Health Survey for England informs public policy on obesity
Submitting InstitutionUniversity College London
Unit of AssessmentPublic Health, Health Services and Primary Care
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Economics: Applied Economics
Summary of the impact
UCL research, from the Department of Epidemiology & Public Health,
has underpinned the Health Survey for England's (HSE) role in informing
obesity policy in England. HSE data quantified the extent and escalation
of obesity within the population as a whole as well as specific
sub-groups, resulting in this issue being given significant attention in
government. HSE data has underpinned strategy development, the modelling
of future scenarios, the identification of inequalities, and the creation
of clinical guidance. HSE data has showed early indications that the focus
on childhood obesity is paying off, with wider evaluation shifting further
strategy work to adults. HSE data has also played a role in this area,
defining the adult target group for the Change4Life programme.
Furthermore, HSE data are underpinning new agreements with the food
industry through the Responsibility Deal.
The Health Survey for England (HSE) is an annual, cross-sectional health
examination survey of the general population in England. It combines
self-reported data (including demographic, socio-economic, health, and
lifestyle data) with objective measures of health (such as measured
height, weight, and waist circumference) . It has been run by
the Joint Health Surveys Unit of UCL and NatCen Social Research since
1994; the 23rd survey is currently in the field. HSE provides
data from nationally representative samples to monitor trends in the
nation's health; identifies the prevalence of specified health conditions
in the general population; measures the rates of certain risk factors and
combinations of risk factors; examines differences between subgroups of
the population; and monitors progress towards selected health targets. The
UCL contribution to the HSE falls into three categories: providing the
clinical and methodological expertise for the survey; jointly writing and
editing the annual HSE reports; and leading the work on secondary data
analysis and policy evaluation. The fieldwork and operational side of the
HSE are conducted by NatCen, with UCL providing clinical oversight.
UCL has developed internationally acclaimed expertise in survey
methodology. For example, we have compared the effect of mode and context
of survey on response rates, non-response bias, and responses; and of
demographic and socio-economic variation in survey participants by time
and day interviewed .
HSE is one of the few health surveys in Europe to obtain objectively
measured anthropometric data, rather than relying on self-reporting which
consistently under-reports obesity. HSE provides objective, national,
general population data on prevalence of general and abdominal obesity [3,
4]. Extensive demographic and socio-economic data also permit
assessment of inequalities in obesity by age, sex, geography, and several
markers of socio-economic position.
The HSE team at UCL have conducted a considerable amount of secondary
analysis work using the HSE data. In 2009, for example, we used HSE data
to analyse trends in obesity, and to make projections into the future .
In 2011 we conducted the analyses and wrote the commentary for the section
of the Chief Medical Officer's 2011 report on co-occurrence of multiple
risk factors, which could be determined in the general population only
through use of HSE data. We identified obesity as one of the main risk
factors behind the differences in prevalence of multiple lifestyle risk
factors by age and by socio-economic position, and for which the trend was
upwards, unlike most other lifestyle risk factors . Our 2012
paper used HSE data to demonstrate that waist circumference (a marker for
central/abdominal obesity) had increased in adolescents at a greater rate
than generalised obesity (as shown by measuring BMI) .
Since 2005, the UCL team has been led by Dr Jennifer Mindell in the
Health and Social Surveys Research Group of the Research Department of
Epidemiology & Public Health, with substantial contributions from Dr
Nicola Shelton and a number of post-doctoral and junior researchers.
References to the research
 Details about each report can be found here: http://www.natcen.ac.uk/series/health-survey-for-england
 Mindell J, Becares L, Aresu M, Tolonen H. The right time for a
survey? Socio-demographic variation in survey responses by time of day and
day of week. Eur J Public Health.
 Stamatakis E, Zaninotto P, Falaschetti E, Mindell J, Head J. Time
trends in childhood and adolescent obesity in England from 1995 to 2007
and projections of prevalence to 2015. J Epidemiol Community Health.
 HSE annual report chapters on obesity, e.g.: Tabassum F. `Adult
anthropometric measures, overweight and obesity.' Chapter 7 in Craig R,
Hirani V (eds). The Health Survey for England 2009. Leeds: NHS Information
Centre, 2010. (Copy available on request.)
 Zaninotto P, Head J, Stamatakis E, Wardle H, Mindell J. Trends in
obesity among adults in England from 1993 to 2004 by age and social class
and projections of prevalence to 2012. J Epidemiol Community Health.
 Mindell JS, Dinsdale H, Ridler C, Rutter HR. Changes in waist
circumference among adolescents in England from 1977-1987 to 2005-2007.
Public Health. 2012 Aug;126(8):695-701.
Details of the impact
Worldwide, obesity represents one of the most challenging health
problems, with the UK having among the highest rates in Europe. The
associations between obesity and health problems such as type 2 diabetes
are set to add substantially to health service costs in the future.
Measurements taken as part of the Health Survey for England (HSE) have
been used extensively at every stage of obesity policy making and
monitoring. Public Health England describes HSE as "currently the most
robust data source to monitor trends in adult obesity in England" [a].
HSE data are used extensively by the Department of Health, NHS and local
authority staff, the media, and the public. In one year alone (1 April
2012-1 April 2013) there were 36,803 page views (26,928 unique) of HSE
pages on the Health and Social Care Information Centre (HSCIC)'s website.
The three months April-June 2013 saw 7,796 downloads [b]. The UK
Data Service reported that the HSE was the second most frequently
downloaded dataset in the UK in 2011 [c]. Here we present key
evidence for how, during the period 2008-13, HSE has informed the
quantification of the obesity problem, the development of Government
policy and strategy, the development of clinical guidelines, and the
monitoring of progress.
