.
• The Suffolk Health and Wellbeing Board in their recent meeting that discussed the policy
on ‘Aspiring to a tobacco free Suffolk: Moving towards a tobacco free generation’ agreed to
include smoking cessation before elective surgery as one of their recommendations.
A coherent, community-wide, multi-agency approach should be in place to address obesity
prevention and management. Partners should adopt an integrated approach to preventing
and managing obesity. In the short term, there should be discussions on developing
integrated pathways for weight management.
Local authorities and the NHS should be exemplars of good practice: e.g. develop internal
policies to help staff, service users and the wider community achieve and maintain a healthy
weight; and promote healthier food and drink choices (and discourage less healthy choices)
in all onsite restaurants, hospitality suites, vending machines, outreach services and shops.
Ensure the local adult population is aware of the health benefits for adults who are
overweight or obese of losing even a relatively small amount of weight and keeping it off in
the long term, or avoiding any further weight gain.
Clinicians play an important part in encouraging and motivating their patients to improve
their life style. Commissioners and providers should work together and consider developing
policies on access to elective surgery for smokers and those with high BMI, as the evidence
is clear on the impact of smoking and obesity on surgical outcomes.
70
References:
1
Butland B, Jebb S, Kopelman P, Mc~Pherson, Thomas S, Mardell J, Parry V. 2007. Foresight Tackling Obesities: Future
Choices – Project Report (http://www.foresight.gov.uk).
2
Vandenbroeck, I.P., Goossens, J. and Clemens, M. 2007. Building the Obesity System Map. Foresight Tackling Obesities:
Future Choices (http://www.foresight.gov.uk).
3
The Health and Social Care Information Centre (2014). Statistics on obesity, physical activity and diet: England 2014.
London: The Health and Social Care Information Centre.
4
Foresight (2007). Tackling obesities: future choices – project report. London: Government Office for Science.
5
Lobstein, T. and Jackson Leach, R. 2007. International Comparisons of Obesity Trends, Determinants and Responses.
Evidence Review. Foresight Tackling Obesities: Future Choices. (http://www.foresight.gov.uk).
6
Kopelman, P. 2007. Health Risks Associated with Overweight and Obesity. Short Science Review. Foresight Tackling
Obesities: Future Choices. Obesity Reviews, 8(s1):13–17 (http://www.foresight.gov.uk).
7
McPherson, K., Marsh, T. and Brown, M. 2007. Modelling Future Trends in Obesity and the Impact on Health. Foresight
Tackling Obesities: Future Choices (http://www.foresight.gov.uk).
8
Department of Health (2011). Healthy lives, healthy people: a call to action on obesity in England. London: Department of
Health
9
National Audit Office (2001).Tackling obesity in England, National Audit Office, London.
10
Puhl RM, Heuer CA (2009). The stigma of obesity: a review and update. Obesity 17: 941–64.
11
National Obesity Observatory. 2010. Briefing note: obesity and life expectancy. Online:
http://www.noo.org.uk/NOO_pub/briefing_papers
12
Kings fund (2012) Transforming the delivery of health and social care
13
Gatineau M, Dent M (2011) Obesity and Mental Health. Oxford: National Obesity Observatory.
14
Marchesini G, Moscatiello S, Domizio SD, Forlani G (2008) Obesity-Associated Liver Disease. Journal of Clinical
Endocrinology Metabolism. 93:74-80.
15
Guh DP, Zhang W, Bansback N, Amarsi Z, Birmingham CL, and Anis AH (2009) The incidence of co-morbidities related to
obesity and overweight: A systematic review and meta-analysis BMC Public Health. 9: 88.
16
Department of Health (2013) Improving quality of life for people with long term conditions.
17
Wang YC, McPherson K, Marsh T et al (2011). Health and economic burden of the projected obesity trends in the USA
and the UK. The Lancet 378: 815–25.
18
Clinical Resource Efficiency Support Team. Guidelines for the management of obesity in secondary care. June 2005.
http://www.gain-ni.org/images/Uploads/Guidelines/obesity-guidelines-report.pdf
19
Department of Health (2011). Start Active, Stay Active: A report on physical activity for health from the four home
countries’ Chief Medical Officers.
