undergraduate dissertation

A critique of government strategies to reduce obesity in children over the last decade

comparing national and local

strategies and findings.

A project report submitted in partial fulfilment of the requirements for the Degree of Bsc

(Hons) in Sport and Exercise Science.

Programme Code: (C601)

By Christopher Kear

Faculty of Applied Sciences

Department of Sport and Exercise Sciences

University of Sunderland

SSP331

Submission date: 30/3/12

Supervisor: Morc Coulson

Declaration: I Christopher Kear confirm that I have read and understood the University

regulations concerning plagiarism and that the work contained within this project report is my

own work within the meaning of regulations.

Signed.................................

A critique of government strategies to reduce obesity in children over the last decade comparing national and local strategies. University of Sunderland, Chris Kear, 2012

Acknowledgments

The author would like to acknowledge the support and assistance given; particular thanks go

to Kelly Johnson coordinator of the LAF programme in Sunderland. In addition thanks go to

Moira Scales, Health Coordinator for the Children’s Centres in Sunderland. Helen Nugent for

the information provided on the HENRY Programme. Finally special thanks to Morc

Coulson, Senior Lecturer Health Related Exercise and Programme Leader Sport & Exercise

Science, at University of Sunderland; who provided guidance and support throughout this

report.

2


Title Page number

1.0 Introduction 5

2.0 Rates of Obesity 7

3.0 Causes of Obesity 10

4.0 Measurement of Obesity 11

5.0 Diet 14

5.1 Nutrition in Infancy 14

5.1.1 National strategies to increase breastfeeding 16

5.1.2 Local strategies to increase breastfeeding 17

5.2 Nutrition in childhood 18

5.2.1 National strategies relating to diet 19

5.2.2 Local strategies relating to diet 26

5.2.2.1 Early years 27

5.2.2.2 School aged children 28

5.3 Food in Schools 31

5.3.1 National Food in Schools 31

5.3.2 Local Food in Schools 34

3


6.0 Activity 38

6.1 National strategies relating to activity 39

6.1.1 Activity in infancy 40

6.1.2 Activity in childhood 43

6.1.2.1 Sport England 45

6.2 Local strategies relating to activity 47

6.3 Activity in Schools 49

7.0 Conclusion 55

8.0 References 61

9.0 Appendices 67

Appendix 1 68

Appendix 2 69

Appendix 3 70

Appendix 4 71

Appendix 5 72

Appendix 6 73

Appendix 7 74

4


1.0. Introduction.

There are several definitions of obesity and overweight. The World Health Organisation

(WHO, 2011) defines ‘overweight’ and ‘obesity’ as abnormal or excessive fat accumulation

that may impair health. Being overweight or obese is associated with increased health risks

both in children and adults. Obese children have an increased risk of experiencing breathing

difficulties, bone fractures, hypertension, developing cardiovascular disease, insulin

resistance and may also suffer psychological effects (WHO, 2011). Furthermore, obese

children have a higher chance of becoming obese adults and developing conditions including

heart disease, stroke, osteoarthritis and certain cancers, which could lead to, premature death

and disability (WHO, 2011). The probability of childhood obesity persisting into adulthood is

estimated to increase from approximately 20% at 4 years of age to approximately 80% by

adolescence (Guo and Chumlea, 1999). According to Ebbeling et al (2002), the psychological

stress of social stigmatisation imposed on obese children may also be as damaging as the

medical morbidities.

Since 1995 the UK has seen a 22% increase in overweight (including obese) and a 38%

increase in childhood obesity (National Child Measuring Programme, 2009/10). It is

estimated that the increased health risks associated with these high rates are costing the

National Health Service more than £5bn each year (Healthy Lives, Healthy People, 2011).

This is placing a huge strain on the NHS and concerns have been raised that this may be

unsustainable in future if the rates continue to rise.

In an attempt to reverse this trend there has been a plethora of strategies released at national

and local levels. The main strategies nationally have been Choosing Health (2004), The

Foresight Report (2007) and Healthy Weight, Healthy Lives: A Cross-Government strategy

for England (2008). These have driven policies both at national and local levels.

5


The objective of this study is to evaluate the effectiveness of strategies introduced at both

national and local levels to reduce childhood obesity.

6


2.0. Rates of Obesity.

The obesity levels throughout the world have more than doubled since 1980 (WHO, 2011)

and obesity has been described as a worldwide epidemic. The rates in the UK are amongst the

highest in Europe and the developed world (Health Profile of England, 2009).

Figure 1. Overweight or obese population, % of total population 2007.

(Health Profile of England, 2009).

7


Table 1. Rates of overweight and obesity in England from 2000-2010.

Children's overweight and obesity prevalence, by survey year, age-groupChildren aged 2-15 with a valid height and weight measurement 2000-2010

BMI status

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010% % % % % % % % % % %

ALL CHILDREN 2-10 Overweight 12.8 15.2 13.5 14.6 14.8 14.6 12.8 13.6 13.4 13.9 13.6Obese 12.1 13.3 15.8 14.1 14.6 17.3 15.5 15.5 13.9 14.4 14.6Overweight including obese 24.9 28.5 29.3 28.7 29.4 31.9 28.3 29.2 27.3 28.3 28.211-15 Overweight 12.6 16.1 15.0 15.6 16.2 15.0 15.9 15.4 15.7 14.6 15.5Obese 18.7 18.5 20.0 21.3 25.5 20.8 17.6 18.8 19.5 17.7 18.3Overweight including obese 31.3 34.7 35.0 36.9 41.7 35.8 33.5 34.2 35.2 32.3 33.82-15 Overweight 12.7 15.5 14.0 15.0 15.4 14.8 14.0 14.3 14.3 14.2 14.3Obese 14.5 15.2 17.4 16.9 18.9 18.6 16.3 16.8 16.0 15.7 16.0Overweight including obese 27.2 30.7 31.4 31.9 34.3 33.4 30.3 31.1 30.3 29.8 30.3

Health Survey for England-2010 (2011).

In children over 23% of 4- 5 year olds are now overweight or obese, as well as 33% of 10-11

years (Childhood Obesity National Support Team, 2011). Trends in overweight and obesity

are socially patterned, with higher rates in areas of deprivation, low income households,

lower socio-economic groups and inner city areas (Jotangia et al. 2005; Taylor et al, 2005).

8


Sunderland has relatively high deprivation levels; the 2007 Index of Multiple Deprivation

(IMD) ranks Sunderland as the 35th most deprived local authority (out of 354). Sunderland is

also in the bottom 10 primary care trust areas (Annual Report, 2009). Sunderland has high

rates of children classified as either obese or overweight (see table 2). Over a quarter of all

children are overweight or obese on starting school in Sunderland. By the time they start

secondary school this rate is almost a third.

Table 2. Prevalence of overweight and obese children in Sunderland in 2010/11.

Years Prevalence (%)

Overweight Obese

Reception 13.7 14.6

Year 6 10.2 22.1

Lifestyle Statistics (2011).

9


3.0. Causes of Obesity.

The causes of childhood obesity are complex and include genetic, biological, psychological,

socio-cultural, and environmental factors.

Obesity has been strongly linked with familial influences. According to Arluk (2003) the

strongest independent predictor of childhood obesity is maternal obesity. However this is

believed to be through familial influences attributed to environmental factors rather than

genetic.

It is most likely that the increasing rates of obesity are linked to changes in diet and lifestyles

associated with modern living. This is supported by the World Health Organisation (2011)

who state that there have been dietary changes globally with an increased intake of energy-

dense foods that are high in fat, salt and sugars but low in vitamins, minerals and other

micronutrients. Furthermore, this has been combined with a decrease in physical activity

levels, linked to a number of different factors associated with modern day living such as

sedentary forms of work, changing modes of transportation, and increasing urbanisation

(WHO, 2011). The Foresight Report (2007) defined this as 'obesogenic environment' which

is: 'the total sum of influences in the environment on promoting obesity in individuals and

populations'. Simply stated by the Department of Health (Healthy Lives, Healthy People,

2011), obesity is a direct consequence of eating and drinking more calories and using up too

few.

The government’s drive to reduce obesity has been high on the political agenda for several

years and there has been a plethora of strategies introduced to help to reduce the rates of

obesity. These strategies lie in two main areas; diet and exercise.

10


4.0. Measurement of Obesity.

The recognised measurement used to assess whether adults or children are overweight or

obese is Body Mass Index (BMI). BMI is calculated by dividing an individual’s weight (kg)

by the square of their height (m), (kg/m²) (see figure 2). Adults are classified as obese if their

BMI exceeds 30kg/m², or overweight if their BMI is greater than 25kg/m² (Dinsdale, Ridler

and Ells, 2011).

