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Bexley Obesity Strategy

Creating a whole systems approach to tackle obesity

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Executive Summary ................................................................................................................... 3

Section 1: Context ....................................................................................................................... 4

Introduction ......................................................................................................................... 4

The Local Picture ................................................................................................................. 5

Wider determinants of obesity ........................................................................................ 11

Our Vision and Aims ........................................................................................................ 13

Section 2: What are our priorities?......................................................................................... 14

Theme 1: Shaping the built environment to foster healthy lifestyles ........................ 14

1.1 Increasing the availability of healthier foods ........................................................ 14

1.2 Creating an environment that inspires physical activity .................................... 19

Theme 2: Supporting a community culture that sees healthy eating and physical activity as the norm ........................................................................................................... 24

2.1 Early years .................................................................................................................. 24

2.2 School & College Settings ......................................................................................... 26

2.3 Work based settings .................................................................................................. 28

2.4 Community spaces .................................................................................................... 29

2.5 Embedding social value into policy and practice ................................................. 29

Theme 3: Prompting individuals to make healthier lifestyle choices ........................ 30

3.1 Programmes to identify children and adults with excess weight ...................... 30

3.2 Programmes to support children and adults to lose weight .............................. 31

3.3 Enabling individuals to take responsibility for their own health ...................... 33

Section 3: Governance ............................................................................................................. 35

Table of Contents

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Bexley has among the highest rates of obesity in London, with nearly a quarter of children entering primary school already overweight and obese. As children get older, this figure continues to rise with 36.6% of children aged 10-11 leaving primary school with excess weight. Childhood obesity has also been shown to track into adulthood and can predispose individuals to an increased risk of long term conditions, including type 2 diabetes, cardiovascular disease such as stroke and heart disease and musculoskeletal conditions, and can negatively impact on mental health. It is widely recognised that the causes of obesity are multifactorial, with many and varied determinants of excess weight, from individual biology and physiology to income, education and social groups to the wider environment and infrastructure. These determinants have been highlighted in the Foresight Map produced in 2007. Despite this, for many years efforts to tackle obesity and support people to lose weight have largely focused on individual behaviour change, focusing on the simplistic nature of excess weight gain through encouraging people to eat less and move more. Positively, the landscape has changed, and momentum has been built by Government through publication of the Childhood Obesity Plan, chapter one and two in 2016 and 2018, respectively. Local Authorities are positioned to continue this momentum within their local areas by tackling the wider determinants of obesity such as the built environment and partner with local organisations to impart system wide change. Making obesity everybody’s business and working towards a shared vision to reduce obesity levels and improve the health of residents’ can only be achieved through taking a whole system approach. This approach capitalises on ‘Health in All Policies’ and recognises that we can do better by working together with the community and wider system to the deliver sustainable long-term benefits. The Obesity Strategy aims to implement a sustainable whole system approach and sets five-year targets for a reduction in levels of excess weight for children and adults. It draws upon the wider system by addressing three key themes across the life-course: Theme 1. Shaping the Built Environment to foster healthy lifestyles. This corresponds to several actions that increase the availability of healthy foods and inspire people and communities to do more physical activity. Theme 2. Supporting a community culture that sees healthy eating and physical activity as the norm. This recognises the value of community settings and institutions and the importance of embedding healthy behaviours into cultural norms in settings such as workplaces, schools, colleges and community spaces. Emphasis is also put on recognising the social value in policy planning and commissioning of services. Theme 3. Prompting individuals to make healthier lifestyle choices. This reflects the need to continue screening and providing individual support to people to help them to manage their weight, from universal to targeted services that enable people to take ownership of their own health and wellbeing. Achieving the three themes requires input and commitment from a wide range of internal and external stakeholders, with the community being at the core of the whole system approach. Engaging with key partners and local people will inspire them to build healthy environments, look after their health and contribute to improving the health and wellbeing of future generations, where obesity no longer poses a threat to public health.

Executive Summary

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Introduction

Obesity is one of the most serious public health challenges of the 21st century1, with estimated social care costs of £352 million, NHS costs of £5 billion per year and 16 million sickness days attributed to obesity2.

The environment and cultural norms have become increasingly obesogenic and these dynamic changes are having an impact on people’s lives now and across future generations. Obesity poses a significant threat to our physical health by increasing the risk of chronic diseases such as type 2 diabetes, hypertension, stroke, musculoskeletal conditions and some cancers, as well as impacting on mental and emotional wellbeing.

In 2011 the Government set out its commitment to tackling obesity in its Healthy Lives, Healthy People: a call to action on Obesity in England (2011) report which set out its ambitions to achieve a sustained downward trend in the level of excess weight in children by 2020 and a downward trend in the level of excess weight averaged across all adults by 2020. Since this time and amidst a growing obesity epidemic, the new Government released Childhood Obesity: A Plan for Action in 2016, followed by chapter two in 2018. Within these publications is the ambition to halve childhood obesity and significantly reduce the gap in obesity between children from the most and least deprived areas by 2030. With the Childhood Obesity Plan the platform to start conversations at local level, local authorities are uniquely positioned to continue the momentum and impart influential change to tackle the drivers of obesity, moving beyond education and provision of healthy eating and weight management services to influencing and addressing infrastructure and the environment.

The ‘Health in All Policies’ initiative reinforces this direction by drawing on the importance of a collaborative approach at local level and recognizes the value of engaging with the local community and maximizing local assets to achieve better results long term3.

A whole systems approach encompasses ‘Health in All Policies’ and draws upon the many complex behavioural and societal factors that combine to contribute to the causes of excess weight. The Foresight report (2007) referred to a “complex web of societal and biological factors that have, in recent decades, exposed our inherent human vulnerability to weight gain”.4 The obesity system map presented in the Foresight report confirms that energy balance is not determined by one sole factor, rather multifaceted determinants that interlink together and are influenced at different stages of life and by generational and environmental factors. Implementing a whole systems approach allows stakeholders to work together with a shared ambition and operate across the whole system.

The key national strategy, the National Policy Planning Framework (NPPF) and the regional planning strategies including The London Plan (LP) and The Mayors Transport Strategy (MTS) contribute to the

1 Tackling obesity - Local Government’s new public health role (2013) 2 PHE, 2017 Health matters: obesity and the food environment [Available] https://www.gov.uk/government/publications/health-matters-obesity-and-the-food-environment/health-matters-obesity-and-the-food-environment--2 3 Health in all Policies (2016) 4 Foresight Report, 2007, Tackling Obesities: Future Choices – Project Report [Available] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/287937/07-1184x-tackling-obesities-future-choices-report.pdf

Section 1: Context

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whole systems approach, by each having an emphasis on active travel, liveable neighbourhoods, connected communities and creating health promoting built environments. These priorities are also reflected in Bexley’s Local Plan.

The Local Picture

Body Mass Index (BMI) is the most commonly used measure for determining overweight and obesity in adults. For growing children, BMI z-score is used to provide a measure of relative weight adjusted for age and gender.

Bexley has among the highest rate of excess weight in London for reception aged children and is the highest amongst its closest and most similar neighbours. Nearly three in ten children (23.4%) are classified as overweight or obese when they start primary school which increases to 36.6% by the time they leave primary school in year six5. Children who are overweight or obese are more than likely to become overweight adults, with the population of Bexley adults aged 18 and over with excess weight at 64.6%, greater than London and England6.

Figure 1: Prevalence of overweight and obesity in Bexley

Health inequalities exist in Bexley with higher rates of child obesity observed in areas of higher deprivation; North Bexley compared to the more affluent areas in the south. Figures 2 and 3 represent the percentage of excess weight among children aged 4-5 and 10-11 by wards.

