Our children and

young people

are healthy

Focussing on:

Babies born with

a low birth weight

Breastfeeding

rates, either fully

or partially at 6-8

weeks

% of reception

age children who

are overweight or

obese

March 2017

Progress report

on the Outcomes

Based Accountability

Process

Improving outcomes for young children in Jersey.

‘Our children and young people are healthy’

Focussing on:

• Babies born with a low birth weight

• Breastfeeding rates, either fully or partially at 6-8

weeks

• % reception age children who are overweight or obese

Progress report on the Outcomes Based Accountability

Process

March 2017

2

Contents

Background ................................................................................................................ 3

Turning the curve reports ........................................................................................... 7

Summary of recommendations for Steering Group .................................................. 11

Appendix 1: Turning the curve workshops: summary of discussions ....................... 14

1. Turning the curve on babies born with a low birth weight ..................................... 15

2. Turning the curve on breastfeeding rates ............................................................. 20

3. Turning the curve on obesity in young children .................................................... 23

Appendix 2: Turning the curve workshop attendees................................................. 27

Appendix 3: A rapid review of the evidence and policy context ................................ 31

Appendix 4: A map of early years service provision in Jersey .................................. 48

3

Background

In 2014, Optimus (founded by UBS) commissioned Professor Philip Wilson and Dr Louise

Marryat to examine opportunities for enhancing early childhood development. The report

uncovered a range of issues (e.g. a lack of data on children's developmental stage) that may

have a negative impact on children's early childhood experiences and later outcomes. The

report made several recommendations to help improve childhood experiences including:

- Improving current service provision (availability and quality of services);

- Improving access to services;

- Improving overall ECD capacity through better data collection systems and processes;

- Putting in place robust evaluation system for new services.

In response to the recommendations made in the above report, in late 2015 Optimus

Foundation appointed NCB as the partner of choice to support the Early Childhood

Development Programme (ECDP). The programme has five strands, including:

1. Development of an Outcomes Framework for Jersey, co-produced with stakeholders;

2. Securing the support of the States of Jersey Government for the project.

3. Implementation of evidence-based approaches to improve the quality of early years

settings and service provision (including extending the Making it REAL project1);

4. Supporting improved partnership, communication and collaboration across relevant

services

5. Dissemination of up to date knowledge of ‘what works’ to support early child

development, making it accessible to practitioners and parents.

NCB has facilitated the implementation of an Outcomes Based Accountability2 approach to

support improvements in children and young people’s outcomes. The approach, set out by

Mark Friedman in his book ‘Trying hard is not good enough’3 provides a disciplined way of

thinking to move from thought to action. Key definitions in this approach include:

1 Making it REAL sets out to improve the way practitioners work with parents; to hand over knowledge and build confidence through meaningful early literacy activities to support the early home learning environment and ultimately improve literacy and wider outcomes for young children and their families. 2 For more information on Outcomes Based Accountability (also known as Results Based Accountability) see: http://resultsaccountability.com/about/what-is-results-based-accountability/ 3 Friedman, M. (2005) Trying hard is not good enough: How to produce measurable improvements for customers and communities. PARSE Publishing.

4

Outcomes: conditions of well-being that we want to achieve for the overall population e.g.

all children, families and communities in Jersey

Indicators: measures that help quantify the achievement of these outcomes.

Turning the Curve: the planning process within OBA which helps to move from talk to

action and identify potential ‘what works’ ideas which will improve the prioritised indicators.

The ECDP is informed by the 1001 critical days manifesto4 and the work of the Jersey Early

Years taskforce. The vision is for all children and young people to grow up in a safe,

supportive Island community in which they achieve their full potential and lead happy,

healthy lives. Key outcomes are for all children and young people to:

• Be healthy;

• Be safe;

• Achieve and do;

• Grow confidently;

• Be responsible and respected; and

• Have a voice and be heard.

To support the prioritisation of these outcomes, and to select indicators on which to focus

initial work of the ECDP, an audit of available data was completed by NCB5. The audit

aimed to:

• Provide an overview of all available indicators data for children aged 0-18 in Jersey to

build a picture of children’s health and well-being

• To look more closely at indicator data for children aged 0-5 to identify where support is

most needed.

Following initial training in the Outcomes Based Accountability approach for key

stakeholders, the ECDP Steering Group met on 13th September 2016 to consider the first

outcome of focus, ‘All children in Jersey are healthy’, and agree a prioritised set of

4 The 1001 Critical Days: The importance of the conception to age two period. A cross-Party Manifesto. http://www.1001criticaldays.co.uk/sites/default/files/1001%20days_Nov15%20%2800000002%29.pdf 5 Jersey Early Childhood Development Programme. Report 1: An analysis of data on children and young people’s well-being and development. NCB, February 2017.

5

indicators. The steering group reviewed the full data report and used three criteria to

determine what indicators best informed the progress of an outcome:

• Communication power: does the indicator communicate to a broad and diverse

audience?

• Proxy power: does the indicator say something of central importance about the

outcome?

• Data power: do we have quality, reliable and consistent data on a timely basis?

Turning the curve on health indicators

Outcome: ‘All children and young people in Jersey are healthy’

Given the current data available the following indicators were chosen as the best fit6:

Prioritised indicators:

• Breastfeeding rates (either fully or partially) at 6-8 weeks

• % babies born with a low birth weight

• % reception age children who are overweight or obese

OBA encourages collaboration and engagement working towards overall outcomes. The

process for building that engagement is called “Turning the Curve”, and involves asking the

following questions:

1. What are the quality of life conditions we want for the children, adults and families

who live in our community? (outcomes)

2. What would these conditions look like if we could see or experience them?

3. How can we measure these conditions? (indicators)

4. How are we doing on the most important measures?

5. Who are the partners that have a role in doing better?

6. What might work to do better?

7. What do we propose to do? (Action plan)

6 P15, Jersey Early Childhood Development Programme. Report 1: An analysis of data on children and young people’s well-being and development. NCB, February 2017

6

A wide variety of stakeholders are invited to take part in Turning the Curve workshops to

examine each of the prioritised indicators and begin to inform what should happen to

improve that indicator. Two sets of these Turning the Curve workshops have taken place to

consider actions to move ahead on prioritised indicators (December 2016 & January 2017).

Alongside the audit of available data, NCB also completed an audit of the early years

services (conception to age 4) currently delivered in Jersey (see appendix 4), and provided

reviews of current evidence and relevant policy to inform the discussions on ‘what might

work to do better’. This additional information helps to better inform discussions at the

workshops.

This report sets out the progression on the selected health indicators, and includes:

• Turning the Curve one-page reports based on discussions at the workshops

• Recommendations for further consideration by the ECDP Steering Group.