20
Department of Health (2004) At least five a week - evidence on the impact of physical activity and its relationship to
health - a report from the Chief Medical Officer
21
Chipperfield, T., O’Brien, R., Bolderson, T., Eidinow, E., Shafner, l., Parry, V. 2007. Visualising the Future: Scenarios to
2050. Foresight Tackling Obesities: Future Choices (http://www.foresight.gov.uk).
22
Vandenbroeck, I.P., Goossens, J. and Clemens, M. 2007. Obesity System Atlas. Foresight Tackling Obesities: Future
Choices (http://www.foresight.gov.uk).
23
Maio, G., Manstead, A., Verplanken, B. et al. 2007. Lifestyle Change. Evidence Review. Foresight Tackling Obesities:
Future Choices (http://www.foresight.gov.uk).
24
Maio, G.R., Haddock ,G. and Jarman, H.L. 2007. Social Psychological Factors in Tackling Obesity. Short Science Review.
Foresight Tackling Obesities: Future Choices. Obesity Reviews, 8(s1):123–125 (http://www.foresight.gov.uk).
25
Chipperfield, T., O’Brien, R., Bolderson, T., Eidinow, E., Shafner, l., Butland, B. 2007. Qualitative Modelling of Policy
Options Foresight Tackling Obesities: Future Choices (http://www.foresight.gov.uk).
26
Jackson, A. and Harris, P. 2007. Perspectives of 10-Year-Olds. Foresight Tackling Obesities: Future Choices
(http://www.foresight.gov.uk).
27
Jackson, A. and Harris, P. 2007. Perspectives of 13-Year-Olds. Foresight Tackling Obesities: Future Choices
(http://www.foresight.gov.uk).
28
Bel, D.W. and Esses, V.M. 2002. Ambivalence and Response Amplification: A Motivational Perspective. Personality and
Social Psychology Bulletin, 28:1143–1152.
29
Barker, D.J.P. 2007. Obesity and Early Life. Short Science Review. Foresight Tackling Obesities: Future Choices. Obesity
Reviews, 8(s1):45–49 (http://www.foresight.gov.uk).
30
Singhal, A. and Lanigan, J. 2007. Breast-Feeding, Early Growth and Later Obesity. Short Science Review. Foresight
Tackling Obesities: Future Choices. Obesity Reviews, 8(s1):51–54 (http://www.foresight.gov.uk).
31
Wardle, J. 2007. Eating Behaviour and Obesity. Short Science Review. Foresight Tackling Obesities: Future Choices.
Obesity Reviews, 8(s1):73–75 (http://www.foresight.gov.uk).
32
Reilly, J., Dorosty, A. and Emmett, P. 1999. Prevalence of Overweight and Obesity in British Children: Cohort Study.
British Medical Journal, 319(7216):1039.
71
33
Lindstrom, J., Ilanne-Parikka, P., Peltonen, M. et al. 2006. Sustained Reduction in the Incidence of Type 2 Diabetes by
Lifestyle Intervention: Follow-Up of the Finnish Diabetes Prevention Study. Lancet, 368(9548): 1673–1639.
34
Knowler, W.C., Barret-Connor, E., Fowler, S.E. et al. 2002. Reduction in the Incidence of Type 2 Diabetes with Lifestyle
Intervention or Metformin. New England Journal of Medicine, 346(6)393-403.
35
Duggan, M,, Lawrence, M., Butland, B. 2007. Obesogenic Environments. Summary of Discussion Workshops. Foresight
Tackling Obesities: Future Choices (http://www.foresight.gov.uk).
36
Fox, K.R. and Hillsdon, M. 2007. Physical Acitvity and Obesity. Short Science Review. Foresight Tackling Obesities: Future
Choices. Obesity Reviews, 8(s1):115–121 (http://www.foresight.gov.uk).
37
NICE 2014. Clinical Guideline 43: Guidance on the prevention, identification, assessment and management of overweight
and obesity in adults and children. Issued: December 2006 last modified: May 2014. National Institute for Health and Care
Excellence.
38
NICE 2014. Clinical Guideline 189: Guidance on the prevention, identification, assessment and management of
overweight and obesity in adults and children. Issued: November 2014. National Institute for Health and Care Excellence.