Ward level data for adult excess weight is not available locally. However, using national data from The Health Survey for England (2017) we can identify gender differences in excess weight with 40% of males overweight and 23% obese in London, compared to 30% of females overweight and 22% obese. Locally in Bexley, using the 2016/17 public health outcomes indicator for the number of finished admission episodes with a primary diagnosis of obesity, 26/100,000 admissions were male compared to 41/100,000 females. Uptake of tier 2 weight management services is also lower for men, with around 16% uptake to Bexley’s adult weight management scheme delivered by Slimming World.

5 NHS Digital (2017), National Child Measurement Programme England 2017/18: http://digital.nhs.uk/catalogue/PUB30113 6 PHE Public Health Outcomes Framework 2016/17: https://fingertips.phe.org.uk/profile/public-health-outcomes-framework/

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The national public health indicators shown in figure 4 also provide a picture of the level of obesity in Bexley and the connections between other determinants of health. The indicators provide a perspective on how obesity is impacting on people’s lives and their connections with the environment and creates a benchmark for the whole systems approach. It is of importance to note that some of the indicators are relatively static due to the nature of data collection.

There are multiple drivers of obesity such as the environment, biology, economy, culture and behaviour, however at a simplistic level excess weight gain occurs when energy intake exceeds energy expenditure. The fast-paced nature of our daily lives has led to environmental changes which are conducive to encouraging sedentary lifestyles and convenience foods. An increasing number of people are eating outside of the home, consuming foods that are high in calories and purchasing hot food from takeaways selling foods high in fat, salt and sugar. These energy dense foods are dietary risk factors for obesity and it is widely recognised that the food environment influences individual behaviour and has a large role to play in addressing obesity and improving the landscape of the food offer. The Mayor of London has set out his commitment in The London Plan to improve the food landscape for children by imposing a 400m restriction on hot food takeaways around schools.

Local Authorities also have a statutory duty to improve the health of their residents and to continue the momentum from The London Plan into The Local Plan. In support of this, Figure 5 provides a map of the density of hot food takeaways in Bexley by ward, the saturations of outlets can be comparable to the percentage of excess weight for children highlighted in figures 2 and 3. It is important to note, that the map excludes premises that sell hot food takeaways that have seating for indoor eating.

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Figure 2. Excess weight in 4-5year olds from National Child Measurement Programme data

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Figure 3. Excess weight in 10-11year olds from National Child Measurement data

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Public Health Outcomes Framework Indicators

Indicator Data refresh frequency

Data available

Bexley England Benchmark

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Prevalence of overweight (including obesity) among children in Reception (4-5 year olds)

PHOF 2.06i NCMP – Annual

2017/18 23.4% 22.4%

Prevalence of overweight (including obesity) among children in Year 6 (10-11year olds)

PHOF 2.06ii NCMP – Annual

2017/18 36.6% 34.3%

Percentage of adults (aged 18+) classified of overweight or obese

PHOF 2.12

Active Lives, Sport

England – Bi-annual

2016/17 64.6% 61.3%

Proportion of eligible adults with a learning disability having a GP health check

NHS Health Checks

Annual 2016/17 37.5% 48.9%

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Proportion of five year old children free from dental decay

PHOF 4.02 Dental health

survey – 10 years

2016/17 85.6% 74.3%

Proportion of the population meeting the recommended ‘5-a-day’ at age 15

PHOF 2.11iv WAY Survey -

Static 2014/15 46.9% 52.4%

Average number of portions of fruit consumed daily at age 15

PHOF 2.11v WAY Survey -

Static 2014/15 2.30 2.39

Average number of portions of vegetables consumed daily at age 15

PHOF 2.11vi WAY Survey -

Static 2014/15 2.27 2.40

Proportion of the population meeting the recommended ‘5-a-day’ on a ‘usual day’ (adults)

PHOF 2.11i

Active Lives, Sport

England – Bi-annual

2016/17 57.0% 57.4%

Average number of portions of fruit consumed daily (adults)

PHOF 2.11ii

Active Lives, Sport

England – Bi-annual

2016/17 2.72 2.65

Average number of portions of vegetables consumed daily (adults)

PHOF 2.11iii

Active Lives, Sport

England – Bi-annual

2016/17 2.66 2.65

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Percentage with a mean daily sedentary time in the last week over 7 hours per day

WAY survey Survey -

Static 2014/15 77.0% 70.1%

Percentage physically active for at least one hour per day seven days per week

WAY survey Survey -

Static 2014/15 12.3% 13.9%

Percentage of physically active adults Active lives,

Sport England Bi-annual 2016/17 61.5% 66.0%

Percentage of physically inactive adults Active lives,

Sport England Bi-annual 2016/17 23.4% 22.2%

Utilisation of outdoor space for exercise/health reasons

PHOF 1.16

Natural England

MENE Survey – Annual

2015/16 13.9% 17.9%

Significantly better than benchmark No significant difference to benchmark Significantly worse than benchmark

Figure 4. Public Health Outcomes Framework – indicators for excess weight

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Figure 5. Density of hot food takeaways by ward

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Wider determinants of obesity

Community assets

Recognising and building upon community assets can help to include and empower local communities to improve their health and wellbeing and reduce health inequalities. All communities have assets that can contribute to positively shaping the environment to improve health outcomes, including social groups, good neighbourhoods and community facilities and green and blue spaces. The maintenance of parks and open spaces including local amenities is vital in supporting people to access these spaces for recreational or structured physical activities. Drawing on the importance of the community the council developed the Stronger Communities Strategy which aims to deliver on the following outcomes:

- Cohesive communities - Healthy communities - Socially active communities - Successful communities

The process of achieving these outcomes involves working with the local community to understand their needs and barriers and allowing them to take ownership of their health and community. These idealisms utilise a whole system approach.

Sleep deprivation

Sleep is essential for positive health and wellbeing. Lack of sleep has been associated with health issues including obesity, stress and diabetes7. The Sleep Council and NHS recommend children aged between 4-16 get nine to eleven hours of sleep and adults seven to nine hours of sleep a night8.

Research by the Sleep Council in 2013 showed variation in sleep duration in England with 30% of the population sleeping six to seven hours and 62% only five to six hours per night. Quality of sleep reduces when sleep duration is below five hours and is when mental and physical problems become more pronounced1. For children and adults, poor sleep can affect concentration and mood, and this can lead to increased hunger and poor eating habits during the day9. Over time long-term sleep deprivation can lower physical activity levels, increase weight gain and risk of depression and anxiety. Evidence suggests that children who do not get sufficient sleep are at an increased risk of becoming overweight10, with risk increasing further among very young sleep deprived children. Adults who sleep less than seven hours a day are 30% more likely to be obese.

Sleep problems have also been linked with lower incomes, with 15% of people likely to visit their GP due to sleep issues, whilst 64% of those on high incomes report sleeping well1. Currently there is limited local data to provide a picture of sleep patterns on the Bexley population, however data from Bexley’s recent workplace lifestyle event indicates that 30% of staff do not get a good night’s sleep.

Addressing sleep deprivation is an important factor to address in tackling obesity. Equipping professionals and workplaces with the tools needed to recognise signs of sleep deprivation is one step towards supporting people to improve their sleep quality and duration. Public Health England

7Sleep council (2013) – www.sleepcouncil.org.uk 8 NHS (2017) – https://www.nhs.uk/live-well/sleep-and-tiredness/how-much-sleep-do-kids-need/ 9 NHS (2018) - https://www.nhs.uk/live-well/sleep-and-tiredness/why-lack-of-sleep-is-bad-for-your-health/ 10 BMJ (2011) Carter, Williams & Taylor Longitudinal analysis of sleep in relation to BMI and body fat in children: the FLAME study; 342

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have summarised the signs of sleep deprivation in figure 6 which can be a useful tool to assist conversations about sleep.