• Full reports on detailed discussions at the Turning the Curve workshops (appendix 1)

• Full list of attendees who have been involved in the workshops (appendix 2)

• Reviews of evidence and policy to inform discussions (appendix 3)

• Service map of early years provision in Jersey (appendix 4)

7

Turning the curve reports

OUTCOME: All young children in Jersey are healthy

STORY BEHIND THE BASELINE

• Smoking during pregnancy

• Maternal health issues e.g. obesity, diabetes, mental health

• Social factors: economic downturn leading to poverty & deprivation

• Maternal age: high rate of older mums, some young mums

• High rate of IVF and therefore multiple births

• Prohibitive cost of accessing antenatal care and education

• Lack of legislation supporting access to healthcare

Suggestions for what might work:

• Improve uptake of current smoking cessation programme- e.g. opt out rather than opt-in, health needs assessment and referrals made at booking appointment, better sharing of information between healthcare professionals

• Preventative education in schools (for boys and girls)

• Engaging dads during antenatal period to educate and ensure they are equipped to support mum

• Flexible services to support working mums during pregnancy to enable them to make the most of support

Additional partners required:

• Midwives

• Wider health professionals (GPs, Paediatricians, social workers, dieticians)

• National Childbirth Trust (antenatal education providers)

• Parents

• Education & youth service reps

• Perinatal mental health/child health nurse

•

Data Development Agenda:

• Breakdown of data by maternal age

• Individual and family health history (e.g. smoking, pre-existing medical conditions, social care, prior interventions, family health trends

• Length of residency in Jersey

INDICATOR: % babies born at a low birth weight (below 2.5kg)

% babies born at a low birth weight in relation to gestational age

0

1

2

3

4

5

6

2012 2013 2014 2015

Per

cen

tage

Babies birth weight in relation to gestational age

% small for gestational age % large for gestational age

Source: Public Health Statistics Unit, States of Jersey (2017)

Source: Jersey Health Intelligence Unit (2016)

9

OUTCOME: All young children in Jersey are healthy

STORY BEHIND THE BASELINE

• Baby Friendly Initiative not currently implemented, but planned for 2017

• High Caesarean rates

• Higher maternal age in Jersey

• Current maternity legislation, high rates of working mothers

• Lack of universal antenatal education

• Cultural and generational attitudes to breastfeeding

• Lack of data sharing facilities between health professionals and inconsistency in messaging given

Suggestions for what might work:

• Implementation of the Baby Friendly Initiative (planned 2017)

• Education for healthcare practitioners (all those who have contact with an expectant mother) to ensure consistent messaging

• Roll out of a universal antenatal education programme e.g. a modified version of NSPCC Baby Steps

• Change in legislation to support longer paid maternity leave

• Focus on peer support training and provision

• Cultural/attitudinal change through public awareness campaign

• Rebranding of programmes/initiatives already in place to make more inclusive e.g. currently have breastfeeding cafes which could be renamed ‘infant feeding group’ to include support for weening etc., These should be women only (low cost)

• Education for the wider family, and in particular involving dads

Partners required:

• Wider relevant health professionals including GPs and Paediatricians,

• Education practitioners

• Parents / parents to be

• Wider family, in particular dads and grandparents

• Chamber of Commerce

• Social Security

• Social Security representative

• Education practitioners (representing all school ages as preventative role as important)

Data Development Agenda:

Information needed on drop-off point for breastfeeding and reasons behind stopping:

• Initiation rates for exclusive breastfeeding

• Breastfeeding rates at discharge and 14 weeks currently collected

• Ideally would like data at 6 months- currently pick this up retrospectively at 9 months

• How many mums gave up breastfeeding on return to work

• Reasons why mums give up breastfeeding

INDICATOR: Breastfeeding rates (either fully or partially) at 6-8 weeks

Source: Jersey Health Intelligence Unit (2016)

10

OUTCOME: All young children in Jersey are healthy

STORY BEHIND THE BASELINE

• Changes in modern living- working parents, driving rather than walking, technology, move away from compulsory PE

• Pressure on parents from media to provide treats

• The price of ‘healthy’ foods compared to ‘junk’

• Lack of skills, opportunities and facilities (in particular inadequate housing – bedsits etc.) to prepare healthy meals.

• Differences in preschool provision for hot meals- private vs state

• Family dynamics and cultural differences

• Food and nutrition strategy due shortly

Suggestions for what might work:

• Junior Parkrun

• Children’s menus in restaurants (mini portions of adult food)- Links to ‘Real food for kids’ scheme (Caring Cooks & Co-op initiative)

• Cross-departmental forum to share good practice

• Free fruit in supermarkets (Tesco already running this)

• Community mobile outreach re cooking skills, specifically targeted at minority ethnic groups and providing bilingual support to reduce inequalities (Caring Cooks** planned initiative)

Partners required:

• Nursery/primary education representative

• Jersey sports partnership

• Parent representative from target groups

• Retail Steering Group representative/ Chamber of Commerce

• Wider healthcare professionals e.g. GPs, paediatricians

• Practitioners working with Polish/Portuguese families

• Private health providers (Cleaveland Clinic, Leicester Surgery)

• Relevant Ministers

Data Development Agenda:

• Parish information on nutritional provision in pre-schools

• Data on eating behaviours of young children (e.g. fruit intake)

• Information on ethnic/cultural differences in dietary habits

• What proportion of 2 year olds are currently overweight?

• Relative food costs (e.g. Jersey vs UK)

• Physical aspects of the curriculum e.g. knowing about outdoor space

• Children’s dental health

Source: Child Health System, Public Health, Jersey (2016)

INDICATOR: % reception age children (typically age 4 or 5) who are overweight or obese

Summary of recommendations for Steering Group

1. % babies born at a low birth weight (below 2.5kg)

% babies born at a low birth weight in relation to gestational age

Suggestions for what might work:

• Improve uptake of current smoking cessation programme- e.g. opt out rather than

opt-in, health needs assessment and referrals made at booking appointment,

better sharing of information between healthcare professionals

• Preventative education in schools (for boys and girls)

• Engaging dads during antenatal period to educate and ensure they are equipped

to support mum

• Flexible services to support working mums during pregnancy to enable them to

make the most of support

Actions: A new indicator, ‘birth weight by gestational age’ has since been developed and

first data is now available. This shows that only 2% of babies born in 2015 had a low

birthweight for gestational age, suggesting less of an issue than initially considered. It is

proposed that no further work to be undertaken in relation to the low birth weight indicator,

and efforts are refocused on the other priority indicators.

2. Breastfeeding rates (either fully or partially) at 6-8 weeks

Suggestions for what might work:

• Implementation of the Baby Friendly Initiative (already planned but impact won’t be

immediate)

• Roll out of a universal antenatal education programme e.g. a modified version of

NSPCC Baby Steps

• Education for healthcare practitioners (all those who have contact with a pregnant

person) to ensure consistent messaging which is informed by service user

feedback

• Statutory support- primarily a change in legislation to support longer paid maternity

leave

• Focus on peer support training and provision

12

• Rebranding of programmes/initiatives already in place e.g. currently have

breastfeeding cafes which could be renamed ‘infant feeding group’ to include

support for weening etc., using language that is more inclusive. These should be

women only (low cost)

• Education for the wider family, and in particular involving dads

Action: Ideas of what might work to be considered by ECDP Steering Group for

discussion, priority actions agreed and action plan developed.

