16/05/16 – Hopes and prospects for stage 2 of the child obesity strategy

Speakers: Professor Jason Halford, University of Liverpool; Joanna Saunders, Leeds Beckett University; and Pippa Bagnall, Head of Wellbeing, Mytime Active

26th May 2018

All-Party Parliamentary Group on a Fit and Healthy Childhood

Hopes and prospects for stage 2 of the child obesity strategy

Chair: Baroness (Floella) Benjamin

Speakers: Professor Jason Halford, University of Liverpool; Joanna Saunders, Leeds Beckett University; and Pippa Bagnall, Head of Wellbeing, Mytime Active 

Chair’s Opening Remarks:

Good evening everybody and welcome to this, the 35th meeting of the All-Party Parliamentary Group on a Fit and Healthy Childhood. I’m sure we’ll all agree that the theme of our meeting today is very timely, because the Government will shortly be publishing Stage Two of the Childhood Obesity Strategy.

Those of you who have accompanied me on our APPG journey from the start will probably be experiencing a sense of déjà vu! We’d hoped for so much from Stage One but the reality came as rather a rude awakening. A 64 page draft had been trimmed to a skimpy 13 pages, and it’s fair to say that the end product was nationally critiqued as a lot of sound and fury about – not very much.  The Strategy lacked ambition and vision.  It was very much ‘a work in progress.’

Now we will soon be debating the pros and cons of Stage Two. Some policies have been trailed in advance, to include possible curbs on TV junk food advertising during prime time viewing. There will no doubt be further progress on the reformulation of popular food products and possibly a change to food labelling; although the crucial balance between statutory and voluntary provision is unlikely to alter much. What else will be there?  More importantly, what does the APPG on A Fit and Healthy Childhood want to see in Stage Two?

The answer to the last question is easy because the contents of our nine published Reports give a very comprehensive answer. More ideas will, of course, arise as a result of tonight’s meeting and I’d like to say here and now that while we won’t be shrinking violets when it comes to telling Government what we think. As always, this APPG wants to be constructive.

If you’re not invited to be in on the discussions, you can’t influence the outcome! I can promise you that influencing the Government in the best interests of children everywhere is, and remains, our unique mission.

Let’s hope that our discussions tonight will launch us in the right direction so that we in turn, can offer the best advice to Government after Stage Two of the Strategy is published. It’s a great opportunity. Let’s seize it with both hands and make the most of it!

We are pleased to welcome our speakers, thank you all for sparing us a little time this evening.

Professor Jason Halford, University of Liverpool

Hopes and prospects for stage 2 of the child obesity strategy: in this talk I will discuss three areas: marketing to children; household food insecurity; and the first 1001 days.

Food Marketing to Children

  • The childhood obesity plan (2016) did not commit the Government to strengthen polices to further restrict food marketing to children despite robust evidence.
  • Nonetheless CAP have introduced new rules (2017) to restrict non-broadcast unhealthy food marketing to children (came into effect summer 2017).
  • Based on broadcast media doubts remain about how effective these rules will be in reducing children’s actual exposure (implementation, monitoring and enforce in practice).

Marketing: Recommendations

  1. 9pm watershed for TV food advertising for high fat, sugar, salt (HFSS) foods and beverages.
  2. Robust independent review of efficacy of CAP rules.
  3. If guidelines shown to be ineffective must commit to consult on statutory legislation for non-broadcast media.
  4. Develop policy to cover food packaging, in store promotion and sponsorship activities.
  5. Adopt updated Nutrient Profiling Model from PHE anticipated to include more stringent thresholds for sugar for all food marketing policies.

Family Food Insecurity

  • Recommitment to Healthy Start Scheme to support those on low incomes purchase healthy food is welcome and does provide some level of nutrition and food security.
  • Threatened / limited by i) price rises, ii) narrow eligibility restrictions and iii) only aimed at families four and under.
  • Greater availability of energy dense foods (HFSS) and unhealthy food outlets in more deprived areas will drive SES disparities in obesity.
  • Need to recognise psychological mediators (distress, eating to cope, emotional eating) between low SES / food insecurity and diet quality / body weight.