Figure 6. Signs of sleep deprivation (Source: Public Health England (2018) Sleep and recovery: a toolkit for employers)

Alcohol

Alcohol is a significant source of calories of no nutritional value with each gram of alcohol containing 7 kilocalories. Alcohol inhibits the metabolism of other nutrients including fat, carbohydrate and protein and has been correlated with increases in BMI, with stronger associations found with the amount or intensity of alcohol per drinking session. Intense drinking sessions, otherwise known as ‘binge drinking’ leads to the accumulation of central fat mass, larger waist circumference and increased risk of obesity11. Alcohol has also been associated with overeating due to stimulation of reward systems in the brain.

In Bexley 21.2% of adults currently drink more than the recommended 14 units of alcohol per week12. Key data from Public Health England13 shows that Bexley has the highest level of harm from alcohol compared to our most similar neighbours, based on the number of hospital admissions where alcohol was the main reason for the illness. Consumption of alcohol also places significant harm on behavioural and mental health disorders and the incidence of alcohol related cancer continues to increase, currently contributing to the highest level of harm for males14.

11 Traversy G & Chaput JP (2015) Alcohol consumption and obesity: An Update, Current Obesity Report 4:122–130 12 Health Survey for England (2011-2014) 13 Public Health Outcomes Framework (2016/17) 14 NHS Digital (2014-2016)

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Our Vision and Aims

The vision for the Obesity Strategy is to create a local environment that supports everyone to have a healthy weight, to halt the rise of excess weight among children and adults and create a downward trajectory by 2024. The aim of the Obesity Strategy is to develop and implement a whole system approach spanning across five years that:

1. Reduces the rate of excess weight in children (aged 4-5 and 10-11) by a minimum of 2%, with a stretch target of 5%

2. Reduces the level of excess weight in adults by a minimum of 2%, with a stretch target of 5%

3. Embeds a whole system approach to obesity prevention maximising community assets and collaborative working

4. Increases the percentage of physically active adults by 10%

5. Delivers on the commitments made in Bexley’s Growth Strategy which aims to create “healthy places for all”

6. Creates healthy environments at school, in workplaces and throughout the Borough

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Section 2: What are our priorities?

The evidence highlights that tackling obesity is challenging due to the complex nature of the condition.6 Tackling obesity requires a multi-pronged approach and an acknowledgment that obesity is not just a public health problem or an acute health problem. Tackling obesity needs to be systematically addressed across the council, partners, and the wider-public, so that it becomes a core component of everyday business.

The Foresight report identified the need to modify the environment so that it enables people to adopt healthy, active lives.15 The term “obesogenic environment” was first coined in the 1990s and refers to environmental factors (social, cultural and infrastructural) that influence an individual’s ability to adopt a healthy lifestyle. For example, technological advances like cars and computer games have reduced the need to use physical exertion. Moreover, the proliferation of takeaways selling high calorie dense fast food provides a convenient and cheaper alternative to home cooked healthier meals. This is further compounded by the strong relationship between obesity and deprivation. People on low incomes are more likely to live in communities with unsafe spaces for physical activity; have less access to fresh fruit and vegetables, and to live in areas with a denser supply of fast-food outlets.16

Bexley’s strategy aligns to national and regional guidance on healthy weight and through consultation with all stakeholders across the system, including external teams, this strategy draws together the key priorities in order to formulate coordinated actions. The Strategy focuses on three key themes, which support more people to eat healthily, be physically active and have a healthy body weight.

1.1 Increasing the availability of healthier foods

National research has shown more than a quarter of all the country’s food outlets offer fast food, with the highest concentrations found in the most deprived neighbourhoods17. With an average portion of chips contributing 54% of total energy intake and 43% of saturated fat of an adult’s recommended daily intake, it is important that we explore how to manage the proliferation of fast food outlets in Bexley. The density of fast-food outlets in a given area is measured by counting the number of fast food outlets per 100,000 people. The density of fast food outlets in Bexley is 84.0 per 100,000 populations, slightly lower than the London average (88 per 100,000). The East and West of the borough have a higher density of fast food outlets; the lowest offer is in the North.

Children of school age and their families, particularly those on lower incomes, are more likely to purchase from fast food outlets18. The food is appealing due to the convenience and affordability

15 Government Office for Science (2007). Foresight: Tackling Obesities: Future Choices. [Available] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/287937/07-1184x-tackling-obesities-future-choices-report.pdf 16 World Health Organisation (WHO, 2014). Obesity and inequities: Guidance for addressing inequities in overweight and obesity. Available at: http://www.euro.who.int/__data/assets/pdf_file/0003/247638/obesity-090514.pdf 17 DS to Check 18 DS to check

Theme 1: Shaping the built environment to foster healthy lifestyles

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value. Portion sizes tend to increase as takeaways compete for customers. Research indicates that when offered larger portions, people consume more.19 This is a concern in areas where there are a number of fast food outlets within close proximity to each other. The result of this is evident in Bexley; schools within close proximity to several fast food outlets had a higher than average child obesity rate.

The draft London Plan sets out a policy to exclude new fast food outlets from opening within 400 metres of schools. This will be reflected in Bexley’s Local Plan and is a positive step in addressing the proliferation of fast food outlets close to schools. Setting limits on fast food outlet saturation is paramount. Public Health will work closely with the Growth and Regeneration Department to develop planning policies that limit the concentration of fast food outlets in town centres.

Good Food for London 2018 sets out how London boroughs can help secure a healthy and sustainable food future. They provide a working definition of good food, as follows, ‘it should be produced, processed, bought, sold and eaten in ways that provide social benefits, contribute to thriving local economies that create good jobs and secure livelihoods, enhance the health and variety of both plants and animals (including the welfare of farmed and wild creatures), protect natural resources such as water and soil and help tackle climate change’. The guidance sets out 11 measurable indicators to help boroughs achieve good food. Boroughs are awarded points based on their progress in each measure. Throughout this strategy, the seven measures that we are working towards area highlighted, including Bexley’s 2018 progress against that measure.

1.1.a. Improve healthy and sustainable food offer across the Borough

We will create a profile of the current food situation in the borough, so that we have a firm basis upon which to develop our Good Food Retail Plan. The term ‘Good Food Retail’ refers to outlets that sell food mainly for consumption at home or to eat on the go. As well as traditional shops, this covers markets, stalls, box schemes, food co-ops, or home delivery, as well as small-scale production kitchens and bakeries that have a retail outlet. Though this process, we will work with a range of partners including Business Improvement Districts, national chains and independent retailers to understand the challenges and opportunities for food-related activity in the Borough and identify a holistic approach to the way we produce and eat food. Fruits and vegetables are important components of a healthy diet. There are significant benefits to eating five portions of fruits and vegetables a day. There is a nationally recognised programme to encourage people to eat five portions per day, known as the 5-a-day campaign. In Bexley, 57% of adults consume five portions of fruits and vegetables on a “usual day”, which is similar to the national average. However, in Bexley, less than half of all 15 year olds (46.9%) are reported to consume their 5 a day. This value is lower than average. Accessibility to fresh fruit and vegetables is paramount to achieving this goal. Bexley’s Growth Strategy sets a vision of creating healthy streets and lifetime communities. It sets a view to establish walkable communities, where local shops, services and employment are accessed easily by foot rather than by car. We are committed to understanding fresh fruit and vegetables availability within our more deprived communities. There are limited traditional markets or farmers markets in operation in the borough due to legal issues regarding market boundaries. However, there is a need to work collaboratively with the Growth and Regeneration department as well as the community sector to help assess

19Hollands, G.J., Shemilt, I., Marteau, T.M., Jebb, S.A., Lewis, H.B., Wei, Y. & Ogilvie, D. (2015) Portion, package or tableware size for changing selection and consumption of food, alcohol and tobacco. Cochrane Database System Review, 9.

