Child Obesity

Preventative Public Policy and Childhood Obesity Case Studies in England and the Netherlands
ECORYS Research Programme
Nicola Hall, Kate Crosswaite and Allice Hocking (ECOTEC Research & Consulting) Wija Oortwijn, Emmy Nelissen, Judith Mathijssen (ECORYS) Professor Carolyn Summerbell (University of Durham)
Date of submission: 19th December 2008.

Preventive public policy and childhood obesity: case studies in England and the Netherlands
ECORYS Research Programme Programme Management Office ECOTEC Research & Consulting 31-32 Park Row Leeds LS1 5JD T 0113 290 4100/4104 E. chris.simpson@ecotec.com W www.ecorys.com
Table of contents
Executive Summary 1. Introduction 2. Background and Rationale 3. Methodology 4. The UK Case Study 5. Netherlands Case Study 6. Conclusions and Recommendations Glossary 1 Introduction 1.1 Aims and Objectives 1.2 Content of this report 2 Background and Rationale for the Study 2.1 Definitions 2.2 The Size of the Problem 2.3 Preventive public policy 2.4 The relationship between health behaviours and obesity 2.5 Health consequences 2.6 The role of the environment in obesity 2.7 The European Policy Context 2.8 What works? The evidence for effective practice and policy in preventing childhood obesity 2.9 Approaches and the theoretical basis 2.10 The Evidence base 3 Study Methodology 3.1 Parameters of the Study 3.2 Methodology 4 The English case study: Crewe and Nantwich 4.1 Overview of Crewe and Nantwich 4.2 Preventing Childhood Obesity in Crewe and Nantwich: the Interventions 5 The Dutch case study: Beverwijk in middle and south Kennemerland 5.1 Policy context 5.1.1 National health policy and strategic context 5.1.2 Regional and local activities to combat childhood obesity
5 5 5 6 6 7 7 10 12 13 13 14 14 15 17 17 19 20 21 22 22 23 25 25 27 33 33 34 47 47 47 49
5.2 Overview of Beverwijk in middle and south Kennemerland 5.3 Prevention of childhood obesity in Beverwijk and middle and south Kennemerland 6 Discussion, Conclusions and Recommendations 6.1 Introduction 6.2 The policy and strategic context for prevention of childhood obesity 6.3 Crewe and Nantwich and Beverwijk and Kennemerland how do they compare? 6.4 Preventive public policy: comparative analysis of interventions identified in England and the Netherlands 6.5 Conclusions 7 Annex 1: Overview of interventions in the English case study 8 Annex 2: Overview of interventions in the Dutch case study 9 Annex 3: Selection of Case Study Areas 10 Annex 4: Identified typologies for interventions to prevent childhood obesity 11 Annex 5: Topic Guide for Interviews Childhood Obesity 12 Annex 6: References
50 52 68 68 68 69 69 74 78 86 102
111 115 123
Executive Summary
1. Introduction
This study was supported by the Ecorys Research Programme as part of the preventive public policy strand. The aim of the study was to investigate preventive public policy in relation to childhood obesity in two case study areas in England and the Netherlands, enabling a comparative analysis of the approaches and the wider context for prevention. 2. Background and Rationale Obesity is a growing problem globally and in Europe. The number of European children affected by overweight and obesity is estimated to be rising by more than 400,000 a year, adding to the 14 million plus of the EU population who are already overweight (including at least 3 million obese children); across the entire EU25. Being 'overweight' affects almost 1 in 4 children across the EU. Levels of obesity are in higher in the UK than in the Netherlands. Recent data for England indicates that 29.7% of children were classed as overweight or obese compared to only 16% in the Netherlands1 . This difference and the reasons behind it are a core focus for this study. The key question is: are there any differences in the preventative approaches each country adopts in tackling childhood obesity? This study focuses on the aspects that determine an effective public preventive appr oach to the problem of childhood obesity in two comparable municipalities in the Netherlands (Beverwijk in the region of Kennemerland) and England (Crewe and Nantwich in the county of Cheshire). Preventive public policy addresses the physical, social and cultural environment in which people live and the way in which people behave. Factors that are found to have the most significant influence on health are often called determinants or drivers of health. Although age, sex and hereditary factors are key in influencing health, individual lifestyle factors such as diet and physical activity levels also have a key role to play in determining health; and these factors along with social and economic factors work together in a complex and dynamic manner. Since many countries are now attempting to implement policy in this area, the European Commission has called for further investigation and sharing of examples of good practice.
Data for 2006 and 2003 respectively.
This study provides such information for two specific case study areas in England and the Netherlands.
3. Methodology The study focussed on school-aged children aged 5-19 years. The case study areas in the UK and the Netherlands were selected as broadly representative of each country via an analysis of population data. Using a list of intervention 'typologies' (identified from recent guidelines regarding the prevention of childhood obesity) a series of primary prevention interventions were identified in each case study area that conformed to agreed criteria. Data on each of the identified interventions was collated through desk-based research and through interviews with key stakeholders in each area. The interviewees were identified from web-based information and a 'snowballing' process. Intervention data from both interviews and desk-based work was used to populate an intervention framework that supported cross-national analysis and ensured that consistent information was collected for each case study area. 4. The UK Case Study In the English case study area, Crewe and Nantwich, eleven interventions were identified that met the agreed criteria. In general the interventions aimed to improve child health by increasing levels of healthy eating and physical activity, and providing support for this behaviour change. Nearly one half of the interventions were part of national programmes and initiatives , including Healthy Schools and Healthy Start. Healthy eating was given greater prominence overall than efforts to raise physical activity levels, in particular through changes to the food available in school. Partnership and cross agency approaches were a prominent feature of the approaches taken, in the school or the community setting. The study found that very little evaluation of the interventions had been undertaken, and activity at the local level tended to be focused on ad-hoc informal feedback from participants and project monitoring data. Some national evaluation activity was relevant to the large scale programmes, but this was restricted to set up and early impact stages only. The Healthy Schools programme provided a good example of a comprehensive intervention that addressed both healthy eating and physical activity, and that incorporated the involvement of parents, environmental actions and the wider school community. Some of the smaller local interventions linked into the Healthy Schools programme extending its impact and reach. The interventions identified in Crewe and Nantwich largely conformed to current guidance on delivery with partnership approaches featuring prominently. However, due to the absence of evaluation and cost effectiveness evidence, it was not possible to draw conclusions regarding attributable reductions in childhood overweight and obesity.
5. Netherlands Case Study In the Netherlands case study, there was extensive national support for regional and local preventative interventions to address childhood obesity. For example, in the region of Kennemerland a large number of interventions were carried out through national, regional and local funding. Some of these interventions had already shown encouraging results while for others the (cost) effectiveness was not yet clear. The setting of the different interventions varied. A small majority were embedded in a community setting, but the school setting was also highly relevant. Almost all the interventions included a multi-component approach, addressing a range of factors influencing childhood overweight and obesity. The majority of interventions focussed on physical activity and interventions including a healthy eating component were much less common. Interventions tended to target children (and/or parents) of primary school age with or without overweight and obesity problems, or targeted children indirectly by targeting the family or sport associations. Some municipalities within the region of Kennemerland were running more interventions than Beverwijk. For example, the municipalities of Heemskerk and Zandvoort funded many different interventions due to multi-annual campaigns while the municipality of Beverwijk was struggling to gain political support to get the subject of childhood obesity on the political agenda. As a result, only a minimum of 6 out of 18 interventions identified at regional level were operational in Beverwijk itself. Partnership approaches also proved a key success factor in the Netherlands. One of the most important stakeholders in relation to childhood obesity in Kennemerland was the regional project group Overweight Kennemerland (a partnership of the Sportservice Noord-Holland (regional organisation responsible for sport activities); as well as the GGD Kennemerland (regional public health service for children aged 4-18); JGZ Kennemerland (regional juvenile health care provider for children aged 0-4); Zorgbalans and ViVa! Zorggroep (regional health care providers). The Dutch concept of Brede School also proved effective in establishing cooperation between all stakeholders (e.g. schools, childcare, sport associations, libraries) in the upbringing of children and young people. One weakness of almost all the interventions was a dependence on time-restricted local (municipal funding), regional (provincial funding), and/or national (e.g. Ministry of Health) subsidies. This made the sustainability of the interventions highly dependent on the level of political prioritisation of childhood obesity. Another weakness as in the UK case study was the lack of (long-term) evaluation and monitoring. None of the identified interventions in either case study could provide a clear overview of the total costs involved. As a result, it was impossible to evaluate the costs and cost-effectiveness of the interventions. This impedes informed decision making regarding what interventions to implement in the future. 6. Conclusions and Recommendations Key conclusions emerging from a comparison of the case studies were as follows.