Food Security: Recommendations

  1. Legislation to prevent the proliferation of unhealthy food outlets in low income areas.
  2. Increase access to and address cost issues around fruit and vegetables.
  3. Widened fruit and veg voucher schemes to more families living in poverty (ensuring F&V is available locally) and promote alternative models such as community food hubs (alternative to food banks).
  4. School breakfast and holiday food clubs need to be funded (widen free school meal eligibility).
  5. Need to acknowledge that maternal stress and mental health associated with obesity and food insecurity which undermine healthy choices (and by implication address it).

Pregnancy and Early Nutrition

  • The childhood obesity plan (2016) made little commitment to the first 1001 days from conception to the age of 2 years. Despite cross party recognition in the 1001 Critical Days Manifesto.
  • Optimal nutrition during this period has a profound impact on a child’s growth and development. Effect are observed across the lifespan – key window of opportunity for intervention.
  • Consider evidence on i) maternal weight, ii) maternal F&V intake during pregnancy, iii) breast feeding and F&V intake after birth, iv) bottle feeding practices, and v) introduction of solid foods.

First 1001 days: Recommendations

  1. Promote the benefits of health weight to women prior to pregnancy and sign post services.
  2. During pregnancy identify those at risk and offer life style change support.
  3. Educate Health Care Practitioners and parents on the benefits of varied F&V consumption during pregnancy to promote infant F&V acceptances later.
  4. After birth offer advice on the benefits of breast feeding and the importance of F&V consumption in shaping infants preferences.
  5. Specific address breast feeding difficulties particularly in women with obesity and be realistic on advice.
  6. Monitor maternal and infant weight regularly in those at risk.

Other Recommendations

  1. Continue to push for reformulation of products to reduce energy density and to reduce portion sizes – dual approach will contribute to reduced energy expenditure (carrot as well as stick).
  2. Fully evaluate the SSB levy in terms of impact on industry behaviour as well of consumers and consider the potential to look at other categories and nutrients and alcohol
  3. Calorie labelling for alcohol.
  4. Ensure nutrition and obesity become part of medical / health professionals education.
  5. Promote  non-stigmatizing approaches to patient care (no evidence that stigmatisation is anything but counter-productive and harmful).
  6. Ensure any recognition of obesity as a disease translates into funding for both prevention and treatment.

Joanna Saunders, Leeds Beckett University

Leeds Beckett University has a strong reputation in the field of childhood obesity and has done a great deal of research and development of evidence-based interventions to reduce and treat obesity. We have been commissioned by Public Health England to deliver a Whole Systems Approach (WSA) to tackling obesity, and we provide expert advice to governmental departments and commercial organisations.

Obesity is far from simple. The causal roots are many and complicated, with positive and negative influences coming from a wide range of sources.

So what progress has been made on stage 1 of the strategy?  It is hard to find a summary of progress (against all 14 measures) in one place, but good progress has been made with the soft drinks levy, sugar reduction, nutrient profile and promotion of healthy options in public sector, and there is a plan for supporting PA in schools. But this is not WSA.

On the other hand, some things don’t appear to have changed, for example clearer food labelling; health professionals supporting families; a rating scheme for schools/early years settings; and subsidised food for those in need.

Local Authorities tend to deliver similar actions to tackle obesity, and currently these are weighted in one direction with most of them being down- to mid- stream actions. This is despite the fact that most causes have been identified as upstream. We need a greater balance of upstream and downstream actions.

We need more research to find out how we can work with LAs to identify upstream actions that alter environments we live, work, grow, and play in. We also need to conduct research on how we can re-think how we conceptualise ‘actions’ – the current narrative points towards helping people.

Models such as the WDOH do not adequately consider the complexity of our systems, but what would we like to see?