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availability, understand the barriers to accessing healthy food, and identify strategies to address inequalities within these communities.

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Food Partner-

ships

Local food partnerships bring together the public sector, civil society, businesses and community members to work together to create a healthier and more sustainable food system. Taking a joined-up approach within a borough allows partnerships to address a wide range of food issues including obesity and diet-related disease, economic regeneration, food poverty and ecological issues such as climate change and food waste, as well as attracting more funding for local initiatives, reducing duplication of work and improving collaboration.

The Sustainable Food Cities networks supports food partnerships around the UK and offers three levels of Awards to recognise and celebrate the success of those places taking joined-up, holistic approach to food and that are achieving significant positive change on a range of key food issues.

Bexley

2018 progress

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Food for Life

The Food for Life Served Here award is an independently awarded accreditation for caterers from the Soil Association. The award helps organisations ensure they are recognised for serving more local, fresh and honest food.

In achieving the Bronze standard, caterers must demonstrate that they are using fresh ingredients which are free from trans fats and better for animal welfare and cooking from scratch. At Silver and Gold, caterers are recognised for practises such as making healthy eating easier, championing local producers and sourcing environmentally friendly and ethically produced ingredients. The scheme has been cited by NHS England as a way to improve hospital food, and by the Department for Education as a national framework to support caterers to increase uptake of quality school meals.

Bexley

2018 progress

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Food Growing

For this measure Capital Growth assesses what actions councils are taking to support community food growing across four areas: access to land; integration of growing in different council departments; provision of information and promotion of food growing; and building the capacity of growers. This measure additionally assesses whether community food growing is recognised in local planning policy.

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Bexley

2018 progress

Source: https://www.sustainweb.org/resources/files/reports/GoodFoodForLondon2018.pdf

1.1.b. Increase the uptake of the Healthy Start programme

The Healthy Start programme is a means-tested scheme that provides mums with vouchers to help buy some basic foods spend with local retailers. Pregnant women and children over one and under four years old can get one £3.10 voucher per week. Children under one year old can get two £3.10 vouchers (£6.20) per week. Women and children getting Healthy Start food vouchers also get vitamin coupons to swap for free Healthy Start vitamins. We will make it simple and easy for eligible families to access the Healthy Start scheme and utilise the vouchers widely across the borough. We will also support families to make the most of the foods bought with the vouchers by providing cooking classes and sharing recipes. We will initially focus on the north of Bexley, where there are fewer outlets participating in the scheme. We will engage with existing retailers to understand the barriers to uptake and work jointly to overcome these. We expect to increase the quality and types of food on offer, as well a potentially identifying new outlets to ensure improved spatial availability. We anticipate that increased saturation and visibility of outlets will also increase acceptance of the scheme. We will engage with eligible families with young children from diverse communities to understand better their beliefs, challenges and barriers to registering and using Healthy Start. We will explore specifically whether stigma plays a role in preventing use of the scheme and together identify ways to overcome this, including addressing cultural dynamics by engaging with those who hold power over household shopping budgets. The uptake up of this programme was just 57% in Bexley (Dec 2018) compared to a London region average of 65%. We will increase and maintain the uptake of this programme to 75% over the life of this strategy.

1.1.c. Increase the number of food businesses achieving Healthier Catering Commitment accreditation

There are over 180 fast food outlets currently in operation across Bexley. We want to encourage our existing fast food outlets to offer healthier options, for instance, grilled food alternatives, and to include salads on the menu as well as reducing portion sizes. The Healthier Catering Commitment is a pan-London voluntary project, locally run to encourage restaurants, cafes and takeaways to make a commitment to adopting healthier food preparation practices and offer healthy options. In Bexley, 17 caterers have signed up since the award programme was launched in 2015.

We are committed to increasing the uptake of the scheme across the borough, particularly with those businesses within the 400-metre buffer zone of our schools. We will reinvigorate this programme through robust engagement with the BIDs and in partnership with the Environmental Health Team to identify local champions who can actively promote the benefits of the scheme for their business. This intervention has been undertaken in other London boroughs with some success20. We also intend to make it mandatory for new outlets to sign-up to the Healthier Catering Commitment to encourage business to offer healthier food and drink to customers, as well as

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diversifying the types of businesses that can get accreditation, such as cinemas and bowling alleys. We will work with businesses to create the business case for supporting healthy lifestyles and explore the possibility of instigating a Bexley Business Award focused on Healthy Lifestyles.

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Healthier Catering

Small changes to food processes and ingredients can make a big difference to improving diets, particularly for the benefit of diverse and lower-income communities. This can be simple steps like choosing a healthier version of cooking oil, using more fruit and vegetables in a recipe or reducing salt content by restricting added salt.

The Healthier Catering Commitment supports caterers and food businesses to make straightforward changes to processes and ingredients. It is a partnership project between environmental health teams in councils with support from public health colleagues, the Association of London Environmental Health Managers (ALEHM) and the London Food Board. Food outlets that adopt healthier ingredients and cooking practices can use HCC promotional materials including displaying window sticker.

Encouraged by local and national public debates on obesity and the need to tackle the problem locally, the HCC has become increasingly popular as councils look for whole systems approaches to improve food and reduce obesity and other diet-related conditions such as heart disease and diabetes.

Bexley

2018 progress

Source: https://www.sustainweb.org/resources/files/reports/GoodFoodForLondon2018.pdf

1.1.d Decrease the visibility of foods and drinks high in fat, sugar and salt (HFSS)

An HFSS product is a food or soft drink that is high in fat, salt or sugar as classified by the Department of Health’s nutrient profiling model. A substantial body of evidence links the consumption of HFSS foods to an increased risk and incidence of certain diseases such as type 2 diabetes, cardiovascular disease, certain cancers as well as contributing to high levels of obesity both for children and adults

We will identify best practice examples of ‘healthy tills’ initiatives and establish the business case for implementing this simple measure. We will identify the opportunities for offering healthier foods and drinks through vending machines, and explore how we can use restrictions in advertising to reduce the promotion of HFSS items, particularly in close proximity to children. We will learn from Lewisham’s imminent pilot programme on this.

1.1.e Improve access to free drinking water across the Borough

Water is a healthy and cheap choice for quenching your thirst at any time. It has no calories and contains no sugars that can damage teeth. Our bodies needs water or other fluids to work properly and to avoid dehydration. That’s why it's important to drink enough fluids. In climates such as the

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UK's, we should drink about 1.2 litres (six to eight glasses) of fluid every day to stop us getting dehydrated. In hotter climates or when we are physically active, the body needs more than this. We will Sign up for and actively promote Refill London scheme, and install public water fountains in town centres to support people to drink more water, whilst reducing the use of plastic bottles.

