National Assembly for Wales

Children and Young People Committee

CO 31

Inquiry into Childhood Obesity

Evidence from : Wales Dietetic Leadership Advisory Group and Public Health Dieticians in Wales

A Collated response from: The Wales Dietetic Leadership Advisory Group (WDLAG) and Public Health Dietitians in Wales (PHDiW)

WDLAG is a Statutory Advisory Group to the Welsh Therapies Advisory Committee (WTAC). Membership comprises Heads of Service and Operational Dietetic Managers from all NHS Wales Health Boards/LHB and Velindre Trust, and representation from Registered Dietitians in Public Health Wales and Cardiff Metropolitan University. It’s role is to address issues relevant to managing Nutrition and Dietetic Services in NHS Wales and to provide specialist dietetic advice to WTAC.

PHDiW (formerly known as Community Dietitians in Wales), are a group of Specialist Dietitians employed within University Health Boards or Public Health Wales (NHS). Public Health Dietitians provide credible and unbiased nutrition information, accredited training and resources to support key settings (such as nurseries, schools, and care homes), organisations (such as Communities First, Families First and the voluntary sector), communities, and members of the public to make healthy food choices with knowledge and confidence. Community Dietitians are trusted stakeholders frequently engaged in a range of local and national working groups, and have assisted, or led in the development of food/ nutrition related policies and guidelines, including the All Wales ‘Infant Feeding Guidelines’, ‘Food and Health Guidelines for Early Years and Childcare Settings’ and Appetite for Life Action Plan/ Guidance.

WDLAG and PHDiW welcome the opportunity to consult on and respond to the National Assembly for Wales’ Children and Young People Committee Inquiry into Childhood Obesity. The following information represents our collated views:

(1) The extent of childhood obesity in Wales and any effects from factors such as geographical location or social background

The collection of data on rates of childhood obesity in Wales is in its infancy. For example, the Child Measurement Programme for foundation phase (reception) children has not yet completed a single year cycle in most areas.  At present it is not clear whether this surveillance measure will allow for the delineation of data into a format which can help to determine if geography or wealth are key predictors of obesity risk specific to the Welsh population.

Statistics represented within the Welsh Health Survey data (2012) indicate that in 2011 35% of children are classified as overweight or obese, including 19% obese.  Data has been gathered since 2007 and general trends indicate there has been little change in overweight/ obesity figures over the last 5 years. The survey is said to be representative of people living in private households, though it  excludes children and young people living in institutions (e.g. care settings) who may be experiencing poorer health, this needs due consideration with respect to future inclusion. Whilst the figures do not (on the surface) appear to be worsening it’s not clear whether there may be a ‘masked’ worsening or increasing ‘divide’ e.g. between children from low income vs higher income families.

In summary, the data currently gathered appears to require further development and continued investment to enable a fuller perspective on child obesity prevalence with the sensitivity to detect variations that may exist related to social background or geographical location.  From available data, the current prevalence is concerning and is a trend that Dietitians along with partners would want to focus attention on reversing.

(2) The measurement, evaluation and effectiveness of the Welsh Government’s programmes and schemes aimed at reducing the level of obesity in children in Wales specifically:

Health related programmes including: Change4Life, MEND

Health related programmes can be separated into those that have population reach and are for primary prevention of obesity i.e. Level 1 of the Welsh Government All Wales Obesity Pathway (2010) and those that are targeted interventions for those who are already overweight or obese, (Level 2/3) although there is  a degree of overlap across the levels.

Change4life (C4L) is a social media campaign that aims to reach the whole population. We support the C4L social marketing brand and believe the key messages and materials promote family friendly messages that provide support and encouragement to make positive lifestyle change. It will take time for this to be embedded to effect longer term lifestyle change and also requires a multifaceted approached as part of a wider public health framework to address these complex issues.  Registered Dietitians incorporate C4L messages and materials across the range of accredited food and nutrition learning opportunities provided as part of Nutrition Skills for Life (see below, pg 5).

The C4L ‘sister’ brand Start4Life (S4L) includes a range of materials to support breastfeeding and early years nutrition.  We would welcome the opportunity to extend the suite of materials to include promotion of nutrition and physical activity messages for pregnancy (including preconception).  Materials covering this topic have recently been developed as part of S4L in England and therefore could be adopted and translated for use within Wales.

