Thursday, 3 April 2014

Fat of the Land : More work needed on childhood obesity

An Assembly inquiry into childhood obesity revealed underperformance in public
health policy, underlining the need for firm action to address the problem.
(Pic : BBC)
Wales has some of the fattest kids in the UK.

In the last Welsh Health Survey (2011), 16% of Welsh children were classed as overweight, and 19% obese (a total of 35% overweight or obese) – near enough the same levels as a previous survey in 2007.

Last week, the National Assembly's Education, Children and Young People Committee reported back on their inquiry into the issue (pdf), making six recommendations.

The Welsh Government should :
  • Monitor the progress Local Health Boards (LHBs) are making in implementing the All Wales Obesity Pathway, identifying weaknesses.
  • Make specialist (Level 3) obesity services for children available across Wales.
  • Ensure performance of obesity programmes can be monitored properly.
  • Extend the Child Measurement Programme, stating how the data can be used to improve obesity programmes.
  • Publish a report into cabinet-level actions taken to improve sports participation amongst young people, taking into account the impact of austerity on local council leisure services and actions taken across government departments to boost physical activity.
  • Set out how future legislation (Future Generations Bill, Planning Bill, Public Health Bill) can be used to combat childhood obesity.
How do the Welsh Government deal with childhood obesity?
There are currently no specialist obesity services for children in Wales,
while its suggested the Child Measurement Programme be expanded.
(Pic : NHS Wales)
The 2010 All-Wales Obesity Pathway (AWOP) guides public policy on obesity for the next twenty years. It sets out four levels of obesity treatment/intervention :
  • Level 1 – Community-based intervention, focusing on advice and getting people active (public health campaigns etc.).
  • Level 2 – Primary care services (GPs) focusing on weight management for children and their families.
  • Level 3 – Specialist weight-management services for obese children who have developed other diseases as a result.
  • Level 4 – Bariatric surgery (gastric bands, stomach stapling etc.), which is currently unavailable to under-18s. The Assembly's Health Committee are undertaking a separate inquiry into this, and I'll return to it when they report back.

The AWOP is "generally welcomed", although Public Health Wales (PHW) were worried about patchy implementation. There are currently no Level 3 services for children and young people in Wales, said to be a key concern of "a number of witnesses".

Health Minister, Mark Drakeford (Lab, Cardiff West), said progress in the AWOP is monitored annually, with Level 1 & 2 interventions being the priority for childhood obesity as they were "preventative". He said this was, "the most effective way of trying to get the biggest benefit for most children" so they don't become so obese that they need Level 3 & 4 services.

There are too many competing obesity strategies. The Royal College of Physicians (RCP) listed eight different ones between 2003-2010. It's also said there's too little data to properly judge how well many of these schemes are performing on the ground.

Another weakness was the perceived lack of leadership. PHW described isolated initiatives as "futile", saying obesity required, "strong leadership and sustained commitment". Sustrans Cymru echo this, saying many pilot schemes have been launched to target obesity but have never been properly joined up, while investment has been kept "small scale".

On funding, the RCP said money would be better spend on early intervention, when currently just 4% of the Welsh NHS budget is spent on prevention. They suggest things like healthy food vending machines in schools and hospitals, as well as curbs on advertising unhealthy food and increasing physical activity. The WLGA and PHW expressed support for ring-fencing funding for public health initiatives.

Many witnesses said one way of addressing obesity was to intervene in whole families (I presume they mean obese parents with obese children), under the umbrella of schemes like Flying Start, as well as working with education and social services.

One key way of monitoring childhood obesity is the Child Measurement Programme, where Body Mass Index (BMI) of primary-age children is recorded by taking height and weight measurements. The 2011-12 results showed 30% of 4-5 year olds had an unhealthy body weight, and 12.5 % were obese.

Participation amongst schools in the measurement programme is said to be "high", though the RCP advocate expanding the scheme to cover 6-11 year olds. PHW would prefer a second cohort of 8-9 year olds be measured. The Minister said the scheme would enable the government to "learn lessons", and also allows parents of children at-risk of becoming obese to be alerted.

Changing Appetites

Some high-profile public heath campaigns are said to have fallen short of
what they set out to do, with Change4Life singled out for particular criticism.
(Pic : Physical Activity and Nutrition Networks Wales)
Three public health campaigns aim to reduce childhood obesity :

Change4Life (here)

A pan-UK social media campaign about getting families to make healthier food choices and exercise. Witnesses, and the Health Minister, believed the scheme had "fallen short of its potential to change behaviour". The Health Minister added that Change4Life was more accessible to socio-economic groups who don't have a problem with obesity anyway.

High levels of obesity in mothers and low levels of breast-feeding are specific concerns. Betsi Cadwaladr LHB suggested Change4Life should be used to promote healthy pregnancies. PHW added that many deprived communities are less likely to have a healthy diet, raising the issue of food poverty, where households spend money on cheaper processed foods to save money.