Over the next 5 years we will:

• Improve healthy and sustainable food offer across the Borough - Create a profile of the current food situation in the Borough - Develop a Good Food Retail Plan aligned with the London Food Strategy (2018)

- Scope the feasibility of introducing the Soil Association’s Food for Life standards across the borough’s health and education facilities

• Increase the uptake and utilization of the Healthy Start Scheme across Bexley, with a focus on most deprived wards

• Increase the number of food businesses achieving Healthier Catering Commitment accreditation

• Decrease the visibility of foods and drinks high in fat, sugar and salt (HFSS) • Install public water fountains in town centres

1.2 Creating an environment that inspires physical activity

Physical activity is essential for good health and should be encouraged from birth. Inactivity contributes to obesity, long term health conditions and premature death. Physical activity among adults in Bexley (61.5%) is similar to London figures (64.6%) but significantly lower than the national average (66.0%). The percentage of Bexley residents making regular visits to the natural environment for health and exercise purposes (13.9%) is significantly lower than London (18.0%) and England (17.9%). Low income areas are associated with lower quality housing and less access to good quality green space21 National surveys show that only a small proportion (22%) of children aged 5 to15 years met the physical activity guidelines in 201522 highlighting the need to improve physical activity levels in children, adults and families. Local data is not available on activity patterns of children. The built environment plays an influential role in enabling adults and children to be more physically active. Active travel is defined “as walking or cycling as an alternative to using motorised transport

21 Houses of Parliament Parliamentary Office of science and technology, 2016)Green space and health POST note 538 22 The health survey for England 2015

- Explore with BIDs and retailers innovative ways to increase healthy food/drink offer that make business sense, such as new market stalls and healthy food pop-ups in empty shops

- Review effectiveness of Community Fridges increasing access to healthy food - Explore the potential of promoting an existing App that repurpose surplus

restaurant food as a means of increasing healthy eating among low-income families - Map and review large scale food waste locally and explore how this can be directed

to support low-income families - Review and prioritise how we can encourage and support food growing through

current and future activities - Scope the feasibility of expanding the Sugar Smart Campaign as part of Good Food

for London.

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for making every day journeys”.23 Just over half of adults in Bexley (50.6%) reported walking for at least 10 minutes at least five times per week.24 This health challenge is particularly acute for children, as they need to do more physical activity to stay healthy. London has the highest levels of childhood obesity in England and streets and places provide important opportunities for children to get the activity they need through travel and play. Eight in ten children in London do not get the minimum one hour a day of physical activity.25

As set out in Bexley’s Growth Strategy, the liveable, lifetime communities commitment is focussed on enabling more people to walk or cycle to local shops and services, instead of driving. This integration of physical activity into daily life improves physical and mental wellbeing. The London Plan and Draft Local Implementation Plan refers to the Healthy Streets approach which should be central in local decision making, aiming for everyone to use cars less and to walk, cycle and use public transport more.

1.2.a Leverage Planning opportunities to ensure that new developments provide an environment that is conducive to outdoor activity

Sport England’s Active Design takes a fresh look at the opportunities to encourage and promote sport and physical activity through the design and layout of our built environment to support a step change towards healthier and more active lifestyles.

23 Public Health England (2016). Working Together to Promote Active Travel: A briefing for local authorities (p. 10). [Available] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/523460/Working_Together_to_Promote_Active_Travel_A_briefing_for_local_authorities.pdf 24 Physical Activity profile from Public Health England. Available at: https://fingertips.phe.org.uk/profile/physical-activity/data#page/3/gid/1938132899/pat/6/par/E12000007/ati/101/are/E09000004/iid/92471/age/164/sex/4 25 Healthy Streets in London (2017) http://content.tfl.gov.uk/healthy-streets-for-london.pdf

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Source: https://www.sportengland.org/media/3964/spe003-active-design-published-october-2015-high-quality-for-web-2.pdf

We will ensure that Health Impact Assessments are undertaken by developers for all large new developments and that Active Design principals are applied in the development of new buildings and spaces.

1.2.b Ensure the existing built environment is optimized for outdoor activity

The Healthy Streets Approach is a system of policies to deliver a healthier, more inclusive place where people choose active transport. There are 10 evidence-based indicators including the following: Everyone feels welcome, people to choose to walk and cycle, people feel relaxed, easy to cross, clean air, not too noisy, places to stop and rest, people feel safe, things to see and do, Shade and shelter. Improving the feeling of safety can be particularly beneficial for more vulnerable groups (including older people and children), and could be an important factor in helping them to be physically active.26

26 TFL, 2017, Healthy Streets for London

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We are committed to achieve the commitments set out in the Growth Strategy and the Draft Local

Implementation Plan. We aim to oversee the creation of walkable neighbourhoods using the Healthy Streets Approach and to support the availability of local services and goods that are accessible by walking and cycling. We wish to be a key driver in the provision and maintenance of parks, open spaces and playing fields, and the green links that connect them.

1.2.c Maximise the use of existing parks and open spaces

In addition to integrating physical activity into daily life, people must have access to recreation and leisure facilities to support a range of activities, from parks and green links, where people can walk their dogs, to playing fields where local clubs can play sport. For children, outdoor play and activity is vital to their health and well-being. Play is an important way for children to connect with the world, learn, and develop their imagination. Compared with previous generations, children spend less time playing outdoors and have lower participation rates in active transport. Studies have also identified lack of neighbourhood safety as a potential barrier to children's physical activity.27

We will review the Parks and Open Spaces Audit and ensure there is a future focus on equitable provision across the borough. We will support the setup of structured ‘green gym’ programmes which aim to provide people with a way to enhance their fitness and health while taking action to improve the outdoor environment. Green gyms enable people who would not normally attend a conventional gym or sports centre to get fit.

1.2.d Support people to walk more

We will create a social movement to encourage people to #walkmore by expanding walk-ability courses, promoting active travel to school and work, supporting more community-led healthy walks, establishing clear route signage and wayfinding, supporting the Daily Mile in schools, and exploring the feasibility of Apps to inspire and incentivise people to walk more in Bexley.

1.2.e Support people to cycle more

We will Continue spatial improvement activities including greening streets, maintaining or updating street furniture for cyclists, expand bike-ability courses in schools and ensure the activation of cycling in line with Bexley’s Growth Strategy.

1.2.f Increase access to structured exercise for high risk groups

Scope availability of structured physical activity opportunities for vulnerable / high risk groups, including, people with physical and learning difficulties, including children with special educational needs, and those with Severe Mental Illness. We will actively encourage continued and new exercise during pregnancy and explore the links between exercise and falls prevention.

Over the next 5 years we will:

27 Carver A, Timperio A, Crawford D: Playing it safe: the influence of neighbourhood safety on children's physical activity - a review. Health and Place. 2008, 14 (2): 217-227. 10.1016/j.healthplace.2007.06.004.

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• Leverage Planning opportunities to ensure that new developments provide an environment that is conducive to outdoor activity

- Ensure Health Impact Assessments are undertaken by developers for all large new developments

• Ensure the existing built environment is optimized for outdoor activity

- Ensure ongoing dialogue and senior leadership for promoting sport, health and physical activity across the planning and wider political spectrum

• Maximise the use of existing parks and open spaces

- PH to support the set up structured ‘green gym’ programmes targeted at those most at risk

• Support people to walk more

- Initiate a #walkmore social movement

• Support people to cycle more

• Increase access to structured exercise for high risk groups - Scope availability of structured physical activity opportunities for vulnerable and

high-risk groups - Explore obesity related challenges for children with Special Educational Needs and

develop actions

- Promote the use of Active Design Principles to inform joint working with planners, transport and green spaces professionals

- Apply ‘Healthy Streets’ principles whenever work is undertaken to improve the built environment

- Review the scope of the Parks and Open Spaces Audit to ensure focus on equitable distribution and availability of amenities (toilet, water, infant facilities)

- Ensure equitable access to 5k Park Run events in the North of the Borough

- Expand walk-ability courses in Schools - Introduce active travel to and from school: Increase no of schools who achieve TFL

STARS (Sustainable Travel: Active, Responsible, Safe) Gold accreditation - Explore the feasibility of expanding yellow lines exclusion zones around schools &

enforcing current zones - Support communities to develop more locally led walking groups - Establish clear route signage and wayfinding including installation of new signage

and decluttering where appropriate - Explore the feasibility of Apps to inspire (& possibly incentivise) people to walk more

in Bexley - Support schools to sign up and implement the Daily mile

- Expand Bike-ability courses in Schools - Identify where installing new cycle racks might support increased cycling (in both

public and residential places) - Continue spatial improvement activities including greening streets, maintaining or

updating street furniture for cyclists - Identify and prioritise behaviour change programmes in Bexley through education

and campaigns - Ensure the activation of cycling in line with Bexley’s Growth Strategy

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This section sets out how we will utilise settings to engage and activate communities at critical times across their life course, to prompt healthy attitudes and behaviours. Obesity often starts in childhood and if not tackled early, can lead to many health problems in adulthood. Bexley is intending to create an Integrated Universal Children’s Service based in part on the re-design of the 0-19 Children’s Service (high quality support for families from health visitors and school nursing) and integration with other services and resources that operate in this space, including Children’s Centres, Nurseries, Primary Care, Community Health and Mental Health services, Voluntary sector services, schools, colleges, youth services, which will shape the way in which we deliver obesity prevention.

