National Assembly for Wales

Children and Young People Committee

CO 47

Inquiry into Childhood Obesity

Evidence from : Cwm Taf Health Board

Cwm Taf Health Board area is made up of four localities – the Cynon Valley, Merthyr Tydfil, the Rhondda Valleys and the Taff Ely area. It is the second most densely populated Health Board in Wales, covering 3% of the landmass of Wales with approximately 289,400 people. The Health Board serves the most deprived population in Wales. Healthy life expectancy is the lowest of all Health Boards in Wales and the population can expect to have up to six more years of disability than the Welsh average. This poor health means that the Health Board provides care for a greater proportion of people’s lives, there is a higher incidence of disease and the prevalence of chronic conditions is higher than in all other Health Boards.

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

Wales has a significant and rising burden of obesity[1] and it is clear that this presents an increasing public health challenge. Overweight and obesity are important determinants of a wide range of avoidable morbidity and mortality including cardiovascular disease, diabetes, cancer and arthritis. Most alarmingly for the future, 60% of children who are overweight before puberty will be overweight in early adulthood, reducing the average age at which non-communicable diseases become apparent, and greatly increasing the burden on health services[2]. Latest information for Wales shows that 35% of children aged 2-15 are overweight or obese, including 19% obese[3]. Although overweight and obesity statistics are not available for children at Health Board level, we know that a higher percentage of adults in Cwm Taf are overweight and obese compared to Wales as a whole, and the local rates appear to be increasing at a faster rate. Cwm Taf is the most deprived area in Wales. Children living in the most deprived areas have statistically significantly higher rates of overweight and obesity than children living in the least deprived areas.

The causes of overweight and obesity are complex, resulting in the need to implement a range of approaches to address individual, social, and environmental determinants[4]. It has also been acknowledged that the best long term approach to tackling overweight and obesity is prevention from childhood[5]. To that end, a Healthy Weight, Healthy Valleys Strategy has been developed, with a broad range of partners, to promote an environment where Cwm Taf residents have access to nutritious food, regularly build physical activity into their daily routines and have good support to maintain a healthy weight. This strategy has been incorporated into the Single Integrated Plans of Rhondda Cynon Taff and Merthyr Tydfil local authorities.

The recent Health Improvement Review[6] undertaken by Public Health Wales has recommended that obesity should be tackled as a priority through an integrated approach.

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,

· Programmes related to nutrition in schools including Appetite for Life,

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

Change4Life

The Department of Health provided £75m investment into the Change4Life (C4L) social marketing campaign and associated interventions as part of the Healthy Weight, Healthy Lives cross‑governmental strategy for England[7]. In Wales, a range of C4L promotional materials are available, but do not relate to any strategic context here, for example, any interventions. In addition, there is considerable confusion with the Health Challenge Wales brand which had already been developed.

MEND

Evidence from Public Health Wales Health Improvement review indicates that the MEND programme has not achieved full potential. Access and other issues were clearly identified as a problem and as a result the number attending was unlikely to make an impact at population level. The review recommends that alternative options for population level impact should be explored. In Cwm Taf, it has been difficult to organise, deliver and recruit to MEND. This is partly due to the funding processes. Local partners support the development of a local programme, led by the National Exercise Referral Service. To facilitate this it would be helpful if funding was devolved, using a formula that had regard to rates of overweight and obesity in children, perhaps using the surveillance data from the Children’s Heights and Weights Measurement Programme.

Appetite for life

Following the launch of the Appetite for Life Action Plan in 2007, schools in Merthyr Tydfil participated in an action research study to explore the issues and make recommendations on the implementation of the Draft Guidelines for school food[8]. The Appetite for Life guidelines have been used to inform changes in the provision of food and drink in schools for a number of years. These improvements include free access to drinking water throughout the school day; fruit snacks; and advice for parents on healthy lunchboxes. Nutritional messages are integrated into the school curriculum and embedded in school policies; many of which have been developed with active participation from pupils. The majority of primary school children now have only fruit, water or milk provided at break time, and sweets are rarely used as a reward for good behaviour. Healthy Eating messages are firmly linked with oral health education and the promotion of physical activity.

However, some issues still need to be addressed:

· The guidelines apply to the ‘meal of the day’, and have been more challenging to implement in secondary schools, where pupils have a wider choice of options.

