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1 Appendix 1: Report to Lambeth Children’s Services Scrutiny Sub-Committee Title Addressing Childhood Obesity and Promoting Healthy Weight in Lambeth Date March 2019 Author Bimpe Oki, Consultant in Public Health, [email protected] 1. Introduction This report has been produced for Lambeth Children’s Services Scrutiny Sub-Committee to provide an update on childhood obesity locally and the efforts, challenges and opportunities to effectively address the issue. This report specifically provides; a brief background to childhood obesity in Lambeth the scale of the problem a summary of the evidence of what works to address childhood obesity the local approach and action being taken challenges, mitigation and opportunities to tackling childhood obesity recommendations 2. Background 2.1. Childhood obesity is a growing public health concern nationally and in Lambeth. Being overweight has now become a normal condition in the UK. Childhood obesity can cause social, psychological and health problems. Obese children are more likely to be ill, be absent from school due to illness, experience health-related limitations and require more medical care than healthy weight children. Overweight and obese children are likely to experience bullying and stigma. There is a suggestion of a ‘conveyor belt’ effect in which excess weight in children continues into adulthood. Approximately 70% of obese children will become obese adults, giving rise to a higher risk of ill health, disability and premature mortality in adulthood. 2.2. The causes of obesity and overweight are complex and multifactorial and it will take several decades to reverse the factors that are driving current trends. It is a consequence of interplay between a wide variety of variables and determinants related to individual biology, eating behaviours and physical activity, set within a social, cultural and environmental landscape. Human biology, growth and development early in life, eating and physical activity behaviours, people's beliefs and attitudes and broader economic and social drivers all have a role to play in determining obesity. It is now generally accepted that the current prevalence of obesity in the UK population is primarily caused by people’s biological system struggling to maintain an appropriate energy balance within a changing modern environment that includes more sedentary lifestyle and increased dietary abundance. 1 3. The scale of childhood obesity in Lambeth 3.1. The main source of local data for childhood obesity is from the National Childhood Measurement Programme (NCMP). The NCMP is an annual measurement of the height and weight of reception class (4-5 year olds) and year 6 (10-11 year olds) children in England. The programme has been implemented in Lambeth since 2006-7. The purpose of the NCMP is: to inform local planning and delivery of services for children to gather population level surveillance data to allow analysis of trends in growth patterns and obesity 1 Foresight (2007) Tackling obesities: future choices project report. London: Government Office for Science

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Page 1: Appendix 1: Report to Lambeth Children’s Services …...1 Appendix 1: Report to Lambeth Children’s Services Scrutiny Sub-Committee Title Addressing Childhood Obesity and Promoting

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Appendix 1: Report to Lambeth Children’s Services Scrutiny Sub-Committee

Title Addressing Childhood Obesity and Promoting Healthy Weight in Lambeth

Date March 2019

Author Bimpe Oki, Consultant in Public Health, [email protected]

1. Introduction

This report has been produced for Lambeth Children’s Services Scrutiny Sub-Committee to provide an update on childhood obesity locally and the efforts, challenges and opportunities to effectively address the issue. This report specifically provides;

a brief background to childhood obesity in Lambeth

the scale of the problem

a summary of the evidence of what works to address childhood obesity

the local approach and action being taken

challenges, mitigation and opportunities to tackling childhood obesity

recommendations 2. Background 2.1. Childhood obesity is a growing public health concern nationally and in Lambeth. Being overweight has now become a normal condition in the UK. Childhood obesity can cause social, psychological and health problems. Obese children are more likely to be ill, be absent from school due to illness, experience health-related limitations and require more medical care than healthy weight children. Overweight and obese children are likely to experience bullying and stigma. There is a suggestion of a ‘conveyor belt’ effect in which excess weight in children continues into adulthood. Approximately 70% of obese children will become obese adults, giving rise to a higher risk of ill health, disability and premature mortality in adulthood. 2.2. The causes of obesity and overweight are complex and multifactorial and it will take several decades to reverse the factors that are driving current trends. It is a consequence of interplay between a wide variety of variables and determinants related to individual biology, eating behaviours and physical activity, set within a social, cultural and environmental landscape. Human biology, growth and development early in life, eating and physical activity behaviours, people's beliefs and attitudes and broader economic and social drivers all have a role to play in determining obesity. It is now generally accepted that the current prevalence of obesity in the UK population is primarily caused by people’s biological system struggling to maintain an appropriate energy balance within a changing modern environment that includes more sedentary lifestyle and increased dietary abundance.1 3. The scale of childhood obesity in Lambeth 3.1. The main source of local data for childhood obesity is from the National Childhood Measurement Programme (NCMP). The NCMP is an annual measurement of the height and weight of reception class (4-5 year olds) and year 6 (10-11 year olds) children in England. The programme has been implemented in Lambeth since 2006-7. The purpose of the NCMP is:

to inform local planning and delivery of services for children

to gather population level surveillance data to allow analysis of trends in growth patterns and obesity