Measuring the obesity problem
HSE data have enabled the extent and escalation of obesity within the
population to be quantified, drawing the attention of Government and
policymakers to the issue. Importantly, HSE data enabled the
quantification of the obesity problem within sub-groups of the population,
highlighting the high rates in children and among adults from lower
socioeconomic positions. The Foresight Report, funded by the Government
Office for Science, used HSE 1994-2004 data to project population trends
to 2050 and examine future impacts on life expectancy and economic costs
of overweight and obesity [d]. The 2010 adult update [e]
used HSE data from 1993 to 2007. The adult obesity projections varied
little: future health problems were predicted to soar, with
obesity-related diabetes rising by 98%, strokes by 23%, and heart disease
by 44% by 2050.
Influencing Government policy and strategy
HSE measurement data are used by Government to produce evidence-based
strategies to combat obesity. The Chief Medical Officer (CMO), the
Government's most senior medical advisor, publishes an annual report to
identify priorities in health and recommend action to improve public
health. The CMO's 2011 report used a range of HSE data, including on
obesity [f]. The UCL team were responsible for the analyses which
identified obesity as one of the main risk factors behind the differences
in prevalence of multiple lifestyle risk factors by age and by
The research on the HSE that was cited in the Foresight report was used
to justify investment of money and Government focus on obesity. For
example, in the 2008 Healthy Weight, Healthy Lives: A Cross-Government
Strategy for England, a range of commitments for reducing obesity
were identified [g]. It states: "the Government will make
available an additional £372 million for promoting the achievement and
maintenance of healthy weight over the period 2008-11." The 2011
document Healthy Lives, Healthy People: A call to action on obesity in
England set out specific plans for dealing with the obesity problem
[h]. One specific area in which our data influenced this report was
in relation to the Change4Life campaign, an extensive public
health programme run by the Department of Health which started in 2009.
HSE data were used to choose the appropriate adult age group to target for
a new phase of the health promotion campaign entitled Change4Life: One
Year On [i]. In addition, a calorie reduction target set out
in this document was derived from HSE weight gain data, to estimate that a
mean reduction in daily energy intake of 100 calories (kcal) per person
would correct the energy imbalance nationally. This was also set out
within in Responsibility Deal — a series of pledges that food
manufacturers, retailers, caterers, suppliers and service organisations
such as restaurants signed up to with the goal of providing "a mechanism
for the food and drink industry to make and record its contribution to
helping the population meet the calorie reduction challenge" [j].
Informing clinical guidance
The National Institute of Health and Care Excellence (NICE) clinical
guidelines on the prevention, identification, assessment and management of
overweight and obesity in adults and children, currently being reviewed
and updated, used HSE data to justify the document's creation, quantifying
the issue of obesity, attaching economic costs to this, and assessing
cost-effectiveness of clinical treatments. NICE 2012 guidance Obesity:
working with local communities also used HSE obesity data to
quantify the extent of the problem [k]. Mean measured height by
age and sex from the Health Survey for England were used by the Standing
Advisory Committee on Nutrition (SACN) in the SACN Dietary Recommendations
for Energy to calculate energy requirements [l].
Monitoring and evaluating the success of obesity strategies.
HSE data have been used to monitor targets and evaluate the success of
obesity strategies. HSE data showed early indications that the focus on
childhood obesity was paying off, with wider evaluation shifting further
strategy work to adults. One area of particular importance has been the
monitoring of equality considerations. For example, equality impact
assessments for the two Government reports Healthy Weight, Healthy
Lives and Healthy Lives, Healthy People used HSE BMI data
related to age, sex and ethnicity to show that the strategies met their
legal requirements and could be implemented [m, n]. HSE is one of
the Department of Health's main data sources for Parliamentary Questions
on obesity (for example, PQ48492 in 2011) and Parliamentary debates (for
example, House of Lords, 7 Jan 2010).
Sources to corroborate the impact
[b] HSE Web Analytics, 1 April 2012 to 1 April 2013 and April to June
2013. Provided the Health and Social Care Information Centre, 12 August
2013. Copies of the email and the Excel sheets available on request.
[c] Economic and Social Data Service webpage `ESDS facts and figures:
Most used data for 2011'
[d] Foresight, Tackling Obesities: Future Choices — Project Report, 2nd
Edition, Government Office for Science http://www.bis.gov.uk/assets/foresight/docs/obesity/17.pdf
[e] Brown M, Byatt T, Marsh T, McPherson K (2010) Obesity Trends for
Adults. Analysis from the Health Survey for England 1993 - 2007. London:
National Heart Forum.
[f] Annual report of the Chief Medical Officer 2011. London: Department
of Health, 2012.
See chapter 3 for obesity, and p222-3 for the section on risk factors.
[g] Cross-Government Obesity Unit (2008) Healthy Weight, Healthy Lives: A
Cross-Government Strategy for England. Equality Impact Assessment
[h] Healthy Lives, Healthy People: A call to action on obesity in England.
See page 18 for reference to the foresight report, and HSE annual report;
see page 6 and 8 for initiatives quoted.
[i] Department of Health (2010) Change for Life: One Year On. See
p78 and ref 39 to HSE 2007.
[j] Department of Health (2012) Calorie Reduction. https://responsibilitydeal.dh.gov.uk/f4-factsheet
[k] National Institute for Health and Clinical Excellence (2012) Obesity:
working with local communities. NICE public health guidance 42. http://guidance.nice.org.uk/ph42/
[l] Scientific Advisory Committee on Nutrition (2011) Dietary
Reference Values for Energy.
[m] Cross-Government Obesity Unit (2008) Healthy Weight, Healthy Lives: A
Cross-Government Strategy for England. Equality Impact Assessment
[n] Department of Health (2011) A call to action on obesity in England