Measurement Units Formula and Calculation

Kilograms and meters (or

centimetres)

Formula: weight (kg) / [height (m)]2

The formula for BMI is weight in kilograms divided by height in

meters squared. Since height is commonly measured in

centimetres, divide height in centimetres by 100 to obtain height in

meters.

Example: Weight = 68 kg, Height = 165 cm (1.65 m)

Calculation: 68 ÷ (1.65) 2 = 24.98

Pounds and inches Formula: weight (lb) / [height (in)] 2 x 703

Calculate BMI by dividing weight in pounds (lbs) by height in

inches (in) squared and multiplying by a conversion factor of 703.

Example: Weight = 150 lbs, Height = 5'5" (65")

Calculation: [150 ÷ (65)2] x 703 = 24.96

Figure 2. Calculating BMI.

(http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html#Interpreted)

11


Calculating the BMI of children is more complex than calculating the BMI of an adult as

there are several factors which need to be taken into consideration. Therefore, instead of

using fixed BMI thresholds to calculate children’s BMI, variable thresholds are used that take

into account the child’s age and sex. These thresholds are usually derived from a reference

population, known as a child growth reference. They are calculated by weighing and

measuring a large sample of children to identify how BMI varies by age and sex across the

population. As well as showing the pattern of growth, these data also provide an average BMI

for a boy or girl at a particular age, and the distribution of measurements above and below

this value. This means that individual children can be compared to the reference population

and the degree of variation from an expected value can be calculated (Dinsdale, Ridler and

Ells, 2011). BMI thresholds are defined in terms of a specific range or centile, on a child

growth reference. Once a child’s BMI centile has been calculated, this figure can then be

checked to see whether it is above or below the defined thresholds for the child growth

reference used (Dinsdale, Ridler and Ells, 2011).

Due to variations in populations there are a number of different child growth references

available. The recommended child growth reference for the UK is the British 1990 growth

reference (Cole, 1996). This provides centile curves for BMI for British children from birth to

23 years. They are based on a sample of 32,222 measurements from 12 distinct surveys

collected between 1978 and 1994. The BMI reference curves are part of the wider British

1990 growth reference which also includes height, weight, head circumference and waist

circumference. The UK90 BMI reference is available on printed growth charts for boys (See

appendix 1), and girls (See appendix 2), where the centiles are shown evenly spaced at 2/3rds

of a standard deviation. This means the 0.4th, 2nd, 9th, 25th, 50th, 75th, 91st, 98th and 99.6th

centiles are shown. The classification for overweight is the 85th centile for population

monitoring or the 91st centile for clinical assessment. The classification for obesity is the

12


95th centile for population monitoring and the 98th centile for clinical assessment (Dinsdale,

Ridler and Ells, 2011).

Annual statistical information on height and weight measurements for around one million

children in the UK is provided by the National Child Measurement Programme (NCMP).

This incorporates the majority of the child population across two age groups, reception (age

4-5 years) and Year 6 (age 10-11 years); the large sample provides reliable information about

patterns of child body mass index (Dinsdale and Ridler, 2011).

13


5.0. Diet.

5.1. Nutrition in Infancy.

The World Health Organisation (WHO, 2011), state ‘nutrition and nurturing during the first

years of life are both crucial for life-long health and well-being’. Breastfeeding is known to

have many health benefits for infants; one of these is its association with a reduction in the

risk of developing childhood obesity (Armstrong and Reilly, 2002). The WHO recommend

that babies should be exclusively breastfed up to 6 months of age, with continued

breastfeeding along with appropriate complementary foods up to two years of age or beyond.

Adversely, statistics show that worldwide, only one in three infants are exclusively breastfed

during the first six months of life. Through most of the twentieth century, initiation and

duration of breastfeeding declined worldwide as a result of rapid social and economic change,

including urbanisation and marketing of breast milk substitutes.

Statistics on infant feeding in the UK are collected from infant feeding surveys which are

commissioned by the NHS and conducted every five years. Prior to 2008/9 data collected was

on the initiation of breastfeeding only. However, since 2008/9 each primary care trust has

been required to submit breast feeding statistics for more sustained breastfeeding. Statistics

now provide data on the incidence, prevalence and duration of breastfeeding and other infant

feeding practices from birth up to around nine months of age. There are three stages of data

collection to capture feeding practices at different ages.

Stage 1 at 6-10 weeks old

Stage 2 at 4-6 months old

Stage 3 at 8-10 months old

14


This was a significant change in the data collection. The statistics for initiation of

breastfeeding includes babies who are put to the breast following birth, even if this only

occurs once. Therefore it could be argued that more valuable information is collected at 6-8

weeks, 4-6 months and 8-10 months as this provides data showing more sustained

breastfeeding.

Table 3 shows the breastfeeding initiation rate in Sunderland was well below the national

average at only 20.9% in 2000. However in 2010/11 increases have been seen both nationally

and locally, although Sunderland remains well below the national rate.

Table 3. Breast feeding initiation rates.

Year National Sunderland

2000 69% 20.9%

2010/11 73.7% 51.4%

Infant Feeding Survey 2010: Early Results, (2011).

Table 4 shows the breastfeeding rate at 6- 8 weeks following birth. No data was collected in

2000 to enable comparisons to be made. However in 2010/11 low rates are seen both

nationally and locally and these rates are significantly lower than the initiation rates.

Table-4. Breastfeeding rates at 6-8 weeks.

Year National Sunderland

2000 No data available No data available

2010/11 45.2% 21.2%

Infant Feeding Survey 2010: Early Results, (2011).

15


Evidence suggests breastfeeding rates vary according to the mother’s education, socio

economic group, age and if she has other children. The highest incidences of breastfeeding

are found among mothers from managerial and professional occupations, those who were

aged 18 when left full-time education, those aged 30 or over, and among first time mother

(Infant Feeding Survey 2010: Early Results, 2011). Official figures show a clear link between

breastfeeding and poverty. Sunderland has one of the lowest breast feeding rates in the

county and bottle feeding is entrenched in the local culture.

5.1.1. National Strategies to Increase Breastfeeding.

In an attempt to increase the breastfeeding rates the WHO developed several strategies. The

Global Strategy for Infant and Young Child Feeding (2003) aimed to revitalise efforts set to

promote, protect and support appropriate infant and young child feeding. It built upon the

Baby-Friendly Hospital Initiative (UNICEF, 1991), which was principally aimed at support

for mothers in hospitals, and addressed the needs of all children. However, it was recognised

it is not enough just to help a mother initiate exclusive breastfeeding; she needs to be able to

go back to an environment that is conducive to sustain breastfeeding. The strategy examines

the role of communities and community-based resource persons in providing support.

The Strategy recommended that all governments:

• Review progress in national implementation of the International Code of Marketing of

Breast milk Substitutes, and consider new legislation or additional measures as needed to

protect families from adverse commercial influences.

• Develop legislation protecting the breastfeeding rights of working women and

establishing means for its enforcement in accordance with international labour standards.

16


The World Health Organisation banned the marketing of artificial formulas 30 years ago.

Following the recommendations of The Global Strategy for Infant and Young Child Feeding

(2003) the UK government banned the advertising of infant formula for babies up to six

months in 2008 however; the advertising ban did not include follow-on formula milk

products. Children's charities want the Government to impose an outright ban on the

promotion of all powdered formula milks as they claim it encourages women to give up

breastfeeding too early.

Healthy Weight, Healthy Lives: A Cross-Government strategy for England (2008) recognised

the importance of breastfeeding in the battle against childhood obesity and set out new

strategies to increase breast feeding rates nationally. Underpinned by Foresight Report (2007)

it identified that employers, individuals and communities need to work together to achieve

this.

5.1.2. Local Strategies to Increase Breastfeeding.

In order to increase breastfeeding rates in Sunderland the Teaching Primary Care Trust

(TPCT), City Hospital Maternity Unit and Children’s Centres are working towards the

prestigious WHO/UNICEF Baby friendly award which is a globally recognised quality

standard for breastfeeding support in the health care system. It is hoped that this will be

achieved by 2013. As part of this project Sunderland PCT has organised breastfeeding

courses to raise staff knowledge and skills to UNICEF standards.

Breastfeeding support in Sunderland is also provided by peer counsellors who provide

support and advice to mothers. The peer counsellors are qualified volunteers who have

successfully breastfed their own children and attended a 10-week course. This is endorsed by

17


The National Institute for Clinical Excellence (NICE), who state peer support is one of the

most effective ways of helping mums to succeed in breastfeeding.