1 Foresight (2007) Tackling obesities: future choices – project report. London: Government Office for Science

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to increase public and professional understanding of weight issues in children

to act as a useful vehicle for engaging with children and families about healthy lifestyles and weight issues

3.2. The data from the Lambeth NCMP has allowed us to observe local trends and assess how local obesity levels compare to other boroughs and England as a whole. The most recent findings (2017/18) show that 10.5% of Lambeth Reception children are classified as being obese compared to 10.1% and 9.5% for their London and England counterparts. For Year 6 in Lambeth, 24.6% are deemed obese against 23.1% for London and 20.1% nationally. (See figures 1 and 2).

Figure 1: Weight Categories for Lambeth Reception Year Children (2009/10 – 2017/18)

The overall trend for obesity for Reception Year children in Lambeth shows a reduction. For Lambeth Year 6 children, the trend shows a plateauing. (See figures 3 and 4).

3.3. Nationally and locally, the NCMP shows a strong, positive relationship between deprivation and obesity prevalence for children in each age group. Inequalities are also evident between certain ethnic groups, with children in Black ethnic groups having a significantly higher risk of obesity than those in Mixed, Asian, Other and White ethnic groups. 3.4. A multi-variate analysis of the NCMP data over a five year period showed that in Lambeth

Boys are more likely to be obese compared to girls

All ethnic subgroups are more likely to be obese compared to White British group with Black Caribbean and Asian nearly twice as likely to be obese

Childhood poverty is significantly associated with obesity 1.5 to 2 times higher for the most deprived compared to the least deprived

1.1% 1.9% 1.6% 1.0% 1.0% 1.3% 1.2% 1.2% 1.5%

72.5% 72.7% 75.5% 75.2% 74.4% 75.0% 75.5% 74.4% 74.6%

13.5% 13.2% 12.2% 11.9% 12.6% 13.6% 12.3% 14.0% 13.3%

12.9% 12.1% 10.7% 11.9% 12.0% 10.1% 11.1% 10.4% 10.5%

0%

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20%

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2009-10 2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 2017-18

% o

f ch

ildre

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Reception

Underweight % Healthy weight % Overweight % Obese %

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Figure 2: Weight Categories for Lambeth Year 6 children (2009/10 – 2017/18)

Figure 3: Obesity Trends for Lambeth, London and England Reception Year children (2006-2018)

0.8% 1.0% 1.0% 1.0% 0.7% 1.1% 1.2% 1.7% 1.2%

57.6% 59.2% 60.1% 59.1% 58.1% 57.1% 59.4% 59.1% 59.3%

16.9% 15.1% 14.9% 16.0% 16.6% 15.1%16.3% 13.6% 14.9%

24.7% 24.8% 24.0% 23.9% 24.7% 26.6% 23.2% 25.6% 24.6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2009-10 2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 2017-18

% o

f ch

ildre

n

Year 6

Underweight % Healthy weight % Overweight % Obese %

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Figure 4: Obesity Trends for Lambeth, London and England Year 6 children (2006-2018)

3.5. The “What About YOUth”2 survey is the best available data that provides an indication of levels of the percentage who eat 5 or more portions of fruit and vegetables a day. It suggests that for 15 year olds in Lambeth, 54% eat 5 or more portions of fruit and vegetables a day. This is fairly similar to 56.2% for the whole of London and 52.4% nationally. Children aged 5 to 15 are recommended to be at least moderately active for at least 60 minutes every day. The survey shows 10.9% of Lambeth 15 year olds physically active for at least one hour everyday 72.2% of Lambeth 15 year olds spend an average of 7 hours /day in sedentary time. 3.6. Since 2004, the Schools Health Education Unit survey has been conducted in Lambeth schools. It provides some indication of health behaviour of children using self reporting. Findings in 2018 show that 27% of primary pupils said that they had five or more portions of fruit and vegetables the day before and 53%.of primary pupils who report enjoying physical activities 'a lot'. 21% of secondary pupils said they had at least 5 portions of fruit and vegetables the day before. 14% of secondary pupils said that they exercised enough to get out of breath and sweaty on at least 5 days in the previous week. 3.7. There has been extensive local qualitative and engagement work done which shows that there is a lack of recognition of obesity and it is mainly defined in aesthetic and functional terms. Culture and social conditions has an impact on eating and activity behaviour. Lambeth commissioned a research study to identify the knowledge, behavioural choices and attitudes associated with healthy foods amongst Black Caribbean, West African, White British, Portuguese and Somalian mothers residing in Lambeth. The Lambeth study concluded that:

There was awareness, across all communities, of the recommended five fruits and vegetables a day and the link between poor diet and health

Most people consumed more carbohydrates and meat, and less fruit and vegetables than the recommended amounts, with meal portions often very large

Participants defined being overweight in aesthetic terms and obesity and health in functional terms

2 2 Department of Health, What About YOUth (WAY) survey, 2014/15

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Most respondents did not identify with people who lived a healthy lifestyle (consisting of consuming five fruits and vegetables and doing 30 minutes of physical activity daily)

Stressful lives, expense and children disliking fruits and vegetables were seen as major and additional barriers to achieving healthy lifestyles.

In addition, the research revealed frequent use of convenience foods and takeaways particularly with the White British, Black Caribbean and West African mothers. In the West African community, a number of respondents reported that it was common to eat what would count as a full meal in terms of calorie intake (such as take-away fried chicken, a hamburger or a sandwich) but to regard this as a mere snack to be followed by a “proper” meal later. Generally, this seemed to be rooted in the view that a “meal” is what is eaten at home, at regular time and in the company of others, while everything else is treated as a “snack”. 4. What works to effectively tackle childhood obesity? 4.1. Over the last 10- 15 years evidence has been emerging about what works to effectively tackle childhood obesity. Key guidance comes from the Foresight Obesity Report3 and The National Institute of Health and Care (NICE)4 and highlights include:

• A cross-cutting, comprehensive, long-term approach that brings together multiple stakeholders is essential. This should comprise of a portfolio of interventions targeting a broad set of variables and different levels within the obesity system

• Interventions need to cover the entire terrain; otherwise continued drivers acting on one part of the obesity system might undermine positive action elsewhere

• Single isolated initiatives do not work • Social, environmental and economic factors must be considered in addressing the

obesogenic environment. • The distinction between prevention and treatment is important. Emphasis on

prevention is vital. However, there are already significant numbers of obese people requiring treatment and the numbers will require short-term measures. Treatment interventions are therefore also needed

• The need for short-term action and impact must be balanced against the drive for longer-term sustainable change

4.2. Specific evidence-based interventions to prevent of childhood obesity: Obesity prevention does not simply mean preventing normal-weight individuals from becoming obese; it encompasses a range of strategies that aim to prevent:

the development of overweight in normal-weight individuals

the progression of overweight to obesity in those who are already overweight

weight regain in those who have been overweight or obese in the past but who have since lost weight

These lead to the general reduction of the average weight of the whole population. For early years, promoting breastfeeding, good introduction to solids and developing positive healthy eating and activity behaviours is important. For primary school children, the development of life-long healthy eating and physical activity practices through a whole, healthy school approach (pupils, staff, parents, curriculum, environment, school policies and practices) is necessary.

3 Foresight (2007) Tackling obesities: future choices – project report. London: Government Office for Science 4 NICE has produced over 12 obesity related guidance documents since the 2006 NICE clinical guidance:

Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and

children . The most recent obesity related guidance is the NICE: Managing overweight and obesity among

children and young people (2013). www.nice.org.uk

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These specific interventions highlighted above for early years and primary school should be supported by universal services that promote healthy eating and physical activity. Within these universal services there should be targeting more resources proportionately to those who are more disadvantaged or are at greater risk. Examples of universal service include:

Health and social care practitioners routinely raising the issue of weight and providing brief evidence based advice and signposting to appropriate services

Transport and built environments plans that promote physical activity (e.g. active travel and play)

Environmental and planning strategies that increase access to, and opportunities for physical activity and healthy food (e.g. provision of and access to safe green open space and opportunities for play and food growing, working with food businesses)

Leisure and culture strategies to improve access to and facilities for structured leisure programmes and unstructured opportunities for physical activity (e.g. access to parks, open spaces and safe play areas, ensuring access to all including those with disabilities).

