28/03/18 – The launch of our report ‘The Impact of Social and Economic Inequalities on Children’s Health’

Speakers: Dr. Victoria Randall from the University of Winchester; Helen Clark, Lead Author of the report; and Anna Ford from the Food Foundation

28th March 2018

All-Party Parliamentary Group on a Fit and Healthy Childhood

Launch of our report ‘The Impact of Social and Economic Inequalities on Children’s Health’ and a discussion on PHE’s new calorie reduction programme and the Food Foundation’s work on child poverty and obesity

Chair: Lord Palmer

Chair’s Opening Remarks:

Good evening everybody and welcome to this, the 33rd meeting of the All-Party Parliamentary Group on a Fit and Healthy Childhood.  I am Lord Palmer, an elected hereditary crossbench peer. In case you hadn’t noticed, I am not Baroness Benjamin who has been called away at short notice to fulfil a filming commitment

Tonight we are launching an excellent new report ‘The Impact of Social And Economic Inequalities on Children’s Health’. I want to thank Danone for the financial support that made this report possible. As with all our sponsors, Danone neither requested nor received approval of its contents.

We will also discuss Public Health England’s new calorie reduction plan and Anna Ford from the Food Foundation will be discussing her work on obesity and poverty. These matters are all connected and we look forward to a lively and interesting discussion.

I have asked them for about 7 minutes each before we go in to the usual Q&A session.

Dr Victoria Randall, University of Winchester

In November 1989, the United Nations adopted 54 articles that established children’s rights

Two of these articles stated that:

“Every child has the right to the best possible health. Governments must provide good quality health care, clean water, nutritious food, and a clean environment and education on health and well-being so that children can stay healthy.”

“Every child has the right to a standard of living that is good enough to meet their physical and social needs and support their development”.

This ninth report by the All Party Parliamentary Group on a Fit and Healthy Childhood highlights that as one of the richest countries in the western world, the UK can, and must, do more to address health inequalities for young people. It brings together a common thread from the previous eight reports, showing that social inequality has a huge impact on  a child’s health in its many forms: from dental health, maternal health, obesity, play and physical activity. The importance of this report lies in its detail. It examines the issues of child health from not only the macro level of society but from the individual and personal perspective of the child. Health occupies multi-disciplinary spaces and is ubiquitous within every aspect of our society.  The challenges facing young people’s health today is therefore complex. This report highlights that it is not acceptable to disconnect a child’s health and wellbeing from the wider context of where they live, economic implications, health care support, disability and educational opportunities; or to even assume that health inequalities within childhood is exclusively isolated to areas where there are high levels of social deprivation. Children from affluent areas of society can also experience a number of health implications.  The reasons for this might be different, but the outcome of a healthy childhood should be the same for all children.

We now have enough evidence to know what the issues are, and where they are.  The crucial question is what are we going to do about it …yes in the short term ….but also for future generations too if we are to make a significant change in health trajectories for young people. The challenges young people face in our modern world means that addressing issues within health inequality should be and must be our most important priority.

As an educator I believe there is nothing more important for a child to own, know and understand than their body. Part of my work within physical education is to help young people, and their teachers, recognise that physical development is not a disconnected process from the development of the child’s emotions, confidence, social engagement or cognition.

Recent government policy around child health has focused on increasing physical activity and cutting down on sugar. In January this year, Public Health England launched their 100 calorie snacks campaign with an aim to reduce the amount of sugar intake children currently gain from snacks (currently around 7 sugar cubes a day, comes from unhealthy snacks and sugary drinks).

As a snapshot of this issue they highlight that each year children are consuming:

•           almost 400 biscuits

•           more than 120 cakes, buns and pastries

•           around 100 portions of sweets

•           washed down with over 150 juice drink pouches and cans of fizzy drink.

•           On average, children are consuming at least 3 unhealthy snacks and sugary drinks a day, with around a third consuming 4 or more. The overall result is that children consume 3 times more sugar than is recommended.