With a Whole Systems Approach, we get the big picture and a shared understanding of what causes obesity. This means cross-sector approaches to address obesogenic environment, involving local people; and consistent support for 4 million overweight children instead of the existing situation where treatment services are limited and in some areas non-existent

We need to change the environment!

Of course, there are several barriers to achieving WSA – funding, for example, both central and LA funding. Some other barriers are:

  • Join up at central government and local authority levels – beyond remit of LA
  • Burning platform for LAs? Competing priorities and reduced spend
  • Risk of widening health inequalities – school sports premium – unintended consequences
  • Negative impact of social media, weight stigma

What does WSA mean?

  • LAs “holding the ring”
  • Engage stakeholders and communities
  • Commit time and resources – build on existing achievement
  • Everyone sees their role in preventing and reducing obesity
  • Programme based on review of literature and experience

Pippa Bagnall, Head of Wellbeing, Mytime Active

Mytime Active is a social enterprise specialising in evidence in wellbeing. The four pillars of wellbeing are:

  • Eat well
  • Be active
  • Be positive
  • Have a community around you

Picking up on an earlier point about the number of children who are measured as obese at age 5, it is clear that something is not working when we find that 100% more are measured as obese at age 11. We need a much bigger commitment and we believe that the focus should be on fitness – not on obesity and not on losing weight, We need to promote the positive aspects of being fit. Schools should encourage fitness with a “whole school” and a “whole systems” approach. It doesn’t have to cost a lot of money: local golf courses (etc.) can be used.

At Mytime Active we have a whole-life approach. The seven stages of man means different things at different ages, and different things to different people. We want to work with partners: local authorities, charities, companies, etc. on long-term (20 year) goals rather than short-term goals.

Baroness Benjamin: Yes, we’re looking at the whole child and everyone should have a responsibility for all children. Please do send me questions to raise in the House.

At this point, Baroness Benjamin left the meeting because of another engagement.

Phil Royal: The Mental Health in Childhood report is in its final stages of editing and the members of the working group have all received a draft. We’ll shortly be announcing a report looking into the positive and negative aspects of Marketing, which is to be sponsored by Quorn.  I’d like to also take this opportunity to mention that Pippa’s organisation, Mytime Active, have previously sponsored reports and as always we are very grateful for the involvement and financial support of our sponsors.

Questions and Comments

Giles Platt, London & SE Primary PE Health and Wellbeing Development Association: There are too many recommendations and not enough statutory requirements: it’s the Wild West out there with a lot of malpractice. We all know that health and wellbeing is the gateway to improved behaviour so why doesn’t the Government upgrade PHSE and PE to statutory core status?

Jason Halford: I completely agree. We’re awash with guidance but some things need to be statutory and monitored.

Giles Platt: The Government has spent more on treating obesity that on the entire English primary school budget.

Joanna Saunders: It’s pointless just having lots of guidance unless you have something to go with it. We need a better link-up between school improvement and public health within local government – that’s quite an untapped area and there are, for example, opportunities for engaging school nursing services.

Pippa Bagnall: The Government puts it all in a “too difficult” box. We need to adopt a long-term strategy. We have all the evidence. Past reports have said that if we don’t do something we’ll have a crisis. Well, we’re now in that crisis and will remain there until we get a commitment – it has to be statutory.

Estelle Mackay, Public Health Nutritionist: (To Jason Halford) We’ve (in the APPG) used the fantastic papers that have been coming out of Liverpool. Have you been able to speak to Matt Hancock (Secretary of State for Culture, Media and Sport) about any of your work?

Jason Halford: Unfortunately not.

Estelle Mackay: Can you tell us about the conference in Vienna?

Jason Halford: Vienna is the big European Obesity Conference and one of the things we’ve been doing alongside the WHO is disseminating best practice and guidance around statutory and voluntary regimes looking at marketing, and implementation in terms of monitoring.