Community led initiatives using community action and assets to support individual and community action to promote healthy weight. (e.g. grow, cook and eat clubs)

4.3. Specific evidence based interventions to treat childhood obesity: Treatment strategies refer to weight management services. In the case of children, most of the time these services do not aim for weight loss but weight maintenance to allow children to “grow into their weight.”. Guidance from NICE indicates that evidence based children weight management services should be multi-component (comprising of behaviour change, physical activity and diet) and family focused, i.e. involve parents and carers. Single-strategy approaches to managing weight are not recommended for children. A range of weight management services must be available to effectively support children with different severity of overweight and obesity. These services should be accessible for all children who have been part of the National Child Measurement Programme and would benefit from this support.

5. The Approach to tackling childhood obesity and promoting healthy weight in Lambeth

5.1. Lambeth is taking a system wide evidence based approach to address this strategic priority and has a good track record of implementing a systematic and evidence based approach. The work to tackle childhood obesity in Lambeth was developed using a good evidence base, and over the years have continued to build on this using feedback and local intelligence from stakeholders including children, young people and families from different backgrounds, communities, schools, practitioners, and businesses. It has involved research and insight to understand local cultural practices in early years including breastfeeding and the introduction to solids, an understanding of the perceptions, attitudes and views of different population groups in Lambeth around issues such as overweight, obesity, healthy eating and physical activity.

5.2. The borough’s work has been of national interest and it has been used as regional and national case studies5; and has also received international recognition. It has also been

5 Childhood obesity: a plan for action (DH, 2016) https://www.gov.uk/government/case-studies/lambeth-council

National Childhood obesity: a plan for action Chapter 2 (DH, 2018)

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/718903/childh

ood-obesity-a-plan-for-action-chapter-2.pdf

Healthy weight, healthy futures Local government action to tackle childhood obesity (LGA, update 2018)

https://www.local.gov.uk/sites/default/files/documents/22.16%20%20Health%20weight%2C%20healthy%20fut

ures_WEB.pdf

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externally endorsed by Public Health England (PHE), a few years ago Lambeth was the only borough in the country to have a significant reduction in childhood obesity for both Reception and Year 6. PHE conducted a deep dive to understand what Lambeth was doing. The findings from the external assessment of PHE (link) has also helped to continue to inform the local work.

5.3. Lambeth is taking is this whole systems approach to enable a population shift towards more children being in the healthy weight category and fewer children moving towards being overweight and obese. Taking this population approach means working towards

shifting more underweight children into the healthy weight category

supporting healthy weight children to maintain their healthy weight status

preventing overweight children from becoming obese and helping them achieve healthy weight status; and

reducing the proportion of children that are obese by moving them towards the healthy weight category

The ultimate aim is to have a greater proportion of healthy weight children within the population (see figure 5 illustrating shifting weight distribution).

Figure 5 : Illustrative Chart Showing the Aim to Shift Weight Distribution in the Population to a Healthy Weight in Lambeth

(DH 2008)

Shifting the weight distribution in the desired direction requires long term sustained co-ordinated action. 5.4. Achieving a reduction in childhood obesity levels require both preventive and treatment measures. Lambeth is implementing both measures which rely on addressing or modifying risk behaviours of unhealthy eating and physical inactivity. The interventions and programmes

% of population

% of population

The aim is to reduce the proportion of the population that are in the

underweight, overweight and obesity categories and moving them

into the healthy weight category thereby increasing the proportion of

the population that is of a healthy weight

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range across prevention and treatment interventions at individual, community and at borough policy level.

5.5. A local evidenced based pathway children’s healthy weight pathway (0 -4 years old and 5-12years old) is in place and there are relevant specific commissioned interventions which support the pathway. These interventions have been reviewed and evaluated and over the years the learning has provided a wealth of local intelligence to support the future implementation of programmes to address childhood obesity.

5.6. Commissioned interventions form only part of local actions taken, however a summary of the commissioned services, output and learning have been summarised.