Preventing childhood obesity has been prioritised nationally in both the UK and the Netherlands, and multidisciplinary interventions are being implemented in both countries to address it. However, the nature of those interventions is distinctly different. While in the Netherlands more attention was placed on encouraging increased physical activity; in the UK healthy eating received greater attention. Also, in the Netherlands, interventions were predominantly integrated in the community while in the UK, interventions tended to take place within schools. In the UK, interventions tended to target all school-age children, while in the Netherlands attention was more focussed on specific age bands particularly the 4-13 age groups (i.e., primary education level) and in the UK, school staff and parents were targeted in addition to school-age children. In addition, in the Netherlands case study, several interventions specifically targeted school-age children with overweight problems whereas this kind of targeting was not in evidence in the UK. In several of the Dutch interventions, other groups were targeted in addition to school staff and parents (e.g. ethnic minority women with children, professionals, low income families and sport associations). In both countries, a common weakness of the identified interventions was their dependence on temporary public funding (local, regional and/or national) which meant the sustainability of the interventions was highly dependent on continued political attention on childhood obesity. Partnership approaches were central to the success of interventions identified in both countries. The reliance on schools to deliver interventions is a key issue in both countries. Schools were already burdened with delivery of a full educational curriculum and often struggled to take on additional responsibilities and the need to balance a wide range of demands on their time and resources. The dearth of local evaluation and monitoring was a key finding in both of the case study areas, with only a minority of all the interventions being subject to evaluation. Where evaluation has been completed this was often only in relation to impact and short term outcomes (e.g. participant feedback on the intervention or self-reported behaviour change) rather than the measurement of longer term reductions in overweight/obesity. The lack of evidence for effectiveness has hampered opportunities for evidence-based practice. Generally there was little funding in both case study areas specifically ear-marked for evaluation studies to enable rigorous research to be undertaken. Information regarding cost effectiveness was absent from both case studies suggesting a significant gap in information about the extent to which investment in interventions is worthwhile. Therefore, as a consequence, there was a lack of clarity regarding the real costs and economic benefits associated with efforts to reduce obesity. Recommendations Considerable efforts in both the UK and the Netherlands at all levels have ensured that childhood obesity has a high priority on political agendas, for example through national frameworks to shape the delivery of interventions. Policy and strategic approaches at the
EU, country, and local levels emphasise multi-component approaches addressing both healthy eating and physical activity delivered via sustainable partnerships. The importance of partnership working is evident and it is recommended that all future approaches continue to emphasise this multi-partnership working. It is also recommended that funding bodies allocate resources over a number of years to support cost effectiveness and evaluation research. Links to national policies and programmes play an important role in securing longer term funding and thus sustainability. It is thus recommended that in order to support a coherent approach across localities, links with national and regional strategies are fundamental to approaches to the prevention of obesity.
Glossary
Below is a glossary of terms used in the report.
Body Mass Index (BMI) A measure of body mass that uses height and weight measurements Covenant A binding agreement Ethnicity In the Netherlands, ethnicity is determined on the basis of the birth country of the caring parent. EU European Union General A doctor of general practice Practitioner/GP GGD In the Netherlands, GGD offices carry out public health care in assignment of municipalities. GGD offices are often organised on a regional level. There are 36 regional GGDs in the Netherlands. Health intervention An activity undertaken to prevent, improve or stabilise a medical condition. IOTF International Obesity Taskforce (IOTF) Inequalities in health Avoidable health inequalities arise because of the circumstances in which people grow, live, work and age and the systems put in place to deal with illness. The conditions in which people live are shaped by political, social and economic factors. Local authority A local authority is an administrative entity composed of a clearly defined territory and its population and commonly denotes a city, town, or village, or a small grouping of them. A municipality is typically governed by a mayor and a city council or municipal council. Known in the Netherlands as a municipality. Motivational Motivation conversations are organised using a method of conversations motivational interviewing. This is a special technique which requires special training. The counsellor does not try to convince the student, but instead tries to empathise and show the difference between current behaviour and goals and values of the student and support the student to believe they can change their behaviour themselves. Municipality A municipality is an administrative entity composed of a clearly defined territory and its population and commonly denotes a city, town, or village, or a small grouping of them. A municipality is typically governed by a mayor and a city
Obesity Prevention Primary Care Trust Province Public Health Public policy Region SES
WHO
council or municipal council. Known in the UK as a local authority. An excess of body fat that results in significant impairment of health Activities designed to reduce the incidence of illness in a population Type of NHS trust and part of the National Health Service in England A territory governed as an administrative or political unit of a country or empire. The approach to medicine that is concerned with the health of the community as a whole community health. Laws, regulatory measures, courses of action and funding priorities covering a given topic. A specified district or territory. In the Netherlands, socio-economic status (SES) is measured on the basis of level of education, income and level of occupation. A high outcome indicates a high level of education, income or level of occupation. World Health Organisation
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1 Introduction
ECOTEC Research & Consulting (ECORYS in the UK) and ECORYS NL are delighted to present this research report. The research was kindly supported by the ECORYS Research Programme. This document contains the results of a twelve month collaborative research study into preventative public policy around childhood obesity. There is an increasing volume of evidence to indicate that obesity is a significant public health problem that requires immediate and appropriate policy responses at the European, national, regional and local levels. As an important area of social policy research, obesity has been funded in the preventative public policy strand of the 2007-08 ECORYS Research Programme (ERP) providing an opportunity for in-depth investigation and the completion of a comprehensive research study. The ECORYS Research Programme was designed to bring together researchers from across the ECORYS group, to further knowledge and work on collaborative studies. Following the submission of proposals to the ERP in October 2007, ECOTECs Social Policy Division (UK) and ECORYS MSB Division (Netherlands) were awarded funding of 10,000 by the ERP to deliver an exploratory paper on the subject of obesity, and to develop a joint proposal for collaborative work in the field of childhood obesity. Findings from the exploratory paper 1 highlighted the significant problem that obesity poses for social policy. It established that the challenge for policy makers at all levels is, and will be, to tackle obesity across the range of policy areas including: regeneration, environment, health, education and community. Young people are a particularly important target group; recent statistics suggest that obesity levels are rising among children and that the consequences of this will present major policy challenges for the future. Following the completion of this exploratory paper, subsequent funding of 85,000 was granted by the ERP for the proposed childhood obesity research and completion of the full study to investigate prevention approaches in two case study areas. This report includes information on all stages of the study and brings together results from research teams in the Netherlands and England, offering a cross-national perspective on this area of preventive public policy. Throughout the study, Professor Carolyn Summerbell, School of Medicine and Health, at the University of Durham, has acted as expert adviser.
1.1 Aims and Objectives