However, while these figures are truly awful and unquestionably require immediate attention, I would argue that our current fixation on health in a negative way is itself unhealthy. What I mean by this is that policy, money and education should focus on a positive sense of health and wellbeing, happiness and enabling environments, the very thing we are trying to achieve, rather than the use of language or implementation of strategies which are pejorative in the language it uses – such as obesity and in-activity.

Furthermore these ‘issues’ in themselves cannot be addressed through an over simplified message of eat less sugar and play more sport – for me this is the social equivalent of putting sticky a plaster on it. Whilst it might ameliorate the issue, it doesn’t address the main reasons that result in poor nutrition; depression or inactivity that leads to poor health in the first place.

The APPG’s Report focuses on recommendations that seek early intervention in order to address children’s health.  This is crucial.  While schools and other statutory providers can go some way to make better the adverse of poor health in our young people, the older a child becomes the more difficult this becomes.

For example, in the context of obesity, it is known that the number of fat cells stay constant in lean and obese individuals, even after weight loss; therefore the number of adipocytes is set during childhood and adolescence. In 2015/16, the child measurement programme reported that 1 in 5 children in reception (age 4 or 5) was overweight or obese, this jumps up to 1 in 3 by the end of Year 6 (10 or 11 years old). Whilst we can go some way to shrink fat cells through a healthy diet and regular physical activity, we cannot get rid of them altogether (well not without surgical intervention or high cost short lived procedures).  Addressing the prevention of obesity in early childhood, or even earlier, will have the greatest impact on reducing obesity outcomes for young people; further sustained by excellent education and opportunities as they move towards adulthood.

A further level of inequality exists across countries in the UK.  Northern Ireland presents some of the most worrying statistic in the devolved UK parliament, with the highest levels of child mortality, 28% of children reported to be overweight or obese, and the least amount of funding into research to support child health.

So to conclude, I would like to highlight a few summary points.

Firstly, our negative fixation on poor health is, in itself, unhealthy.  To change a growing trajectory of poor health outcomes for children we need to represent positive messages about well-being, happiness, friendship and healthy environments.  Although this is clearly idealised, the reinforcement that moving more and eating healthy are functions to counter act something bad, negates the fact these things are good in their own right.

Secondly within health policy, we need to recognise that the child, mind and body, is one being.  Separating issues are not only costly and time inefficient, we are in danger of never fully understanding health in its many complex forms.  For example in previous meetings of the APPG we have heard that obesity in childhood, with high sugar intake, is also an indicator of poor dental health.  A connected understanding of childhood health is required across education, health and industry.

Finally, the earlier we can intervene or support families, from all areas of society, the greatest impact we will have on improving children’s health outcomes.  Beyond the Early Years we can of course make some difference, but this will become harder as the child grows older with developed patterns of habit and greater societal influence.

Helen Clark, Lead Author of the Report

Victoria has set us off well by encapsulating the 80-odd pages of the report in her opening remarks.

Please everyone, do try to get through it all as it isn’t all in the executive summary. We write these reports in a complex and detailed way, but also in a way that sections can be extracted: you can take one chapter out and look at that on its own and then move on to the next, and so on.

I’d like to give thanks to our sponsor Danone for their enthusiasm and support over the whole process, and also thanks to all the contributors, regardless of the size of the submissions and contributions. It’s great to see so many faces here today who have made contributions to all our reports over the years.

Our reports are a work in progress When we started the group we focussed very much on childhood obesity but we found in our first report “Healthy Patterns for Healthy Families”, which became a blue print for the following ones, that a key aspect was inequality and that theme has carried on through all the reports. It’s something we just couldn’t get away from.

We’re living parallel lives, with neighbouring people living totally different lives, e.g. economics, housing, immigration, etc. Are there opportunities and money for them? In our Physical Activity report we reported that children from independent or private schools have much more opportunity to get and stay fit, while there are other children who have little or no opportunity. Governments of all persuasions agree that this is unfair,  but it’s a question of money. If we invest heavily in child health when it matters we will save money later, but the Government will say that we can’t afford the investment.