2.1 Early years

The Government Strategy Healthy Weight, Healthy Lives states; “evidence shows that breastfeeding, delaying weaning until babies are six months old, introducing children to healthy foods, controlling portion size and limiting snacking on foods high in fat and sugar in the early years can all help to prevent children becoming overweight and obese”27.

2.1.a. Increase breastfeeding initiation and maintenance

Breastfeeding offers a variety of health benefits to babies, one of these being the prevention of obesity.28 Mothers should be encouraged to breastfeed during pregnancy and those who choose to breastfeed, should receive appropriate support to continue breastfeeding for as long as they wish. Breast-feeding initiation rates and 6-8 week breastfeeding data for Bexley are unknown due to data quality reasons, however there are concerns that although initiation levels are fair, mothers who continue to breastfeed to 6-8 weeks and beyond reduces significantly. Improving the data quality is critical to improving rates and monitoring progress.

The Health Visiting Service has achieved stage 3 UNICEF Baby Friendly accreditation and there is an intention to extend this to the maternity service. The role of Health visitors is essential in our ability to identify those families who need extra steer and guidance in feeding and weaning. Research demonstrates that babies exposed to a wide variety of foods through weaning, help to develop a taste for a greater variety of food as they grow29. Research highlights that one of the main barriers to breastfeeding is a lack of confidence breastfeeding in public. We aim to challenge the social stigma associated with breastfeeding. The strategy aims to enable mothers to breastfeed with confidence in public and create places around the borough that are welcoming to breastfeeding families including libraries, children’s centres and local businesses.

With nearly 3 in 10 children arriving at school overweight or obese, the early years is a critical time for instilling healthy habits, attitudes and behaviours in children. Parents and childcare providers will have an influential role in exposing children to opportunities to be active, develop healthy eating habits and can act as positive role models. We need to provide consistent and clear information about the benefits of limiting snacks, physical activity and controlling portion sizes.

28 DS to add 29 DS to add

Theme 2: Supporting a community culture that sees healthy eating and physical activity as the norm

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Baby Friendly

Breastfeeding improves the health and wellbeing of both mothers and babies. It provides protection against a range of childhood illnesses and helps decrease the incidence of overweight, obesity, and sudden infant death.

The Unicef UK Baby Friendly Initiative is an externally evaluated programme for improving infant feeding and parent-infant relationship building, and the health and wellbeing outcomes of all infants. Implementation of the standards is recognised by the DH, PHE and NICE, and helps ensure good quality support is available across the community for all mothers and babies, whether breastfeeding or bottle feeding.

Bexley

2018 progress

Source: https://www.sustainweb.org/resources/files/reports/GoodFoodForLondon2018.pdf

2.1.b Promote unstructured outdoor play

Just like other forms of physical activity, unstructured outdoor play helps kids get the right amount of exercise every day. Children who build active and healthy bodies from a young age are less likely to suffer from obesity and other health issues in later life. We will establish a Healthy Physical Environment Commitment Scheme Kite mark to recognise early years settings committed to development of the environment, curriculum and attitudes in respect of public health and offer training in outdoor play activities to staff in early years settings.

2.1.c Equip Early Years Practitioners to support heathy start for life

We will develop specialist childhood nutrition training for health visitors and other early years workers, linked to the development of an interactive resource pack for parents, ‘Born Ready, School Ready, Bexley Ready’. Over the next 5 years we will:

• Increase breastfeeding initiation and maintenance

- Bromley Healthcare to aim to achieve the Baby Friendly Initiative Sustainability Award by 2024

- To maximise contact opportunities with families to discuss breastfeeding and weaning

- Scope how the built environment and venues/facilities can be better equipped to support women to breastfeed in public spaces Bromley Healthcare 0-19 service to achieve UNICEF Baby Friendly Stage 3 Initiative by 2019

• Promote unstructured outdoor play - Establish a Healthy Physical Environment Commitment Scheme Kite mark to

recognise early years settings committed to development of the environment, curriculum and attitudes in respect of public health

- Engage all early year’s settings to prioritise and incorporate outdoor play

- Bromley Healthcare 0-19 service to achieve UNICEF Baby Friendly Stage 3 Initiative by 2019

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- Offer training in outdoor play activities to staff in early year settings • Equip Early Years Practitioners to support heathy start for life

- Development of an interactive resource pack for parents, ‘Born Ready, School Ready, Bexley Ready’

- Develop specialist childhood nutrition training for health visitors and other early years workers

2.2 School & College Settings

There are vast inequalities in rates of excess weight amongst schools in the borough – at year 6 the lowest rate of excess weight is 25% (School in Sidcup) and the highest is 53% (School in Erith). This does not appear to have any relation or correlation to rates for the reception year. Schools have an important role in promoting healthy eating and physical activity. National guidance recommends that all children and young people should engage in moderate to vigorous intensity physical activity for at least 60 minutes every day.30 Many schools offer an average of two hours of PE or other physical activities per week, which is a portion of what is deemed ideal. Food served in some schools and academies in Bexley are subject to the School Food Standards in England to ensure children receive a healthy, balanced diet. Schools receive sports and PE allocations each year, we know some schools spend this money on the sports premium package. We wish to better understand how this funding is being used and provide guidance where necessary. With more academy schools than grant-maintained schools in the borough, achieving engagement and support across all schools in the borough can be challenging. There is a need to work closer with all schools to understand their dietary and physical activity offer. An opportunity here is to re-launch the Healthy Schools Programme. There are examples of good practice currently running in schools effectively supporting our healthy eating and active travel objectives. We aim to expand the reach of these programmes where possible:

• Food Growing schools – Working collaboratively with the “Food Growing Schools: London Partnership” and Project Learning Garden to deliver workshops, support and equipment to encourage schools to start growing their own food.

• Bexley’s Road Safety team run various safety educational and training projects with schools and colleges to promote safer behaviour on our roads including Walkability and Bikeability courses in schools and in the community setting.

We will map Healthy Schools programme against current offer from a variety of LBB Teams (Waste, Sport & Leisure, PH) and against other standards, including OFSTED and School Food Standards & assess the feasibility of delivering Healthy Schools within current capacity. We will engage schools and governors who are currently achieving Healthy Schools status to understand their successes and challenges. Based on the findings, we will establish a health promoting schools programme and support primary and secondary schools to achieve accreditation. Finally, we will limit new fast food outlets within 400 metre proximity of schools, and work with existing outlets to provide a healthier offer.

30 Childhood obesity: a plan for action, 2017,

2.2.a Launch a health promoting schools programme in the borough

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in schools

National evidence and good practice advises schools to adopt a whole school approach to food in order to improve children’s health, as well as support sustainable food systems. Food for Life, a project of the Soil Association, works with schools, nurseries, hospitals and care homes to achieve the vision of making good food the easy choice for everyone.

Healthy Schools London is a Mayor of London awards scheme that supports and recognises schools doing good work to help their pupils and staff be healthy and happy. It uses a whole school approach to health and wellbeing and gives schools a framework for their activity with pupils and staff. Examples of work includes improved cooking skills, healthy packed lunches growing fruits and vegetables, healthy tuck shop and snacks and regular water drinking.