The aim of this study was to investigate preventive public policy interventions in relation to childhood obesity in two case study areas in England and the Netherlands, enabling a comparative analysis of the approaches and context for prevention in both countries. The study objectives were to: Undertake literature and policy reviews to provide a review of the evidence for effectiveness of interventions to prevent obesity, and the wider policy context for intervention. Use national data to identify a case study area in England and the Netherlands that best reflects the overall population of each country. Develop a profile of each case study area including health, population demographics and socio-economic data. Systematically collect information on preventive interventions taking place on the snapshot day in each case study area, in line with an agreed intervention framework and using agreed criteria for selection. Identify stakeholders in case study areas to provide further data on interventions and address gaps in the intervention framework. Compare the results of the case studies in line with the evidence base and identify differences and commonalities in approach, and the intervention context for each country.
1.2 Content of this report

The report includes the following: Chapter 2 provides an introduction to the topic and offers an assessment of the size of the problem; this includes an outline of the significant public health challenges posed by the rise in obesity among young people. In addition a review is given of recent Policy Context and the Evidence Background with a focus on Europe. This section also provides an overview of the many approaches to prevention and health promotion, and the evidence base associated with these. Chapter 3 presents the methodological approach used for the study. Two case studies have been developed providing a snapshot of activity in England and the Netherlands. These are reported in chapters 4 and 5. The discussion and conclusions emerging from the study are presented in chapter 6. The particular focus in this section is on comparisons between England and the Netherlands and the conclusions that can be drawn in relation to future social policy initiatives and areas for further investigation. The annex provides further details on case study interventions, references, interview topic guides used for the study, and further relevant information.
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2 Background and Rationale for the Study
This chapter provides the context and background to the study. Firstly it provides an introduction to overweight and obesity (Section 2.1); then demonstrates the relevance of rising childhood obesity as a public policy issue and looks at the size of the problem at the European level and in our two case study countries (Section 2.2). The rationale for the study also links to the European policy imperative which is placing tackling obesity firmly on the agenda. The chapter therefore provides a brief review of the recent European policy context (Section 2.3). Finally, the chapter provides an overview of approaches to prevention and health promotion, and the associated evidence base to demonstrate what effective preventative public policy might look like and what types of intervention will be explored in the case studies (Section 2.4).
2.1 Definitions
2.1.1
Overweight and obesity
The most commonly used indicator of obesity is the Body Mass Index (BMI), a measure of body weight (in kilograms) divided by height (in metres) squared. The World Health Organisation (WHO) has defined obesity as a BMI 30kg/m2 . The threshold for normal 2 weight is set at 18.5kg/m2 24.9kg/m , for overweight that is 25kg/m2 - 30kg/m2 . Being obese or overweight is associated with a higher likelihood of suffering numerous chronic diseases, including amongst others: cardiovascular disease, diabetes and cancers (WHO, 2003). This indicator is used across Europe, as well as in England and the Netherlands. In the UK there is on-going debate regarding the definition of overweight or obesity in children, due to a recognition that adult BMI measures do not take into account the continuing physical growth and development of children. The following definition is offered by the Department of Health (2007): The clinical definition of overweight and obesity in children is based on BMI percentile charts for boys and girls plotted at different ages from 2-16 years. The National Institute for Health and Clinical Excellence (NICE) recommends that tailored clinical intervention should be considered for children with a BMI at or above the 91st centile, depending on the needs of the individual child and family, and that an assessment of co-morbidity should be considered for children with a BMI at or above the 98th centile.2
2.2 The Size of the Problem

