Health and Adult Social Care Policy and

Scrutiny Committee

	24 January 2022
Report of the Director of Public Health

Childhood Obesity in York Report

Summary

1.    This paper provides an overview of the situation regarding healthy weight in York, with a particular focus on children. It gives information about the national resources produced to tackle childhood obesity and draws on experience from other countries.  It provides and update on work to date in York. The report is for information.

Background

2.    Obesity is associated with both reduced life expectancy and reduced healthy life expectancy. It is a risk factor for a range of chronic diseases, including cardiovascular disease, type 2 diabetes, at least 12 kinds of cancer, liver and respiratory disease, and obesity can impact on mental health. In children, it can also affect educational achievement and self-confidence.

3.    The most widely used method to check if you're a healthy weight is body mass index (BMI). 

4.     For most adults, a BMI of:

•        18.5 to 24.9 means you're a healthy weight

•        25 to 29.9 means you're overweight

•        30 to 39.9 means you're obese

•        40 or above means you're severely obese

5.      BMI is not used to diagnose obesity because people who are very muscular can have a high BMI without much fat. But for most people, BMI is a useful indication of whether they're a healthy weight, and it is useful as a population measure to give an indication of prevalence of obesity.

6.      Abnormal BMI cut-offs in children are determined by age and sex-specific percentiles based on growth charts, as the amount of body fat changes with age and differs between boys and girls. A BMI between the 85th and 94th percentiles is defined as overweight, and a BMI ≥95th percentile is defined as obesity. Severe obesity is defined as BMI of 120% of the 95th percentile.

7.      Children with excess weight have an 85% chance of developing obesity in adulthood. Therefore preventing and addressing obesity in childhood can help to prevent the health issues outlined above.

Consultation

8. Not applicable

Options      

9. Members are asked to consider and note the content of this paper.

Analysis

 Obesity in York

Adults

10. Data on rates of obesity in adults comes from the Active Lives Survey, carried out each year by Sport England. 61.4% of the adult (18+) population in York are currently classified as overweight or obese from the 2019/20 survey. This compares to an England average of 62.8% and a regional average of 65.2%.  The trend in recent years has been increasing in York as well as nationally. When comparing with areas that have a similar population to ours (CIPFA nearest neighbours) the lowest area has 55.4% of its population rates as overweight or obese (Bath and North East Somerset) and the highest rate is in Cheshire West and Chester where 69.1% are overweight and obese. Nearest neighbours average cannot be calculated.

Children

11. Data on obesity is collected for children in reception and year 6 through the National Child Measurement Programme. In York in reception age children 21.4% are currently classified as overweight (including obese).  This compares to 23% in England. The trend is generally increasing in England, rates in York have fluctuated above and below the England rate.  This is 225 children.

12. For year 6 aged children 33.8% are classified as overweight (including obese) compared to 35.2% in England. Again the rates are generally increasing.  In York our rates have tended to be lower that the England rate, but have also been increasing.  This is 245 children.

13. When comparing our data with similar areas CIPFA neighbours) the lowest rates of overweight in reception aged children are found in Trafford (18.8%) and the highest in Plymouth (27.7%). For Year 6 aged children, when looking at similar areas, the lowest rates are found in South Gloucestershire (28.6%) and the highest rates in Darlington (37.8%). The average of our nearest neighbours is 33.3%. Nearest neighbours average cannot be calculated for reception age children.

14. In England, the prevalence of obesity is not spread equally. On average, the greatest rates of obesity are seen in the most deprived parts of the country. In 2019 the obesity gap between the most and least deprived areas stood at 8 percentage points for men and 17 percentage points for women (NHS Digital 2020a). Data on childhood obesity paints a similar picture. For children in Year 6, the gap in obesity prevalence between those from the most and least deprived areas grew by 4.8 percentage points between 2006/7 and 2019/20, from 8.5 to 13.3 percentage points. As with adults, the gap has widened as a result of increases in obesity among the most deprived children while rates among the least deprived have remained steady.

15. This is also true in York.  Whilst we do not have data at ward level for adult obesity, a recent analysis of childhood obesity found that prevalence of obesity was highest in our most deprived wards of Westfield, Clifton and Guildhall. Children from Black ethnic minority groups and boys in York were also found to have higher rates of obesity - JSNA | Starting and Growing Well (healthyork.org)

16. Physical activity is an important aspect of helping to achieve and maintain a healthy weight.  In York we generally have high rates of physical activity.  In York 71% of adults (19+) are physically active. This means they are doing at least 150 minutes of moderate activity in a week, or 75 minutes of vigorous activity, or a combination of the two.

17. The rate of physical activity is higher in York than the England average of 66.4%, and we compare favourable to areas most similar to us (CIPFA nearest neighbours) where the highest rate is 74.2% in Bristol and the lowest rate is 63.2% in Bristol. Nationally this puts us as the 25th most active area in England.  Previously we have been in the top three, and the last couple of years has seen a decline in activity, particularly in 2019/20.

