Appendix 2 Literature Review – Childhood Obesity Obesity – Background All of the literature refers to similar statistics regarding obesity. The list below gives some examples of the data available from the different sources. ¦ ¦ ¦ ¦ Obesity has more than doubled between 1990 and 2000 in Britain. One in 10 six year olds (8. 5%) are obese. One in six (15%) 15 year olds is obese. If the current trends continue, one fifth of boys and one third of girls will be obese by 2020. Obesity is measured using the Body Mass Index (BMI) for an individual.

This is measured through a calculation relating height to weight and age, and there are agreed figures for obesity. This problem is not just limited to the UK. Obesity is rising in other developed countries, most notably the USA. No-one has managed to reverse this trend. 1 Implications of Obesity 1) Premature mortality a) Linked to 30,000 deaths a year b) Shortening of life by an average of 9 years2 2) Cost to NHS a) ? 0. 5 billion pa3 3) Cost to economy4 a) ? 2 billion b) 18 million sick days pa 4) Increased risk of disease. 6 Most are diseases of adult life, but overweight adolescents have a 70% chance of becoming overweight or obese adults. 7 a) Heart disease – the most common cause of premature death among obese people (estimated 28000 heart attacks caused by obesity in 1998) b) Type 2 diabetes – this was previously considered to be an adult disease but has appeared in obese school children c) High blood pressure d) Osteoarthritis and back pain e) Hypertension f) Asthma g) Cancer, especially colon 1 2 Wanless, D.

Select Committee on Public Accounts 3 NAO 4 NAO 5 NAO 6 Ebbeling et al. 7 POST 5) Exercise intolerance8 6) Stereotype/Stigmatisation:9 10 a) Unhealthy b) Academically unsuccessful c) Socially inept d) Unhygienic e) Lazy f) Negative self image – which could also lead to low self confidence and depression in both children and adults Causes of Obesity There are two main causes of obesity – diet and physical activity. 11 However, the literature suggests that some other factors may influence it, and also goes into greater detail about the two main causes. ) Genetic reasons12 a) Possibility that maternal obesity transfers b) Possibility that those children who were bottle fed are more at risk c) The rise in obesity has been considered to be too large for only genetic factors to account for it. 13 2) Environmental stimuli14 a) As children grow older, they become more responsive to external stimuli than internal hunger pangs 3) Increasingly sedentary lifestyle15 16 although there is little direct evidence. The available data reveals: a) Television viewing – lack of physical activity combined with propensity to eat. Possibility that television advertising could affect eating habits (eg. andom sample of children’s tv showed 34% of adverts were for junk food) b) Also includes video games, computers and the internet c) Reduction of physical activity in schools: i) A survey by Sport England showed that the proportion of young people spending two or more hours a week on sport in school declined from 46% in 1994 to 33% in 1999) ii) The National Diet and Nutrition survey (2000) found that 40% of boys and 60% of girls failed to meet a Health Education Authority recommendation that children should engage in at least moderate physical activity for one hour per day. 7 d) Urban environments discouraging physical activity e) Decline in children walking and cycling to school 8 9 Ebbeling et al. Ebbeling et al. 10 POST 11 Wanless, D. 12 Ebbeling et al. 13 POST 14 Ebbeling et al. 15 Ebbeling et al. 16 POST 17 University of York 4) Changes in eating patterns and dietary habits a) Consuming more calories than are expended18 b) Large portion sizes19 c) Content of food (energy dense foods) e. g. fats, carbohydrates, sugar20 d) Quality of food in schools21 – including prevalence of snack vending machines in schools22 e) Increase in fast food and snacks f) Family behaviours e. . dinner in front of the TV, less time to cook ‘proper’ food23 g) Heavy marketing of fast food and very sugared drinks24 h) Decrease in consumption of fruit and vegetables25 5) Convenience culture26 a) Importance of the car b) Remote controls 6) Cost and availability of high fat/high sugar foods compared to healthy food27 7) Lack of knowledge of healthy eating28 Dispersion of Obesity Obesity varies from region to region, by gender, by ethnic group and by socio-economic background.

A more detailed understanding of how these factors affect body weight is needed nationally, and then these results can be applied locally. 29 ¦ ¦ ¦ ¦ ¦ ¦ Increases with age; Prevalence amongst school children increasing; People in lower socio-economic groups have an increased risk; Prevalence higher among manual groups; Prevalence higher in certain ethnic minority groups (Asian30); A growing problem in all regions in England (18 – 22%).