Obesity is not a new problem, but it is a growing problem. This section explores the size of the problem at EU levels and nationally, exploring some of the key factors that have contributed to its rising importance on the policy agenda. The WHO considers obesity has reached epidemic proportions globally. Deaths relating to obesity are estimated at around 300,000 a year in Europe (Branca, Nikogosian and Lobstein, 2007). 3 Childhood obesity within this is a large and growing problem. The International Obesity Taskforce (IOTF)4 highlighted that worldwide one in ten children is overweight, with a total of 30-45 million classed as obese. The number of European children affected by overweight and obesity is estimated to be rising by more than 400,000 a year, adding to the 14 million plus of the EU population who are already overweight (including at least 3 million obese children); across the entire EU25, and being 'overweight' affects almost 1 in 4 children. The situation across Europe is illustrated in figure 2.1 below. IOTF figures indicate that the trend has been towards rising levels of childhood overweight and obesity since the mid 1980s. Data suggest a higher prevalence of overweight in southern European countries, Spain and Portugal in particular. The eastern European (Slovenia, Lithuania, Latvia and Estonia5 ) and some of the northern European countries (Finland, the Netherlands and Poland) have significantly lower rates of overweight children compared to the rest of Europe6 .
Figure 2.1 Mean Body Mass Index in EU-27 adults, 2005

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F inlan d Irelan d L uxemb ourg Polan d Belg iu m Spain United Kingdo m Czech Republic Denmark G ermany Lit huania Netherlands Port ugal Austria Bulg aria Cyprus Est onia France G reece Hung ary Italy Latvia Malta Romania Slovakia Slovenia Sw ed en
Source: WHO, Global InfoBase
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2.2.1
The Size of the Problem: England
Recent (2008) data from the Health Survey for England indicates that 29.7% of children were classed as overweight or obese in 2006. This includes 30.6% of boys and 28.7% of girls 7. Since 1995 there has been a 5 percentage point increase in obesity rates among children showing a trend towards higher levels. This trend towards increasing prevalence of obesity among children has been a concern to UK policy-makers. If obesity is not tackled it has been estimated that by 2050, 50% of boys 6-10 years will be obese and 20% of girls in this age range. Among children aged 11-15 years it has been predicted that rates of obesity for boys will be 23% and for girls 37%. 8.9 Data from the Health Survey for England indicates that in January 2008, boys were more likely to be obese than girls (17% compared to 15%). The survey also found that boys were more likely than girls to meet recommended levels of physical activity but that a higher percentage of girls consumed five or more portions of fruit and vegetables compared to boys (19% and 22% respectively).10 The cost of obesity to the National Health Service (NHS) in the UK is around 4.2 billion, and this figure is forecast to double by 2050. In addition, there are also wider costs to the economy (due to weight problems: e.g. absenteeism and reduced productivity) estimated to be around 16 billion11.
2.2.2
The Size of the Problem: The Netherlands
Figure 2.1 above shows that the prevalence of overweight and obesity in the Netherlands remains low compared to the rest of Europe and particularly compared to England. However, the table below reveals that the prevalence of overweight and obesity in the Netherlands is rising, and at an even faster rate than previously.
Table 2.1 Average proportion of girls and boys (aged 4-16) being overweight (including those obese) in the Netherlands Gender 1980 1997 2003
Boys Girls
Source: Van den Hurk et al., 2007
3.9% 6.9%
9.7% 13.0%
14.5% 17.5%
The prevalence of obesity among girls and boys aged 4-16 also increased in the same period. In 2003, 2.6% of the boys and 3.3% of the girls aged 4-16 years were obese compared to 1980 (boys 0.2%, girls 0.5%) and 1997 (boys 1.2%, girls 2.0%). At the age of 4, 12.3% of the boys and 16.2% of the girls were already overweight.
2.3 Preventive public policy

This study focuses on preventive public policy. Prevention operates at three levels (primary, secondary and tertiary); the focus of this study was on primary prevention which has been defined by the WHO 12 as activities designed to reduce the instances of illness in a population and to reduce the risk of new cases appearing. For example cancer prevention includes avoiding the identified risk factors such as smoking, obesity and a lack of exercise. Public policy is defined in this study as: "a system of laws, regulatory measures, courses of action and funding priorities concerning a given topic promulgated by a governmental entity or its representatives"13. As such 'preventive public policy' addresses the physical, social and cultural environment in which people live and the way in which people behave. Factors that are found to have the most significant influence on health are often called determinants or drivers of health and are depicted in Figure 2.2 below. This illustrates that although age, sex and hereditary factors are key in influencing health (including body mass), individual lifestyle factors such as diet and physical activity levels also have a core role to play in determining health; and these factors along with social and economic factors all work together in a complex and dynamic manner. Figure 2.2: The Determinants of Health
(Adapted from: Ministry of Social Affairs and Health Finland (2006), Health in all policies Prospects and potentials, Finland)
2.4 The relationship between health behaviours and obesity

Obesity is closely related to poor diet and low levels of physical activity. Combinations of factors arising over the past two decades in relation to diet and physical activity have contributed to increasing the concerns relating to obesity.
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The last two decades have seen a number of social and environmental developments that have changed diet and consumption patterns. These include increased energy intake due to increased consumption of: fats (particularly saturated fats and trans-fatty acids), sugar, salt, alcoholic beverages and micronutrient poor foods. This is exacerbated by falling consumption of fresh fruits, vegetables and other sources of dietary fibre and increasing energy density of food overall. Also European citizens are, on the whole, not yet consuming recommended nutrient intake goals suggested by the WHO. For example, in half of the EU Member States, the average fruit and vegetable consumption is less than 70% of the level recommended by the WHO. There is also evidence of decreasing physical activity in the EU. Almost 40% of European adults do not engage in any moderate activity during the week. In crosssectional studies, activity levels have been reported to drop by as much as 50 percent during adolescence.14 Several studies show a marked decline from the age of 12.15 In Europe, only one third of the children achieved the recommended hour of moderate activity five days per week (especially girls), while between 25-50% watch four or more hours of television per day 16. Across all countries and regions internationally, and all age groups, girls are less active than boys, and the gender gap increases with age. The European countries with the highest percentages (over 50%) of boys achieving the recommended amount of physical activity are: Ireland, Austria, Slovenia, the UK, Lithuania, Malta and Finland. Those with the highest percentages of girls (over 40%) are Ireland, Austria, Slovenia, UK (Scotland), Lithuania, Finland, and the Czech Republic. The poorest levels of physical activity for girls (less than 20%) are found in Belgium (Flanders) and France, and for boys (less than 30%) are in Belgium (Flanders) and France17. Several factors influence the relation among diet, physical activity and obesity. For example, socio-economic status plays an important role with respect to diet and physical activity. The data available suggests that the more disadvantaged families are in socioeconomic terms (e.g. low income, low education), the more they depend on the relative pricing and ready availability of foods. Figure 2.1 below illustrates the extremely complex relationships that exist between nutrition, physical exercise and obesity, illustrating that a complex causal web of factors influences people's lifestyle choices about food and exercise at different levels.
Figure 2.1 The causal web of influences on population weight gain
Source: IOTF At the international level, markets and availability of food is one critical factor; at the national level the level of education about healthy lifestyles and the role of media are both vital. At the community level the quality and availability of local health care services is important and the availability of local public transport such as safe cycle lanes and footpaths play a role. Moving to the individual level, individual choices on diet, activity and work situation all play a role. There are thus a variety of different levels of intervention where public policy may be effective. The issue is how they interrelate and are actioned by different agencies that have a responsibility for obesity levels.
2.5 Health consequences