3. % reception age children (typically age 4 or 5) who are overweight or obese

Suggestions for what might work:

• Junior Parkrun

• Children’s menus in restaurants (mini portions of adult food)- Links to ‘Real food

for kids’ scheme (Caring Cooks & Co-op initiative)

• Cross-departmental forum to share good practice

• Free fruit in supermarkets (Tesco already running this)

• Community mobile outreach re cooking skills, specifically targeted at minority

ethnic groups and providing bilingual support to reduce inequalities (Caring

Cooks** planned initiative)

Action: Ideas of what might work to be considered by ECDP Steering Group for

discussion, priority actions agreed and action plan developed.

Consideration to be given to the forthcoming Food and Nutrition Strategy (pending) and

any potential overlap with this work.

Next Steps in the OBA process:

• Consider stakeholders who have been involved in the Turning the Curve process

to date and identify gaps where further stakeholder engagement would be

beneficial. Consider the option of one to one interviews with these identified

partners if required. Proposed stakeholders include:

- GPs

- Business/Chamber of Commerce rep

- NCT

- Parents- new or expectant

- Sport rep (e.g. Jersey Sports Partnership)

13

- Relevant Ministers (Louise Doublet, Tracey Vallois suggested)

- Perinatal mental health nurse (Liz Auld suggested)

• Review of existing evidence on suggestions for what might work, to inform

discussion by ECD Programme Steering Group. Decisions to be made on actions

to improve health outcomes for young children in Jersey.

• Development and implementation of action plans.

14

Appendix 1: Turning the curve workshops: summary of discussions

1. Turning the curve on babies born with a low birth weight

Population: All young children in Jersey…

Outcome: …are healthy

Indicator: % of babies born with a low birth weight (below 2.5kg)

Baseline data:

Midwives advised of a new measurement being collected: low birth weight for gestational

age (below the 10th percentile as per the WHO Child Growth Standards). First data available

Jan 2017. Without available data (Dec 2016), midwives developed the working baseline

below based on collective knowledge:

Direction of curve to turn

Direction of curve to turn

16

The story behind the baseline:

• Smoking during pregnancy is thought to be by far the biggest factor impacting

low birth weight of baby

• Other maternal health factors or conditions, such as obesity, high blood pressure,

diabetes, or anorexia, mental health issues, depression or anxiety, substance misuse

• Social factors, including the economic downturn, poverty and deprivation

• Maternal age: in particular, the increase in the number of older mums (35+) in

Jersey. Younger mums are also more likely to have a low birth weight baby,

although this isn’t as big an issue in Jersey.

• The higher rate of IVF has increased the rate of multiple births, which in turn are

more likely to be low birth weight babies.

• The cost of accessing antenatal care is currently prohibitive and therefore we are

missing a vital opportunity to educate pregnant mums and their partners.

• The lack of legislation supporting access to healthcare is seen as a barrier to

accessing appropriate support and services.

• Several services already exist which were felt to contribute positively to this indicator,

including:

- Baby Steps (NSPCC)

- MECSH

- Ante-natal care / midwifery

- Bumps and Babies (NCT)

- Preventative education in schools

- Help to Quit – referrals to service

- Brighter Futures

- Pathways (FNHC)

Data Development Agenda: To further inform the story behind the baseline, attendees felt

it would be useful to look at data broken down at the following levels:

• Gestational age

• Maternal age

• Pre-existing medical conditions of mother

• Prior interventions received

• Smoking history

• Family health and social care history

• Length of residency in Jersey - this may impact on entitlement to claim benefits.

17

• How does quality of care and subsequent outcomes for Jersey compare to other

areas e.g. UK and further.

Additional partners to be involved:

• Midwives are key- ongoing engagement needed with pregnant mums & partners

• Wider health professionals, including obstetricians, GPs, paediatricians, dieticians,

smoking cessation programme practitioners, social workers

• Charity/voluntary sector representatives e.g. Caring Cooks

• Statisticians

• Schools/education/youth service representatives

• Parents to be

• EAL representatives

• National Childbirth Trust

• Perinatal Nurse/Child mental Health Nurse (Liz Auld suggested)

Suggestions for what might work prioritised?

1. Improve uptake of smoking cessation programme currently in place – ideas include

changing how it is offered, i.e. referring all mothers identified as smoking at booking

appointment, rather than self-referral. Could also consider opt-out method rather

than ‘opt in’. (low cost)

2. Preventative education in schools. In particular, preventative education programme

on healthy lifestyle choices, and the impact of poor health choices during pregnancy

for babies, should be standardised across schools and delivered to both boys and

girls, aged 14-16. Although currently covered in the curriculum, it isn’t examined

therefore not given the focus that it should be, and lacks consistency from school to

school.

3. Completion of a health needs assessment at the booking stage to identify ‘at risk’

mothers earlier. Additionally, timely sharing of information from midwife to health

visitor when an ‘at risk’ pregnant mother is identified at booking appointment,

ensuring that early support can be offered within window of opportunity for change.

4. Engaging dads throughout the antenatal period to ensure they are informed and

educated & are equipped to support mums, particularly on health and lifestyle

factors impacting on birth weight. Recent change in legislation means fathers now

have parental responsibility and their wider involvement must be supported.

18

5. Services that are available to support working mums during pregnancy should be

flexible to maximise accessibility, e.g. appointments offered in the evening rather

than during the working day. Flexibility of employers also needed to facilitate

attendance at day time appointments.

6. Provision of vouchers for fresh fruit and vegetables for pregnant mums.

Actions taken and recommendations for consideration by the Steering Group

The audit of data completed by NCB (Dec 2016) alongside the discussions at the TTC

workshops have highlighted the need for good quality data to demonstrate effectively the

issues facing young children. Discussions around birthweight brought up the concern that

babies born early would naturally weigh less; it was felt that weight relative to gestational

age would be a more representative statistic. The Department of Health have now

confirmed that this data is available and will be reported moving forward.

New indicator ‘Baby birth weight in relation to gestational age’

The following information has been provided by the Department of Health, States of Jersey:

A baby is considered to be of healthy birthweight (a weight appropriate for its gestational

age) when it lies between the 5th and 95th centile for weight at its gestational age. Babies

whose birthweight is above the 95th centile are considered ‘large for gestational age’,

while those below the 5th centile are considered ‘small for gestational age’.

Gestational age is a way of expressing the age or development of a baby. It is typically

based on an antenatal ultrasound scan; however, it may also be estimated from the number

of weeks since the mother's last normal menstrual period.

The data used in this indicator are produced by comparing the birthweights and gestations of

births of Jersey resident babies with a set of standard tables based on

UK-WHO Child Growth Standards (UK 1990).

19

Source: Public Health Statistics Unit, States of Jersey

Coverage of indicator: 92% (2012) – 97% (2015)

The first data available on this new indicator shows only 2% of babies born in 2015 had a

low birthweight for gestational age, suggesting less of an issue than first thought.

This new data does however show that 5% of babies are born overweight for gestational

age; we suggest that this is the more pressing issue, and should be considered in

conjunction with the third indicator ‘children who are overweight or obese at reception age’.