39
NICE 2012. Public Health Guidance 42: Obesity: working with local communities. Issued: November 2012. National
Institute for Health and Care Excellence.
40
NICE 2014. NICE pathway: Obesity overview. Pathway last updated: 27 May 2014. National Institute for Health and Care
Excellence. http://pathways.nice.org.uk/pathways/obesity
41
NICE 2014. NICE pathway: Overweight and obese adults. Pathway last updated: 27 May 2014. National Institute for
Health and Care Excellence. http://pathways.nice.org.uk/pathways/obesity
42
NICE 2014. NICE pathway: Managing weight through lifestyle change in adults. Pathway last updated: 27 May 2014.
National Institute for Health and Care Excellence. http://pathways.nice.org.uk/pathways/obesity
43
DH 2013. Developing a specification for lifestyle weight management services. Department of Health.
44
Peto R, Darby S, Deo H, Silcocks P, Whitley E & Doll R (2000). Smoking, smoking cessation, and lung cancer in the UK
since 1950: combination of national statistics with two case-control studies BMJ 2000; 321:323 Online at:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC27446/
45
NICE (2013) ‘Smoking Cessation: supporting people to stop smoking’ [Online] Available at:
http://www.nice.org.uk/guidance/qs43/resources/guidance-smoking-cessation-supporting-people-to-stop-smoking-pdf
46
ASH (2014) ‘Smoking Statistics: illness and death’ [Online] Available at:
http://www.ash.org.uk/files/documents/ASH_107.pdf
47
Callum C, Boyle S, Sandford A. Estimating the costs of smoking to the NHS in England and the impact of declining
prevalence. Health Economics Policy & Law, 2010.
48
Allender, S. The burden of smoking-related ill health in the UK. Tobacco Control, 2009; 18: 262-267.
49
NICE (2009) ‘Commissioning a smoking cessation service for people having elective surgery [Online] Available
at:http://www.gserve.nice.org.uk/usingguidance/commissioningguides/smokingcessationserviceelectivesurgery/commissi
oning.jsp (accessed 24th December 2014)
50
Public Health England (2011) ‘Smoking in England’ [Online] Available at:
http://www.lho.org.uk/LHO_Topics/National_Lead_Areas/NationalSmoking.aspx
51
HM Government (2013) ‘Healthy Lives, Health People: a tobacco control plan for England [Online] Available at:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213757/dh_124960.pdf
52
Department of Health (2013) ‘Cardiovascular Disease Outcomes Strategy: improving outcomes for people with or at risk
of cardiovascular disease [Online] Available at:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/217118/9387-2900853-CVDOutcomes_web1.pdf
53
Department of Health (2014) Living Well for Longer: national support for local action to reduce premature avoidable
mortality [Online] Available at:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/307703/LW4L.pdf
54
Cancer Research UK. 2014. Let’s beat cancer sooner. Lifestyle and Preventable Cancers. Available online:
cruk.org/preventable
55
Doyle SL; Lysaght J; Reynolds JV (2010). Obesity and post-operative complications in patients undergoing non-bariatric
surgery. Obesity Reviews, December 2010, vol./is. 11/12(875-86), 1467-7881;1467-789X.
56
NHS England (2013). Interim Clinical Commissioning Policy: Knee replacement, Nov 2013.
http://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2013/11/N-SC021.pdf
57
The Royal College of Anaesthetists (2011). NA P4 Report and findings of the 4th National Audit Project of The Royal
College of Anaesthetists: Major complication of airway management in the UK. RCOA, London.
58
Lloret-Linares C; Lopes A; Decleves X; Serrie A; Mouly S; Bergmann JF; Perrot S (2013). Challenges in the optimisation of
post-operative pain management with opioids in obese patients: a literature review. Obesity Surgery, September 2013,
vol./is. 23/9(1458-75), 0960-8923;1708-0428.
59
Mullen JT, Moorman DW, Davenport DL. The obesity paradox: body mass index and outcomes in patients undergoing
nonbariatric general surgery. Ann Surg. 2009 Jul;250(1):166-72
60
McElroy MJ; Pivec R; Issa K; Harwin SF; Mont MA (2013). The effects of obesity and morbid obesity on outcomes in TKA.