5.6.1. Breastfeeding: The promotion of breastfeeding is included as an integral part of the Lambeth Healthy Weight programme, adopting the UNICEF Baby Friendly Initiative. Lambeth is now a fully accredited Baby Friendly borough. This accreditation was supported by a Breastfeeding Needs Assessment carried out by Lambeth Public Health. Some of the key findings show that mothers under 24 years and those over 45 years old were least likely to exclusively breastfeed. They tended also be Black African, Black Caribbean and Asian mothers, those from the most deprived areas and those with children born of low birth weight. Feeding in public (including public attitude and places to feed), social influence (media, family and friends), knowledge and Information (culture, unrealistic expectations, milk supply) and conflicting messages (not enough information on breastfeeding before birth) were all seen as local barriers to breastfeeding. Whilst breastfeeding services (Milk Spots and midwife influence), breastfeeding culture in Lambeth were deemed enablers. The needs assessment highlighted the importance of having support for families from antenatal and crucially in the early weeks in regards to breastfeeding. Having peer support that include people from groups less likely to breastfeed appears to be more effective in reaching these groups. 5.6.2. Promoting healthy weight in early years settings: community nutrition support is offered through children centres to provide healthy weight promoting environments. It includes conducting introduction to solids sessions and has Community Food workers whose roles are to provide practical support and offer family cooking sessions, shopping and cooking on a budget. Learning from the work suggests that although families know the healthy eating messages, they struggle to apply it in their lives. Cultural practices play a role in early introduction of solid food and families benefit from having practical support around buying and cooking which takes into account their social and cultural circumstances. 5.6.3. Bespoke multiagency (health and non- health) capacity building on children’s healthy weight: equipping health and non-health workers with knowledge, skills and tools to effectively work with local children and their families to tackle obesity by providing training to:

• Understand local context and the Lambeth Children’s Multi-agency Care Pathway. • Receive up to date knowledge on healthy weight; overweight; nutrition & physical

activity in the local context • Know how to effectively raise the issue of healthy weight with children & families • Be able to provide evidence based advice & assist children & their parents to access

local support and services. • Understand how to use information and practical tools in the Resource Pack • Incorporate learning into routine practice

Over 1,500 participants in Lambeth (clinical. non-clinical and voluntary sector backgrounds) have been trained, an independent evaluation showed that:

• 82.3% felt the training fully achieved the objective of providing individuals with information about healthy weight; overweight; nutrition & physical activity,

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• 80% felt the training fully achieved objective of showing how to raise the issue of healthy weight with children & their families

• 100% felt that their knowledge of the subject had been enhanced. • 77.6% of attendees have, on return to their work, instigated more dialogues about

healthy weight for children with clients, with 45.7% of these saying clients had actively taken on the advice , & made positive healthy weight

• 87.5% found the bespoke resource pack useful

The evaluation showed that these workshop are popular with frontline staff and effective for making healthy weight for children “everybody’s business” and is reaching significant numbers working in a variety of different environments. The majority of those who have attended the training seem to have improved their skills, confidence, and behaviours with clients leading to more dialogues about healthy weight for children with their clients, with examples of changing behaviours. The value of bringing together participants from a wide spectrum of different roles is beneficial, with positive interaction adding value and applied learning to the overall experience.

5.6.4. A bespoke capacity building training for Lambeth GPs around childhood obesity showed that:

• Less than 5% of GP staff were able to identify a very overweight child by visual inspection

• When provided with data, less than 10% were confidently able to interpret the BMI for this child

• 98% of participants reported feeling more confident in raising the issue of weight in children, with parents/carers having completed the training workshop.

5.6.5. Lambeth schools healthy weight promotion programme: this programme supported schools and their staff to effectively promote healthy weight. A prerequisite of the delivery of this programme was to ensure that senior staff were engaged and attended the training such as School Governors and Head Teachers. Due to budget savings, the schools programme has been integrated to the wider multi-agency capacity building programme. However the evaluation of the programme showed

• >80% indicated that the majority of the content is highly relevant, and majority of attendees acquired new knowledge related to childhood obesity, and their potential role in combating it.

• Direct contact with over 400 school management and staff, 800 pupils & 150 parents • Curriculum & other school resources developed for the online VLE

Prior to the workshop, no staff had the correct interpretation of BMI, none had heard of the term ‘Obesogenic Environment’ and none had any knowledge of the NCMP. The evaluation concluded that:

• Schools are limited in the amount of time they can offer for the training, delivery must be flexible

• Training appears to be a powerful tool in changing school staff perceptions of childhood obesity, and their potential roles in combating it. Findings validate the underpinning rationale for the intervention.

• The training provides an important ‘first foot’ in the door that could lead to greater penetration and influence within schools.