Interventions to help prevent and manage child obesity should commence at the very

beginning of the ‘life course’. S upport for programmes targeting women pre, during and after pregnancy are urgently required.  Data emerging at a Health Board/ regional level indicates an alarming number of women are entering pregnancy obese (BMI ≥30).  There is credible and mounting evidence linking maternal obesity with congenital malformations, infant mortality, reduced likelihood of breastfeeding and an increased risk of obesity in childhood and adolescence (CMACE, 2010; Tennant et al, 2011; Rasmussen et al 2011).

We support the application of a ‘settings’ based approach to addressing health and well being by creating supportive environments, specifically within early childcare, school and community based settings.  The National Healthy and Sustainable Pre School Scheme (HSPSS) and Welsh Government Food and Health Guidelines for Early Years and Childcare settings promote a whole setting approach to nutrition in pre school/early child care settings.  Dietitians in four Health Boards in Wales also deliver local Healthy Snack Award Schemes for pre school settings.  Provision of healthier food to preschool settings is addressed through the HSPSS and local healthy snack and drink award schemes in Wales.

Dietitians within Wales would welcome the opportunity to explore food and drink provision in other settings where children, young people and families frequent; these might include play groups and play areas.

Current childhood obesity interventions to meet Level 2 of the All Wales Obesity Pathway e.g. MEND are targeted at children who are already overweight or obese and their families.

It is clear that there needs to be provision of evidence based interventions for weight management in children. The child obesity intervention programme (MEND) is an evidence based multi component intervention with a published evidence base that has demonstrated both clinical and cost effectiveness.  It provides the only intervention currently being offered to meet Level 2 of the Obesity Pathway.  However, at this time it is not clear whether there is sufficient support for programmes such as MEND to continue delivering.  The recent Public Health Wales Health Improvement Review Draft recommendations indicate a potential to dis-invest in the programme.  This will leave a considerable gap in provision at a time when the need continues to increase. Shared experiences from Dietitians that have supported MEND across Wales indicates there have been considerable difficulties in delivering the programme to the maximum number of children within the provision agreed and we feel there are technical issues in the way that funding is allocated.  However where programmes have been delivered successfully, both children and parents have demonstrated extremely positive outcomes. We hope that the need is still identified for such a programme beyond the current contracting period to 2014, following the Health Improvement review final recommendations. It needs to be clarified who funds it and holds the budget and engage equal partners across sectors to make it work.

Currently the funding allocation from Public Health Wales enables local areas to run the MEND 5-7 years and 7-13 years programme. Dietitians in Wales believe there is a need to provide interventions earlier on in the life course, and incorporate more of these principals into  parenting and support groups e.g. in Flying Start and Families First programmes . Dietitians in Wales would welcome opportunities to expand the quality assured nutrition training model that is currently used across Wales (Nutrition skills for Life) to this effect (see page 5).

Programmes related to nutrition in schools including Appetite for Life (AFL)

School based nutrition programmes hold significant potential for improving the food and nutrition choices of children and young people.  The opportunities offer both direct and indirect methods of influencing positive health and well being outcomes.  Improving the quality of food and drinks available on school sites directly influences choice, but there are wider opportunities which should be explored including using the expertise of Dietitians in Wales to further develop curriculum based activities in food and nutrition skills.  Input could also be given to support the curriculum of teacher training courses in Design and Technology to include increased food and nutrition messages.  Funding now within local authorities needs to be protected to ensure that the Healthy Eating in Schools Regulations (A4L) are fully resourced with the appropriate support, training and pupil involvement to enable successful implementation.

This important regulation crosses catering, education and health.  The involvement of dietetic services would ensure a consistent, standardised approach to nutrition training to support effective implementation of the regulations and a whole school approach to food and nutrition.

Local Authority Leisure facilities that are sited next to / within close proximity of school premises that provide a range of food and beverages (including vending) has in some areas caused complications in terms of supporting schools to work towards achieving the AFL food and drink based guidelines.  Opportunities to review leisure centre food and drink provision and perhaps explore capacity to roll out schemes such as the ‘Healthy Options Award’ operated by Environmental Health would be welcomed and would help promote a more consistent message to children, young people and families.  Guidance is also available on healthier food and drink provision for youth and leisure centres however there needs more strategic approach from all public sectors to ensure the healthy option is the easiest option for children and young people.