The Journal of Knee Surgery, April 2013, vol./is. 26/2(83-8), 1538-8506;1538-8506.
72
61
Vincent HK; Horodyski M; Gearen P; Vlasak R; Seay AN; Conrad BP; Vincent KR (2012). Obesity and long term functional
outcomes following elective total hip replacement. Journal of Orthopaedic Surgery, 2012, vol./is. 7/(16), 1749-799X;1749799X.
62
Kerkhoffs GM; Servien E; Dunn W; Dahm D; Bramer JA; Haverkamp D (2012). The influence of obesity on the
complication rate and outcome of total knee arthroplasty: a meta-analysis and systematic literature review. Journal of
Bone & Joint Surgery - American Volume, October 2012, vol./is. 94/20(1839-44), 1535-1386.
63
Samson AJ; Mercer GE; Campbell DG (2010). Total knee replacement in the morbidly obese: a literature review. ANZ
Journal of Surgery, September 2010, vol./is. 80/9(595-9), 1445-1433;1445-2197.
64
Springer BD, Parvizi J, Austin M, et al. 2013. Obesity and Total Joint Arthroplasty: A Literature Based Review. The Journal
of Arthroplasty 28 (2013) 714–721
65
Jämsen E, Nevalainen P, Eskelinen A, et al. Obesity, diabetes, and preoperative hyperglycemia as predictors of
periprosthetic joint infection: a single-center analysis of 7181 primary hip and knee replacements for osteoarthritis. J Bone
Joint Surg Am 2012;94(14):e101.
66
Malinzak RA, Ritter MA, Berend ME, et al. Morbidly obese, diabetic, younger, and unilateral joint arthroplasty patients
have elevated total joint arthroplasty infection rates. J Arthroplasty 2009;24(6 Suppl):84.
67
Mantilla CB, Horlocker TT, Schroeder DR, et al. Risk factors for clinically relevant pulmonary embolism and deep venous
thrombosis in patients undergoing primary hip or knee arthroplasty. Anesthesiology 2003;99(3):552 [discussion 5A].
68
Kim YH, Kim VE. Factors leading to low incidence of deep vein thrombosis after cementless and cemented total knee
arthroplasty. Clin Orthop Relat Res 1991;273:119.
69
Kim YH, Suh JS. Low incidence of deep-vein thrombosis after cementless total hip replacement. J Bone Joint Surg Am
1988;70(6):878.
70
Lubbeke A, Stern R, Garavaglia G, et al. Differences in outcomes of obese women and men undergoing primary total hip
arthroplasty. Arthritis Rheum 2007;57(2):327.
71
Grant JA, Viens N, Bolognesi MP, et al. Two-year outcomes in primary THA in obese male veterans administration
medical center patients. Rheumatol Int 2008;28(11):1105.
72
Haverkamp D, Klinkenbijl MN, Somford MP, et al. Obesity in total hip arthroplasty–does it really matter? A meta-analysis.
Acta Orthop 2011;82(4):417.
73
Davis AM, Wood AM, Keenan ACM, et al. Does body mass index affect clinical outcome post-operatively and at five years
after primary unilateral total hip replacement performed for osteoarthritis? A multivariate analysis of prospective data. J
Bone Joint Surg Br 2011;93(9):1178.
74
Kluczynski MA; Bisson LJ; Marzo JM (2014). Does body mass index affect outcomes of ambulatory knee and shoulder
surgery? Arthroscopy, July 2014, vol./is. 30/7(856-65), 0749-8063;1526-3231.
75
Hernandez AV; Kaw R; Pasupuleti V; Bina P; Ioannidis JP; Bueno H; Boersma E; Gillinov M (2013). Association between
obesity and postoperative atrial fibrillation in patients undergoing cardiac operations: a systematic review and metaanalysis. Annals of Thoracic Surgery, September 2013, vol./is. 96/3(1104-16), 0003-4975;1552-6259.