5.2. Nutrition in Children.

Following breastfeeding a balanced, healthy diet is required to promote growth and

development in children.

Table 5. Recommended daily calorific intake for children.

Age Boys Girls

1–3 1,230 1,165

4–6 1,715 1,545

7–10 1,970 1,740

11–14 2,220 1,845

15–18 2,755 2,110

http://www.weightlossresources.co.uk/children/nutrition_calorie_needs.htm.

Children are particularly at risk of eating unhealthy, processed and fast foods as they are

tempted by marketing agencies that target and portray these types of foods as exciting and

appealing. This was supported by the Food Standards Agency who commissioned a ‘Review

of Research on the Effects of Food Promotion to Children’ (2003), which found children’s

food promotion was dominated by television advertising. Furthermore, research undertaken

by the Office of Communications (Ofcom), which regulates broadcasting, also recognised

that food promotion is having an effect on children, particularly in the areas of food

preferences.

18

http://www.weightlossresources.co.uk/children/nutrition_calorie_needs.htm


Ofcom uses the nutrient profiling (NP) model as a tool to differentiate foods on the basis of

their nutritional composition and they restrict TV advertising of food and drink to children

where products are high in fat, salt and sugar. However they fell short of introducing a total

ban on television advertising of food and drinks to children, which they suggested would be

ineffective. The approach is supported by government, who believe that in a democratic

society individuals should not be told what to eat and should be free to make choices about

diet and physical activity. The government acknowledge that children need a protected

environment as they learn about making lifestyle decisions, that impact on their health and

they suggest they should share this responsibility with parents (Choosing Health, 2004).

A common theme running through policies is that individuals need to take some

responsibility and make changes to control their weight in order to improve health although it

is acknowledged they should be supported with this. The government identified this requires

a joint approach from national and local governments, retailers, marketing, media and local

communities. A plethora of strategies were developed in an attempt to achieve this.

5.2.1. National Strategies to Improve Children’s Diet.

At a macro level the World Health Organisation implemented a Global Strategy on Diet,

Physical Activity and Health (WHO, 2004). This strategy indicated the actions needed

globally, nationally and regionally to improve diets and physical activity patterns of the

population.

In response, Choosing Health (2004) was published which set out key principles at a national

level to provide support for the public with the aim of enabling individuals to make informed

19


choices. Consultations about how to achieve this included producers, retailers, marketing,

media and communities.

The Foresight Report (2007) took a strategic view of obesity and made recommendations for

changes in diet at various levels including individual, family, community and population. The

key message from the Foresight Report (2007) was that policies to reduce obesity should be

directed at multiple levels. Furthermore, the Government needed to focus its actions in five

main policy areas:

1. To promote children’s health.

2. To promote healthy food.

3. To build physical activity into lives.

4. To support health at work and provide incentives more widely to promote health.

5. To provide effective treatment and support when people become overweight or obese.

One area identified for improvement was food labelling. The government identified that a lot

of information provided on packaged and processed foods was confusing with no

standardised method of giving information. Choosing Health (2004) recommended that food

should be clearly labelled with simple information to empower people make healthy choices.

It recommended that the food industry needed to adopt universal standards for information on

food labelling and also had a responsibility to increase the availability of healthier foods. The

Foresight Report (2007) recognised that in order to improve information about food

organisations would have to work together.

In recent years improvements have been made in the information provided to individuals

about food. The Food Standards Agency (FSA) has worked with the food industry to

20


introduce front of pack labeling to make it simpler for families to make healthier choices.

Currently the preferred mode is based on a traffic light system which clearly illustrates the

amounts of sugar, fat and salt contained in foods (figure 3).

Figure 3. Traffic light system.

The traffic light system has been adopted by many major retailers and manufacturers;

however they have not been universally adopted. Healthy Weight, Healthy Lives: A Cross-

Government strategy for England (2008) planned to finalise a Healthy Food Code of Good

Practice, in partnership with the food and drink industry, and other relevant stakeholders to

ensure this. However, to date there is no universal system for providing the public with

simple information about food.

The promotion of unhealthy food and drink to children was another factor identified by

Ofcom. Restrictions have been made by Ofcom which apply to the advertising of food

products high in fat, salt and sugar within programming of particular interest to children. The

restrictions initially applied to programmes aimed at under 10s; from 2008 they have also

applied to programming aimed at under-16s.

Healthy Weight, Healthy Lives: A Cross-Government strategy for England (2008) also

acknowledged the influences of fast food outlets on children and the government is currently

working with local authorities to enable effective management of fast food outlets in

particular areas, e.g. near parks or schools.

21


To support the public and professionals to make changes, Change4Life (2004) was released.

This was England’s first ever national-social marketing campaign to promote healthy weight,

it aimed to prevent people from becoming overweight, by encouraging them to eat well,

move more and live longer. It targeted parents of children aged 5–11, particularly those from

segments of the population where parental attitudes, beliefs and behaviours indicated that

their children were most likely to gain excess weight. The programme provides information

and advice for consumers through a wide range of routes television and radio ‘filler’

advertising, printed resources including leaflets, posters, booklets, a website, PR and

magazine adverts and articles (See appendix 3).

Change4Life also incorporates the 5 a day campaign based on the recommendation from the

World Health Organisation, that consuming 400g fruit and vegetables a day can reduce risks

of chronic diseases, e.g. obesity, heart disease and some cancers. These guidelines state

everyone should eat at least five portions of fruit and vegetables a day.

The recommended portion size for children is:

1 portion of vegetables (80g).

1 portion of fruit (80g).

1 portion of dried fruit (30g).

22


Table 6. Children’s fruit and vegetable consumption from 2001-2010.

Children's fruit and vegetable consumption, by survey year and age

Children aged 5-15 2001-2010Portions per day Survey year 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

% % % % % % % % % %

ALL CHILDREN None 11 10 10 9 6 6 5 6 5 6Less than 1 portion 5 5 7 5 3 3 3 3 3 41 portion or more but less than 2 25 25 26 23 19 18 18 17 18 182 portions or more but less than 3 22 23 21 20 22 20 22 22 22 203 portions or more but less than 4 16 16 16 18 20 18 19 19 18 184 portions or more but less than 5 10 10 10 13 13 14 13 14 14 155 portions or more 11 12 11 13 17 21 21 19 21 20Mean portions 2.5 2.6 2.5 2.7 3.1 3.3 3.3 3.2 3.3 3.3

Health Survey for England-2010 (2011).

Since the introduction of Change4Life in 2004, there has been a 7% increase in the number of

children eating 5 potions or more of fruit and vegetables per day. The greatest increase was

seen in the first 2 years following the release of the Change4Life marketing campaign. This

rate was generally maintained in the subsequent years until 2010; however the results show

that on average children are still not eating the recommended daily amount of 5 portions of

fruit and vegetables a day.

In an attempt to combat this, the School Fruit and Vegetable Scheme was introduced in 2004.

All four to six year old children in local education authority maintained infant, primary and

special schools are entitled to a free piece of fruit or vegetable each school day. Over the past

few years, the share of children on the School Fruit and Vegetable Scheme eating ‘5-A-

DAY’ has increased from just over a quarter to just under a half (Blenkinsop, et al, 2007).

This is a valuable resource for many children as evidence suggests fruit and vegetable

consumption in children is lower in poorer households living in deprived areas and greater in

households with higher incomes and in more affluent families (Morgan et al. 2006). In

23


another attempt to improve this, the Convenience Stores Programme was introduced in 2008.

This partnership between the Department of Health and the Association of Convenience

Stores, aimed to increase the availability of fresh fruit and vegetables in areas which may

have limited access to them. Evaluation of the stores participating in the programme, reported

an increase in the sales of fruit and vegetables by up to 50% in some stores. In 2011, the

Association of Convenience Stores have pledged to expand this throughout the country.

In 2010 a new three-year marketing strategy (2011–14) was introduced for the Change4Life

programme. New materials for parents of very young children were launched via a new sister

brand of Change4Life called Start4Life (DOH, 2010). The Start4Life programme will

continue to provide information and support materials for distribution to the public via

healthcare professionals. In addition, recognising that excess weight gain in pregnancy is the

start of an overweight family; Start4Life will pay more attention to diet during pregnancy.

The Start4Life, (DOH, 2010) recommended behaviours for the under-two’s are:

• Mum’s milk – initiating breastfeeding.