5.6.6. Specialist Healthy Weight School Nurse: This is a unique and innovative role and has been used as national example of good practice. This role is pivotal to the Lambeth Healthy Weight Care Pathway and the post has a key role in the identification, assessment and referrals of children and families to appropriate services to address healthy weight issues,

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as well as establishing links with key staff and practitioners working to support healthy weight issues across the Borough. The post provides:

• Dedicated support to proactively follow up “at risk” families identified through the NCMP

• Provision of expert advice and resource for children, families, schools, health and non-health sectors

• Assessment of families to enable the most appropriate service and/or support • More engagement of and support to the most vulnerable families and those with

complex needs

The Specialist school nurse has been working closely with wider school nursing team to develop capacity and to enable prioritisation of most “at risk” families. Approximately 500 NCMP children are followed up every year. Multiple approaches to engage with families are used (letters, phone calls, drop in sessions, face to face assessment) Families outside the NCMP are referred by a range of health and non-health practitioners. Good relationships have been built with key stakeholders e.g. School heads, GPs, family support workers, social workers, children centre staff and the Lambeth Children Healthy Weight Care Pathway providers.

The developmental nature of the Specialist nurse role allowed for innovation for relation building, e.g. Pre NCMP sessions with parents, involvement with children at school on a regular basis. There is increased confidence of general school nursing team to address the issue of unhealthy weight. The role provides a key contact for referral to programmes and interventions supporting the local care pathway. There is better understanding of family context and offers of support, in particular for the more vulnerable and complex cases. It increases the ability to continue to motivate and follow up post intervention and supports a holistic approach to addressing obesity

5.6.7. Lambeth Ready, Steady, Go! Weight Management Service: This is led by the Council’s Healthy Lifestyles team; and delivered by a consortium with My Time Active (MEND). The Service focuses on treating overweight and obese children and their families, using targeted prevention and early intervention.

The service is locally designed, offering both evidence based structured and a developing flexible access weight management programme components, for overweight and obese children aged 4- 6 years old and 5 -12 years old. It supports children and their families to make sustained behavioural changes to achieve increased physical activity & reduction in sedentary behaviour; improved eating behaviour and quality of diet; and improved emotional wellbeing and self -esteem. The primary outcome is a reduction in the BMI (Z-score) of children engaged. Secondary outcomes includes physical activity, diet, self-esteem and include equity of access and outcomes.

Evaluation of the service showed that of those who participated, about 52% were male and 48% female, with approximately 75% from Black heritage background and 50% from the most deprived wards. There was a completion rate of 73% and about 82% of the children had a reduction in their BMI z scores. These results were seen alongside significant improvements in nutrition, physical activity and well being, with a reduction in sedentary behaviour.

The amount of time and effort required to engage with children and families through schools, social networks and media campaigns to encourage take up of programme should not be underestimated. However once families engage, outcomes are very positive. Innovative ways of attracting families and helping them to commit include running specific school sessions, incentives such as links to sports clubs.

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5.6.8. Level 3 Specialist Weight Management Service for Lambeth is a ‘tailor made’ weight management service for obese children aged 4-12 years with additional social and / or medical needs. It combines family therapy paediatric health nutrition, physical activity using systemic and family therapy principles and practice. This approach offers a dynamic way of thinking about family difficulties whilst at the same time, focusing on family strengths and resources Central to its understanding is the importance of context e.g. race, culture, family and community

Findings from the evaluation revealed that about 56% of users of the service were male and 44% female. About two thirds come from a Black heritage background and a similar proportion from the most deprived wards. 45% live in a family unit where both parents live together and 43.3% live in single parent households and over half were the youngest sibling in the family. Psychosocial factors were recorded for 41.0% of referrals including parents with English as their second language; incidents of domestic violence in the family; and child protection issues in the family. The service managed to stabilize or reduce the BMI Z-Score of 82.6% of clients.

This programme has revealed that there is clear association between children’s excess weight and family psycho-social issues and is effective in helping to tackle underlying family issues either directly or by referrals to appropriate services.

5.7. Alongside these commissioned services, Public Health has taken a leadership role at community and policy levels. Examples of these include:

• Policy to restrict more fast food premises opening near schools through the Local Plan • Signing up as the first borough to sign the Local Authority Declaration on Healthier

Food and Sugar Reduction. Through the Declaration, Lambeth has committed to pledges around advertising and sponsorship, improving the food influenced or controlled by the Council, actively promoting drinking water, healthy catering commitment awards to food businesses, healthier public events and raising public awareness

• Facilitating and securing additional resources for Lambeth schools as part of the proceeds of the national Sugar Levy to promote healthy eating and physical activity. Feedback from schools regarding the process and support has been extremely positive. An example of how one of our schools and children have used the sugar levy and the reaction of the school children can be seen here: https://www.jessopprimary.org.uk/News/Outside-Gym/

• Having inner London Food Flagship borough status in recognition of the good work locally on healthy weight and promoting a healthier and more sustainable food system. Associated funding from the Flagship enabled consolidation of some locally developed food related programmes as well as piloting innovative interventions

• Working to tackle food poverty with a range of stakeholders. Lambeth has been recognised by Sustain- the alliance for Good Food as the borough doing the most to address food poverty. This recognition was given both in 2016 and 2018

• Promoting the uptake of food schemes for vulnerable families such as the Healthy Start vouchers with a local supplement for additional fruit and vegetables (Rose vouchers) from Brixton market

• Working with local food businesses to commit to healthier catering through the provision of healthier food and drink options.