Bexley

2018 progress

Source: https://www.sustainweb.org/resources/files/reports/GoodFoodForLondon2018.pdf

2.2.b Develop a Health Promoting Colleges Programme

We will call on Colleges to invoke the Okanagan Charter for health promoting universities and colleges to, ‘Embed health into all aspects of campus culture, across the administration, operations and academic mandates’. We will support them to identify health champions among their own students and staff to lead the development of a healthy lifestyles programme.

Over the next 5 years we will:

• Launch a health promoting schools programme in the borough – Map Healthy Schools (HS) programme against current offer from a variety of LBB

Teams (Waste, Sport & Leisure, PH) and against other standards, including OFSTED and School Food Standards & assess the feasibility of delivering HS within current capacity

– Explore how the Sugar Smart Campaign can be incorporated as part of the HS programme

– Engage with schools (and Governors) who are currently achieving HS status to understand their successes & challenges

– Based on findings, establish a health promoting schools programme and support Primary & Secondary schools to achieve accreditation

– Limit new fast food outlets within 400m proximity of schools – Review emerging evidence for School Superzones and how this initiative may benefit

Bexley • Develop a health promoting colleges programme

– Identify ‘health champions’ at the Colleges to support the development of Healthy Lifestyles programmes for students and staff

– Utilise student learning time / projects / interests to develop and deliver health promoting change

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2.3 Work based settings

A large proportion of people are in desk-based roles which means they spend a lot of their time sitting down each day. An office environment is an ideal place to introduce healthy initiatives to support people to move more and to counteract the negative impact of being sedentary. There are several benefits of cultivating a healthy workforce, including reduced absence, increased motivation to stay in work, recover from sickness quicker and are at less risk of long-term illness. The London Healthy Workplace Charter provides a framework for action to help employers build good practice in health and work in their organisation. The charter supports all types of employers, large and small, from the public, private and voluntary sectors. Three standards relevant to this strategy include:

• Physical activity – the ways in which the organisation actively promotes the importance and benefits of regular physical activity and creates opportunities for employees to become involved.

• Healthy eating – the ways in which the organisation actively encourages and enables staff to eat healthily.

• Mental health and wellbeing –the ways in which the organisation protects and promotes the mental wellbeing of its staff, including appropriate policies, management training and support mechanisms.

Return on investment:

• Workplace Health- £2.87 - £4.59 gained from £1 invested

• Subsidised or free gym membership £4.56 - £23.00 gained from £1 invested 2.3.a Work towards promoting healthy behaviour and workplace wellbeing in the Bexley Civic Offices

We will achieve the London Healthy Workplace Charter Award at the Civic Centre.

2.2.b Work towards promoting healthy behaviour and workplace wellbeing in external workplaces

We will support other organisations to achieve the London Healthy Workplace Charter Award, including libraries and leisure centres, health and education providers and private employers.

Over the next 5 years we will:

• Work towards promoting healthy behaviour and workplace wellbeing in the Bexley Civic Offices

– Achieve London Healthy Workplace Charter Award at Civic Centre – Consider the feasibility of providing facilities for lactating mothers returning to work – Develop online training modules about health and wellbeing – Deliver a series of ‘health-promoting days’ in the Civic Centre – Identify and utilise ‘health champions’ to support the improvement of work-based

health through team engagement, with a particular focus on reducing sedentary behaviour in the workplace

– Ensure onsite food offer provides healthy options and limits foods HFSS

• Support others to achieve Healthy Workplace Charter Award. For example, libraries, leisure centres, health and education providers and private employers

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2.4 Community spaces

Bexley is one of the greenest boroughs in London, with 106 parks and open spaces. We have a vibrant community and voluntary sector with 850 registered charities and 1100 informal community groups. Surprisingly, only 13.9% of residents report to use outdoor space for exercise and health reasons. We want to see parks and other public spaces being well utilised by the community. Nurturing strong, resilient, healthy communities is a key priority for the Council. This is evidenced in the Stronger Communities Strategy, The Corporate Plan and the Growth Strategy. As a council, we aim to promote social connections by building better connections between neighbours, communities and local services across the borough.

2.4.a Promote healthy lifestyles, community cohesion and tackle health inequalities

London Play Streets, also known as ‘playing out sessions’ or ‘play streets’ is a simple, effective and low-cost way for children to be able to play out in the streets where they live. Local authorities use their existing powers to allow temporary street closures to allow children to play whilst local parents and other residents act as marshals. We will explore the appetite for reinvigorating London Play Streets.

2.4.b Encourage the provision of healthy foods at community events

We will scope the feasibility of a policy to ensure council-led events /activities provide healthy eating and health promoting facilities and explore ways to influence healthy food provision at non-council led events.

Over the next 5 years we will:

• Scope health promoting libraries as part of a universal approach to healthy eating promotion in early years

• Explore the appetite for reinvigorating London Play Streets • Encourage the provision of healthy foods at community events

– Scope the feasibility of a policy to ensure council-led events /activities provide healthy eating and health promoting facilities

– Explore ways to influence healthy food provision at non-council led events

2.5 Embedding social value into policy and practice

The Social Value Act 2012 requires the public sector to ensure that the money spent on services creates the greatest economic, social and environmental value for local communities. Embedding social value in contracts means that the wider benefits are considered throughout the commissioning cycle and a set of social accountabilities are defined as part of the procurement process.

Bexley Council procure a plethora of contracts and we need to ensure that social value is embedded within each one. We want to explore this opportunity within the council, CCG, our partners and our contractors.

2.5.a Health in All Policies

Health in All Policies (HiAP) is an approach to policies that systematically and explicitly takes into account the health implications of the decisions we make; targets the key social determinants of

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health; looks for synergies between health and other core objectives and the work we do with partners; and tries to avoid causing harm with the aim of improving the health of the population and reducing inequity. We will support the development of a Bexley approach to Health in All Policies (HiAP)

2.5.b Embed social value in council and CCG contracts

We will ensure our approach to contracting and procurement embeds social value and does no harm to public health.

2.5.c Ensure social value is integral to planning decisions

We will ensure that planning decisions are in the best interest of public health.

Over the next 5 years we will:

• Support the development of a Bexley approach to Health in All Policies (HiAP)

• Introduce a clause in contracts that ensures the contractor is signed up and working towards achieving the London Healthy Workplace Charter award

• Introduce a clause in food and confectionary contracts (concessions) that ensures businesses offer healthy alternatives to sugary or high fat food, drinks and snacks

• Include a clause in events management contracts that food offer must include healthy options

• Identify system change required to ensure public health informs planning decisions

3.1 Programmes to identify children and adults with excess weight

3.1.a Integration of the NCMP into tiered child weight management services

The National Child Measurement Programme (NCMP) measures the height and weight of children in Reception class (aged 4 to 5) and year 6 (aged 10 to 11), to assess overweight and obesity levels in children within primary schools.

We will continue to deliver NCMP and effectively utilise datasets to inform future policy, planning and service models.

3.1.b Continual improvement of screening programmes

The NHS Health Check programme is a national initiative designed to ‘put prevention first’ and consists of a series of tests, measurements and risk management interventions which can be delivered in different settings to suit the needs of a local population. The Programme is primarily a vascular risk management programme for those aged between 40 and 74 who do not have existing diagnosed vascular disease. The purpose of the NHS Health Check is to identify and invite an individual’s who met the priority key groups to reduce their risk of coronary heart disease, stroke, diabetes and kidney disease. The newly commissioned NHS Health check programme aims to prioritise and increase the reach and also up take by patients in six key groups.