It’s important to note that if you have something statutory it doesn’t necessarily do everything for you. We know that you could drive a bus through the regulation that we have in the UK, but it’s still held up as gold-standard. For example, after the regulations on TV advertising came in, there was increased targeting of children during school holidays. Marketing behaves like a squeezed balloon – when you put pressure and restrictions on one area they will find another area to target. Advertisers were moving away from television anyway, and ITV had already reduced their children’s programming before the ban even came in.

The big problem is that someone needs to monitor it independently, and that is an awful lot of work that industry won’t do and Government won’t pay for. Bloggers, vloggers and internet celebrities have millions of followers online and they are giving out information on all kinds of topics (exam cheating, for example, as well as promoting food products). The young people who follow them are unaware that the bloggers are usually being paid to do this promotion, and the whole area is completely unregulated. But trying to get on top of it is difficult.

Estelle Mackay: Yes, as you control one area they move into another.

Phil Royal: A Secretary of State for Children would go a long way to combatting this and we are still campaigning for that post.

Paul Wright, WRS: Working in smoking-cessation years ago there was a problem with NHS staff feeling that they couldn’t tell patients to stop smoking when they themselves smoked. There is a similar problem now with combatting obesity – “who am I to tell other people what to do?” And regarding statutory PHSE, it’s often the youngest, newest and most inexperienced teachers who get given the job, and they are not always going to be the best people for the job.

Jason Halford: Some of the training needs to be around how to have a difficult conversation, and how to deal with responses such as “you can’t tell me, because . . .  “

Pippa Bagnall: PHSE teacher training is inadequate with only 20 hours being devoted to it. It’s a much bigger message than just getting them outside to play.

Paul Wright, WRS: Fitness is for life but if it’s not fun then people won’t do it. Teachers need to be confident.

Joanna Saunders: Training is important but also we need to challenge some of the health professionals’ views. There is a lot of stigma associated with weight and unhealthy lifestyles and it can mean that it is easier sometimes to not address those issues.

Giles Platt: There are no league tables for fitness. Key to all this are the Senior Leaders of schools. There is a conveyor belt of conferences and initiatives.

Paul Wright: It’s always better to have schools as community hubs, with all members of the community using them. It should be possible for example for parents to go in to learn about food and healthy eating. We know how difficult it is but I think that the statistic that the level of obesity doubles between ages 5 and 11 means that it is primary schools that need to address this problem.

Jillian Pitt, Mytime Active: There was an excellent framework in place called Healthy Schools, but this was scrapped in 2010. The then Mayor of London, Boris Johnson, picked it up just before the 2012 Olympics and ring-fenced resources. As a result 3 West London boroughs have the best results because they have free nutritionists, activity leaders, etc. It’s frustrating that something like this that demonstrably works isn’t implemented more widely. Why can’t it go into stage 2 of the obesity plan?

Estée Mathias, Little Dish: One of the levers in the fight would be the education of children (within the curriculum) about marketing. They should be helped to understand that they are being sold to and manipulated, and to learn to differentiate between what’s true and what isn’t.

Phil Royal: As I mentioned earlier, we hope to address these issues in the forthcoming Marketing report. Some people are talking about setting up a Vegetable Marketing Board.

Estelle Mackay: (to Joanna Saunders) I was at the recent Health Select Committee and was interested to hear about your PHE document using case studies. We are always looking for good case studies and examples of good practice. When does your funding run out?

Joanna Saunders: It lasts until March 2019 but we are looking at opportunities to extend it. We are very grateful to PHE for choosing us, and the Whole Systems Approach is very transferable. On our website there is a lot of material and a link to sign up to the community of learning.

Estelle Mackay: What can we learn internationally, e.g. from Amsterdam?

Joanna Saunders: To think about political leadership – both national and local, also sustained funding. Goals and gains need to be considered in a short- medium- and long-term framework.

Pippa Bagnall: In Amsterdam yearly measurements have proved useful.

Joanna Saunders: Yes, but with support. Just measuring without support is pointless.

Pippa Bagnall: The letter that goes out to parents of obese children is appalling.

There was a little more discussion on the letter and then the meeting closed at 7.15 pm.