Our argument is that this attitude is short-sighted. It is analogous to saying we won’t spend on important infrastructure projects. If we don’t invest now we will pay later, whether it’s housing, social service, criminal justice or whatever.

There are lots of examples in the report, but let’s pick one or two where early investment could make a huge difference.

Dentistry – money is bleeding from the NHS because of the cost of young children taking up beds because of teeth problems. We should be investing in good dental treatment early on to avoid this.

Mental health – a lot of children who are living in social and economic deprivation are often trapped in a particularly vicious spiral. Very often we find that one or even both parents and wider family members suffer from mental health problems that isn’t being addressed and is cascading down.

A few very brief words to finish: our  keynote is “holistic”. While we agree that current initiatives are very important (e.g. calorie reduction) we absolutely must keep in mind all the other aspects: education, nutrition,  etc.

Anna Ford, Food Foundation

The Food Foundation is a think tank working on food policy to deliver healthy and more sustainable diets. My comments will build on Helen Clark’s points about early intervention and equality of opportunity. I want to particularly focus on dietary inequality an why it’s complicated and not well understood. There are two key factors: 1) the issue of money and low income, but also 2) low income combined with unhealthier choices being the easier ones – those two combined have disastrous outcomes for our children. I would argue that while it’s true that we’re all subject to the same environment it’s a particularly lethal combination in low income families. There’ a big divide: in the most deprived parts of Britain there is double the obesity rate of the least deprived.

So this toxic combination is pretty devastating in childhood, and the issue is a little bit challenging. Looking at obesity levels across Europe, UK is 8th worst, and in terms of severe food insecurity, the UK stands out as being the worst, with 10% of children living in households where they are severely food-insecure.

That poses a challenge for the narrative. We published UN data a couple of years ago and one of the tabloid newspapers had a headline saying that food insecurity statistics were hard to believe, against a picture of a very obese person. To some extent that’s a fair point, so what are we actually talking about because those figures don’t sit very well alongside a massive obesity crisis.

So that’s where the challenge is because what we know about this combination of the current food environment and a low income is that that unhealthy calories are 3 times cheaper than healthy ones, that we often have a whole generation with very few cooking skills, that there are people in poor housing with no mandatory standards for cooking facilities, e.g. in private accommodation there’s no requirement that you have anything more than a microwave. “Kettle food” is being talked about now: food that you can just prepare with a kettle.

And then of course, there’s time too, with many people being time-poor and trying to manage irregular work patterns and multiple jobs which make it difficult to establish healthy eating patterns and habits.

So it’s no surprise then that food insecurity and obesity go hand-in-hand.

So what are we doing about this? I just want to mention a couple of things that the Food Foundation is doing and then, although I’m not a spokesperson for PHE, I’ll talk about the calorie reduction programme.

At the Food Foundation, we’ve been trying to establish a national measure for food insecurity, because while there’s no agreed government data on the scale of the problem we can’t have a proper conversation on what needs to be done about it. The classic mantra “what gets measured gets done” is important here. Defra is looking into food insecurity and also the Labour MP Emma Lewell-Buck has sponsored a 10 minute rule bill on it, trying to get this onto the agenda, and it has already had its first reading.

Secondly we are working with two APPGs – this one and Phillipa Whitford’s national enquiry into child food insecurity in all four UK nations. That’s a year-long enquiry gathering evidence and information from a range of sources, but at the heart of it is hearing directly from children who can talk about their experiences of living in food insecurity.

The MPs Sharon Hodgson and Phillipa Whitford are co-chairing  that enquiry and I have circulated a card with some information to enable you to contribute evidence or keep in touch with the proceedings. Full details are on the website: www.foodfoundation.org.uk.

So those are two important things and then there is the very important work that PHE are doing around calorie reduction. It’s important because ultimately what they are trying to do is to change what we eat with us really knowing. They made those changes essentially through reformulation of foods that we’re very heavily dependent on in order to reduce the amount of sugar or the amount of calories that we eat. We have a good track record because it’s been done well with salt and PHE is putting tight targets into this process and publishing data, which is really important in terms of accountability.