The way ahead:

No further work to be undertaken in relation to babies with a low birth weight for gestational

age, however the data from this new indicator will contribute to the story behind the baseline

for indicator 3: ‘reception age children who are overweight or obese’.

0

1

2

3

4

5

6

2012 2013 2014 2015

Per

cen

tage

Babies birth weight in relation to gestational age

% small for gestational age % large for gestational age

20

2. Turning the curve on breastfeeding rates

Population: All young children in Jersey…

Outcome: …are healthy

Indicator: Breastfeeding rates (either fully or partially) at 6-8 weeks

Baseline:

Source: Jersey Health Intelligence Unit, 2016

The story behind the baseline:

• Baby Friendly Initiative not currently implemented however this is planned (2017) and

should increase breastfeeding rates longer term (although not expected to produce

an immediate change due to implementation timeframe).

• High caesarean rates (30%) and higher maternal age (35+) in Jersey- both have

been identified in evidence as having a negative impact on breastfeeding rates.

• Current maternity legislation is not supportive of breastfeeding, in particular the return

to work policy and current short paid maternity leave. A review of legislation is

currently ongoing however no update has yet been provided.

Direction of curve to turn

21

• Linked to above, Jersey currently has the highest rates of working mothers in the

world.

• Lack of provision of universal antenatal programme across Jersey, due to staff

capacity issues; parents are not receiving the education that they need which may

impact on decision to initiate/continue breastfeeding.

• Society and attitudes to breastfeeding create a negative and unsupportive culture

which may act as a deterrent to breastfeeding. Wider family involvement and support

needed e.g. older generations, dads etc. There are also changing family structures

and lack of close family nearby to support, particularly a concern for immigrant

families.

• There appears to be inconsistent information on breastfeeding provided by different

healthcare professionals due to varying knowledge base.

• Data can’t be shared between midwives and health visitors which is an obstacle in

providing the bigger picture for individual mums to be.

Data Development Agenda:

• Need to be able to identify drop-off point for breastfeeding so need to collect/collate

data at additional points in time.

o Initiation rates for exclusive breastfeeding

o Breastfeeding rates at discharge and 14 weeks currently collected

o Ideally would like data at 6 months- this is currently picked up retrospectively

at 9 months

• How many mums gave up breastfeeding on return to work or cite this as the reason

they gave up?

• Information to be included from other sources such as breast feeding working group

(chaired by Michelle Cummings), and Chamber for Commerce (alongside States of

Jersey, this is the biggest employer)

• Length of residency & parish of residency

Additional partners to be involved

• Wider relevant health professionals including GPs and Paediatricians,

• Parents / parents to be

• Wider family, in particular dads and grandparents

• Chamber of Commerce/ business representatives

22

• Social Security representative

• Education practitioners (representing all school ages as preventative role as

important)

Suggestions for what might work prioritised?

1. Implementation of the Baby Friendly Initiative (already planned but impact won’t be

immediate)

2. Roll out of a universal antenatal education programme. Consideration should be

given to customising the NSPCC Baby Steps programme to become a universal

programme for all- this programme begins earlier in pregnancy than traditional ante-

natal education, therefore provides opportunity to get information to mothers at risk of

having a low birth weight baby. Could also consider other dissemination methods for

educational information to make it more accessible e.g. leaflets at the GP, pharmacy

etc.

3. Education for healthcare practitioners (all those who have contact with a pregnant

person) to ensure consistent messaging which is informed by service user feedback

4. Statutory support- primarily a change in legislation to support longer paid maternity

leave

5. Focus on peer support training and provision

6. Rebranding of programmes/initiatives already in place e.g. currently have

breastfeeding cafes which could be renamed ‘infant feeding group’ to include support

for weening etc., using language that is more inclusive. These should be women only

(low cost)

7. Education for the wider family, and in particular involving dads

The way ahead

Ideas for what might work to be considered by ECDP Steering Group for discussion, priority

actions agreed and action plan developed.

23

3. Turning the curve on obesity in young children

Population: All young children in Jersey…

Outcome: …are healthy

Indicator: % reception age children who are overweight or obese

Baseline:

Source: Child Health System, Public Health Jersey (2016)

The story behind the baseline:

• Inconsistency in education and information provided to parents around healthy

choices, including at the antenatal stage and in the early years. Lack of school

education too, e.g. home economics

• Changes in modern living- working parents, density of road and therefore

convenience of driving rather than walking, general lack of physical activity

opportunities, technology, compulsory PE

Direction of curve to turn

24

• Pressure on parents from media- the need to provide treats and price of ‘healthy’

foods compared to ‘junk’. Demands from children.

• Lack of skills, opportunities and facilities (in particular inadequate housing – bedsits

etc.) to prepare healthy meals for children. Particularly a problem for low income

families.

• Differences in preschool provision for hot meals- private day-care likely to provide hot

healthy meal while state preschools are less so.

• Cultural challenges, in particular availability of healthy eating information in

appropriate translations to ensure accessible for Polish and Portuguese people

• Changing family dynamics- cooking skills and knowledge previously handed down

however many families no longer have extended families living nearby to provide this

support.

• Nurseries currently provided with nutritional guidance, however no knowledge in the

system about what is done with this information.

• Lots of existing programmes in place, e.g. mile a day happens in some schools,

some nurseries have their own chefs, parent cooking classes are available, however

again consistency is an issue

• Work-life balance- Parents are ‘time poor’ which may impact their ability to prepare

healthy meals

• Convenience and processed foods perceived to be cheaper and more accessible

than healthy ones

• Draft food and nutrition strategy is due to be launched early 2017, so by 2020

positive changes in trend should begin to be evident. Healthy Start vouchers are

beginning in 2018.

• Impact of potential sugar tax

• Healthy School Programme

• Improving the Public Realms Strategy- which will support improvement in public play

and outdoor spaces

• 4 steps to a fitter future campaign

Data development Agenda

Further information to inform the story behind the baseline include:

• Information on nutritional provision in pre-schools broken down by parish

• Data on eating behaviours of young children (e.g. data on fruit and veg intake - this is

currently collected for older age groups, Year 6 etc.)

25

• Information on ethnic/cultural differences in dietary habits

• What proportion of 2 year olds are currently overweight? (based on health visitor

growth measurements), broken down by postcode/school

• Relative food costs (e.g. Jersey vs UK)

• Physical aspects included the curriculum e.g. knowing about outdoor space

• Children’s dental health

Additional partners to be involved:

• Nursery/primary education representative

• Jersey sports partnership

• Parent representative from target groups (ID’d via data)

• Retail Steering Group representative (Chamber of Commerce/Department of

Economic Development)

• Wider health practitioners e.g. GPs, paediatricians, dentists

• Practitioners working with Polish/Portuguese families

• Private health providers (Cleaveland Clinic, Leicester Surgery)

• Ministers (in particular Louise Doublet, Tracey Vallois)

Suggestions for what might work prioritised*:

1. Invest in ‘Real food for Kids’ programme, a partnership developed by Caring Cooks

in conjunction with Co-op and working with farms, shops, restaurants and

incorporating a half price scheme on adult food in restaurants for children. (Melissa

Nobrega key contact).