76
Eom BW; Joo J; Yoon HM; Ryu KW; Kim YW; Lee JH (2014). A body shape index has a good correlation with postoperative
complications in gastric cancer surgery. Annals of Surgical Oncology, April 2014, vol./is. 21/4(1115-22), 1068-9265;15344681.
77
Hrabe JE; Sherman SK; Charlton ME; Cromwell JW; Byrn JC (2014). Effect of BMI on outcomes in proctectomy. Diseases
of the Colon & Rectum, May 2014, vol./is. 57/5(608-15), 0012-3706;1530-0358.
78
Watanabe J; Tatsumi K; Ota M; Suwa Y; Suzuki S; Watanabe A; Ishibe A; Watanabe K; Akiyama H; Ichikawa Y; Morita S;
Endo I (2014). The impact of visceral obesity on surgical outcomes of laparoscopic surgery for colon cancer. International
Journal of Colorectal Disease, March 2014, vol./is. 29/3(343-51), 0179-1958;1432-1262
79
Zhang SS; Yang H; Luo KJ; Huang QY; Chen JY; Yang F; Cai XL; Xie X; Liu QW; Bella AE; Hu RG; Wen J; Hu Y; Fu JH (2013).
The impact of body mass index on complication and survival in resected oesophageal cancer: a clinical-based cohort and
meta-analysis. British Journal of Cancer, November 2013, vol./is. 109/11(2894-903), 0007-0920;1532-1827.
80
Bickenbach KA; Denton B; Gonen M; Brennan MF; Coit DG; Strong VE (2013). Impact of obesity on perioperative
complications and long-term survival of patients with gastric cancer. Annals of Surgical Oncology, March 2013, vol./is.
20/3(780-7), 1068-9265;1534-4681.
81
Smith RK; Broach RB; Hedrick TL; Mahmoud NN; Paulson EC (2014). Impact of BMI on postoperative outcomes in patients
undergoing proctectomy for rectal cancer: a national surgical quality improvement program analysis. Diseases of the Colon
& Rectum, June 2014, vol./is. 57/6(687-93), 0012-3706;1530-0358.
82
Hirao M; Tsujinaka T; Imamura H; Kurokawa Y; Inoue K; Kimura Y; Shimokawa T; Furukawa H (2013). Overweight is a risk
factor for surgical site infection following distal gastrectomy for gastric cancer. Gastric Cancer, April 2013, vol./is. 16/2(23944), 1436-3291.
83
Hirao M; Tsujinaka T; Imamura H; Kurokawa Y; Inoue K; Kimura Y; Shimokawa T; Furukawa H (2013). Overweight is a risk
factor for surgical site infection following distal gastrectomy for gastric cancer. Gastric Cancer, April 2013, vol./is. 16/2(23944), 1436-3291.
84
Pata G; Solaini L; Roncali S; Pasini M; Ragni F (2013). Impact of obesity on early surgical and oncologic outcomes after
total gastrectomy with "over-D1" lymphadenectomy for gastric cancer. World Journal of Surgery, May 2013, vol./is.
37/5(1072-81), 0364-2313;1432-2323.
73
85
Watanabe M; Ishimoto T; Baba Y; Nagai Y; Yoshida N; Yamanaka T; Baba H (2013). Prognostic impact of body mass index
in patients with squamous cell carcinoma of the esophagus. Annals of Surgical Oncology, November 2013, vol./is.
20/12(3984-91), 1068-9265;1534-4681.
86
Amri R; Bordeianou LG; Sylla P; Berger DL (2014). Obesity, outcomes and quality of care: body mass index increases the
risk of wound-related complications in colon cancer surgery. American Journal of Surgery, January 2014, vol./is. 207/1(1723), 0002-9610;1879-1883.
87
Wu XS; Wu WG; Li ML; Yang JH; Ding QC; Zhang L; Mu JS; Gu J; Dong P; Lu JH; Liu YB (2013). Impact of being overweight
on the surgical outcomes of patients with gastric cancer: a meta-analysis. World Journal of Gastroenterology, July 2013,
vol./is. 19/28(4596-606), 1007-9327;1007-9327.