• Every day counts – encouraging continued breastfeeding.

• No rush to mush – delaying weaning.

• Taste for life – encouraging a wide range of age-appropriate foods.

• Sweet as they are – avoiding sugar.

• Baby moves – physical activity.

In an attempt to be the first government to reduce obesity and support people to maintain a

healthy weight, Healthy Weight, Healthy Lives: A Cross-Government strategy for England

(2008) was introduced. It brought together employers, individuals and communities to target

24


the 5 policy areas outlined by the Foresight Report, (2007). The initial focus is on children,

who, according to Sconfield-Warden and Warden, (1997) can have their behaviour more

easily modified than adults as their patterns of behaviour are not fixed. This is supported by

evidence which suggests that programmes to prevent and tackle obesity in children have

greater potential for success. The government hoped to achieve their target to reduce the

proportion of overweight and obese children to 2000 levels by 2020 (Healthy Weight,

Healthy Lives, 2008).

The strategy focuses on five key areas:

1. The healthy growth and development of children.

2. Promoting healthier food choices.

3. Building physical activity into our lives.

4. Creating incentives for better health.

5. Personalised advice and support.

The government’s goal is for every child to grow up with a healthy weight, through eating

well and being active. In early years, they aim to increase breastfeeding rates, empower

families to be knowledgeable and confident about healthy weaning and feeding of children to

ensure that their children eat healthily and are active and fit.

Healthy Weight Healthy Lives (2008), recommended immediate plans to:

Identify at-risk families as early as possible and promote breastfeeding as the norm for

mothers.

Give better information to parents about their children’s health by providing parents

with their child’s results from the National Child Measurement Programme (NCMP).

25


Invest to ensure all schools are healthy schools, including making cooking a

compulsory part of the curriculum by 2011 for all 11–14 year-olds.

Ask all schools to develop healthy lunch box policies, so that those not yet taking up

school lunches are eating healthily.

Develop t programmes in schools to increase the participation of obese and

overweight pupils in PE and sporting activities.

Invest £75 million in an evidence-based marketing programme which will inform,

support and empower parents in making changes to their children’s diet and levels.

5.2.2. Local Strategies to Improve Children’s Diet.

At a micro level strategies have been developed to support the governments drive to reduce

childhood obesity. In Sunderland the Teaching Primary Care Trust adopts a 3 tiered obesity

service for children (see figure 4) to identify the appropriate intervention.

Figure 4. Sunderland TPCT 3 tiered obesity service for children.

26

Tier 2

Tier 1

Children

Evidence of effectiveness

PreventionTreatm

ent

Tier 3 Interventions for obese children (including complex needs)

Interventions for overweight children

overweight children

Universal Interventions


Sunderland City Council and its partners in the Primary Care Trust and City Hospitals have

developed joint strategies to prevent and manage overweight and obesity in children of

different ages.

5.2.2.1. Early Years.

Sunderland has developed an Early Years Food Policy (see appendix 4) to provide guidance

for all professionals involved in the care of very young children including child minders and

nurseries. The aim of this is to provide valuable information on foods to encourage healthy

eating in children. This is incorporated by information provided by Change4Life and the

Schools Food Trust.

Sunderland was recently selected to run a pilot programme aimed at preschool children. This

study provided the opportunity to deliver a programme aimed at early years children. The

HENRY programme (Hunt and Rudolf, 2008) was delivered and evaluated over a period of 1

year (2010-2011). All groups were delivered in the East locality of Sunderland, 2 cohorts

were residents of the City’s Lower IMD populate and the 3rd cohort was a targeted Young

Parent Group. In all 3 cohorts childhood obesity statistics were high.

Attendance and recruitment for HENRY:

Ryhope area – 13 invited, 8 commenced programme, 6 completed programme.

Hendon (middle) area – 15 invited, 6 commenced programme, 5 completed

programme.

Hendon and East End area– 12 invited, 8 commenced programme, 5 completed

programme.

27


In evaluating the programme parental comments were mainly positive, however, the overall

impression was that HENRY was a parenting course and did not specifically address

childhood obesity issue in Sunderland.

Recommendations for future included:

To continue to deliver HENRY as a parenting course.

To ensure tracking of the attendees both pre and post course monitoring health. To

address reduction in childhood obesity statistics, record behavioural changes in the

family and ensure improved health outcomes.

To design a pre HENRY course that incorporates healthy eating/lifestyles and

practical cookery skills for parents.

Sustained long term funding for HENRY in combination with weaning and what’s

cooking together courses.

To maintain a coordinated approach to address the childhood obesity problem.

To maintain a commitment from all strategic managers to drive the Childhood

Obesity agenda forward.

5.2.2.2. School Age Children.

The Lifestyle, Activity, Food Programme (Sunderland City Council, 2011) (See appendix 5)

is aimed at families with children aged five to fifteen who have been identified as overweight.

The programme consists of a free eight-week course with each weekly session consisting of 1

hour of physical activity and 1 hour of education. The sessions focus on promoting healthy

eating and lifestyles through fun activities such as cookery sessions, food tasting, fun games

28


and family walks. The programme acknowledges that interventions likely to be successful are

those that engage the whole family to try to change behaviour therefore, interventions are

delivered in a fun interactive manner, in non clinical environments such as leisure centres and

community venues. It uses a multi agency approach including City Hospitals Dietetic

Department, Sunderland's Wellness Service and Sunderland's Food in School Team. Families

are referred into the programme by health practitioners who have identified overweight or

obese children.

Aims and Objectives of LAF:

To support identified overweight and obese children and their families.

Increase child and family physical activity levels.

Improve understanding about healthy eating.

Improve understanding of weight maintenance.

The programme also focuses on prevention of obesity through health promotion. They work

in partnership with the Food in Schools team delivering:

Nutritional training for school based staff.

Training to lunchtime supervisors to make the lunchtime experience more fun.

Deliver family learning activities to increase skills on healthy cooking.

Evaluation of LAF Programme

During the period April 2010 – March 2011, 253 families were referred to the LAF

programme by GPs, school nurses and other health care professionals.

The families were accommodated as follows:

29


115 families started the programme from April 2010 – March 2011.

64 families to start a programme in May 2011.

26 were referred to Dietetics Department for specialist support from the Dietician.

7 were referred to the adult Exercise Referral and Weight Management.

programme because they were 16 years or older.

41 declined the programme after being referred.

Of the 115 families starting the programme from April 2010 – March 2011, 77 (88.5%)

completed the programme, 18 did not attend, and 20 dropped out. All children on the

programme completed pre and post questionnaires to provide a range of information to

identify lifestyle behaviours. In addition, a range of body measurements were taken,

including:

Weight.

Height.

Body Mass Index (BMI).

Waist circumference.

The following outcomes were achieved from the programme:

77 off the 115 children and families starting the programme completed.

72 of the 77 children gained height over the course of the programme.

53 of the 77 children lost/maintained weight.

60 of the 77 children decreased/maintained their Body Mass Index.

58 out of 77 children lost / maintained inches around their waist.

92% of families completing the programme rated the service they received as

at least satisfactory.

5.3. Food in Schools.

30


5.3.1. National Food in Schools.

Schools can make a very significant contribution to secure, maintain and improve children’s

and young people’s health, through the taught curriculum and the wider school environment:

through the types of foods and drinks sold in vending machines, tuck shops and through the

school meals service.

In 1995 the Chest Heart and Stroke Association published the results of a survey of a number

of secondary schools, based on one week’s menus. The survey showed that 46% of the

calories in the meals served came from fat, that most school meals did not normally provide

enough iron, calcium or folate and that many did not provide enough vitamin C. One of the

Association’s recommendations was that the Department of Education should review its

guidelines on the nutritional standards of school meals.

Schools responsibility in ensuring children had access to healthy food was reviewed in

Choosing Health (2004) which recommended revised primary and secondary school meal

standards aimed to reduce the consumption of fat, salt and sugar and increase the

consumption of fruit and vegetables and other essential nutrients. However, it was in 2005

when the subject of school dinners was brought to the forefront when TV chef Jamie Oliver

broadcasted ‘Jamie’s School Dinners’. Jamie Oliver identified the poor nutritional value and

quality of school dinners and launched the ‘Feed Me Better’ campaign to improve the quality

of Britain’s schools dinners. This did have a lot of support from the public however some

disagreed with the changes to school dinners claiming it removed their choice to eat what

they wanted. Adversely, images of parents were seen on national television handing over take

away food to children in the school yard.