2. Children’s menus in restaurants as small portions of healthier adult choices rather

than burgers/sausages/chips etc.

3. Community mobile outreach on cooking skills, specifically targeted at minority ethnic

groups and providing bilingual support to reduce inequalities (Caring Cooks**

planned initiative – contact as above).

4. Cross-departmental/ cross-sectoral steering group with an interest in children’s

nutrition (led by education) to be formed to provide a forum for sharing good practice

and ensuring consistency of messaging throughout the life course.

5. Implementing Junior Parkrun (for young children)- Parkrun already in place

6. Free fruit on entering supermarket (this is already in place in Tesco)

7. Vouchers for fruit and vegetables

26

*Draft Food & Nutrition Strategy is due to be launched in early 2017 by department of

Health, this could provide a policy vehicle by which to move forward with these

actions and inform content of existing broad actions; important to make links. (Martin

Knight key contact)

**Steering Group noted that the focus must be on 0-5 year olds- Caring Cooks focus

is school age upwards.

The way ahead:

Ideas for what might work to be further distilled and presented to ECDP Steering Group for

discussion, agreement of priority actions and development of an action plan.

27

Appendix 2: Turning the curve workshop attendees

28

TTC Attendees: Monday 5th December 2016

Indicator

Name Organisation Low Birth

Weight

Breastfeeding

Rates

Obesity

Melissa

Nobrega

Caring Cooks of Jersey x

Martin Knight Head of Health

Improvement, States of

Jersey

x

Fiona Vacher JCCT x

Julie Mycroft Head of Midwifery x x x

Kerrie Touzel Little Oaks Nursery x

Jessica May Public Health x x x

Julie

Luscombe

Public Health x

Marie Raleigh Family Nursing & Home

Care

x x

Racheal

Stewart

Early Help Coordinator x x x

Kathy Palmer Community Midwifery

Manager

x x x

Sarah Wright Family Nursing & Home

Care

x x x

Jane Bravery Early Years Inclusion Team x x x

Mandy Le

Tensorer

Child Accident Prevention x x x

Kirsten Park Brighter Futures x

Urszela Sliwka Research Student x x x

Rhonda Hales Ante-natal Clinic Manager x x

Penny Byrne JCCT Trustee x x

Michelle

Cummings

Family Nursing & Home

Care

x

12 13 12

29

TTC attendees: Monday 23rd January 2017

Indicator

Name Organisation Low Birth

Weight

Breastfeeding

Rates

Obesity

Monica

Fernandes Westmount Day Nursery

x

Urszula Sliwka Health/Research Student x x

Jill Birbeck Head of Health Intelligence x x

Anna Hamon

Policy Officer, Social

Policy

x x x

Gill Speed Manager, Pathways x x x

Lisa Nash Midwife x x

Nicky Hay Nursery Teacher x x x

Julie

McCallister

Early Years Advisory

Teacher

x

Emma Eden Nursery Manager x x

Cathy Hamer Chair, EYCP x

6 6 8

The following gaps in terms of contributing stakeholders were identified during TTC

workshops:

Low Birth Weight Breastfeeding Rates Obesity

• Midwives are key-

ongoing engagement

needed with pregnant

mums & partners

• Wider health

professionals, including

obstetricians, GPs,

Paediatricians,

dieticians, smoking

cessation programme

• Wider relevant health

professionals including

GPs and Paediatricians,

• Education practitioners

• Parents / parents to be

• Wider family, in

particular dads and

grandparents

• Chamber of Commerce

• Social Security

representative

• Nursery/primary

education representative

• Jersey sports

partnership

• Parent representative

from target groups (ID’d

via data)

• Retail Steering Group

representative (Chamber

of

Commerce/Department

30

practitioners, social

workers

• Charity/voluntary sector

representatives e.g.

Caring Cooks

• Statisticians

• Schools/education/youth

service representatives

• Parents to be

• EAL Service

• Representative from

NCT

• Perinatal Nurse/Mental

Health Nurse – (e.g. Liz

Auld)

• Education practitioners

(representing all school

ages as preventative

role as important)

of Economic

Development)

• Diverse representation

for cultural input

• Wider health

practitioners e.g. GPs,

paediatricians

• Practitioners working

with Polish/Portuguese

families

• Private health providers

(Cleaveland Clinic,

Leicester Surgery)

• Ministers (Louise

Doublet, Tracey Vallois)

31

Appendix 3: A rapid review of the evidence and policy context

to inform turning the curve on low birth weight, breastfeeding

rates and childhood obesity

32

Introduction

To inform the ‘Turning the Curve’ discussions, NCB has compiled a brief overview of local

policies, services and highlights from contemporary published evidence on influential factors

and what might work to:

1 Reduce the number of babies born with a low birth weight

2 Increase breastfeeding rates (either full or partially) at 6-8 weeks

3 Reduce the % of reception age children who are overweight or obese

Which Jersey strategy/policy documents are relevant to these issues?

Children and young people specific documents

Children and Young People: A strategic framework for Jersey7 (Nov 2011): Which sets

out what is to be achieved for children and young people under six outcomes (be healthy, be

safe, achieve and do, grow confidently, be responsible and respected, have a voice and be

heard) and aims to facilitate better collective decision making about the services and

facilities needed. The document makes specific reference to concerns about pre-term births,

low birth weights, breast-feeding rates and obesity in young children and alludes to several

activities that were being developed to bring about improvements in these areas.

1001 Critical Days manifesto (January 2015): lays the foundation to give every child in

Jersey the Best start in life. Supported by the 1001 Days and Early Years Taskforce. 1001

Days commits to the wider implementation of the UNICEF Baby Friendly Initiative.

Wider policies/strategies

States of Jersey, Strategic Plan 2015-20188: which lists improving health and well-being

as one of the Council’s priorities and specifically refers to the development of a new ‘Health

7 https://www.gov.je/SiteCollectionDocuments/Government%20and%20administration/R%20StrategicFrameworkFullVersion%2020111121%20CPG%20v1.pdf 8 http://www.gov.je/SiteCollectionDocuments/Government%20and%20administration/R%20States%20of%20Jersey%20Strategic%20Plan%202015-18%2020150430%20VP.pdf

33

and Wellbeing Framework’ including a strategy on food and nutrition and a new strategy for

Children’s Services.

Health and Social Services: A new way forward (20129): outlines proposed changes to

health and social care for the next 10 years in Jersey and covers three planning phases

2013 – 15, 2016 – 18 and 2019 – 2021. In the first phase, early intervention services for

children aged 0-5 was identified as a priority area and included improving skills & knowledge

about parenting, with particular focus on the antenatal period, increased community

midwifery to offer choice of service and location for antenatal care and specific early

intervention services for families with additional needs during the antenatal period.

Mental health strategy for Jersey 2016-202010: includes a commitment to prevention

services for ante- and post-natal care.

Sustainable Primary Care Strategy for Jersey 2015-202011: this strategy sets out the

future plans for the delivery of primary care services which include Family Nursing & Home

Care and the childhood immunisation programme.