Obesity is associated with a range of health risks and chronic diseases, including 18: Diabetes, Hypertension (high blood pressure), Coronary Heart Disease and stroke, Cancers (10% of cancer deaths are associated with obesity), Osteoarthritis, Reproductive function, and Liver disease.
It has been estimated that overall, obesity is responsible for more than 9,000 premature deaths in England per year and due to the link between obesity and chronic disease places a tremendous burden on the NHS. Obesity also has an impact on childrens mental health and the following psycho-social risks have been identified 19: Social stigmatisation,
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Poor self-esteem, Depression, Poor social functioning, Bullying, and Social exclusion.
Research has highlighted the need for effective intervention at all levels. Understanding current activity in relation to the prevention of childhood obesity and learning from practice across Europe can make an important contribution to the knowledge base. This research study therefore aims to contribute to the current debate and to further understanding of some of the key issues by drawing on cross-national comparisons.
2.6 The role of the environment in obesity

The environment also has a role to play in rising obesity levels. Despite rises in knowledge and awareness levels regarding healthy lifestyles and significant investment in health education, the recent rise in the prevalence of obesity across Europe has been described as a pandemic20. Over the last decade increasing acknowledgment of the wider influences on health and obesity in particular has informed the concept of the obesogenic environment, resulting in a move away from a more traditional understanding of obesity primarily as a self-determined state. The concept of the obesogenic environment views obesity as a normal response to an essentially abnormal environment (normal physiology within a pathological environment Egger, 1997). It is argued this reflects the complex interplay between human physiological mechanisms and the physical, economic and socio-cultural environment operating at the macro level. Therefore as long as the macro-environment remains obesogenic, levels of obesity will continue to rise and will be unlikely to fall without significant modification of a range of environmental factors. The necessary environmental change needs to be substantial and is likely to be difficult to implement. Required environmental changes, while varied and wide ranging, could include: regulation of the food industry, changes to building design and the built environment, and a shift in the balance between pedestrians and vehicles in favour of the pedestrian. The Public Health response to obesity and to the obesogenic environment requires comprehensive policy interventions that address obesity at both the micro and the macro level, requiring a multi-agency and partnership approach. This holistic approach is emerging as the model for promoting health and is exemplified by the Healthy Schools and Healthy Town initiatives in Europe. The EPODE initiative in France offers one example of an intervention that adopts a whole town approach 21 to tackling obesity. This initiative involves ten French towns and uses a range of community-based approaches, is based on social marketing principles, and has partnerships operating at all levels, with a range of sectors across each of the towns.
2.7 The European Policy Context

In 1997, obesity and overweight were identified as serious threats to global public health by the World Health Organization (WHO) and the previous section identified the size of the problem.22 This major health problem is leading policy makers to explore effective policy interventions. The WHO followed this by advising the governments of middle- and high-income countries to urgently consider the steps necessary to manage the risks posed by noncommunicable health threats such as obesity in 2002. 23 In 2005, the European Commission (EC) launched the EU Platform on diet, physical activity and health to provide a common forum for all interested actors at European level where they can explain their plans to contribute concretely to the pursuit of healthy nutrition, physical activity and the fight against obesity, and where those plans can be discussed; and outcomes and experience from actors performance can be reported and reviewed, so that over time better evidence is assembled of what works, and best practice can be more clearly defined.24 In 2006, the WHO organised a European Ministerial Conference on Counteracting 25 Obesity with the aims :

to place obesity high on the public health and political agendas; to foster greater awareness and high-level political commitment to action; and to promote international and inter-sectoral partnerships.26 27
At the meeting, EU Member States of the WHOs European Region signed a European Charter on Combating Obesity. The following year, the EC set up the High Level Group that consists of representatives of national governments, with the role to:
offer an overview of all government policies in the area of nutrition and physical activity; facilitate effective exchange of policy ideas and practices between Member States; and improve liaison between the EU Platform for Action on Diet, Physical Activity and Health and representatives of national governments, enabling relevant public-private partnership possibilities to be quickly identified and agreed upon.
The High Level Group and the EU Platform together form a framework that can work to create European solutions to the health issues related to obesity and overweight.28 In 2007, the EC, Directorate-General Health and Consumer Protection (DG SANCO) published a White Paper on a comprehensive nutrition and physical activity strategy. The main strategic objective is to reduce the prevalence and incidence of conditions related to diet and physical activity and to reduce suffering caused by the mortality and morbidity of these conditions (i.e. reverse the trend of rising prevalence of obesity in the EU by 2015). The secondary goal is to reduce costs associated with these conditions, improve overall economic productivity and sustainability throughout the EU and ultimately to
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increase the economic, physical and quality-of-life aspects of citizens welfare in line with the Lisbon Strategy. 29 From the White Paper it became clear that policy actions are needed with regard to both physical activity and food systems to increase positive environmental factors, reduce the negative factors that promote unhealthy diet and low levels of activity and weaken or sever the positive feedback loops by which problems in one aspect contribute to problems in another. There is general agreement on the need to tackle obesity via a multipolicy or multi-strategy approach, i.e. the integration of policies across several arenas: from food to sport, education and transport.30 These actions have to be conducted at all levels of decision-making, from local to EU level.
2.8 What works? The evidence for effective practice and policy in preventing childhood obesity
Policymakers have recognised that all public health issues, including obesity, need policies and strategies which are based on sound evidence. A range of (policy) instruments can be used at different levels, including legislation, networking, public-private approaches, and engaging the private sector and civil society. However, to be effective and cost-effective, action is needed from a wide range of private organisations, such as the food industry and civil society, and statutory and voluntary organisations at a local level, such as schools and community organisations. For example, the design of a community can influence health status by stimulating physical activity through safe cycle paths and the availability of playing fields for children. There is some available evidence and evaluation of policy interventions, particularly at the local and regional level , although these are often limited in terms of assessing impact on change in health status. Evidence at European and national levels (e.g. the UK) are more limited .
2.9
Approaches and the theoretical basis
As depicted in Figure 2.1, the relation between nutrition and physical activity is complex. Variables that influence the balance between energy intake and energy expenditure include:

Physiological variables, e.g. blood pressure; Changes in dietary or physical activity behaviour, e.g. walking to school; Mediating behavioural, economic and neighbourhood variables where these lead to behavioural change at an individual level, e.g. price of food; Knowledge, perceptions or attitudes relating to obesity-relevant factors, where these lead to changes in individual behaviour or policy, e.g. safety of cycle paths; Factors relating to availability or access, e.g. access to sport facilities.31
Overweight and obesity are thus related to societal, environmental, economic and personal factors.32
It is likely that the needs of children and young people differ from the needs of the general population. 33 The causal pathways of obesity-relevant factors may also be different since what diet is influenced by (family-related) preferences, and by our utility for available food choices, and by our income, attitudes and behaviours.34 Also, it is known that physical activity behaviours and leisure-time activities in children and young people differ from adults. 35 The approach taken to tackle the rising prevalence of overweight and obesity, as advised by most public health analysts, is to empower the individual to make healthy decisions. This implies a combination of interventions focusing on individuals own responsibility and their children, but also shaping the environment to making healthy decisions easier. This so-called holistic approach is applied in different settings (e.g. schools, local communities) in several European countries. Examples include free fruit at schools, increasing physical activity in the school curriculum. Also, several governments provide guidance to local areas regarding the tackling of overweight and obesity and achieving a healthy weight for the local population. In the UK, the government published such guidance aimed at primary care trusts, local authorities and frontline staff in early 2008. This guidance sets out suggestions for how local partners can develop their own plans, set goals and choose interventions, and also ensure evaluation.36 In the Netherlands, municipalities receive support and guidance from the government and other organisations to set up local preventive policy to tackle the issue of overweight and obesity. An example of a guideline offered by the Dutch government is the manual Prevention of overweight in local health policy (Handleiding Preventie van overgewicht in lokaal gezondheidsbeleid). This manual was published in 2007 by the Foundation Food centre Netherlands (Voedingscentrum Nederland), in cooperation with municipalities, Public Health Service Netherlands (GGD Nederland) and several national partners. It contains practical information, concepts, and examples for local policy makers and other local stakeholders to set up local preventive policy to overcome overweight and obesity. 37
2.10 The Evidence base

Effective preventative policies need to be based on sound (scientific) evidence. It is known that the evidence base of the effectiveness of preventative interventions is limited and not yet fully explored. The UK's National Institute for Health and Clinical Excellence (NICE) has published guidelines regarding the prevention, identification, assessment and management of overweight and obesity in both children and adults. 38 The guidelines are based on several systematic reviews that focus on lifestyle and behavioural interventions, rather than on social and environmental interventions. Little review-level evidence is available on the impact of social and environmental interventions for children and young people. Most reviews consider research relating to whole populations. Reviews contain limited evidence from robust prospective study designs relating to large-scale macro-level interventions, such as policy change, taxation, or changes to the built environment. There are few systematic reviews of communitybased programmes which primarily targeted obesity and measure a range of outcomes. Also, very limited data exist that is relevant to health inequalities or to the costeffectiveness of interventions. Since many countries are now attempting to implement policy in this area, guidance to the mass of available evidence, effective monitoring and evaluation is required. The European Commissions obesity white paper (2007) called for further investigation and
Preventive public policy and childhood obesity: case studies in England and the Netherlands 23
sharing of examples of good practice, and in the UK, for example, there is growing political interest in developing a better understanding of preventative policy relating to obesity. The recently published Foresight Report (which generated media interest around the question of whether obesity will be as big a problem as climate change) suggested that further evidence of effective policy interventions will need to be explored in the UK: Most of the research we reviewed focused on identifying and defining problems. We found insufficient evidence of effective programmes that have reduced obesity, from which learning may be extrapolated and applied to other situations. Indeed we were told these do not exist. Finding (or if necessary creating) practical examples of successful national-level programmes or structures might be a fruitful area of further work.39 This suggestion was also highlighted by the EC in its impact assessment that was published in 2007. More specifically, the key aims of the EC for the coming three years will be to determine the range of policies and actions in place within Member States, as well as to strengthen monitoring and evaluation of their impact. Sharing of information in the area of good practice in nutrition and physical activity, and obesity prevention is one of the main tasks. This study is focusing on identifying good practices in both England and the Netherlands for two specific municipalities.
3 Study Methodology
This chapter describes the research parameters set for the study and the methods used.
3.1 Parameters of the Study