Obesity in children is also higher among manual groups and ethnic inequalities in the prevalence of overweight are also apparent, with higher rates among Asian groups. Strategies to Deal with Obesity Strategies ultimately need to deal with eating less and becoming more physically active. 31 18 19 20 NAO POST Ebbeling et al. 21 Wanless, D. 22 All-Party Parliamentary Group on Obesity 23 Ebbeling et al. 24 POST 25 University of York 26 Ebbeling et al. 27 Wanless, D. 28 Wanless, D. 29 Select Committee on Public Accounts 30 Wanless, D. 1 Ebbeling et al. Currently, there is no national intergovernmental plan for healthy eating and exercise although most PCTs are drawing up obesity strategies. 32 Action needs to be taken at all levels, including national, local, community and individually and concentration should be on solutions, not problems. 33 However, it is noted that as obesity is a long-term problem, it is not necessarily attractive for governments. 34 There is a lack of good quality evidence which supports the effectiveness of interventions to prevent obesity. 5 However, the Health Development Agency has looked at this issue and a summary of evidence of success of interventions is presented at Appendix A. 1) Prevention36 2) Further research37 a) Research on prevention and effective interventions b) Research on policy options c) Research to improve understanding of societal and cultural factors behind this trend eg. child poverty 3) Department of Health38 a) Appraisal of the effectiveness of treatments b) Build on NSF for coronary heart disease c) Disseminate guidelines for the management of obesity d) Research through a ross-departmental group e) Development of a cross-Government strategy to promote health benefits of physical activity 4) Public Services a) Initiatives should be implemented at local level – public services should take the lead by promoting healthy eating and increased physical activity in public places eg. schools, hospitals. 39 See below for further discussion. b) Need for extra resources to tackle “complex” problem40 5) Local Health Improvement Programmes within the NHS a) Few local strategies nationally to address obesity specifically – patchy.