Sports Strategy: In 2013, the Fit for Future Strategy was launched covering the period

2014-2018 and set out to promote sports and physical fitness activities. Its aims to promote

uptake of sports activities from a very early age both within school and outside of school. As

well as providing general support to schools and to those who work with children and young

people, the strategy contained specific commitments to invest in particular sports such as

swimming.12

9 http://www.statesassembly.gov.je/AssemblyPropositions/2012/P.082-2012.pdf 10 https://www.gov.je/SiteCollectionDocuments/Health%20and%20wellbeing/R%20Mental%20Health%20Strategy%2020151105%20LJ.pdf 11 https://www.gov.je/SiteCollectionDocuments/Health%20and%20wellbeing/R%20Sustainable%20Primary%20Care%20Strategy%2020151204%20LJ.pdf 12https://www.gov.je/SiteCollectionDocuments/Government%20and%20administration/C%20Sports%20Strategy%20%20Phase%202%2020131014%20TM.pdf

34

1. Increasing breastfeeding rates (either full or partially) at 6-8 weeks

What relevant service provision currently exists in Jersey?

Local services which will have a role to play in increasing breastfeeding rates include:

• Breastfeeding Buddies

• Midwives

• NCT Antenatal courses

• Community Nursery Nurse

• GP

• Well Baby & Child Health Clinics

• Health Visiting

• MESCH/MESCH Playgroup

• Baby Steps

• Little Gems

What does the evidence tell us about influential factors and what might work?

As breastfeeding has been shown to have a positive impact across a wide range of infant

and parent outcomes, including physical health, social and emotional development and

attachment, interventions to encourage and increase breastfeeding rates are widely

evidenced worldwide.

Influencing factors:

The following key factors have been identified as having a potential impact on breastfeeding:

• Father and wider family support

• Post Natal Depression

• Low birth weight

• Age of mother

• Socio-economic background of mother

• Employer support

• Deprivation

• Caesarean

35

• Ethnic background

• Restrictions on marketing strategies for formula

Some of the key reasons identified reasons for stopping breastfeeding include:

• Physical difficulties (for mother or infant, e.g. mastitis, tongue-tie (evidence still

uncertain as to extent that this is a problem)

• Concerns about the infant’s growth, i.e. they aren’t getting enough nutrition

• Negative public perceptions of breastfeeding, making it more difficult to continue

Main factors influencing a woman’s choice to breastfeed13:

• Bonding/attachment and the positive impact that breastfeeding has.

• Body image, insecurity and dislike of the physical act of breastfeeding- mostly a

negative impact

• Self-esteem/confidence- new mothers not breastfeeding often felt guilt that it was

part of their role as a ‘good mother’ and they were failing.

• Female role models: exposure to breastfeeding mothers throughout pregnancy has a

positive impact on their own decision to breastfeed. ‘Horror stories’ of bad

experiences can have a negative impact. Support from those immediately

surrounding the new mother (including partner and close family). Peer support

networks are also important.

• Lifestyle: including work or educational commitments and how breastfeeding can be

fitted in. Also, perceived impact on social life, including lack of facilities for

breastfeeding in public which limits the options for some breastfeeding mums.

• Social attitudes to breastfeeding in public.

• Knowledge and source of education: information from health professionals can have

both positive and negative impact. Some new mums felt professionals could be

pushy and judgemental, with information given out biased towards breastfeeding.

The ecological model is important here, as these factors don’t all work in isolation, rather it is

the combination of several which will impact breastfeeding.

13 C.L. Roll, F. Cheater. A rapid review of factors affecting a new mother’s attitude to breastfeeding. International Journal of Nursing Studies 60 (2016) 145–155

36

What works to support breastfeeding?

The WHO & UNICEF Baby Friendly Initiative14 (which Jersey signed up to as part of the

1001 critical days manifesto) is an accreditation scheme developed in 1994 and aiming to

educate and equip practitioners to promote and support breastfeeding. The approach is

evidence based and identifies the following10 steps to successful breastfeeding:

• Have a written breastfeeding policy that is routinely communicated to all healthcare

staff

• Train all healthcare staff in skills necessary to implement this policy

• Inform all pregnant women about the benefits and management of breast feeding

• Help mothers initiate breast feeding soon after childbirth

• Show mothers how to breast feed and maintain lactation, even if they should be

separated from their infants

• Give new-born infants no food or drink other than breast milk, unless medically

indicated

• Practice rooming in—allow mothers and infants to remain together 24 h a day

• Encourage breast feeding on demand

• Give no artificial teats or pacifiers (dummies or soothers) to breastfeeding infants

• Foster the establishment of breastfeeding support groups and refer mothers to them

on discharge from the hospital or clinic

Various reviews of the impact of the BFI15 have been carried out and show a range of

positive impacts, including the increased initiation of and continuation of breastfeeding.

Interventions and approaches to support breastfeeding are generally targeted at the

following key areas:

• Antenatal education

• Peer support:

• Education and support for the partner and wider family

• Midwives role in supporting breastfeeding

14 https://www.unicef.org.uk/babyfriendly/what-is-baby-friendly/ 15 Being baby friendly: evidence-based Breastfeeding support J Cleminson, S Oddie, M J Renfrew and W McGuire (2014) Archives of Disease in Childhood. Fetal and Neonatal Edition Volume: 100 Issue 2 (2015)

37

• Maternity leave and employer support

Antenatal education

In the period building up to the birth, antenatal education provides an opportunity to improve

knowledge and understanding of both parents on the benefits of breastfeeding. Education

has been shown to increase openness to breastfeeding, however alone it doesn’t

necessarily increase uptake. Antenatal education must also focus on develop a mother’s

confidence and self-esteem, which has been shown to increase likelihood of initiation of

breastfeeding16. Discussions on antenatal education include:

• Timing of education: antenatal education combined with practical support

immediately after birth is most effective.

• Natural process vs a skill to be learned: a combination approach is considered the

best approach to be taken in antenatal education. This removes the burden of

‘failure’ from women who have difficulty in initiating breastfeeding, while recognising

the mother’s initiative and experience. 17

• First time mothers were shown to particularly benefit from antenatal education on

breastfeeding, however practical guidance must be combined with knowledge on the

benefits of breastfeeding to the baby, and a strengths based model is recommended

to build self-confidence and self-esteem in the mother.

Peer support18

• A Cochrane review19 of 56,000 mother-infant pairs globally showed that those

receiving additional peer of professional support were more likely to breast feed

(exclusively or not) for a longer duration.

• Peer support has been shown to have a beneficial impact on breastfeeding initiation

and continuation, particularly when provided both pre and post-natally, and when

combined with a wider primary care package.