Fruit and Vegetable co-ops are another example of a community approach to improving

access to affordable healthy food options.

Dietitians have also historically supported the Healthy Schools Scheme that continues to operate across local authority education departments in Wales.  Such partnership programmes support the delivery of peer education.  This enables young people to become more actively engaged with food and nutrition and have more meaningful input into the issues that are relevant to them, their peers and the wider school environment. 

Dietitians in Wales were disappointed to see (within the recent Public Health Wales Health Improvement Review Draft Recommendations) a recommendation to potentially disinvest in the Cooking Bus initiative.  We recognise as a programme (if viewed in isolation) that it may not have the impact/outcomes that demonstrate health improvement, however in the long term it does play a valuable role in the development of cooking skills amongst children and young people.  A lack of knowledge of what constitutes a healthy diet and lack of skills to prepare healthy foods are recognised barriers to healthy eating that can contribute to the establishment of poor eating habits which may in term contribute to obesity.  Providing training and support to teachers, teaching assistants, youth and community workers to enable them to incorporate evidence based nutrition messages and food skills into classroom activities provides sustainability.  The dietetic profession recognises the need for programmes that enable people to develop cooking skills alongside nutrition knowledge and would welcome the opportunity to look at how best this resource could be used more effectively and reach more people. Cooking skills programmes can positively influence eating habits in the long term and this is something we would like to see prioritised going forward. It is clear that development of these essential life skills (cooking skills and nutrition knowledge) cuts across health and education policy. A joint approach to planning, implementing and evaluating these initiatives will be beneficial.

Cross cutting programmes for example leisure and sport related programmes (Creating an Active Wales; planning policy)

The Foresight report (Government Office for Science, 2007) into obesity revealed the complexity of interactions which can influence the prevalence of obesity.  It is therefore important to move away from a blame culture where the individual is vilified as solely to blame for their situation.  Taking an environmental and sustainable approach to obesity reduction means that a multi-agency, cross-cutting, multi-stranded approach will yield greater results.

The impact of local authority planning decisions and the potential to lesson or heighten the ‘obesogenic’ environment is important to consider. Wrexham Local Authority (for example) successfully prohibited future planning applications for hot food takeaways within a 400m radius of schools or colleges in the county.  This approach requires continued high level commitment and support to remain upheld, and should pave the way for other Local Authorities in Wales. Cross policy commitment to health is needed to prevent overturning decisions through the appeals process. http://www.wrexham.gov.uk/english/planning_portal/lpg_notes/lpg09.htm

Breastfeeding is a recognised protective factor with respect to obesity.  A continued effort for Health Boards to achieve and maintain UNICEF breastfeeding friendly status is vital.

The Welsh Government Breastfeeding welcome scheme supports breastfeeding mums to identify premises where they can safely and comfortably feed their baby.  This is an excellent scheme however; Dietitians are currently unsure of how ‘visible’ the scheme is to members of the public and wonder whether there is scope to widen promotion locally and nationally across Wales.

(3) The barriers to reducing the level of childhood obesity in Wales

This has been considered in part by the responses above. Dietitians believe it is vital that a respectful approach is considered. Media headlines suggesting that Local Authorities are discussing issues including taxing of fatty foods (which may be misplaced, for example inclusion of olive oil) and that the obese who refuse to exercise should have their benefits cut are not helpful; it’s not just the poor or socially disadvantaged who are obese. We need to develop an intelligent dialogue which considers the needs of all individuals and we need to develop the skills of all health and social care professionals so that they are confident in discussing this sensitive topic in a productive manner which moves forward the agenda.

A continued, strengthened and concerted effort to engage with the food and drink industry and to promote responsible advertising is vital if we are to send a consistent message to children and young people about the link between eating, nutrition and health.

A key priority should be for all policies (and therefore a more joined up approach) to focus attention on reversing the obesogenic nature of our environments. Current obesity rates amongst Welsh adults and children are too high and whilst support for individuals to ‘counteract’ obesogenic environments will continue to be important, national policies will be key to achieving future success.  “Our obesity epidemic will not be reversed without government leadership, regulation, and investment in programmes, monitoring, and research.” (Swinburn et al, 2011).