Appropriate strategies need to be developed focusing on those most at risk. 41 i) Action is currently being taken through the prevention themes of national CHD and cancer programmes ii) It is also part of the NSFs such as for CHD and diabetes42 b) Should be included in all plans and policies. 43 c) Need to develop realistic milestones and targets to improve nutrition and diet, promoting physical activity and for stopping rising trend of obesity, including indicators of progress in reducing health inequalities. 4 32 33 HSJ RCP/FPH/RCPCH 34 All-Party Parliamentary Group on Obesity 35 University of York 36 NAO 37 RCP/FPH/RCPCH 38 NAO 39 RCP/FPH/RCPCH 40 All-Party Parliamentary Group on Obesity 41 NAO 42 Wanless, D. 43 RCP/FPH/RCPCH 44 NAO d) Objectives to improve health outcomes and tackle obesity, need to be given equal weight in the NHS performance management and inspection systems to waiting times. 45 e) Training should be given for doctors, nurses and other health professionals. 6 f) Target to increase breast feeding already in place47 6) General Practice a) General advice on diet and exercise and onward referrals48 i) Current referral options tend to be state-registered dieticians, followed by private sector slimming organisations, physicians, community based programmes and trained exercise specialists and surgeons49 ii) Could use persuasion and give advice, and any more formal agreements could be made between the GP and the patient50 b) Scope to clarify role of primary care and spread good practice c) More information needed on how to address weight issues effectively; guidance would be appreciated51 d) Confusion of roles; guidance needed on expectations e) Engage a wider range of professionals f) Evaluation of prescribed treatments and guidance for NHS professionals needed. 52 g) Reminders to prescribe diets h) Inpatient obesity clinics and treatments53 7) Other health professionals a) Currently have little training or guidance in nutrition, exercise and behavioural change – needed. ) There is a shortage of specialist professionals including dieticians54 c) NICE and the HDA will be producing guidance on obesity d) The Children’s NSF will include standards for implementing measures to promote healthy eating and lifestyle55 8) Physical exercise programmes and initiatives a) DfES to ensure children’s entitlement of 2 hours of physical exercise is being delivered in schools and to monitor and publish progress56 b) Central government departments to encourage local targets to support healthy modes of travel including school journeys c) Central government departments to consider joint targets to increase number of people engaging in physical exercise d) A joint national group to monitor the success of physical exercise programmes57 e) Improved cycle paths58 9) Promotion of healthy eating 45 46 47 Wanless, D. RCP/FPH/RCPCH POST 48 NAO 49 Wanless, D. 50 Prime Minister’s Strategy Unit 51 NAO 52 Select Committee on Public Accounts 53 HSJ 54 HSJ 55 Wanless, D. 56 Select Committee on Public Accounts 57 NAO 58 Select Committee on Public Accounts ) DoH to work with the food industry to improve the balance of diet and establish ways of monitoring initiatives to achieve this59 b) Improved labelling of food products c) Ensure that the importance of fruit in a balanced diet is communicated and promoted in schools d) Development of a code of conduct with regard to amount and nature of food advertising to children60 e) Tax on unhealthy foods61 f) Eat more fibre62 g) Healthy Start will start this year – it will provide the means for disadvantaged families to buy healthier food 10) Joint working a) Obesity is not simply a matter of public health and so departments need to work together to look for solutions63 b) Emphasis on partnership working and co-ordinating policy c) Cabinet level cross-governmental task force should be established to develop national strategies and to oversee the implementation of these strategies. 64 11) Schools – “there is evidence to support the use of multi-faceted school-based interventions to reduce obesity and overweight in school children, particularly girls. 65 Current initiatives include: a) Healthy Schools Programme i) Aims to make children, teachers, parents and local communities more aware of the role of schools in improving health ii) Also includes National School Fruit Scheme and Safe Active Travel to School initiative b) Food in Schools Programme (DoH) i) Helps to ensure children have access to healthy food options in schools ii) DoH is promoting pilots for healthy eating tuck shops, vending machines and nutritional packed lunches iii) Free fruit at school (National School Fruit Scheme) iv) Cookery clubs The literature also suggests the following strategies for schools: c) d) e) f) g) h) i) j) Education on nutrition Promotion of physical activity Reduction of sedentary behaviour Behavioural therapy Teacher training Curricular activity Modification of school meals66 Guidance on sponsorship67 (see Appendix B for examples of current sponsorship) 59 60 NAO Select Committee on Public Accounts 61 HSJ 62 POST 63 All-Party Parliamentary Group on Obesity 64 RCP/FPH/RCPCH 65 HDA, pp. 2. 66 HSJ 67 NAO k) Lack of evidence for physical activity programmes led by specialist staff/teachers preventing obesity68 l) Measurement and evaluation of schools based on initiatives that they undertake with regard to children’s diets, nutrition and physical activity (should be incorporated into OFSTED inspections). 9 12) Support for the individual (not blaming)70 13) Targeting parents and children for physical activity and health promotion a) This works in cases where the child is already obese or where the parent takes primary responsibility for diet and exercise changes (targeting them together); it does not work for behaviour modification programmes involving sustained contact with children and parents71 b) There is also limited evidence suggesting that behaviour modification programmes work without the support of the parents. 72 c) Lifestyle health component in parenting classes, including advice on healthy eating73 14) Laboratory based exercise programmes74 15) Workplace health promotion programmes75 16) Responsible food promotion a) Public education campaign from government – to improve eople’s understanding of the benefits of healthy eating and to motivate people to eat a more healthy diet and adopt a more active lifestyle76 b) Guidance to media organisations77 c) Jointly agreed standards in food labelling and marketing (Food Standards Agency and food industry)78 d) Improved regulation/legislation from government79 e) Incentives to encourage production, promotion and sale of healthier food80 f) Tax on fatty foods suggested by the BMA but no evidence to prove this would be desirable or feasible81 17) Behaviour Changes82 a) Need to have an intention to address weight problem b) Need to have positive viewpoint to dieting successfully c) Need skills to lose weight (see promotion of healthy eating, above) 68 69

HDA All-Party Parliamentary Group on Obesity 70 All-Party Parliamentary Group on Obesity 71 HSJ 72 HDA 73 Prime Minister’s Strategy Unit 74 HSJ 75 HSJ 76 RCP/FPH/RCPCH 77 FSA 78 RCP/FPH/RCPCH 79 Prime Minister’s Strategy Unit 80 RCP/FPH/RCPCH 81 Prime Minister’s Strategy Unit 82 Wanless, D. Local Authority Good Practice PCTs in Camden and Islington ¦ ¦ ¦ ¦ ¦ ¦ ¦ Fruit tuck shops for schools; Breast feeding and healthy eating information for Sure Start mums; Exercise referrals from GPs to LA leisure services; Two specialist services offering obesity surgery; GP’s being funded to prescribe NICE recommended drug therapies; Hoping to launch joint initiatives with commercial slimming organisations; Hoping to provide training for primary care staff on weight loss (currently only available to dieticians).