16 Avery A., Zimmermann K., Underwood P.W. & Magnus J.H. (2009) Confident commitment is a key factor for sustained breastfeeding. Birth 36 (2), 141–148 17 Locke, A. (2009) Natural versus taught: competing discourses in antenatal breastfeeding workshops. Journal of Health Psychology, 2016, vol 14 (3), pp 435-446 18 Ingram, J. (2013) A mixed methods evaluation of peer support in Bristol, UK: mothers’, midwives’ and peer supporters’ views and the effects on breastfeeding. BMC Pregnancy and Childbirth (2013) vol 13, p192 19 Renfrew MJ, McCormick FM, Wade A, et al. Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database Systematic Review 2012;(5):CD001141

38

• Universal antenatal peer support doesn’t necessarily increase breastfeeding initiation

rates alone; however targeted peer support has been shown to be beneficial for

some. Peer support has been shown to be particularly beneficial in areas of

deprivation or more rural areas.

• Peer support has been found to increase self-confidence and self-esteem, improve

knowledge and change attitudes to breastfeeding, which may in turn support

continued breastfeeding.

Education and support for the wider family

Wider support for new mothers has a significant impact on their likelihood of sustained

breastfeeding. While to a lesser extent than previous generations, new mothers still gain

much of their knowledge on breastfeeding from their own mothers and close female

relatives. Education and support must therefore focus on these key influences in a new

mother’s life. Partners are also critical, with mothers more likely to initiate and sustain

breastfeeding if they have a supportive partner. One study20 on dad’s thoughts on

breastfeeding showed that:

• Fathers were generally positive about their partners breastfeeding and had some

knowledge of the benefits

• Most fathers felt it was the mother’s choice as to whether she breastfed or not.

• Fathers would like to receive more information, directed specifically at them, showing

how they can practically support their partner in breastfeeding.

• They want to know more about the health benefits for the baby

• Fathers feel excluded by healthcare professionals during the breastfeeding education

and initiation process and must be recognised as a key partner in the process.

Midwives role in supporting breastfeeding

A systematic review21 of midwives’ experience of supporting breastfeeding mums identified

the following key issues:

20 Brown, A. & Davies, R. (2014) Fathers’ experiences of supporting breastfeeding: challenges for breastfeeding promotion and education. Maternal and Child Nutrition (2014), 10, pp. 510–526 21 Swerts, M., Westhof, E., Bogaerts, A., Lemiengre, J. Supporting breast-feeding women from the perspective of the midwife: A systematic review of the literature. Midwifery, 37 (2016), pp32-40

39

Midwifery care is considered either:

• Breast-centred, where the technical process of delivering food to the baby is the

central goal, and the midwife is a ‘technical expert’ and the woman a novice who

needs taught what to do. Often very hands on and impersonal, the woman is treated

as a ‘milk-producing machine’ and language used is often patronising e.g. sweetie,

ladies, girls.

• Person centred, where the focus is on the attachment relationship and the role that

breastfeeding can play- here, the midwife is seen as a ‘skilled companion’. The

woman is recognised as having the ability to breastfeed autonomously and the

midwife is a companion who supports as and when needed.

Barriers to providing effective support include:

• Time restraints

• Staffing capacity in hospitals, leading to high caseloads

• Frustrations at conflicting advice from other health professionals e.g. paediatricians.

GPs

• Personal experience of the midwife of breastfeeding may influence their own

approach- some without children were seen as not fully understanding the

complexities.

• Midwives have been seen to ignore hospital or policy guidelines and give baby a

bottle when the mother has intended to breastfeed exclusively- this may be down to

capacity issues.

Factors contributing to more effective support by midwives include:

• Commitment to evidence based practice and guidelines, e.g. WHO

• Job satisfaction.

Maternity leave and employer support

A sufficient period of maternity leave is essential to enable mothers to establish and continue

breastfeeding their babies. Indeed, evidence suggests that mothers who intend to return to

work full time are less likely to initiate breastfeeding22. Jersey currently has the highest

population of working mothers in the world. Statutory maternity leave in Jersey is currently

22 https://www.cdc.gov/breastfeeding/pdf/BF_guide_2.pdf

40

up to 18 weeks, however the 1001 Days taskforce recognises the need to increase this to 26

weeks (in line with rest of UK), and preferably 52 weeks to give mothers the opportunity to

sustain breastfeeding longer term. Given the current low maternity leave in Jersey, employer

support for breastfeeding is particularly important.

Employer strategies recommended by the NHS23 include:

• Support for flexible working hours to be arranged around breastfeeding. Mother may

arrange for day care facilities near to the workplace so that they can pop out to

breastfeed on breaks.

• Private, comfortable provision in the workplace to allow for expressing of milk during

working hours

• Storage provision in the workplace for expressed milk

The ACAS24 (Advisory, Conciliation and Arbitration Service) recommends the following

similar steps for employers:

• Appropriate policy should be in place and made accessible to ensure new mothers

wishing to breastfeed are aware of provision in place, as well as the procedures for

accessing.

• Provision of appropriate facilities, including a private space to express milk, and

fridge and storage facilities

• Consideration of requests for flexible working hours and/or additional breaks to

facilitate breastfeeding.

Fathers’ experiences of supporting breastfeeding:

challenges for breastfeeding promotion and education

23 https://www.nhs.uk/Planners/breastfeeding/Documents/breastfeedingandwork[1].pdf 24 http://www.acas.org.uk/media/pdf/j/k/Acas_guide_on_accommodating_breastfeeding_in_the_workplace_(JANUARY2014).pdf

41

2. Reducing the number of babies born with a low birth weight

What relevant service provision currently exists in Jersey?

Local services which may contribute to the reduction of babies born with a low birth weight

include:

• Midwives

• NCT Antenatal courses

• Bumps & Babies

• GP

• Community Nursery Nurse

• MESCH

• Little Gems

• Baby Steps

What does the evidence tell us about influential factors and what might work?

Influential factors:

It is important to note that babies born with a low birth weight may be premature or carried to

full term. Factors increasing the risk of a baby being born with a low birth weight (either full

term or prematurely) include:

Socio-demographic factors, such as:

• Maternal age (younger and older mothers have an increased risk of a baby born with

a low birth weight)

• Environmental factors such as deprivation

• Ethnicity (members of minority ethnic groups more likely to have a low birth weight

baby)

• Marital Status (single mothers are more likely to have a low birth weight baby; this

may be connected to age of mother)

A range of maternal illnesses and conditions can impact on birth weight, including:

• Chronic hypertension

• Gestational diabetes

• Mother’s own weight during pregnancy

42

• Perinatal depression

• Anorexia during pregnancy

Lifestyle choices, such as:

• Drug and/or alcohol use (foetal alcohol syndrome

• Smoking during pregnancy- there is a strong evidence base to support the impact of

smoking on birth weight, and priority interventions centre on smoking reduction.

What might work to reduce the likelihood of a low birth weight baby?

Interventions and approaches to prevent low birth weight babies are generally targeted at

the following key areas:

• Education & awareness raising of the impact that lifestyle choices can have on birth

weight

• Smoking cessation programmes during pregnancy

• Drug/alcohol cessation programmes

• Health monitoring and interventions during the antenatal period

Common interventions are either aimed at reducing risk of preterm births, or reducing risk of

low birth weight baby carried to full term. Approaches include:

Education and awareness raising:

• Antenatal education: this has a particular role to play in helping expectant parents to

understand the impact of drug/alcohol use and smoking on the birth weight, and

subsequent life outcomes, for babies. Universal antenatal education is therefore

critical to ensure all parents receive the same information and support.