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Over the past 5 or 6 years, big changes have been made to school food. All food provided by

local authorities must now meet national nutritional standards introduced in 2007 to ensure

that children are provided with a healthy, balanced diet. The standards required the following:

High-quality meat, poultry or oily fish regularly available.

At least two portions of fruit and vegetables with every meal.

Bread, other cereals and potatoes regularly available.

Deep-fried food limited to no more than two portions per week.

Fizzy drinks, crisps, chocolate and other confectioneries removed from school meals

and vending machines.

However, some parents refer to provide packed lunches for their children, adversely in 2003

research carried out by The Foods Standards Agency found that 9 out of 10 packed lunches

contained too much sugar, salt and saturated fat. The School Food Trust (SFT, 2011) now

provides guidelines to parents to ensure they provide healthy and balanced packed lunches

for their children. The Change4Life campaign and the Food Schools Trust suggest a balanced

packed lunch should contain:

Starchy foods including bread, rice, potatoes and pasta, and others.

Protein foods such as meat, fish, eggs, beans and others.

A dairy item. This could be cheese or yoghurt.

Vegetables or salad, and a portion of fruit.

They recommend chocolate bars and cakes are replaced with fresh fruit, dried fruit or

unsalted nuts.

Statistical data relating to school meals is provided by local authorities as part of the 2011

School Food Trust (SFT) and Local Authority Caterers Association (LACA) annual local

32


authority (LA) survey. It provides, at national, regional and local level, information on the

take up of school lunches and the coverage of the data in England in two categories: primary

schools, together with special schools; and secondary schools, together with academies and

city technology.

Table 7. Percentage take up of school lunches and percentage coverage, primary and

secondary schools, England, 2010-2011 (SFT, 2011).

Region Primary Secondary

England 44.1% 37.6%

Sunderland 54.6% 58.5%

(Nelson et al, 2011).

Primary and special schools have seen an increase of 2.7 percentage points (from 41.4% to

44.1%) in the uptake of school lunches on the previous year. Secondary schools have seen an

increase of 1.8 percentage points (from 35.8% to 37.6%) on the previous year (Schools Food

Trust, 2011). Sunderland has a higher proportion of children taking up school meals, at both

primary and secondary levels, than the national average.

Many schools have also recognised the significant contribution they can make to encouraging

and facilitating healthier eating patterns among children and young people. They have

responded through the implementation of a variety of initiatives and schemes such as

breakfast clubs; healthy snacking schemes, fruit tuck shops; School Nutrition Action Groups

(SNAGs); and the Health Promoting Healthy Schools Programme.

33


The National Healthy Schools Programme (1999) is a joint Department of Health and

Department for Children, Schools and Families project intended to improve health, raise

pupil achievement, improve social inclusion and encourage closer working between health

and education providers nationally. Incorporated in the Healthy Schools Programme, is

raising awareness of food amongst young people which is crucial if they are to make

informed choices about the food they eat. If schools achieve the recommended criteria for the

National Healthy Schools Programme they are awarded ‘Healthy Schools Status’.

Children also need to develop the skills to prepare and cook healthy foods. These are skills

which have declined over recent years with the increased reliance on processed and takeaway

foods. Practical cooking has been strengthened in the secondary curriculum, which was

reviewed in 2008. ‘License to Cook’, 2008, means that all pupils aged 11–16 are entitled to

learn to cook nutritious dishes from basic ingredients, whether or not their school offers

cooking as part of the curriculum The Government plan to expand this and make cooking a

compulsory part of the key stage 3 curriculum in schools.

5.3.2. Local Food in Schools.

Sunderland City Council state that every meal in their local authority schools is freshly

prepared daily by experienced, qualified and skilled staff. There is a huge variety of meals

that a child can choose from in primary (see appendix 6), secondary schools (see appendix 7);

furthermore, if a child requires a special diet the council states this can also be catered for.

The price of school meals in Sunderland for nursery, primary and special school pupils is

£1.80 per day, and the price for secondary school pupils is £1.90 per day. This price is

34

http://en.wikipedia.org/wiki/Department_for_Children,_Schools_and_Families

http://en.wikipedia.org/wiki/Department_of_Health


amongst the lowest in the country. Parents who are in receipt of any of the following benefits

are entitled to free school meals for their children:

Income Support.

Income-based Jobseeker's Allowance.

Income-related Employment and Support Allowance.

Support under Part VI of the Immigration and Asylum Act 1999.

The Guarantee element of State Pension Credit.

Child Tax Credit provided they are not entitled to Working Tax Credit and

have an annual income that does not exceed £16,190.

Working Tax Credit 'run-on' - the payment someone may receive for a further

four weeks after they stop qualifying for Working Tax Credit.

Sunderland has high levels of depravation and therefore the percentage of children many of

entitled to free school meals is higher than the national average (see tables 8 and 9).

Table 8. Maintained nursery and state funded primary school: Number of Pupils

eligible for and claiming free school meals.

Nursery and State Funded Primary Schools

Number on

roll

Number claiming free

school meals

% claiming free

school meals

England 4,176,585 645,105 15.4

Sunderland 23,183 4,246 18.3

Department for Education (2011).

The number of children receiving free school meals in nursery and state funded primary

schools in Sunderland is higher than the national rate.

35


Table 9. State funded secondary school: Number of Pupils eligible for and claiming free

school meals.

State Funded Secondary Schools

Number on

roll

Number claiming free

school meals

% claiming free

school meals

England 3,262,635 376,865 11.6

Sunderland 17,137 2,724 15.9

Department for Education, (2011).

The number of children receiving free school meals in state funded secondary schools in

Sunderland is also above the national rate.

Sunderland Healthy Schools Team was recently awarded a £10,000 grant from the School

Food Trust, to help make school lunchtimes happier and healthier. In conjunction with the

council the team have created a “let’s make lunchtime fun” programme, available to all the

city’s nurseries and primary schools. Improvements to school meals include:

Modern, light and informal dining environments with music and televisions.

A 'grab and go' provision for pupils who do sports at other activities on a

lunchtime.

Reducing frustrations of queuing by setting up satellite service points.

Themed lunches.

The result of the improvements is that the uptake of secondary schools meals in Sunderland

remains well above the national average (see table 7).

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Sunderland has also been involved in the Healthy Schools Programme which is a national

initiative to improve health and well being. Since 2011 it has become a local programme,

known as Healthy Schools Sunderland and 91% of schools in Sunderland have achieved

Healthy Schools Status. The government has affirmed its commitment to Healthy Schools as

a means to improve the health and wellbeing of children and young people (Sunderland City

Council, 2011). It plans for all schools to be Healthy Schools, and states that parents who

need extra help will be supported through children’s Centres, health services and their local

communities (Healthy Weight, Healthy Lives, 2008). This is happening in Sunderland,

‘What’s Cooking’ is a local initiative held in a variety of venues across the city to improve

cooking skills, nutritional knowledge and food safety of vulnerable young people in the city.

This has won national recognition.

6.0. Activity.

37


The increase in childhood obesity has been closely linked to decreases in activity levels

associated with sedentary lifestyles including car travel, socialising, reading, and listening to

music, as well as long periods spent sitting at school. The estimated direct cost of physical

inactivity to the NHS across the UK is £1.06 billion (Start Active, Stay Active, 2011).

Lower levels of physical activity have particularly affected children across all ages even in

the very early years as children are particularly attracted to television and computer games

which require little or no physical activity. According to Goldsmith (2005) obesity risks in

children increase by 6% for every hour of TV watched each day.

Table 10. Children's physical activity levels, by survey year and age.

Children's physical activity levels, by survey year and age

Children aged 2-15

2002, 2006, 2007

Levels of Age

physical activity 2 3 4 5 6 7 8 910 11 12

13 14 15 ALL

% % % % % % % % % % % % % % %ALL CHILDREN Meets recommendations

2002 66 77 69 67 69 6865 66

69 71 62

59 53 60 66

2006 69 68 69 70 62 6368 69

65 64 64

65 59 57 65

2007 71 72 69 66 69 7074 73

66 71 65

62 64 57 68

Some activity

2002 12 12 15 16 14 1416 15

14 12 16

19 17 14 15

2006 13 15 17 17 20 1716 15

19 16 16

16 18 19 17

2007 13 15 18 19 15 1711 14

17 15 14

15 16 17 15

Low activity

2002 22 11 16 17 17 1818 20

17 17 22

21 29 26 19

2006 18 17 14 13 18 2116 16

16 20 20

19 23 24 18

2007 16 13 13 15 16 1315 13

16 14 21

23 20 26 17

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Physical activity includes all forms of activity, such as everyday walking, active play, active

recreation including, dancing, or playing active games, as well as organised and competitive

sport (Start Active, Stay Active, 2011). There is evidence to support associations between

physical activity and health benefits, in particular preventing overweight and obesity (Hills et

al, 2007). Moreover, higher levels of activity in childhood lead to more sustained

participation in physical activity in later years (Dumith et al, 2011). Thus it is important to

establish a high level of activity at the earliest age in order to encourage activity patterns later

in childhood that are sufficient to benefit health (Start Active, Stay Active, 2011).