We’re doing something alongside that. Consider the fact that we get about 50/60% of calories from highly processed food, that work that PHE is doing to change those highly processed foods and make them a bit healthier is really important. But the big prize is to shift the balance in favour of minimally processed or fresh foods, and so we have a campaign called “Peas please” which aims to make it easier to eat vegetables. Consumption of vegetables, in spite of the 5-a-day campaign, has been declining since the 1970s.

Vegetables represent the only area of the diet that everyone agrees on: there is no argument that we need to be eating more of them and the early childhood story is particularly important as children need to have taste preferences laid down early.

So the Peas Please campaign runs alongside the PHE campaign and it’s mobilising a lot of businesses to take steps that will encourage people to eat more.

Questions and Comments

Sarah Clothier, Slimming World: What is the definition of food insecurity?

AF: Not having enough money to buy food, or concern about not having enough, or when parents go without food because of shortage of money. Children may not necessarily go hungry in food-insecure environments, but parent often do. There’s a calibrated scale of 10 questions as recommended by the UN.

Giles Platt from London & SE Primary PE Health and Wellbeing Development Association: We particularly welcome the report’s findings on the primary PE and sports premium which in its fifth year is still being woefully let down by the quality of governance, accountability and scrutiny, as proven by considerable data analysis that we’ve collated over time. Furthermore, Ofsted promised that a school’s healthy rating system would be in force by September 2017. Also, we’re still waiting for confirmed details concerning the Government’s pledge to conduct accountability reviews due to start in the summer term.

It is very frustrating that now  we’re nine reports in and five years into the strategy – the Government can be judged as either inept or arrogant, but certainly irresponsible with its handling of the PEST premium and active healthy lifestyles. I also want to draw attention to the fact that there are so many recommended guidelines, particularly Public Health England, and yet they are not made statutory.

Victoria Randall: You’ve raised points that the sector is increasingly becoming fractious about. A few years ago we saw a retraction with the DFE’s guidance around PPE and we’ve seen that trying to be addressed in the guidance from September. However what we’re not seeing are the accountability measures as you have pointed out.

We’re starting to try to make sense of something which is incredibly complex in simple ways, and then trying to measure it, so we use the money to increase physical activity, sport and out-of-school opportunities, yet we know that’s not necessarily going to help because our figures and statistics show that children over the primary years are becoming more obese and more unhealthy in that time.

To measure it, Ofsted have a tough job in accountability and finance, but perhaps what we need to do is go back and have a look at how the money is used as a whole school intervention rather than just solving another policy or financial problem which I think is probably the main issue: that the PSP premium is actually solving other issues in schools because of austerity situations and outsourcing staff rather than the very thing it was intended to address. So, it might be tied up in accountability but it might also be embedded in other issues that schools are having to deal with.

Lord Palmer: I’d be grateful if you could send me some points around this topic that I can put down as written questions.

Charlotte Davies, Fit2Learn:  I’m delighted to hear the focus of looking at the whole child. We at Fit2Learn have just produced a book on the PE that children between the ages of 4 and 7 need to undertake. If children don’t do these things they run into problems with double vision, sound processing, perception and other things. If you don’t know where you are in space food actually looks less attractive and we find that children with these issues have a much bigger problem with being addicted to sugar. They go for instant gratification because you need sound processing to sequence, and they can’t delay gratification if they’re not well-developed.

It’s important to look at the whole child and I think that Ofsted, with their bold beginnings, do not understand child development. They’re pushing the fine motor skills before, which unbalances their whole physiology.

Victoria Randall: What we’ve seen over the years is that in trying to address one issue, we’ve seen segregation of the physical from the rest of the child. We know that the physical self is so much more to do with the cognitive, emotional and confidence connections.  It comes back to that point that in trying to correct one issue, it’s created a whole host of other problems. And interesting with the premium we don’t see it yet still as a requirement in early years: it comes in key stage 1 and the research and evidence suggests that by the time wev’ve got our children in National Curriculum key stage 8 phases, we’re trying to undo things that are already well embedded.