· Issues over quantity, quality and availability of food choices. For example, regular reports of “Make Up weeks” at the beginning and end of each half term where food supplied is not that on the menu, due to stock availability. This potentially means that 15% of the food provided to schools is not compliant with Appetite for Life. In addition, there is often limited or no choice for pupils who are not first in line for meals

· Reduction in school lunchtimes, sometimes to as little as 40 minutes.

· Some children are rejecting school meals in favour of packed lunches, including some of those entitled to free school meals.

· On site policies are difficult to enforce when fast food outlets and mobile vendors in the vicinity often offer cheaper, though significantly less nutritious alternatives.

· Snack food and vending. Some schools are located near local authority leisure centres which are frequented by pupils, so it would be helpful if consistent policies on healthy vending were adopted by the local authority.

· The drift away from school meals has a further negative impact on the budget available for sufficient numbers of well trained catering staff

The potential of the Appetite for Life Guidelines to improve children’s diets may be limited unless they are applied consistently, effectively and are adequately resourced.

Leisure/sport/Creating an active Wales

Children and young people's participation in physical activity is important for their healthy growth and development[9]. Funding streams to promote physical activity come from a variety of sources resulting in a scattergun approach to interventions carried out in different local authority areas. In 2012 Public Health Wales identified a wide variety of data sources that can be considered as a basis for outcome measures for the physical activity action plan Creating an Active Wales [10]. It would be useful if this information could be used to develop a more joined up set of indicators and performance measures, leading to better coordination of interventions and related funding.

It is notable that there is a drop in physical activity levels in teenage girls compared with boys[11]. This should be a target group for physical activity to promote lifelong physical activity in this group, but particularly to prevent obesity in the next generation of young mothers and the associated health consequences for mothers and babies.

Planning policy

Urbanisation has contributed to the proliferation of obesogenic environments, typified by high levels of car use, 24-hour food availability, sedentary occupations and low levels of physical activity. Furthermore, Maio[12] concluded that obesity will only decrease if the built environment is adapted to make it easier for people to be more physically active in their daily lives. Local Development Plans should provide a springboard for promoting a supportive built environment to encourage active travel, the use of green spaces and opportunities for physical activity. Measures to address the wider determinants of overweight and obesity should be incorporated into planning priorities so that buildings are designed to encourage people to be more physically active, and open spaces are developed that can be reached on foot or bike. Interventions to make streets cleaner and safer can also promote physical activity and active travel.

It has been shown that there is a strong association between deprivation and the density of fast food outlets, with more deprived areas having more fast food outlets per 100,000 population[13]. Within the existing planning regulations, local authorities are unable to produce local planning policy to refuse or limit consent for any new hot food takeaways in a certain area, for example, near school sites.

3. The barriers to reducing the level of childhood obesity in Wales;

Social and economic conditions can prevent people from changing their behaviour to improve their health and can also reinforce behaviours that damage it. Many of our current interventions to prevent or treat obesity focus on diet, education and promoting physical activity. However, it is counter-intuitive to educate families about healthy eating when they may not have access to quality food locally or have the skills to cook, or to encourage children about becoming more physically active when there are few facilities available to them and we live in a society which is fearful of allowing our children to play in the street.

For many low income families it is appealing to have high energy low cost food e.g. it is cheaper to feed a family pizza and chips at approximately £2 for a family of four when the salad alone, to accompany a meal would be in excess of this sum.

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

If we are to address the root causes of ill health, including obesity, Welsh Government should ensure that policy decisions at all levels of society are reframed in line with the principles of Health Equity[14].

Health improvement should be inherent in all policy decisions through the use of Health Inequality Impact Assessment. The opportunity to do this is currently available following recent Green Paper: A consultation to collect views about whether a Public Health Bill is needed in Wales.

The Active Travel Bill, introduced in February 2013 places a legal duty on councils to create a network of routes for walking and cycling, and will require continuous improvement. This could be extended to include health improvement and equity in primary planning legislation.

NICE guidance recommends that interventions for childhood overweight and obesity should address lifestyle within the family and in social settings[15]. However, there is no systematic implementation and monitoring of NICE or other evidence based recommendations in Wales. Where evidence exists to support health improvement interventions, we should ensure it is being implemented consistently across Wales as a priority⁶.

To achieve large-scale changes to population health, a “bundle” of related, coordinated, preventative measures are needed, rather than one single intervention. These measures may include legislation, public information, policy, specific services, community action and embedding prevention in the work of other sectors. Implemented together they are likely to have a greater effect, and future progress will be achieved by ensuring coordinated action is the norm.