Rates of physical activity in children aged 2–15 years are inversely associated with area level

deprivation (Stamatakis, 2002) furthermore, evidence suggests children from less affluent

families are less likely to achieve recommended levels of physical activity (Morgan et al.

2006).

6.1. National Strategies Relating to Activity.

Choosing Activity (2005) set out Government’s plans to encourage and coordinate the action

of a range of departments and organisations to promote increased participation in physical

activity across England. It summarised how the commitments on physical activity presented

in the public health white paper Choosing Health (2004) were to be delivered.

However, acaccording to the Foresight Report (2007) environmental factors are critical in

this and influence the decisions that individuals and families make about being active.

Research demonstrates the potential for preventing obesity through well co-ordinated and

sustained community interventions, encouraging people to walk and cycle, will not only

tackle obesity but will also improve their health (PESSYP, 2008).

39


Healthy Weight, Healthy Lives, (2008) also identifies the importance of increasing activity

levels in the fight against obesity. This theme continues in government’s recent strategy Start

Active, Stay Active, (2011), which highlights that activity from an early age and throughout

childhood makes an important contribution to healthy growth and development. This is

supported by Hills et al (2007) who suggest habitual physical activity established in the early

years may provide the greatest likelihood of impact on an individual’s life expectancy. Start

Active, Stay Active (DOH, 2011) has produced guidelines, for the first time, on physical

activity for children, even very young children. The guidelines differ across the age groups

because of different needs at different ages and stages of development.

6.1.1. Activity in Infancy.

Children under 5 have not previously been included in UK public health guidelines for

physical activity. However recent evidence indicates that under 5’s spend a large proportion

of time being sedentary and that this is a barrier to physical activity (NHS Information Centre

for Health and Social Care, 2009).

Examples of sedentary behaviour include:

• Time spent in infant carriers, car seats or highchairs.

• Time spent in walking aids or baby bouncers (as these limit free movement).

• Time spent in front of the TV or other screen.

The evidence base for early years is relatively new and comprises different types of studies

including observational and, to a lesser extent, experimental research. Evidence indicates that

regular physical activity is valuable in developing motor skills, promoting healthy weight,

40


enhancing bone and muscular development, and for the learning of social skills (Jones and

Oakley, 2011 and Timmons et al 2007). Overall, it supports the conclusion that regular

physical activity during the early years provides immediate and long-term benefits for

physical and psychological well-being (Start Active, Stay Active, 2011).

The government also suggest that all children under 5 who are overweight or obese can gain

health benefits from meeting the guidelines, even in the absence of any changes to their

weight status. Although they do acknowledge that in order to achieve and maintain a healthy

weight, additional physical activity and a reduction in calorie intake may be required. The

recommendations suggest children under 5 should build up the required quantity of physical

activity across the course of their day and combine them with interspersed periods of rest.

Guidelines for Early Years (under 5’s):

1. Physical activity should be encouraged from birth, particularly through floor-based

play and water-based activities in safe environments.

2. Children of pre-school age who are capable of walking unaided should be physically

active daily for at least 180 minutes (3 hours), spread throughout the day.

3. All under 5’s should minimise the amount of time spent being sedentary (being

restrained or sitting) for extended periods (except time spent sleeping).

The government aim is that promoting physical and psychological development during the

early years will contribute towards establishing patterns of behaviour that may persist into

later childhood and adulthood (Start Active, Stay Active, 2011).

41


As children grow they begin their active lives through play. Evidence suggests that physical

activity, especially in the form of play, is a basic and essential behaviour that must be

fostered and encouraged during the first five years of life (Hall et al 2009). It is important for

their physical, cognitive and social development and is largely dictated by the opportunities

that parents and carers give them. Pre-school children need unstructured, active and energetic

play to allow them to develop their movement skills. It is recommended that pre-school

children who can walk participate in 3 hours of activity a day. This should combine light

intensity activity, active play and more energetic activities, such as running, swimming (Start

Active, Stay Active, 2011).

Table 11. Example of activities at different intensities.

Examples of

activities at

different intensities

Example activities

Sedentary Naps, TV viewing, fidgeting, drawing, reading

Light Pottering, slow movement of the trunk from one place to another,

e.g. moving about, standing up, walking at a slow pace

Moderate to

vigorous (more

energetic)

Rapid movement of the trunk from one place to another, e.g.

climbing, swinging/hanging, playing games in a park with friends,

riding a bike, dancing to music, running, swimming, skipping

(Start Active, Stay Active, 2011).

42


By the time children start school they are developmentally ready to benefit from more

intensive activity, over shorter periods, so a daily minimum of 60 minutes of moderate

intensity activity is recommended (Start Active, Stay Active, 2011).

6.1.2. Activity in Childhood (5–18 years).

Between 5 and 18 children and young people establish behaviour patterns that have important

implications for their immediate and long-term health and well-being. A significant factor in

the level of activity of young people is the levels of social and logistical support provided by

parents and, carers. Between the ages of 5 and 18 patterns of physical activity change from

short bursts of high intensity activity in childhood to more adult patterns of physical activity

and sedentary behaviour in late adolescence. It is important that children and young people

participate in physical activities appropriate for their age and development.

Guidelines for children and young people (Start Active, Stay Active, 2011):

1. All children and young people should engage in moderate to vigorous intensity

physical activity for at least 60 minutes and up to several hours every day.

2. Vigorous intensity activities, including those that strengthen muscle and bone, should

be incorporated at least three days a week.

3. All children and young people should minimise the amount of time spent being

sedentary (sitting) for extended periods.

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Table 12. Examples of activities for children and young people.

Type of activity Examples

Unstructured (children) Indoor or outdoor play, active travel

Unstructured (young people) Social dancing, active travel, household chores, temporary work

Structured (for children and

young people)

Organised, small-sided games with equipment that maximises

success (large racquets, low nets, big balls etc). Educational

instruction that promotes skill development Sport and dance

Muscle strengthening and

bone health (children)

Activities that require children to lift their body weight or to

work against a resistance. Jumping and climbing activities,

combined with the use of large apparatus and toys, would be

categorised as strength promoting exercise

Muscle strengthening and

bone health (young people)

Resistance-type exercise during high intensity sport, dance,

water-based activities or weight training in adult-type gyms

(Start Active, Stay Active, 2011).

Between the ages of 5 and 7, the guidelines build on those for early years. Patterns of activity

commonly involve a mixture of running, jumping, climbing, hopping and skipping activities,

interspersed with short periods of rest. As the child develops activity can also involve the

development of object-control (catching, throwing, striking, kicking) and stability (balancing)

44


movement skills. These activities are characterised by high intensity bursts interspersed with

short periods of moderate and light activity or standing. The activities can cumulatively

contribute towards the recommended 60 minutes a day (Start Active, Stay Active, 2011).

During the teenage years children become more independent and are influenced by friends

and external role models. Activities include participation in sports and dance clubs, gyms,

swimming, cycling, and outdoor adventurous pursuits. Adversely, the transition from primary

to secondary school is often associated with significant decreases in physical activity;

particularly in girl sand the behaviour of older teenagers is likely to be more similar to that of

adults (Start Active, Stay Active, 2011).

It is well documented that a larger quantity of activity at higher intensity (such as playing

sport) can bring further benefits and provide aspiration therefore; it is crucial that young

people develop a lifelong sporting habit at a young age. To achieve this, sport needs to be

seen as an intrinsic life choice. Sport England believe choice and engagement are key to

encouraging young people in to sport and preventing them from dropping out at the critical

point when they are 16-18 years old.

6.1.2.1. Sport England.

Sport England is the governing body responsible for distributing funds and providing

strategic guidance for sporting activity in England. Its role is to build the foundations of a

community sport system by working with national governing bodies of sport, and other

funded partners, to increase and sustain the number of people participating in sport; and help

talented people from all background excel by identifying them early, nurturing them, and

45


helping them move up to the elite level (see figure 5). Since 1994, Sport England has invested

over £2bn of Lottery funds and £300 million from the Exchequer into sports in England.