Pregnancy

18. Mothers who are overweight or obese have increased risk of complications during pregnancy and birth including diabetes, thromboembolism, miscarriage and maternal death. Babies born to obese women have a higher risk of foetal death, stillbirth, congenital abnormality, shoulder dystocia, macrosomia and subsequent obesity. The most recent data for York (18/19) shows that 19% of women were obese at their first booking appointment. The England average was 22.1%. The average for our nearest neighbours cannot be calculated, but the lowest rates in this group are in Swindon (14.7%) and the highest rates in Plymouth (26.4%).

The impact of covid

19. School closures, strained household finances, increased screen time, and marketing of fast foods have increased exposure for many children during the pandemic to the environmental drivers of weight gain. For the most vulnerable children, school closures have often impeded their only source of regular, healthy meals, exacerbating the health divide between more and less deprived households.  The data from the National Childhood Measurement Programme for 2020/21, which is not yet included in the data quoted above, shows that rates of childhood obesity went up nationally.  Those above a healthy weight (including obese) in reception increased from 23% - 27.7% and for those in year 6 from 35.2% to 40.9%.  The programme was not complete in this year due to school closures, and is therefore an estimate, but it is a reasonable assumption that rates of obesity will have gone up due to the pandemic, and that this will be seen when we have the data for York.

Tackling obesity

20. At a very simple level, excess weight gain occurs when energy intake (food eaten) regularly exceeds energy burnt. As such the scientific consensus is that eating fewer calories is key for weight loss, while physical activity also plays a role. Everyone experiences multiple barriers and challenges to maintaining a healthy diet, though these are experienced most acutely by people living in the most deprived parts of England. The environment people live in can be one of the greatest challenges to eating healthily. For example, if people are surrounded by foods that are high in sugar, salt or fat, these can become the default choice. Unhealthy food environments are more prevalent in more deprived areas; for example, there is a strong relationship between deprivation and density of fast-food outlets. It was widely reported a few years ago that the in-year marketing budget of Coca-Cola was greater than the entire budget of Public Health England. Global food conglomerates, producing calorie-rich nutrient-poor food, employ cutting-edge behavioural science in their advertising and are known to relentlessly target more deprived communities, the scale of which dwarfs health promotion efforts by public health agencies.

21. As well as the environmental factors that shape people’s diet, relative price of food is also a key component. Research shows that following healthy eating guidelines is prohibitively expensive for many; following the government’s Eatwell Guide costs nearly three times the current average spend per person per week on food and non-alcoholic drinks.

22. Approximately half of UK households have a food budget that can meet the costs of the guidelines. The barriers to eating healthily are not just about income and choice; there are other psychosocial factors associated with deprivation and poverty that make eating healthily harder. Living in poverty or ongoing food insecurity is associated with high levels of stress, meaning that people may not have the mental energy to make choices or dedicate time and effort to cooking and preparing food that is nutritionally balanced.

23. While physical activity is secondary to diet in terms of causes of obesity, it can support weight loss and improve health. People in more deprived parts of England report lower levels of physical activity than average. 62% of adults in the most deprived areas report that they are physically active compared to a national average of 66%.

24. The reasons for lower levels of physical activity in more deprived areas are multifactorial, cutting across economic, social, geographic and cultural factors. For example, levels of income will affect the relative affordability of accessing sports facilities or exercise classes, while a lack of access to green space or safe green space, can be a significant deterrent to physical exercise. As is the case with diet, some of the psychosocial factors associated with living in poverty will make finding time to exercise or prioritising physical activity difficult. Deprivation is not the only factor associated with physical inactivity, lower rates of physical activity are reported by women as well as by some ethnic minority groups.

25. No area in the UK has seen a sustained reduction in obesity rates in adults or children.  Where there has been a decline in rates this has tended to be temporary, and the overall England rates have shown a trend of increasing.  As an example, in 2019 it was widely reported in the national media that Leeds were the first City in the UK to see a sustained decline in childhood obesity after a 1% drop in rates over a 4 year period.  However, since that time rates appear to be going up again in the City.  Their success was largely accredited to a childhood weight management programme called HENRY. This programme works with families and children to support behaviour change, which helps parents gain the confidence, knowledge and skills they need to help the whole family adopt a healthier, happier lifestyle. The ethos is to support parents to identify the things they are doing well and the things they would like to change, helping them build on strengths and deciding on their own strategies to achieve their goals.

26. The Office of Health Improvement and Disparities (OHID) has piloted work in a number of local authority areas to test out taking a ‘whole systems’ approach to tackling obesity.  This led to the production of tools to assist local areas to work in this way at the end of 2019.  The figure below sets out a process for working in this way, which requires stakeholders to have a shared understanding of the issue, work together to map the factors that impact on obesity in their area, and then develop actions to address these factors.

27. Globally, Amsterdam is cited as an example of an area that has seen a sustained decline in childhood obesity rates, and has been studied extensively.  Amsterdam started their obesity programme (AAGG) in 2012, led by the Deputy Mayor.  Studies looking into why they were successful highlight three key aspects of their programme: leadership; doing things differently; taking a multifaceted approach. The table below shows the 10 pillars that they worked on at a city level. The level of childhood obesity was reduced by 12% in 5 years.  It is very similar to the whole systems approach referred to above.