Charlotte Davies, Fit2Learn:  We have worked a lot with year 1 children and we’ve worked internationally with other experts and we know that our scheme will address the problems created in reception.

Victoria Randall: And the problem isn’t helped when you have people who are not the children’s teacher delivering the physical aspect of their development. The things that the class teacher sees in the classroom connected to e.g. reading, writing, listening, are not being picked up in the focussed physical education time.

Kathryn Peckham:  Physical activity is so closely linked to the emotional wellbeing of the child, but we do keep uncoupling it. My question is basically, how do we raise the holistic view more in the hearts and minds of those delivering the practice, of the parents, and really embedding the idea that it’s so much bigger than just getting out and letting off steam

Helen Clark: I am becoming increasingly worried at the soundings and comments in various parts of strategy that is coming out. What the Government seem to be doing is parcelling things and compartmentalising things. So last year we had stuff about sugary drinks and this time we have to more or less have a calculator in our head to remember if it’s lunch it should be 400 calories, and so on. There’s a feeling that “we don’t need to teach nutrition: it’s been done and it’s embedded in the curriculum” and what we need to do now is ask industry to take out calories so that we don’t have to think about it. In October when the Government has its part 2 strategy, what are we going to be talking about then? My bet is that we will not be talking about it all holistically. Can I ask you when you talk about your specialisms to bring in other areas as well so that we can try to drive home the point that it’s got to be holistic – we cannot have nutrition today, physical activity tomorrow and so on.

Victoria Randall: I work in initial teacher education, working with primary beginning teachers. Their big concern is managing children’s behaviour and if you look through some of the Ofsted reports you can find contradictions, e.g. “the school is promoting lots of initiatives relating to physical activity” together with “they’ve got to address low-level disruptive behaviour” which is considered to be children moving around the classroom. From the child’s point of view, they are being told that moving and fidgeting outside of set times is a bad thing for which they are likely to be punished. New teachers get concerned that they’re going to be professionally judged on how they manage their classes when children move around. I think we need to look at the whole culture of movement and it’s very confusing for children to get these mixed messages.

Paul Wright, WRS Group: I’m concerned about the lack of training, e.g. doctors not getting taught about nutrition. If we’re not careful we’ll have lots of great recommendations but we’ll lack trained people to implement them. I sometimes see tenders in my work where there is money available but due to lack of training in how to use evidence-based data and research, people have no idea how what to do with it or how to spend it.

Helen Clark: Yes, that is a thread going through all our reports, that you absolutely have to train the trainers.

Phil Veasey, Public Health Consultant: I spend a lot of time in town halls and with London’s public health teams, and one thing that hasn’t come out is lack of joined-upness. If you take the National Child Measurement Programme for example, we have enough money to weigh and measure the children but we have no money for action. Take for example the letter that goes home to parents about an overweight child – instead of just informing them it would be far better to have that letter tailored to the community in which the child lives, giving information about what’s going on locally and where they can go. In some areas you have locality managers with a lot of information but they don’t know the school nurses team, and vice versa. So sometimes I think there’s capacity in the system, but there’s a little bit of KPI chasing and focus on short-term initiatives when we should be taking actions that last forever, especially in times of austerity.

Lord Palmer: I’m afraid that’s something you always get when something goes across several different Government Departments.

Tamsin Brewis, Water Babies: On a recent Good Food programme there was a medical professor talking about doctors not being trained in nutrition at medical school, and there is a movement among medical students to address this.  Research shows that if you get nutrition right in pregnant mums it helps with mental health and all the way through to feeding babies and so forth and I wonder if this is something we could actually address to the General Medical Council to get them to teach nutrition even more within the medical profession, and take it down to midwives and health visitors, because that’s basically the starting point of a lot of these problems. It’s unbelievable that doctors don’t know how to talk to their patients about nutrition, and the doctors themselves are now starting to say that they need that information.

The meeting closed at 5.30 pm.