Theme 3: Prompting individuals to make healthier lifestyle choices

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1. South Asians, who have increased risks of heart disease compared to Europeans 2. Males, who if other factors are equal, are at higher risk of cardiovascular disease compared to

females- thus trying to attract more men who would not normally engage with primary health care

3. People with a family history of clinically proven cardiovascular disease (angina, myocardial infarction, transient ischaemic attack, or ischaemic stroke) in a first-degree relative (parent, sibling) before the age of 60 years. In such people the risk of a coronary event is approximately double.

4. People with a history of smoking. 5. People with a BMI of 30 kg/m2 or greater, obesity is a significant risk factor for and

contributor to increased morbidity and mortality, primarily from CVD and diabetes. 6. People residing in areas of higher deprivation by postcode. For given levels of other risk

factors, populations which are more deprived have a higher CVD risk.

3.1.c Increase uptake of health checks for high risk individuals

People with a learning disability often have poorer physical and mental health than other people. These checks are for adults and young people aged 14 or over with a learning disability and involves a physical check-up, including weight, heart rate, blood pressure and blood and urine tests if needed.

3.1.d Ensure Making Every Contact Count is effective for the Obesity pathway

Making Every Contact Count (MECC) is an approach to healthcare that encourages all those who have contact with the public to talk about their health. It is about altering how we interact with people through having Healthy Conversations and learning how to spot opportunities to talk to people about their wellbeing.

We will develop obesity specific MECC training programmes for a variety of different practitioners to increase the number of people access services and activities to support a healthy weight and lifestyle.

Over the next 5 years we will:

• Continue the delivery of the NCMP and integration with child weight management services

• Effectively utilise the NCMP datasets to inform future policy, planning and service models

• Incorporate screening programmes into the Obesity Pathway

• Increase the uptake of Health Checks for people with Severe Mental Illness and Learning difficulties

• Develop obesity specific MECC training programme including a slide resource pack for a variety of practitioners

3.2 Programmes to support children and adults to lose weight

Child weight management

Bexley offers a tier 2 child weight management service for children aged 4-11 who have a BMI above the 91st centile (overweight and obese). The service is provided by Everyone Health who deliver Alive n Kicking in the community. Alive n Kicking is a 12-week multi-component intervention which involves physical activity, behaviour change and nutrition education. The programmes are held at various locations in the borough including primary schools and community centres. A weekly physical activity drop in session is provided at St Paul’s Church for all children who have or are

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attending an Alive n Kicking programme. Everyone Health also provide a School Time Obesity Prevention Programme directly in schools to all children aged 8-11. The programme also provides 6 weeks of nutrition education and 6 weeks of physical activity and is aimed to identify children who may require further support to be referred to the Alive n Kicking programme.

Adult weight management

Bexley provides a tier 2 adult weight management referral scheme to residents or those registered with a Bexley GP and who are aged 16 and over. The service is provided by Slimming World and residents can be referred by their GP or other health professional. Individuals who have a BMI of 30kg/m2 and over or those with a BMI of 27.5kg/m2 with a long-term condition or from a BME group will be able to receive 12-weeks free to attend Slimming World. Slimming World provides a multi-component intervention with a focus of lifestyle and behaviour change, and group motivation. Slimming World provide 39 groups at 25 different locations in the borough during different times of the day so they are accessible to those attending.

Tier 3 weight management South East London have a launched a pilot adult weight management service for patients with a GP in South East London which will run until 31st March 2020. It is a 12-month multidisciplinary-led programme of group based sessions to support the complex needs associated with severe obesity. This CCG funded action learning programme will be delivered by the Department of Nutrition and Dietetics at Guy’s and St Thomas’ NHS Foundation Trust but the programme itself will be delivered locally in the community and is being evaluated by Kings College London. There are currently no bariatric surgery options for patients.

3.2.a Provision of evidence-based tier 2 weight management service for children and adults who are overweight or obese

We review the current Tier 2 service provision and ensure that it is fit for purpose and delivering against set targets.

3.2.b Map weight management service provision for high risk groups

We will Identify the levels of obesity across high risk groups to inform planning and commissioning of services and map the service provision available for high risk individuals in relation to weight management support across all four tiers of weight management support, through engagement with specialist organisations including MENCAP, SLaM and CHEWS. We will utilise the findings to influence support available to children and adults with body image issues, SMI or LD. 3.2.c Develop an obesity pathway

We will Develop an obesity pathway across primary, secondary and tertiary prevention of obesity to reflect both clinical and holistic support that makes it easier for patients and professionals to access / refer to appropriate services. Over the next 5 years we will:

• Continue delivery of tier 2 weight management services

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• Review best practice models for tier 2 weight management interventions, and where possible, pilot models to contribute to the evidence base

• Explore and pilot models to increase engagement and uptake of weight management services by men who are overweight and obese, for example, Football Fans in Training

• Identify the levels of obesity across high risk groups to inform planning and commissioning of services

• Map the service provision available for high risk individuals in relation to weight management support across all four tiers of weight management support, through engagement with specialist organisations including MENCAP, SLaM and CHEWS

• Use findings to influence support available to children and adults with body image issues, SMI or LD

• Develop an obesity pathway across primary, secondary and tertiary prevention of obesity to reflect both clinical and holistic support

• Explore the role of mindfulness and obesity

3.3 Enabling individuals to take responsibility for their own health

Matt Hancock, Health and Social Care Secretary has set out a vision to put prevention at the heart of our nation's health in the strategy, Prevention is better than Cure. “Prevention is also about ensuring that people take greater responsibility for managing their own health. It’s about people choosing to look after themselves better, staying active and stopping smoking and making better choices by limiting alcohol, sugar, salt and fat.”

This has been emphasised with the recent launch of The NHS Long Term Plan (2019) which cites prevention as an essential component of the strategy. A key driver for this priority is to establish a behaviour change communications plan. The activities will effectively challenge social norms and support the progression of long term sustainable change amongst the population. We want to support the practice of healthy behaviours particularly amongst communities most at risk of being overweight and obese. There are two national programmes which can be adopted and localised within Bexley:

• Change4Life is Public Health England’s flagship social marketing programme supporting the childhood obesity agenda. It empowers families with primary school age children to eat well and move more. Over the last ten years, more than four million people have signed up to the programme, and there are over 200 national partners.

• One You PHE's One You campaign encourages adults, particularly those in middle age, to make changes to improve their health. The campaign helps adults to move more, eat well, drink less and be smoke free. One You will also provide information on how people can reduce their stress levels and sleep better. Adults take an online quiz called ‘How Are You’ that provides personalised recommendations based on the individual’s results and directs them to tools, advice and local services to help them take action.

We want to maximise the opportunities presented through digital marketing (e.g. website, social media, e-marketing and apps) not only to provide accessible information but to nudge people to take up healthy behaviours and also signpost them to local services and community interventions.

Smartphone Apps

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Smartphones are the way many people keep connected. They are now firmly established as the most widely owned internet-enabled device, with 76% of adults owning a smartphone.31 A recent study by Deloitte suggests that this is also the case amongst the older generation with 71% of 55-to-75 year olds owning an app-capable handset.

We will explore the wide range of Apps currently available and test with our local audience.

3.3.a Scope and design a media and communications plan to promote healthy lifestyles

We will Identify segments of the population with higher prevalence of obesity and seek to understand the reasons why. Identify appropriate behaviour change approaches and key messages for these populations.

Over the next 5 years we will:

• Create a behaviour change communications plan that incorporates our key messages and successfully signposts people to services, initiatives and resources

• Identify appropriate channels to share key messages, signpost to services, promote events and apps

31 OFCOM, Communications Market Report United Kingdom Published 3 August 2017 ACCESSED HERE [https://www.ofcom.org.uk/__data/assets/pdf_file/0017/105074/cmr-2017-uk.pdf]

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It is proposed that the overall accountability of the Obesity Strategy is to the Health and Wellbeing Board.

Figure 7: Governance structure

Section 3: Governance