10 pillars of action	Policies and action
A. Preventative:	· Screening of infants for risk of obesity · Counselling for expectant mothers · Information provided to pregnant women about healthy diets · Additional support to breastfeed · Additional support for teenage parents and more deprived mothers · Making primary schools healthier places · Cycle routes have been made safer · After-school activities have been arranged for children · Subsidies for sports club membership for low-income families · Community health ambassadors assigned · Working with supermarkets and local food suppliers to; modify menus and reduce portion sizes; manage stock better; create healthier checkout environments; use traffic-light labelling posters ·  Banning unhealthy food and drinks sponsorship of city sports events · Reduce the advertising of unhealthy foods in council-owned locations
1. A ‘first 1000 days’ approach (from the start of pregnancy until age two)
2. Schools approach (including pre-schools and primary schools)
3. Neighbourhood and community approach
4. Healthy environment approach (healthy urban design, healthy food environment)
5. Focus on teens
6. Focus on children with special needs
B. Curative:	· Assigning youth healthcare nurses · Drawing up care plans · Ensure overweight and obese children receive an appropriate level of care · Communicating behaviour insights
7. Helping children who are overweight or obese to regain a healthier weight
C. Facilitate:	· Using an evidence-based approach ·  Observing interventions · Innovating digital tools · Introducing digital health coins · Exploring healthy sleep determinants, and assessing interventions
8. Learning and research approach
9. Use of digital facilities
10. Use of communications and methodologies for behaviour insights

Council Plan

28. In the May update to the Council Plan the local authority reiterated its commitment to supporting the best quality of life for ‘our residents’, especially those who educational, health and economic outcomes could be improved. The plan includes a number of key performance indicators including:

a.      Good Health and wellbeing, and

b.        A better start for children and young people which includes the reduction of health inequalities.

Both of the key indicators are affected and enhanced by access to health practitioners and supporting healthy choices and changing behaviours.

        Implications

29.  Members are asked to note the following implications:

· Financial There are no financial implications within this report

· Human Resources (HR)There are no HR implication within this report.

· Equalities There are no equalities implications within this report.

· Legal There are no legal implications within this report.

· Crime and Disorder There are no crime and disorder implications within this report.

· Information Technology (IT) There are no information technology implications within this report.

· Property There are no property implications within this report.

· Other There are no other implications within this report.

Risk Management

York’s Approach to Healthy Weight

30. In York a Healthy Weight, Healthy Lives Strategy was produced in 2018, and a Healthy Weight Steering Group was established to oversee the implementation of the strategy.  The Strategy sits under the Health and Wellbeing Board as part of the Board’s strategy which prioritises the reduction of obesity.

31. The strategy takes a lifecourse approach as well as having some themes that run across all ages, these are the environment, inequalities and mental health.  Good progress has been made in some aspects of the strategy. For example when the work commenced there was not a pathway for treatment of obesity in York. Working with partners across the system and attracting additional funding, a pathway now exists from tier 1 (information and advice) through to tier 4 (surgery for obesity).  Improvements could still be made here as the funding is often temporary and only funds a small amount of people for such interventions.  It is also focussed on adults.

32. Building on the work in Leeds we have explored implementing the HENRY programme in York. This was delayed due to COVID, but we now have staff in the Healthy Child Service and the Health Trainer Service trained to be able to deliver the HENRY programme for families with children aged five and below. The necessary arrangements should be in place for courses to commence in Spring 2022.  Once this has been implemented we will explore the possibility of extending this offer for families with older children. The Healthy Child Service in York also delivers support to women around breastfeeding, and nutrition and healthy living in pregnancy, which is an important part of the obesity pathway.

33. In terms of tackling the obesogenic environment, as a local authority we signed up to the Healthy Weight Declaration in 2020, and published  a roadmap for action focussed on responsible retailing, advertising, using health evidence in planning decisions, commercial sponsorship, increasing access to fresh fruit and veg, investment in health literacy and increasing physical activity levels. The Healthy Weight Steering Group, which includes multi-agency membership, oversees this declaration and the York healthy weight strategy.

34. Following on from the National Food Strategy, which contains a recommendation for each local area to have its own Food Strategy, work is underway to develop this in York, led by the Communities Directorate.  This work will have a strong link to the Financial Inclusion Group and will consider issues of food insecurity and food poverty. Given the data presented above and the inequalities seen in healthy weight, this work will have a positive impact on the work to address healthy weight and public health will input into this work.

        Recommendations

35. The purpose of this report is to provide Health and Adult Social Care Policy and Scrutiny Committee with an update regarding the Public Health responsibilities regarding obesity.

Scrutiny are asked to:

1. Note the content of the report

2. Note that a report will be provided later in the year on the progress and impact of the HENRY programme.

Contact Details

Author:	Chief Officer Responsible for the report:
Fiona Phillips Assistant Director Public Health Tel No. 01904 565114	Sharon Stoltz Director of Public Health
	Report Approved	√	Date	12.01.2022
Wards Affected:					All	√
For further information please contact the author of the report.