Appetite for Life (here)

A Welsh Government programme to promote healthy diets - primarily within schools - backed by the Health Eating in Schools Measure 2009. It's said the scheme has a "great deal of potential", making a positive impact on school food. Since school nutritional standards have been set centrally there's a more consistent approach across Wales– what Mark Drakeford describes as a "key move".

Specific problems include : poor take up of free school meals, unhealthy foods available from vending machines and nearby fast food outlets, and the reduced length of school lunch breaks.

Many witnesses were disappointed with a Public Health Wales recommendation that funding be withdrawn from the Cooking Bus (mentioned in Watching what we eat), which teaches children cooking skills, and has been used by more than 30,000 pupils since 2012.

Mind, Exercise, Nutrition....Do it! (MEND)

A Level 2 intervention programme for obese children aged 5-13 and their families. PHW say the scheme should be reviewed as it hasn't met its potential (a recurring theme) due to low participation levels. Some LHBs and physician colleges agreed, with Cardiff & Vale LHB saying it "treats the problem once it's occurred", and the Royal College of Paediatrics stressing the need for more obesity prevention programmes.

There are further problems with recruitment and funding. Aneurin Bevan LHB called for up-front funding, while Betsi Cadwaladr LHB said positions in the scheme are hard to fill.

However, the Royal College of Physicians said withdrawing funding would leave a gap in service provision, pointing to the fact that those who've gone through MEND, "have demonstrated extremely positive outcomes". Around 1,700 people have taken part, with 80%-90% completing the full 10-week programme. The Health Minister agreed that funding should continue.

Creating an Active Wales

It's said the planning system has created an "obeseogenic environment",
while active travel in schools often has to overcome multiple hurdles.
(Pic : South Wales Argus)
Yet another strategy covers this – Creating an Active Wales (2009). It aims to improve physical literacy and encourage lifelong participation in sport. It's said just 44% of 7-11 year olds and 35% of 11-16 year olds undertake the recommended 60 minutes of daily exercise five times a week.

The WLGA said sports participation rates have increased since the introduction of the 5x60 scheme, and Sport Wales concurred. However, they were "losing" 12-16 year olds, where participation levels continue to decline. The British Heart Foundation had a specific concern about low levels of participation amongst girls.

The Chief Medical Officer acknowledged the difficulty in convincing people that 60 minutes of exercise 5 times a week was possible, but it was important to help people "make the first steps towards that".

The Active Travel Act 2013 is supposed to encourage walking and cycling. Sustrans Cymru said as active travel isn't actively promoted in schools (it's not their direct responsibility), it's "usually sidelined" with "inadequate funding". They repeat their case that schemes are too "small scale or cut after a short period".

Witnesses said there hasn't been enough work across all government departments to create an active Wales. They believe the planning system has created "obeseogenic environments" by encouraging car use, 24-hour food availability and allowing fast food outlets to be located near schools.

Wrexham Council are attempting/attempted to place a 400metre radius limit on new fast food outlets. Cllr. Arfon Jones (Plaid, Gwersyllt West) of Plaid Wrecsam, submitted a petition to the National Assembly calling for this back in 2012, and it's currently going through the Petitions Committee.

Witnesses advocate the use of Health Impact Assessments in public policy, hinting that it should be included in the proposed Public Health Bill, which has a white paper out for consultation. The Health Minister said he expected them to be used anyway "when appropriate to do so", and it was indeed included in the Bill's green paper. There were concerns though about the introduction of more bureaucracy.

A shambles, but not (entirely) the Welsh Government's fault

The government and health authorities can only do so much.
The responsibility for this ultimately rests with individuals and families.
Good luck with that.
(Pic : BBC)
Yet another failing Welsh health policy?

It looks like some key public health campaigns have flopped, while withdrawing funding from the Cooking Bus seems a bad idea. Nutrition seems to be the poor relation when it comes to tackling obesity, with too much emphasis on sport and the NHS.

Having said that, although government and health authorities can always do more, this is our fault.

We need to drive less, get more exercise, eat healthier foods and drum those habits into children. We, as a society, aren't equipped to do that because of our prevailing attitudes and it's sending out the wrong message to kids.

It's doubtful there's one single answer that lies in new policies. The only thing the government can do is give families and individuals a push in the right direction. Shaking off habits of a lifetime is often very difficult to do - more so for children - so I'd agree prevention is the best way forward in the long term.

But what about children who are obese now? So many children going on to become obese is perhaps evidence preventative measures at Levels 1 & 2 aren't working, so I was surprised there were no "Level 3" services for children.

It all points towards schools having to take a lead on this, as that's where children spend most of their time outside the home.  It's not as if gangs of kids casually pop down to their local health centre or hospital to "access Level 1 intervention services". They'll be driven past on their way to the chippie though.

Whether it means an overhaul of PE, banning junk food in schools or encouraging active travel – I don't know.
It probably means all of that and beyond.

More importantly, we're all going to have to accept we've got a potentially serious problem on our hands here, and it's arguably the single biggest threat to public health since the dangers of passive smoking were first revealed.


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