88
Mantravadi AV; Leonetti JP; Burgette R; Pontikis G; Marzo SJ; Anderson D (2013). Body mass index predicts risk for
complications from transtemporal cerebellopontine angle surgery. Otolaryngology - Head & Neck Surgery, March 2013,
vol./is. 148/3(460-5), 0194-5998;1097-6817.
89
McClendon J Jr; Smith TR; Thompson SE; Sugrue PA; O'shaughnessy BA; Ondra SL; Koski TR (2014). The impact of body
mass index on hospital stay and complications after spinal fusion. Neurosurgery, January 2014, vol./is. 74/1(42-50;
discussion 50), 0148-396X;1524-4040
90
Abdallah DY; Jadaan MM; McCabe JP (2013). Body mass index and risk of surgical site infection following spine surgery: a
meta-analysis. European Spine Journal, December 2013, vol./is. 22/12(2800-9), 0940-6719;1432-0932.
91
Knutsson B; Michaelsson K; Sanden B (2013). Obesity is associated with inferior results after surgery for lumbar spinal
stenosis: a study of 2633 patients from the Swedish spine register. Spine, March 2013, vol./is. 38/5(435-41), 03622436;1528-1159.
92
Jiang J; Teng Y; Fan Z; Khan S; Xia Y (2014). Does obesity affect the surgical outcome and complication rates of spinal
surgery? A meta-analysis. Clinical Orthopaedics & Related Research, March 2014, vol./is. 472/3(968-75), 0009-921X;15281132.
93
Bardens D; Solomayer E; Baum S; Radosa J; Graber S; Rody A; Juhasz-Boss I (2014). The impact of the body mass index
(BMI) on laparoscopic hysterectomy for benign disease. Archives of Gynecology & Obstetrics, April 2014, vol./is.
289/4(803-7), 0932-0067;1432-0711.
94
Harmanli O; Esin S; Knee A; Jones K; Ayaz R; Tunitsky E (2013). Effect of obesity on perioperative outcomes of
laparoscopic hysterectomy. Journal of Reproductive Medicine, November 2013, vol./is. 58/11-12(497-503), 00247758;0024-7758.
95
Gunderson CC; Java J; Moore KN; Walker JL (2014). The impact of obesity on surgical staging, complications, and survival
with uterine cancer: a Gynecologic Oncology Group LAP2 ancillary data study. Gynecologic Oncology, April 2014, vol./is.
133/1(23-7), 0090-8258;1095-6859.
96
Nicoletto BB; Fonseca NK; Manfro RC; Goncalves LF; Leitao CB; Souza GC (2014). Effects of obesity on kidney
transplantation outcomes: a systematic review and meta-analysis. Transplantation, July 2014, vol./is. 98/2(167-76), 00411337;1534-6080.
97
Thomsen T, Villebro N & Moeller A. Interventions for preoperative smoking cessation (Review). Cochrane database of
Systematic Reviews, 2010 (7) Issue 9.
98
ASH (2014) ‘Smoking and Surgery’ [Online] Available at: http://ash.org.uk/files/documents/ASH_711.pdf
99
Theadom A, Cropley M. Effects of preoperative smoking cessation on the incidence and risk of intraoperative and
postoperative complications in adult smokers: a systematic review. Tobacco Control, 2006; 15: 352–8.
100
Azodi OS, Belloco R, Eriksson K, et al The impact of tobacco use and bodymass index on the length of stay in hospital
and the risk of post-operative complications among patients undergoing surgery. Journal of Bone and Joint Surgery, 2006:
(88B) 10:1316-1320.
101
Jones RM. Smoking before surgery: the case for stopping. British Medical Journal, 1985; 290: 1763-1764.
102
Møller AM, Pedersen T, Villegro N. Effect of smoking on early complications after elective orthopaedic surgery. Journal
of Bone and Joint Surgery 2003; (85-B) 178 – 81.
103
Walker NM, Morris SAC, Cannon LB. The effect of pre-operative counselling on smoking patterns in patients undergoing
forefoot surgery. Foot and Ankle Surgery, 2009; 15: 86 – 89.
104
Petrar S, Bartlett C, Hart RD, MacDougall P. Pulmonary complications after major head and neck surgery: a
retrospective cohort study. The Laryngoscope, 2012. 12. 5: 1057-1061
105
Jorgensen LN, Kallchave F, Christensen E, et al. Less collagen production in smokers. Surgery, 1998; 123:450–5.