• Have worked with Leisure service providers to provide healthier options in their vending machines

• Running practical cook and eat sessions for members of the community • Working with local community organisations to promote food growing and access to

other local food related activities

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• Working with colleagues to develop and implement the Active Lambeth strategy (Sport and Physical Activity strategy)

• The implementation of local campaigns and projects to promote and encourage children, young people and families to participate with physical activity, e.g. This Girl Can

• We are part of the London superzone pilot that is looking to promote a healthier environment around schools (within 400m)

• Working across schools and community to encourage children and families to eat more vegetable by aligning with the national programme of Veg Cities.

5.8. Partnership working forms a key element of the approach. This has involved being part of local partnerships, such as LEAP and forging close relationships with external organisations such as Guy’s and St. Thomas’ Charity, Crystal Palace Football Foundation and Veg Power.

5.8.1. Building on learning over the years, Public Health has helped to shape the development of the LEAP intervention around the nutrition and healthy weight outcomes. It aims to take a whole systems approach around food and healthy weight in small geographical areas (i.e. the LEAP wards). The intervention consist of programmes to address healthy weight, diet nutrition, physical activity from conception to reception and includes initiatives to develop capacity of practitioners around these issues, giving practical support to vulnerable families, and working with businesses and the community to create a healthier food environment. The delivery of the programmes are in its early stages however, great progress has been made with the capacity building programme and the recruitment to the post that will be working with local food businesses in the LEAP area to encourage them to become more health promoting places.

5.8.2. Tackling childhood obesity is one of the priorities for Guys and St. Thomas’ Charity. Public Health is working with the Charity to help align the work and add value to the local work. Some of the Charity funded work includes working with school caterers, healthy high streets and scoping potential adolescent obesity work.

5.8.3. Veg Power sponsored by ITV is running the national “Eat Them To Defeat Them” campaign to encourage children to eat more vegetables. Lambeth is amplifying the campaign locally, with additional school activities e.g. cooking demonstrations, and a large community event in Brixton market, GSTC is providing some funding towards the local evaluation.

6. Challenges and Opportunities 6.1. The issue of tackling childhood obesity goes beyond educational and individual behavioural approaches, hence the importance of taking a whole system approach. Addressing obesity is often used as an example of taking a whole system approach due to the fact that almost every part of society can influence obesity and it is strongly associated with health inequalities. Preventive action therefore needs to be taken alongside proximal ones to tackle childhood obesity in Lambeth, however there are a few challenges which need to be recognised and ways sought to try and mitigate against these. 6.2. Poverty: The diets of those on the lowest incomes are, on the whole, unhealthier than those in higher income brackets. Meeting the recommendations of the Eatwell Guide (the national guide to healthy eating) would currently require families on the lowest incomes (those earning less than £10,000) to spend 60% of their disposable income on food. Effectively tackling obesity will require good financial resilience policies in place.