Greater UK legislation on food and health issues is also needed and requires support from Welsh government to lobby its benefits for the people of Wales and the UK.

(4) Whether any improvements are needed to current Welsh Government programmes and schemes and any additional actions that could be explored

The scale of the so called ‘obesity epidemic’ is vast.  Managing this crisis is without doubt costly, but, we cannot, as a small nation, so reliant on the wellbeing of our population, ignore the urgency of this subject.  Obese individuals have poor personal outcomes; their health suffers and this is costly to the NHS, their educational attainment often suffers and this impacts on their life chances, and ultimately on the wealth of our nation. We want a population with a high level of health literacy who understand their risks, who can make informed choices, and seek out one or more of a range of evidence based, accessible solutions to support them to reach their potential.

The British Dietetic Association promotes Public Health Dietetics as a specialist area of work within the profession which adds value to the public health workforce. In Wales, Public Health Dietitians have a key role in health improvement and work with the Consultant Dietitian, Public Health Wales and the National Nutrition Training Facilitator to ensure an evidence based, informed approach to the development of public health nutrition and dietetic practice. ‘Nutrition Skills for Life’ is a programme of quality assured nutrition training delivered by Registered Dietitians in the NHS in Wales. Training aims to develop the nutrition knowledge and skills of a range of community frontline workers including health, social care and third sector staff, volunteers and peer educators to enable them to support healthy eating at a community level.  The programme was externally evaluated by Glyndwr University, Wrexham.  We would recommend this national cascade model of nutrition training is incorporated across policy domains e.g. education, social services and housing and included in a wide range of policy and programme specifications e.g. Flying Start, Families First, and Communities First programmes.  This model could be applied to school health improvement programmes to ensure school based staff are competent to deliver nutrition topics as part of the school curriculum.  The importance of good nutrition and the benefits of healthy eating should be prioritised and reflected in curriculum guidance across all subject areas in schools. Nutrition training is relevant to every health professional discipline and other community professionals and should be assessed at all levels throughout undergraduate/pre registration and postgraduate training (Royal College of Physicians, 2010).

Diet is a key modifiable risk factor in the prevention and risk reduction of obesity, diabetes, cardiovascular diseases (CVD), and some cancers, all of which disproportionately affect those in lower socioeconomic groups.  Action should focus on prevention in the early years and addressing nutrition related inequalities in health.Investment in preventive services needs to address the current gaps in public health dietetic provision to continue to build capacity in communities to support and enable people to improve their health.

Dietitians in Wales would welcome opportunities to contribute to further discussions on this topic and can provide any further information required.

References

Centre for Maternity and Child Enquiries (December, 2010). Maternal obesity in the UK: findings from a national project. London: CMACE. Available from: http://www.healthyweight4children.org.uk/resource/item.aspx?RID=92541  Accessed 24 August 2011

Glyndwr University (2009) The Evaluation of the All-Wales Dietetic Capacity Grant Scheme: Final Report

Government Office for Science (2007). Foresight. Tackling Obesities: Future Choices- Summary of key messages. Available from:

http://www.bis.gov.uk/assets/foresight/docs/obesity/20.pdf

Rasmussen, K.M., Dieterich, C.M., Zelek, S.L. Altabet, J.B., Kjolhede, C.L. (2011). Interventions to increase the duration of breastfeeding in obese mothers: the Bassett Improving Breastfeeding Study. Breastfeeding Medicine 6 (2), 69-75.

Royal College of Physicians (2010) The training of health professionals for the prevention and treatment of overweight and obesity. 

Swinburn, B.A., Sacks, G, Hall, K.D., McPherson, K., Finegood, D.T., Moodie, M.L. and

Gortmaker, S.L. (2011) The global obesity pandemic: shaped by global drivers and local environments. Lancet, 378, 804-814

Tennant, P.W.G, Rankin, J. and Bell, R. (2011). Maternal body mass index and the risk of foetal and infant death: a cohort study from the North of England. Human Reproduction, 26 (6), 1501-11

Welsh Government (2010) All Wales Obesity Pathway

Welsh Health Survey (2012), http://wales.gov.uk/topics/statistics/headlines/health2012/120919/?lang=eng Accessed 28^th April 2013