National Assembly for Wales

Children and Young People Committee

CO 24

Inquiry into Childhood Obesity

Evidence from : Aneurin Bevan Health Board

We welcome the opportunity to contribute to the above inquiry.

The importance of the obesity agenda cannot be underestimated and it is only right that Government is attending to moving on the debate on how to improve the prevalence and reduce the incidence of obesity in children.

In response to the questions raised:

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 School Measurement Programme for foundation phase children has not yet completed a single year cycle in most areas.

It is not clear that 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 Wales population.

The submission of grant application to the British Heart Foundation (BHF) in 2009 for the Hearty Lives Torfaen (HLT) programme used local audit data to show almost 25% of Torfaen children weighed at school entry were overweight or obese.

2. The measurement, evaluation and effectiveness of the Welsh of the Welsh Governments programmes and schemes aimed at reducing the level of obesity in children in Wales specifically:

o Health related programmes including Change4Life, MEND

From a local perspective, whilst we are clear that there are considerable difficulties in delivering MEND to the maximum children within the provision agreed, we feel these are technical issues in the way that funding is allocated.  There is no “up-front” payment, payment is on result of delivering a course.  It is challenging to support such a risk in these straightened financial times.  Making considerable investment in planning for courses which do not ultimately run due to low recruitment and retention, means that teams are put at financial risk.

A review of the funding mechanisms for the MEND programme, for example, an up front allocation would support more robust recruitment, retention and ultimately reduce individual children’s obesity risk.

In ABHB we have had the benefit of experience with both the Welsh Government/PHW funded MEND programmes (2009-2012 age 7-13 and since March 2012 5-7 and 7-13) and been able to compare this with MEND programmes provided as part of the BHF funded Hearty Lives Torfaen (HLT) project.  The HLT experience has been quite different in that as part of the BHF funding we were able to employ a community dietitian to work embedded in the Flying Start team with responsibility for co-ordinating all aspects of delivering MEND programmes funded by BHF grant in Torfaen.

As part of the HLT programme we have also been able to offer the MEND 2-4 programme (not available via the WG/PHW grant).  The likelihood of remaining obese in adulthood is increased if a child is obese at the age of 5.  The MEND 2-4 programme offers early intervention to establish healthy eating and prevent obesity and has proved easier to engage families in.  It has enhanced joint working between members of the Flying Start team facilitating the wider role of the dietitian to improve early years nutrition.

HLT funding ends this summer and an evaluation report will be available in the autumn.  Anecdotally our experience has been that targeting MEND, with appropriate funded staffing, achieves better recruitment and retention.  As mentioned above, one of the greatest difficulties we have experienced with the WG/PHW MEND programmes is the method of funding and degree of financial risk which meant we could not have posts which were dependant on it for funding

It should be recognised that the current range of MEND programmes available through the Public Health Wales grant do not cover under 5’s and those over 13 years of age. The ABHB Dietetic Service receives a significant number of referrals for obese children of all ages, many of whom cannot be accommodated within the available MEND programmes.  Currently the only service we are able to offer them is a clinic appointment system with a dietitian.  This does not provide them with the multidisciplinary care and level of support necessary to achieve and maintain healthy weight.

It is clear that there needs to be provision of evidence based interventions for weight management in children. Government strategy by way of the All Wales obesity Pathway forms part of the rationale for this.  It is not clear at this time, whether there is sufficient support for programmes such as MEND to continue delivering on this agenda.  The recent PHW Health Improvement review paper indicates a potential to dis-invest in the programme; this would leave a considerable gap in provision at a time where the need continues to increase.  Whatever ultimate evaluation outcome indicates with regard to the future of the MEND programme, it is essential that obesity intervention services are provided for children and young people in addition to any prevention initiatives which are adopted.  It must be recognised that there will need to be a range of specialist weight management services as the needs of an obese 4 or 5 year old are very different to those of a 15 year old weighing over 125Kg.

Obesity has a negative impact on the life chances of young people, with poor school attendance, poor attainment, reduced employment prospects fuelling the cycle of deprivation.  The funding of a multidisciplinary treatment service for obese children and young people should be prioritised.

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

School based nutrition programmes hold a great deal of potential for improving the food and nutrition choices of children.  The opportunities offer both direct and indirect methods of influencing 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 Appetite for Life Dietitians to further develop curriculum based activities in food and nutrition skills.  We have been fortunate in Gwent to have some dietetic input to the Appetite for Life initiative in three boroughs, but with the end of the grant funding and inclusion of Appetite for Life funding in the cash allocation to local authorities only Torfaen County Borough Council has opted to continue to employ the skill and expertise of a dietitian.

If school food is to form part of the school inspection process it is important that a dietitian forms part of the inspection team.

Dining facilities and length of lunch breaks need to be addressed and protected as an increasing number of schools are shortening their lunch breaks and are incapable of seating the number of pupils requiring lunch. In order for schools to provide lunches that meet the nutritional requirements this needs to be addressed.  Shortened lunch breaks and lack of seating capacity encourage the ‘grab and go’ culture which does not support the development of healthy eating practices and couldn't be further away from the seated, leisurely meal time exemplified in mainland Europe.

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

The Foresight report into obesity revealed the complexity of interactions which can influence the prevalence of obesity.  It is 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.

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

Mostly covered above but it is vital that a respectful approach is considered. Media headlines suggesting that local authorities are discussing issues including taxing of fatty foods (Olive oil!) and that the obese who refuse to exercise should have their benefits cut are not helpful; it’s not just the poor 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 professional so that they are confident in discussing this sensitive topic in a productive manner which moves forward the agenda.

Parents of obese children, many of whom will also be obese, are clearly part of the problem and have to be part of the solution.

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

See above re MEND and the need for a range of multidisciplinary weight management services for children of all ages.

The Academy of Royal Medical Colleges report ‘Measuring Up’ makes 10 recommendations, many of which could be applied in Wales.  The 4^th recommendation, increasing support for new parents.

….'skilling up' the wider early years workforce to deliver basic food preparation skills to new mothers and fathers, and to guide appropriate food choices which will ensure nutritionally balanced meals, encourage breastfeeding….

This rings very true as many young parents lack these skills and depend on convenience foods, snacks and takeaways to the extent that their young children are unfamiliar with healthy home cooked meals and become selective eaters.

Consideration could be given to expanding the NRS programme to include teenagers who are obese.  This would support and engage those who do not participate in school sport and feel embarrassed and lack motivation to became physically active independently.  Obesity contributes to a far greater extent than may be generally acknowledged to mental illness and depression in young people.

The Royal college of Physicians report 2013 ‘Action on Obesity’ highlights the fact that many obese individuals have experienced physical or sexual abuse.  This is something which became evident to those working within the Torfaen adult specialist weight management strand of the HLT programme; just as the RCP report suggests, the experience there was that these people could not benefit form a specialist weight management programme until they had access to appropriate support to deal with the emotional and mental health issues resulting from this trauma.  Some consideration of this should be accorded to obesity services for children and young people.

The scale of the so called obesity epidemic is vast.  Managing this crisis is costly, there is no doubt about this.  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.

Clare Norris                                                                           Caroline Bovey

Dietetic Manager                                                                  Public Health Dietitian

(Lead for Children’s Dietetics)