A major focus for Sport England is to fulfil the Olympic and Paralympic pledge to get one

million more people taking part in sport by 2012/13. Sport England works with the Youth

Sport Trust to deliver the Government’s PE and Sport Strategy for Young People (PESSYP).

This strategy sets out how the Olympic legacy aim to get more children and young people

taking part in high quality PE and sport will be reached. As part of this the government have

introduced a new national school sports competition based on the Olympic style. The

competition will see young people competing within their own schools and against other

local schools in a wide range of sports. It will culminate in a national competition in 2012 in

the Olympic Park, with formal opening and closing ceremonies and medals. The government

hope to spark a revolution in school sport, and leave a lasting legacy from London’s Olympic

Games to maximise the sporting opportunities available to all. However a true Olympic

legacy needs be judged in the long term, as the benefits of the considerable investment in

sport really take effect.

46


Figure 5. Role of Sport England. (Sunderland City Council 2005).

The most recent strategy launch in January this year, is the Youth and Community Strategy

for Sport England. The strategy describes how over £1billion of National Lottery and

Exchequer funding will be invested over the next 5 five years. The areas of investment will

be:

National Governing Bodies (NGB’s).

Facilities.

Local Investment.

School Games.

47


6.2. Local Strategies Relating to Activity.

Provision for activities in the early years in Sunderland is provided by Children’s Centres

which were developed from The Sure Start Programme. Sure Start was launched in 1999 to

improve outcomes for children; it led a whole range of innovative developments to support

the physical and emotional health of children and their parents in the early years, particularly

those from the most deprived communities. There are a wide range of activities available in

such as’ Busy Bodies’ and’ Fit Kids’ which are aimed at encouraging activities in the Early

Years. These activities are provided free of charge in Children’s Centres and are promoted in

the media and by health professionals working with families of very young children.

Sunderland has also adopted the recommendations of The Play Strategy (2008) to provide

safe high quality play areas for children across the city. Various activities are also held in

local community centres, church halls and swimming pools across the city.

Figure 8. Showing national and local strategies.

48


Sunderland city council recognises the impact of sport and physical activity on the physical

and social health of communities and has developed strategies to support national

recommendations. An important element of this includes the provision of a wide range of

opportunities to participate in sport and physical activity. The Sport and Physical Activity

Strategy (2005) set out how Sunderland’s Local Strategic Partnership would contribute to

this, through the development of sport and physical activity opportunities across the city.

The aim was to:

• Increase Participation - in a wide range of pursuits, such as participating in walking, water

sports, skateboarding, cycling or angling, going to the gym or swimming, playing football,

cricket or golf. It also included playing in the local park or playground, coaching and

refereeing.

• Improve Facilities - including leisure centres, playing pitches, play areas and recreational

water facilities.

• Developing New Facilities to meet new challenges.

The Strategy recognised the wide range of sport and physical activity opportunities delivered

in the city by all agencies including the public and private sector, and crucially, the voluntary

sector. Conversely, substantial improvements have been made across the private and public

sector to facilities and buildings throughout the city. Over the last decade Sunderland has

seen the opening of the new 50 m, Olympic standard swimming pool. Sunderland Teaching

Primary Care Trust and Sunderland City Council together have developed new Wellness

Centres across the city. The council have also demonstrated their commitment to incorporate

activity into daily life by expanding cycle ways across the city.

49


Sunderland Football Club, through the Sunderland AFC Foundation, also plays an important

part in inspiring many young people into sport in the city with their ‘Smart’ education room

and outreach programme. The “Black Cats” make a significant contribution to developing a

positive image for Sunderland.

6.3. Activity in Schools.

Physical Education and sport play an important role in children’s education; it raises

standards, improves health and behavior and develops social skills. In 2004, Choosing Health

set out a commitment that half of all schools would be Healthy Schools by 2006, with the rest

working towards Healthy School Status by 2009.

Physical activity is a core element of the Healthy Schools Programme (1999) to ensure

schools prioritised time and facilities for physical activity and sport both within and beyond

the curriculum. The P.E & Sport Strategy for Young People (PESSYP, 2008), was introduced

to increase the percentage of 5 to 16 year old school children in England, who spent a

minimum of five hours each week on high quality PE and School Sport within and beyond

the curriculum.

The PESSYP (2008) incorporated ten different work strands:

1. Developing club links between schools and community clubs to help young people to take

part in sport outside of school hours.

50


2. Coaching - The implementation of a specific targeted coaching program that places

employed coaches into school settings and helps develop skills in young people in specific

sports.

3. Competition - To develop both intra and inter school competition to increase the number of

children taking part in competitive sports.

4. Continuing Professional Development - Providing the opportunity for teachers and other

professionals to gain valuable experience by attending training courses and developing

accordingly.

5. Disability - Increasing provision to sport for people with disabilities.

6. Gifted & Talented - Developing talented athletes and providing them with the necessary

support and development to become potential stars of the future.

7. Infrastructure - Improving the infrastructure of schools and the SSP to help widen

opportunities that young people have to sport.

8. Leadership & Volunteering - Step into Sport, a programme to increase the quantity, quality

and diversity of young people engaged in volunteering and leadership.

9. Sport Unlimited - to provide funding opportunities for young people to access sport in an

after school setting to engage them in new sports.

10. Swimming - Increasing the percentage of young people who have the ability to swim and

placing this sport onto the curriculum.

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However, in 2010 the new coalition government ended the £162 million PE and Sports

Strategy of the previous government, stating it would to give schools the time and freedom to

focus on providing competitive sport. They stated that in recent years there had been a

decline in young people taking part in traditionally competitive sports such as rugby union,

netball and hockey because teachers and school sports coordinators have been too focused on

top-down targets. This is supported by The School Sport Survey (DFE, 2009-2010) which

showed only around two in every five pupils play competitive sport regularly within their

own school, and only one in five plays regularly against other schools. The new government

aimed to create an Olympic legacy by encouraging more competitive sport and to give

schools the freedom to organise sport themselves.

PE is included in the national curriculum at all levels with pupils having attainments targets

to pursue. At key stage 1 & 2 levels pupils have a variety of sports available to them

including dance, games gymnastics and swimming. Key stage 3 older children can take part

in a variety of sports available including athletics, outdoor and adventure pursuits

(Education.direct.gov.uk, 2011). The Government plan to continue providing two hours a

week of PE and sport within the national curriculum.

Statistical information on PE and sport in schools across England has been collected by

surveys conducted annually since 2003/04. The surveys have provided insight into the

variations in patterns of participation by year group and have provided a valuable means of

tracking changes in participation in PE and sport in schools across the country (PE and Sport

Survey 2009-10). PE and sport was first measured in schools in 2003/04 at that time 62% of

52


pupils achieved the recommended target. This rose over a five year period to 86% in

2009/010 (see table 13).

Table 13. Percentage of pupils participating in at least 120 minutes of curriculum PE at

national level.

Years % Number of pupils participating in 2 hours of physical

activity.

2000-2001 2009-10

Years 1-11 Not Available 86%


Source: the PE and Sport Survey, (2009-2010).

As a broad statement, participation levels tend to be highest in Years 1 - 6, which is where

most progress has been made. On entry to Key Stage 3, participation starts to decline, and

although considerable progress has been made in both Key Stage 3 and Key Stage 4, take up

here remains lower. In particular the recent widening of the survey in 2008/09 to encompass

further education show Years 12 and 13 have much lower levels of participation (PE and

Sport Survey, 2009-2010).

The collection of information on differences between the sexes has added a new dimension to

the survey. It has shown that generally, boys score more highly on most of the survey

measures, and differences between the sexes starts to show on entry to Key Stage 3, and

becomes more exaggerated as pupils progress Key Stage 3 into Key Stage 4. All surveys have

also collected information on competitive activities at both an intra- and inter-school level. A

major finding from this year’s survey has been the very considerable increase in intra- school

53


competition, from 69% across Years 1 - 11 in 2008/09 to the current level of 78%. This

increase is also apparent in the further education survey and represents very considerable

progress, which has also been echoed in the big increase in regular participation in intra-

school competition (up from 28% in 2008/09 among Years 3 – 13 to 39%). There was also an

increase in levels of inter-school competition (PE and Sport Survey, 2009-2010).

In 2005 Sunderland City Council developed the City's PE and School Sport Strategy to focus

upon improving physical literacy and improving the channels for young people between

schools and community based facilities and clubs. Table 14 shows the percentage of children

participating in 2 hours of physical activity a week in Sunderland is similar to the national

average. In theory this would be expected as the national curriculum guidelines are for all

children in state funded schools in England to ensure equality.