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6.3. Austerity & welfare reforms: The UN Special Rapporteur on extreme poverty and human rights used evidence from the University of Liverpool’s Department of Public Health and Policy 6that showed that rising poverty, welfare reform and cuts to local government budgets in the UK have led to harmful effects on health and health inequalities for children and adults. At the same time as rising social and health needs from poverty in the UK, the resources available to health and social care services have been reduced, particularly in the most disadvantaged areas, limiting their capacity to respond to the observed adverse trends in health inequalities for children and adults alike. The researchers claim that the UK government welfare reforms have been deemed to have health damaging effects. These have led to several families transitioning into income poverty, partially reflected by the increase in the use of food banks by the “working poor” which are also being reported locally. The cuts to the wider local government budget has led to a significant reduction in public services, many of which relate to some of the wider determinants of obesity. 6.4. Difficult to plan for and implement sustained action: There is no quick fix to effectively reduce childhood obesity, many of the interventions require time to bed in and make a significant impact. Indeed PHE was highly impressed by the sustained approach Lambeth adopted. Long term planning and implementation is currently challenging partly as a result of the funding uncertainties highlighted, and possibly decision makers not fully appreciating that this multifactorial complex issue requires action across all parts of the system and not just one part. Due to the great interest on childhood obesity generated across all parts of society, including the media, there appears to be a perceived pressure to try to achieve significant positive results within an unrealistic timescale. 6.5. Wider environment, economic and social context: We are seeking to achieve behaviour change at population level. This requires ensuring that where our population live, school, work, interact and shop are designed to support these changes. We are mindful that the fear of crime which is a reality locally is a barrier to children and young people being active outside of school. Access to fresh, affordable healthy food is limited in certain deprived parts of the borough, and there is more incentive for fast food outlets to offer unhealthy food and drinks. People’s eating behaviour is strongly affected by their food environment – the availability, attractiveness and accessibility of food inside and out of the home – and that those living in deprived areas face multiple factors that make it more difficult to eat well. Those living in more deprived areas are likely to be faced with a greater number of unhealthy food options when they step out their door, and likely to have less money and headspace to find healthy alternatives. All this is against a backdrop of the promotion and advertising of high fat, sugar and salt products. 6.6. Mitigation and Opportunities to address identified challenges 6.6.1. Many elements of the challenges identified are beyond our direct control locally, since these need to be addressed across different sectors but particularly central government. However, Lambeth Public Health is continuing to work to seize opportunities and seek in various ways to try and mitigate and/ or help find solutions to some of these challenges. Of particular importance and priority is seeking to embed the Health in all Policies (HiAP) approach to leadership, governance and policy making locally. The WHO defines HiAP as “An approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity”.

6 Assessing the health impact of austerity and rising poverty in the UK: evidence from the University of

Liverpool’s Department of Public Health and Policy. Written submissions – the UN Special Rapporteur on

extreme poverty and human rights to the UK of Great Britain and Northern Ireland (2018)

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The HiAP manual for local government, stresses that HiAP is a collaborative approach to improving the health of all people by incorporating health considerations into decision-making across sectors and policy areas. HiAP is based on the recognition that our greatest health challenges are highly complex and often linked through the social determinants of health. Just one government sector will not have all the tools, knowledge, capacity, let alone the budget to address this complexity. The goal of HiAP is to ensure that all decision-makers are informed about the health, equity, and sustainability consequences of various policy options during the policy development process. A HiAP approach engages a range of partners to work together to improve health and health equity and, at the same time, advance other goals, such as educational attainment, improved housing and green spaces, environmental sustainability, promoting job creation and economic stability. Using HiAP to tackle obesity locally involves working with a range of stakeholders. Public Health continues to invest a lot of time and effort in raising awareness of the stakeholders’ contribution to tackling childhood obesity and ensuring that relevant partner initiatives are co-ordinated and do not unwittingly undermine another part of the system. This approach has also allowed opportunities to be seized when they come along. There is a Lambeth Food, Healthy Weight and Physical Activity Strategic group with representation from the Council’s teams (Public Health, Children’s commissioning, Planning, Food safety, Transport, Sports, Parks and Leisure), the CCG (GP lead, long term conditions commissioner), and the acute trusts (Midwifery, Health Visiting and School Nursing). This group reports into the Lambeth Staying Healthy Partnership Board and provides strategic direction and facilitates joint working on obesity in the borough. HiAP is a priority within the Lambeth Health and Wellbeing strategy and the Lambeth Together strategy. Public Health continues to recommend this approach with partners. However to harness the potential impact of HiAP within the Council and with partners will require a more systematic approach championed by senior leaders. 6.6.2. Specific local childhood obesity interventions will continue to be commissioned based on the best available evidence. We will seek wherever possible to try and scale these up to have sufficient impact although this is gradually becoming more difficult as resources shrink. Any further budget reductions to the childhood obesity budget may well render considering the viability of certain important services. 6.6.3. Public Health advocates on behalf of the Lambeth population to promote healthy weight. Members of the Lambeth Public Health sit on London and national advisory groups to influence policy. Public Health was also on the committee that developed NICE obesity guidance. Public Health will continue to seek opportunities to influence London and national policy that seeks to benefit Lambeth in effectively tackling childhood obesity. 7. Recommendations Lambeth Scrutiny members are asked to: 7.1. Note the update and issues outlined in the report. 7.2. Facilitate the adoption of a Health in all Policies approach across the Council and with

key statutory partners as a way of promoting healthy weight of children in Lambeth.