The money comes from various sources including the National Lottery New Opportunities Fund and the National School Fruit Scheme. They would like to see ringfenced funding but at the moment they are moving resources from somewhere else. Newark and Sherwood PCT ¦ ¦ ¦ ¦ Leads on obesity for the four Nottinghamshire PCTs; Employs community nutrition assistant and active lifestyle officer (funded by NHS but working through district councils); patients referred through GPs, health visitors and social services; Community nutrition assistant teaches home economics to low income groups including supermarket tours and education on healthy eating; Active lifestyle officer runs exercise referral programmes.

Newcastle PCT83 “Newcastle PCT established a Specialist Weight Management Service (SWiMS) following a survey undertaken by Newcastle University that identified high prevalence of obesity among Newcastle residents (41 per cent of men and 54 per cent of women). Funded by Neighbourhood Renewal, the service is staffed by a programme manager, fitness instructor, psychologist, dietician and community nutrition assistant together with administrative support. “The service links with primary, secondary and tertiary care (including diabetes and cardiac rehabilitation services), with physiotherapy and with council funded and private leisure facilities. Referral to SWiMS can be from any of these routes or clients can self-refer. The service offers 3 levels of provision depending on BMI: • • • • Level 1 services are those that were already in existence prior to the development of SWiMS and include primary care advice and management of overweight and obesity, and leisure services. Level 2 services provide weekly groups sessions over a 12 week period offering dietary advice, physical activity and psychological support to those with a BMI >25. Level 3 services are provided for the house bound or those with morbid obesity (BMI >40). 83 Wanless, D. , pp. 61. “Individual or small group interventions are provided with a programme tailored to the individual. This involves a range of activity including physiotherapy, dietary advice and psychological support. For those with morbid obesity the service has links with tertiary care services and can refer directly for assessment of the need for gastric surgery. “Follow-up at 6 and 12 months is provided for all clients. “Evaluation of clients at one year follow-up demonstrated sustained physical activity and weight loss together with a reported increase in self-esteem and confidence. “An independent evaluation of the service has been commissioned from Northumbria University. ” Other Programmes Carnegie International Weight Loss Programme84 Six week programme involving: Dietary modification Physical activity Education Tries to give fun and positive environment for weight loss Does not ‘ban’ e. g. oing to McDonalds but shows children how to behave in that situation Tries to teach children relevant experiences to allow them to make good food choices Supplemented by follow up weight management clinic and home visits – ongoing treatments Works with whole family Difficult to assess success (due to lack of research) but appears that: There is a definite reduction in BMI and percentage of body fat An increase in fitness levels Improved self esteem and self image 84 All-Party Parliamentary Group on Obesity Appendix A Taken from: Health Development Agency (HDA). (2003) The Management of Obesity and Overweight. pp. 6. Appendix B Personal Responsibility and Changing Behaviour: the state of knowledge and its implications for public policy. Pp. 16 Taken from: Prime Minister’s Strategy Unit. 2004) Bibliography All-Party Parliamentary Group on Obesity. (2002) Fat kids equals fat profits: are we exploiting our children’s health? Ebbeling, C. B. , Pawlak, D. B. and Ludwig, D. S. (2002) Childhood obesity: public health crisis, common sense cure. Food Standards Agency (FSA). (2004) Food promotion and children. Health Development Agency (HDA). (2003) The Management of Obesity and Overweight. Health Service Journal (HSJ). (November 2003) The Big Issue. National Audit Office (NAO) Report by the Comptroller and Auditor General. (2001) Tackling Obesity in England. Parliamentary Office of Science and Technology (POST). (2003) Childhood Obesity.

Prime Minister’s Strategy Unit. (2004) Personal Responsibility and Changing Behaviour: the state of knowledge and its implications for public policy Royal College of Physicians, the Faculty of Public Health, the Royal College of Paediatrics and Child Health (RCP/FPH/RCPCH). (2004) Storing up Problems: The Medical Case for a Slimmer Nation. Select Committee on Public Accounts. (2001) Ninth Report: Tackling Obesity in England. The University of York NHS Centre for Reviews and Dissemination (University of York). (2002) Effective Health Care: The Prevention and Treatment of Childhood Obesity. Wanless, Derek. (2004) Securing Good Health for the Whole Population.