Table 14. Percentage of pupils participating in at least 120 minutes of curriculum PE in

Sunderland.

Years % Number of pupils participating in 2 hours of physical

activity.

2000-2001 2009-10



Source: the PE and Sport Survey, (2009-2010).

Sunderland schools have also promoted the governments ‘Walking into Health’ campaign,

which encourages parents and children are now encouraged to walk to school. It is hoped that

this will incorporate exercise into daily life.

54


7.0. Conclusion.

Despite the plethora of strategies introduced both nationally and locally over the last decade

child hood obesity rates are continuing to rise (see table 1). During this time there have been

periods when the government claimed that childhood obesity rates were levelling off

however, Tam Fry, chairman of the Child Growth Foundation and spokesman for the

National Obesity Forum, disagrees," He suggests that government assurances that childhood

obesity levels are levelling are sadly wanting,". He suggests that "The Department of Health

should also be ashamed that a quarter of children arrive at primary school overweight or

obese. Furthermore he states that until its policies allow all UK four-year-olds to arrive at

school with a healthy weight, obesity rates will continue to spiral (The Guardian, 2010).

However, it should be acknowledged that some positive steps have been seen taken both at

national and local level in the fight against childhood obesity over the last 10 years. One area

55


in which improvement has been made is the gathering of a wide range of statistical

information related to childhood obesity which has made it easier to analyse information and

evaluate the effectiveness of strategies. This will be essential for future planning of strategies

to target obesity. A further improvement of the National Child Measuring Programme would

be the addition of a measurement to incorporate older children into the programme.

One area which has seen changes in data collection are the breastfeeding statistics. Over the

past 10 years there has been an increase in the number of mothers initiating breastfeeding

particularly locally (see table 3). However, due to the recent changes in data collection we

can now see that these rates are not being sustained (see table 4). Unfortunately bottle feeding

is entrenched in our culture and breaking this tradition is proving difficult.

Continued promotion of breastfeeding and support for mothers is crucial to encourage them

to breast feed their babies exclusively for 6 months as recommended by the WHO. Mothers

need to feel supported across a wide range of areas including work places, social and leisure

facilities. The statistics (see tables 3 and 4) would suggest that strategies introduced both

nationally and locally have induced an increase in the number of babies who are breastfed;

however this effect has been limited especially with more sustained breastfeeding. Therefore,

continued attention to breastfeeding is needed in order to achieve the sustained behaviour

change; that will lead to a reduction in childhood obesity and an overall improvement in

health outcomes for children. Many believe the government should follow the WHO and

introduce a total ban on the advertising of infant formulas.

As children grow they are also targeted by advertising campaigns from food manufacturers

who particularly target young children and promote foods which have poor nutritional values

and are high in sugar, salt and fat. There have been some restrictions put in place on the

advertising of unhealthy foods aimed at children however; a total ban on the advertising of

56


unhealthy foods would help in the fight against childhood obesity. Christine Haigh of the

Children's Food Campaign states ministers should legislate to protect children from junk food

marketing instead of ‘cosying up’ to the food industry.

Another area which has seen improvement over the last decade is the information available to

people about healthy eating. There are now a wide range of easily accessible resources

available for individuals of all ages. Furthermore, Change4Life has become one of the most

instantly recognisable brands in health improvement, enjoying high levels of trust and

involvement, from the public, healthcare professionals, staff in schools and early years

settings, local authorities, community leaders, charities and businesses (Change4Life Three

Year Social Marketing Strategy, 2011). The new Start4Life programme will also be

beneficial in providing information and support to pregnant women and mothers to enable

them to make informed choices about their child’s diet and lifestyle.

The government’s strategies relating to obesity focus on the premise of individuals making

informed choices about what they eat, however this remains difficult for many. The Food

Standards Agency (FSA) needs to work in partnership with the food industry to introduce

standardised, simple method of food labeling to make it simpler for families to make

healthier choices. Although it must be acknowledged that some improvements have been

made in this area, there continues to be no standardised method of providing simple

information food.

New standards for school meals have improved the quality of food in schools across the

country. Although initially some were opposed to the changes, the uptake of school meals has

increased which has ensured the majority of school age children, even those from low income

families, are receiving nutritious food whilst at school. In Sunderland, the introduction of the

57


Early Years Food policy aimed at pre-school children has also ensured the very young

receive nutritious food in various childcare settings in the city.

The Healthy Schools Programme is raising awareness of food amongst young people which

is crucial if they are to make informed choices about the food they eat. Practical cooking has

been expanded and strengthened in the national curriculum to help children develop the

knowledge and skills required to prepare and cook healthy foods to reduce the risk of obesity.

In Sunderland prevention of childhood obesity has involved strategic, low-cost community-

based efforts. This included providing information and promotion of lifestyle changes,

including promoting healthier foods for children, providing support for parents, increasing

the frequency and intensity and duration of physical activity at, improving access and

opportunities for children to play and participate in fun activities. The LAF programme has

proved to be a successful initiative, with positive results seen. This needs continued support

and promotion locally to broaden its positive effect and reverse the growing trend of obesity

locally.

The HENRY programme, which was the first programme specifically aimed at the early

years, was piloted in Sunderland. However, evaluation of the HENRY programme concluded

that it was more of a parenting course rather than an intervention to reduce obesity.

It could be argued that this is what is required with the very young children. The role of

parents in preventing childhood obesity cannot be underestimated. Parents need to develop

effective parenting skills to ensure they can provide guidance and support for their children.

They need to learn how to implement routines, especially related to mealtimes, to ensure their

children develop good habits for life. Furthermore, they need to learn how to manage

children’s behavior and set boundaries, especially to restrict the amount of time spent on

computers and watching TV. They also need to acquire the knowledge and skills to enable

58


them to provide a healthy diet and lifestyle for their children and most of all; they need to act

as good role models.

Another important area in which parents have a huge influence on their children’s behaviour

is activity. The rates of children achieving the recommended level of activity have increased

slightly from 66% to 68 % (see table 10). However activity remains an area where significant

improvements need to be seen in the fight against childhood obesity.

Schools are helping in this aim; children do have access to high quality PE and sport both

nationally and locally. Activity in schools is one area in which Sunderland is doing well; the

rates of participation are close to the national rate however there is still room for

improvement both nationally and locally.

Government policy over the last ten years has been successful in driving changes related to

activity at local levels. Sunderland City Council, as recommended by government, has been

proactive in working with its local partners in both the public and private sectors and there

has been considerable investment and improvement in facilities across the city to increase the

activity levels of children of all ages. However facilities alone do not improve sport and

physical activity participation.

Sunderland is an area of high deprivation and financial constraints exclude many children

from participating in out of school clubs and sporting activities. Sunderland City Council

have introduced initiatives such as free swimming and subsidised gym membership to help

children of low income families. The strategic partnership has also made improvements to

free local facilities such as parks, skate parks, cycle and walking routes for people to access.

The location of Sunderland, near to the coast also provides fantastic opportunities for children

to be active.

59


The recommendations recently released in Start Active, Stay Active (2011) now provide

clear concise guidelines for activity levels in children of all ages however; children of all ages

require support to achieve them. Parents need to be motivated and active with their children

from the beginning. As children grow parents need to encourage involvement and

participation in sports at all levels.

In conclusion obesity is the greatest threat to child health in this century. Healthy eating and

exercise must become an integral part of an overall lifestyle pattern from an early age if we

are to prevent the rising rates of obesity.

Over the last decade there has been a plethora or strategies produced to tackle childhood

obesity at macro and micro levels. In my opinion these strategies provide sufficient

information and resources at national and local levels for individuals to make ‘informed

choices’ about their lifestyle and prevent obesity. However the underpinning factor is the

motivation to make the changes required.

Understanding and preventing obesity is complex and so far there are no examples anywhere

in the world where the obesity trend has been reversed (The Foresight Report, 2007). A

reduction in childhood obesity will take many years and in this difficult economic climate

cuts are being made in the provision of services both nationally and locally. However, if we

are to see a reverse in the trend of childhood obesity funding must continue to support the

progress made so far.

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Word Count: 11,430

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9.0. Appendices.

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Appendix 1

68


Appendix 2

69


Appendix 3

70


Appendix 4

71


Appendix 5

72


73


Appendix 6

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Appendix 7

75

undergraduate dissertation

Documents

national strategies

local strategies

national food

local food

rates of obesity

causes of obesity

measurement of obesity

definitions of obesity