3.1.1 Overweight and obesity
This study focuses on the categories of overweight and obesity. These are defined as labels for ranges of weight greater than what is generally considered healthy for a given height. Obesity is an excess of body fat that frequently results in a significant impairment of health. For children, overweight and obesity are usually measured using age- and gender specific cut-off points for BMI, such as those developed by the IOTF (see Chapter One for definitions). 3.1.2 Age and gender
Our study focused predominantly on the age range of 5-19 years (male and female). The focus on children and young people is linked to the focus on preventative policy, since there is evidence that obesity at an early age leads to obesity in older age,40 and therefore, the focus for preventative public policy regarding tackling obesity is to catch people earlier to prevent problems later in life. 3.1.3 Geographical spread
This study included a comparison of preventative public policy in addressing overweight and obesity in two countries: the Netherlands and England. Our rational for selecting these two countries is that the Netherlands is an example of a country which has below EU-27 average mean levels of overweight (BMI >25), whereas England is an example of a country with above EU-27 average levels of overweight (see Figure 2.1). In addition, while the challenge in England is an absolute reduction in obesity levels, in the Netherlands the challenge is to stop the increasing prevalence in obesity.
3.1.4
Type of intervention
This report does not attempt to explore the biological aspects of weight gain or look at medical interventions or treatments of obesity (i.e. curative approaches such as surgical procedures and drugs) but instead on preventative interventions. It focuses on the
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relationship between nutrition/diet and physical activity, behavioural change and overweight and obesity. This builds on the contention that the trend towards higher prevalence of obesity among children in Europe is driven by increased energy intake relative to physical activity in the population. The rationale for this focus is that there is a verified role for preventative (as opposed to curative) policy interventions in tackling obesity through diet and exercise (based on WHO evidence). In fact, the WHO suggests that government investment in health promotion (preventative policy) can be effective in reducing obesity and in reducing the associated rising costs of morbidity and mortality. The study therefore focuses on interventions which have been identified by the WHO (2003) as being where evidence is probable or convincing as to its effect on behaviours that are likely to promote healthy weight: regular physical activity; high dietary intake of non-starch polysaccharides (dietary fibre); intake of fruits; and home and school environments that support healthy food choices for children. In our study, a range of interventions to prevent obesity were identified from background research, and specifically the NICE guidance on obesity published in 2006 (appendices 6, 7, 8 and 9)41. Each of these documents lists a range of studies / interventions which have been used to address or prevent obesity and their results (where available). A full list of relevant initiatives was produced, and then identified from this list 20 'typologies'. Definitions for each typology have been included in the annex (see Table 2). The typologies were chosen from across the range of provision areas, such as schools, community and healthcare (see Table 3.1 below).
Table 3.1 Identified typologies for interventions to prevent childhood obesity
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Typology Topic or theme Reduce sedentary activity (watching TV and videos) Change to school meal content Healthy eating Change to provision of tuck in school (i.e. more fruit) Physical activity programme Lifestyle activity Subsidised leisure services Approaches Counselling Postal communication (i.e. newsletters) Workshops Behaviour change therapy / behaviour management therapy Traffic light system Use of incentives / rewards Changes to / incorporation into curriculum and
School
Community Healthcare
x x x x x x
x x
x x x x x x x x
x x x x x x x
Typology use of homework Interactive communication methods for advice 15 and support (e.g. telephone, website etc) 16 Peer support 17 Signposting
School
Community Healthcare
x x
x x x
x x x
3.2 Methodology
The study involved a series of different phases: a desk based review of current policy and the evidence base along with other relevant documents and development of appropriate intervention typologies; the identification of two comparable case study areas in England and the Netherlands; the identification of current interventions in both case study areas in line with agreed criteria; and interviews with key stakeholders. 3.2.1 Theoretical models
Preparing the interview protocols and analysing the preventative interventions identified in our case studies involved the use of a combination of two theoretical models: 1. ANGELO framework (Analysis Grid for Environments Linked to Obesity ANGELO). This is a conceptual model for understanding the obesogenity of environments and a practical tool for prioritising environmental elements.42 This model distinguishes physical, economic, policy and socio-cultural aspects at the micro and macro levels. These factors are analysed to the extent to which they influence preventative interventions (e.g. what is the influence of different cultural backgrounds on healthy eating?). 2. IOTF principles. The International Obesity Task Force (IOTF) emphasizes the importance of a comprehensive public health approach and sets principles to guide national and transnational action.43 The principles include: Principle 1. Education alone is not sufficient to change weight-related behaviours. Environmental and social interventions are also required to promote and support behavioural change. Principle 2. Action must be taken to integrate physical activity into daily life, not just to increase leisure time exercise. Principle 3. Sustainability of programmes is crucial to enable positive change in diet, activity and obesity levels over time. Principle 4. Political support, inter-sectoral collaboration and community participation are essential for success. Principle 5. Acting locally, even in national initiatives, allows programmes to be tailored to meet real needs, expectations and opportunities.
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Principle 6. All parts of the community must be reached not just the motivated healthy. Principle 7. Programmes must be adequately resourced. Principle 8. Where appropriate, programmes should be integrated into existing initiatives. Principle 9. Programmes should build on existing theory and evidence. Principle 10. Programmes should be properly monitored, evaluated and documented. This is important for dissemination and transfer of experiences.44 3.2.2 Desk based review
The literature review set the context for gaining an understanding of the evidence base for interventions aimed at preventing obesity. The literature review also aimed to identify information of relevance to the case study areas, specifically documentation or information on local policy and local interventions45. During the initial phase of the study a general review of the literature was conducted in both England and the Netherlands. A subsequent review was conducted in September 2008 on an agreed 'snapshot day' to ensure that information was current and as a means of duplicating the previous search to ensure accuracy. The approach to the literature review involved the following: A series of key search terms were identified, from initial scoping of the literature. These terms were developed and adjusted during the early phases of the study and were structured into the following categories (full list included in the annex): Clinical Policy Social Markets / Commercial Location. For the case study in England relevant literature was identified from the following databases: Idox Google Scholar Database of Abstracts of Reviews of Effects (DARE) and NHS Economic Evaluation Database (NHS EED) via the Centre for Review and Dissemination search facility 46 British Medical Journal's web-based search47 Healthy Schools web-site (search by region and local projects) 48 For the case study in the Netherlands relevant literature was identified from the following databases: Google Scholar Google Cochrane NHS Database of Abstracts of Reviews (English search terms) Cochrane NHS Economic Evaluation Database (English search terms) British Medical Journal database (English search terms) 49
Gezonde School (equivalent of Healthy Schools database Nederlands Tijdschrift voor Geneeskunde (Dutch Journal for Medicine)51 Centrum Gezond Leven (Centre for Healthy Living) ZonMw (the Netherlands organisation for health research and development) Rijksinstituut voor Volksgezondheid en Milieu (RIVM) (Institute for public health and environment)52 Gemeente Beverwijk53
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On the 'snapshot day' (3 rd September 2008) the second literature search was completed. This was a refined search based on learning from the first literature search, and using the same databases. A limited number of key word combinations were used based on the following terms (translated into Dutch for the Netherlands): Obesity Overweight Food Healthy eating Nutrition Physical activity Young people Children Crewe and Nantwich/Beverwijk Cheshire/Kennemerland public health policy prevention strategy healthy communities 3.2.3 Selection of case studies
The approach to the case study phase of the research commenced with identification of comparable case study areas in England and the Netherlands. The aim was to identify a municipality or local authority area which was representative of each country and of sufficient size and population density to support a range of intervention activity in relation to the prevention of childhood obesity54. Population data (census) was used to inform this process and consideration was given to the following: Population size Levels of deprivation Ethnic populations Health status of the population
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Balance between urban and rural Representativeness of individual local authorities/municipalities of each country as a whole. In order to identify each case study town national data was used. In England this included: 2001 census data55; the Index of Multiple Deprivation56 (IMD) (National Statistics, 2004); and Rural/Urban classifications 57 (DEFRA, 2008). In the Netherlands data sources included the data included: census data (Statistics Netherlands, 2007)58; socio-economic status data (Cultural Planning Office of the Netherlands, 2006); Rural/Urban classifications data (Statistics Netherlands, 2007)59; and ethnicity data all acquired from Statistics Netherlands (CBS) for the year 2007. A shortlist of seven possible case study towns in England was identified and from this list Crewe and Nantwich was initially selected as being close to average for England (close to the mean and median for each of the indicators considered). In the Netherlands ten towns were shortlisted and Beverwijk was selected as being close to the national average. Further details regarding the methods used to identify case study towns have been included in the annex. The Dutch and English areas relate to each other as follows: The North West of England was broadly equivalent to Noord-Holland The County of Cheshire was at a similar level to Kennemerland Crewe and Nantwich was at a similar level to the municipality of Beverwijk.
3.2.4
Identification of interventions within the case study areas
The case study research involved identifying preventative public policy interventions operating at some level on the 'snapshot day' (3rd September, 2008) in the case study areas. Up to twenty interventions were identified using the following methods: Internet searches Resources identified via the literature review Data from documents sourced from local contacts Interviews with stakeholders in the case study areas (the topic guide used for interviews has been included in the annex). The criteria for the inclusion of interventions in the case studies was informed by literature searches, consultation with the expert adviser, and evidence of what works from the NICE guidelines for good practice60. The inclusion criteria were as below: Preventive (primary level) interventions that aim to reduce or prevent childhood obesity or overweight by promoting physical activity and/or healthy eating among children aged 5-19 years, Interventions that conform with typologies identified from the NICE Guidelines (all typologies and their definitions are listed in the annex), Interventions that were operating at some level in the case study area on the 'snapshot day'. Interventions that met these criteria were eligible for inclusion. It was recognised that a number of health promotional and other activity would also impact on school-age
children and play a role in preventing overweight or obesity, for this reason some interventions were excluded as follows: Interventions that involve a medical response and that take place in the secondary healthcare setting (e.g. hospital based surgery or drug treatments). Statutory services that address childhood obesity and that are not time-limited, population-based interventions aimed at prevention (e.g. one-to-one consultations between general practitioners, nurses or dieticians with individuals). Interventions that target school-age children who have been identified as 'obese' or overweight by a clinical specialist e.g. school nurse, health visitor or doctor (secondary level prevention has been excluded). Interventions that were not taking place on the 'snapshot day' (3rd September, 2008). Interventions that do not include school-aged children (5-19 years) in their primary target group or as a target group via interventions aimed at teenage parents. 3.2.5 Interviews
Key stakeholders in the case study areas were initially identified through web-based information for each of the relevant authorities (Primary Care Trusts, Council Councils, Borough Council in the UK, and municipalities; GGD and other public health organisations in the Netherlands), and contacts linked to interventions that had been indentified via internet searches. Thereafter further stakeholders were identified through a 'snowballing' process with additional contacts being suggested by interviewees and those contacted by phone. The interviews were conducted in a location and at an agreed time to suit the interviewee. The interviews focussed on the intervention(s) for which the stakeholder had direct responsibility or the greatest knowledge of. The interview questions were structured in line with the 'intervention framework' in order to capture consistent information regarding each identified intervention (the full topic guide has been included in the annex). The following areas were discussed with interviewees: The policy background with specific reference to local strategies and policies. In depth information on the intervention(s) including the timeframe, target group(s), delivery and the setting for delivery. Participation in the intervention and related monitoring and evaluation. Financing of the intervention(s) and other information on associated costs. Barriers and facilitators associated with the intervention. Examples of 'good practice' in the case study area. Information collected via the interviews and desk-based reviews for each intervention was used to populate an intervention framework, as a means of ensuring a systematic approach to recording interventions and assessing them against established frameworks between both research teams. The intervention framework ensured the collection of information in relation to the following: Background information on the intervention
Preventive public policy and childhood obesity: case studies in England and the Netherlands 31
Data in response to the ANGELO framework (physical, economic, policy and socio-cultural data at the micro and macro levels) and the IOTF Framework, as described above. Any other additional information about the interventions. The completed intervention frameworks for both case study areas were used for the analysis stage and to inform development of a table of case study interventions. A table presenting the intervention frameworks for the England and Netherlands case studies is included in the annex.
4 The English case study: Crewe and Nantwich
4.1 Overview of Crewe and Nantwich