• Wider public awareness raising on the impact of substance misuse, including early

education strategies such as inclusion on school curriculum.

43

Smoking or drug/alcohol use cessation programmes:

• Timing is critical25: mothers who stop smoking before the third month of pregnancy

have been shown to have babies on average the same weight as non-smokers.

Those who stop smoking in the fourth month or onwards are at an increased risk of

delivering a low birth weight baby.

Screening programmes for maternal health conditions:

• A Healthy Start Programme in America26, which screens pregnant women for

depression and links them with appropriate services has been shown to reduce the

likelihood of the baby being born preterm (and therefore low birth weight).

• Medical interventions, such as screening for infections during pregnancy. Evidence

shows that these are not generally effective at a population level, rather are more

effective when targeted at those identified at increased risk.

• Preconception care for those at increased risk of medical conditions.

25 Yan, J. & Groothuis, P.A. (2015) Timing of Prenatal Smoking Cessation or Reduction and Infant Birth Weight: Evidence from the United Kingdom Millennium Cohort Study. Maternal Child Health Journal, 2015, vol 19, pp 447-458 26 Smith, M.V. et al (2011) Perinatal Depression and Birth Outcomes in a Healthy Start Project. Maternal Child Health Journal, 2011, vol 15, pp 401-409

44

3. Reducing the % of reception age children who are overweight or obese

What relevant service provision currently exists in Jersey?

Local relevant service provision includes:

• Breastfeeding Buddies

• Midwives

• NCT Antenatal courses

• Community Nursery Nurse

• Well Baby & Child Health Clinics

• Health Visiting

• GP

• MESCH

• Weaning Support Programme

• Physibods

• Activity Clubs/Day care facilities

• Caring Cooks Meal Service

What does the evidence tell us about influencing factors and what might work?

Influencing factors:

Many factors — usually working in combination — increase a child's risk of becoming

overweight or obese27 including:

• Diet. Regularly eating high-calorie foods, such as fast foods, baked goods and vending

machine snacks, can easily cause a child to gain weight. Sweets and desserts also can

cause weight gain, and more and more evidence points to sugary drinks, including fruit

juices, as culprits in obesity in some people.

• Lack of exercise. Children who don't exercise much are more likely to gain weight

because they don't burn as many calories. Too much time spent in sedentary activities,

such as watching television or playing video games, also contributes to the problem.

27 http://www.mayoclinic.org/diseases-conditions/childhood-obesity/symptoms-causes/dxc-20268891

45

• Family factors. If a child comes from a family of overweight people, they may be more

likely to put on weight. This is especially true in an environment where high-calorie foods

are always available and physical activity isn't encouraged.

• Psychological factors. Personal, parental and family stress can increase a child's risk of

obesity. Some children overeat to cope with problems or to deal with emotions, such as

stress, or to fight boredom. Their parents may have similar tendencies.

• Socioeconomic factors. People in some communities have limited resources and limited

access to supermarkets. As a result, they may opt for convenience foods that are

unhealthy. In addition, people who live in more deprived communities might not have

access to a safe place to exercise.

Looking specifically at very young children (aged 0-3), a study undertaken in the UK with a

large sample size of over 8,000 children found that there were eight key risk factors that

contributed to obesity including, amongst others: whether both parents were obese; very

early development of high body mass index; more than eight hours spent watching television

per week at age 3 years; weight gain in first year; high birth weight, and short (< 10.5 hours)

sleep duration at age 3 years.28

What might work to reduce levels of childhood obesity?

• Policy initiatives may help to support reductions in levels of childhood obesity29. Key

areas that Government could focus action include:

o Regulating the marketing of unhealthy foods and beverages to children

o Better nutrition labelling

o Imposition of Food taxes (to reduce consumption of unhealthy food) and

introduction of subsidies to promote consumption of healthy options

o Introduction of fruit and vegetable initiatives

o Promoting the development of physical activity policies

o Implementation of social marketing campaigns

28 http://www.bmj.com/content/330/7504/1357 29 http://www.who.int/dietphysicalactivity/childhood/WHO_new_childhoodobesity_PREVENTION_27nov_HR_PRINT_OK.pdf

46

• Programmes/initiatives implemented in specific settings (e.g. at school)30. The following

summarise a large-scale synthesis study in relation to a range of interventions to prevent

obesity:

o School based interventions: The strength of evidence is moderate that school-

based diet or physical activity interventions prevent obesity or overweight in

children. The strength of evidence is low that school-based combination diet and

physical activity interventions prevent obesity or overweight in children.

o School and home based interventions: The strength of the evidence is

insufficient that diet interventions within school-based studies with a home

component prevent obesity or overweight in children. However, the strength of

evidence is high that physical activity interventions within school-based studies

with a home component prevent obesity or overweight in children. The strength of

evidence is moderate that combined diet and physical activity interventions within

school-based studies with a home component prevent obesity or overweight in

children.

o School Based with a Home and Community Component: The strength of

evidence is insufficient that school-based physical activity interventions with a

home and community component prevent obesity or overweight, as there was

only one study and it had a moderate risk of bias. The strength of evidence is

high that combined diet and physical activity interventions prevent obesity or

overweight, as one study with a low risk of bias and most of the studies with a

moderate risk of bias showed a favourable effect. Studies on a combination of

diet and physical activity interventions generally showed significant improvements

in weight outcomes. Most interventions focused on education as well as structural

changes to promote a healthful diet and increased physical activity. Many of the

interventions did not specifically target obesity prevention.

o School Based with a Community Component: The strength of evidence is

insufficient that a diet approach or an approach combining physical activity with

self-management can impact weight outcomes in a community and school

setting, as only one study was included for each approach. The strength of

evidence is moderate that diet with physical activity impacts BMI or BMI z-score

30 http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=1523

47

in a community and school setting, as two of the four studies with moderate risk

of bias showed a favourable effect.

o School Based with a Consumer Health Informatics Component (i.e. an

online learning component): The strength of evidence is insufficient that

school-based physical activity interventions with a CHI component prevent

obesity or overweight in children. We graded the body of evidence as insufficient

because it lacked precision and both studies had a moderate risk of bias. The

strength of evidence is insufficient that a combination of diet and physical activity

interventions prevent obesity or overweight in children. We graded the body of

evidence as insufficient because it lacked precision and included studies with

moderate risk of bias.

o School Based with a Consumer Health Informatics Component: The strength

of evidence is insufficient that school-based physical activity interventions with a

CHI component prevent obesity or overweight in children. We graded the body of

evidence as insufficient because it lacked precision and both studies had a

moderate risk of bias. The strength of evidence is insufficient that a combination

of diet and physical activity interventions prevent obesity or overweight in

children. We graded the body of evidence as insufficient because it lacked

precision and included studies with moderate risk of bias

48

Appendix 4: A map of early years service provision in Jersey

from conception to age five

49