106
Sørensen LT, Horby J, Friis E, Pilsgaard B et al. Smoking as a risk factor for wound healing and infection in breast cancer
surgery. European Journal of Surgical Oncology. 2002. 28. 8: 815-820
107
Jones JK, Triplett RG. The relationship of cigarette smoking to impaired intraoral wound healing: a review of evidence
and implications for patient care. J Oral Maxillofac Surg, 1992; 50:237-9.
108
Silverstein P. Smoking and wound healing. American Journal of Medicine, 1992; 93 (1A):22S-24S.
109
Sørensen LT. Wound healing and infection in surgery: the clinical impact of smoking and smoking cessation: a
systematic review and met-analysis. Arch Surg, 2012. 147. 4: 373-383.
110
Møller AM, Maaloe R, Pedersen T. Post-operative intensive care admittance: the role of tobacco smoking. Acta
Anaesthesiol Scand, 2001; 45:345-8.
74
111
London Health Observatory. Stop before the op. LHO and SmokeFree London, 2006.
Delgado-Rodriguez M, Medina-Cuadros M, Martinez-Gallego G, Gomez-Ortega A et al. A prospective study of tobacco
smoking as a predictor of complications in general surgery. Infection control and hospital epidemiology, 2003, 24. 1: 37-43
113
Myers K, Hajek P, Hinds C, McRobbie H. Stopping smoking shortly before surgery and postoperative complications.
Archive of Internal Medicine, 2011. 171. 11: 983-98.
114
Van Domburg R, Meeter K, van Berkel D, Veldkamp RF, van Herwerden L, Bogers AJ. Smoking cessation reduces
mortality after coronary artery bypass surgery: a 20-year follow-up study. Journal of the American College of Cardiology
2000;36:878-83.
115
Sørensen LT, Jørgensen T, Kirkeby LT, Skovdal J et al. Smoking and alcohol abuse are major risk factors for anastomotic
leakage in colorectal surgery. British Journal of Surgery, 1999. 86.7: 927-931.
116
Chang DW, Reece GP, Wang B, Rob G et al. Effect of smoking on complications in patients undergoing free
TRAM flap breast reconstruction. Plastic and Reconstructive Surgery, 2000. 105. 7: 2374-2380.
117
Chimbira W, Sweeney BP. The effect of smoking on postoperative nausea and vomiting. Anaesthesia, 2000.
55. 6: 540-544.
118
Jensen JA, Goodson WH, Hopf HW. Cigarette smoking decreases tissue oxygen - Arch Surg, 1991; 126: 1131-1134.
119
Kotani N, Hashimoto H, Sessler DI, et al. Smoking decreases alveolar macrophage function during anaesthesia and
surgery. Anesthesiology, 2000; 92:1268-77.
120
Akrawi W, Benumof JL. A pathophysiological basis for informed preoperative smoking cessation counselling. Journal of
Cardiothoracic and Vascular Anaesthesia 1997;11(5):629–40.
121
Schwilk B, Bothner U, Schraag S, Georgieff M. Perioperative respiratory events in smokers and non-smokers undergoing
general anaesthesia. Acta Anaesthesiologica Scandinavica 1997;41:348–55.
122
Furlong (2009) ‘Preoperative Smoking Cessation: A Model To Estimate Potential Short Term Health Gain and Reductions
In Length Of Stay’. London Health Observatory
123
Critchley JA, Capewell S. Mortality Risk Reduction Associated With Smoking Cessation in Patients With Coronary Heart
Disease: A Systematic Review. JAMA.2003;290(1):86-97. doi:10.1001/jama.290.1.86
124
Ishikawa SN, Murphy GA, Richardson EG. The effect of cigarette smoking on hindfoot fusions. Foot Ankle Int, 2002; 23
(11): 996–8.
125
Bluman LG, Mosca L, Newman N, Simon DG. Preoperative smoking habits and postoperative pulmonary complications.
Chest, 1998. 113 4: 883-889.
126
Khan MA, Hussain SF Pre-operative pulmonary evaluation. J Ayub Med Coll Abbottabad, 2005.17 4: 82- 86.
127
Moore S, Mills BB, Moore RD, et al. Perisurgical smoking cessation and reduction of postoperative complications.
American Journal of Obstetric Gynaecology, 2005; 192: 1718-21.
128
Nakagawa M, Tanaka H, Tsukuma H, Kishi Y. Relationship between the duration of preoperative smoke-free period and
the incidence of postoperative pulmonary complications after pulmonary surgery. Chest Journal, 2001. 120. 3: 705-710
129
Sorensen LT, Karlsmark T, Gottrup F. Abstinence from smoking reduces incisional wound infection: a randomized
controlled trial. Annals of Surgery, 2003; 238(1): 1-5.
130
Furlong C Preoperative Smoking Cessation: A Model to Estimate Potential Short-term Health Gain and Reductions in
Length of Stay. London Health Observatory, 2005.
131
BTS (2013) ‘The Case for Change: why dedicated, comprehensive and sustainable stop smoking services are necessary
for hospitals’ [Online] Available at: https://www.brit-thoracic.org.uk/document-library/clinical-information/smokingcessation/bts-case-for-change/
132
Donald H. Taylor, Jr, Vic Hasselblad, S. Jane Henley, Michael J. Thun, and Frank A. Sloan. Benefits of Smoking Cessation
for Longevity. American Journal of Public Health: June 2002, Vol. 92, No. 6, pp. 990-996. doi: 10.2105/AJPH.92.6.990
133
van Domburg RT, Meeter K, van Berkel DFM, Veldkamp RF et al. Smoking cessation reduces mortality after coronary
artery bypass surgery: a 20 year follow-up study. Journal American College of Cardiology, 2000. 36.3.
134
Stop Smoking Wales. A summary of the health impact of smoking and short-term benefits of stopping smoking before
an operation in Wales. Welsh Assembly Government, 2007.
135
NICE (2008) ‘Smoking Cessation Services’ [Online] Available at: http://www.nice.org.uk/guidance/PH10
136
NICE (2007) ‘Behaviour Change: the principles for effective interventions’ [Online] Available at:
http://www.nice.org.uk/guidance/ph6
137
British Thoracic Society (2012) ‘Recommendations for Hospital Smoking Cessation Services for Commissioners and
Health Care Professionals’ [Online] Available at: https://www.brit-thoracic.org.uk/document-library/clinicalinformation/smoking-cessation/bts-recommendations-for-smoking-cessation-services/
138
Lindstrom D et al. Effects of a perioperative smoking cessation intervention on postoperative complications: a
randomized trial. Annals of Surgery, 2008; 248: 739-745.
139
Walker NM, Morris SAC, Cannon LB. The effect of pre-operative counselling on smoking patterns in patients undergoing
forefoot surgery. Foot and Ankle Surgery, 2009; 15: 86 – 89.
140
Gorin AA, Phelan S, Hill JO, Wing RR. 2004. Medical triggers are associated with better short- and long-term weight loss
outcomes. Prev Med. 2004 Sep;39(3):612-6.
141
Wing RR, Phelan S. Long-term weight loss maintenance. Am J Clin Nutr. 2005 Jul;82(1 Suppl):222S-225S.
112
75
142
Rigotti NA, Munafo MR, Stead LF. Interventions for smoking cessation in hospitalised patients. Cochrane database of
systematic reviews, 2007 (3).
143
National Institute for Health and Care Excellence. Commissioning a smoking cessation service for people having elective
surgery. NICE.
144
Khullar D, Schroeder SA, Maa J. Helping smokers quit around the time of surgery. JAMA, 2013. 309. 10: 993994.
145
NHS Future Forum 2012. The NHS’s role in the public’s health: a report from the NHS Future Forum.
www.gov.uk/government/uploads/system/uploads/attachment_data/file/216423/dh_132114.pdf
146
Thaler R, Susntein C 2008. Improving Decisions About Health, Wealth and Happiness. Yale University Press.
147
NHS England (2014). Five Year Forward View. [Online] Available at: http://www.england.nhs.uk/wpcontent/uploads/2014/10/5yfv-web.pdf
76