4.1.1 Demographics and health status in Crewe and Nantwich
The Borough of Crewe and Nantwich has a total population of 111,007 persons61 of whom 21,473 (19%) are aged 5-19 years. The borough has been classed as part rural62 and has two main towns: the more affluent Nantwich, and Crewe which has higher levels of deprivation. The borough has significant pockets of deprivation and consequent health inequalities across the district. Neighbourhood Renewal activity is focussed on the five most deprived wards in Crewe. Data from the 2007 and 2008 Crewe and Nantwich Health Profiles63 indicates that with regards to health measures this borough was about average in comparison with England as a whole. However, a lower percentage of people rate their health as not good than the averages for both the North West and England as a whole. While life expectancy in this borough was similar to both the North West and England averages for men, it was lower for women. However, women in the most deprived areas live on average for two years less than those from the least deprived areas, while men from the most deprived areas have a five year lower life expectancy. Although, over the previous decade there has been a decrease in early death rates from cancer, heart disease and stroke, this has been decreasing at a lower rate compared to the rate for England. This indicates a widening gap between Crewe and Nantwich, and England as a whole. 4.1.2 Health and lifestyle of children in Crewe and Nantwich
The 2008 Crewe and Nantwich Health Profile 64 indicates that 8.3% of school children in the reception year (4-5 years) were classed as obese compared to the England average of 9.9%. The percentage of young people (5-16 years) in Crewe and Nantwich who spend at least 2 hours per week on high quality PE and school sport in 2006-07 was 90.5% compared to the England average of 85.7%, suggesting that physical activity levels are significantly better than the England average.
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4.2 Preventing Childhood Obesity in Crewe and Nantwich: the Interventions

A total of eleven interventions that met the agreed study criteria were identified in Crewe and Nantwich. The eleven interventions were selected from a total of sixteen originally identified. Of the five that were excluded: two targeted children/young people who had already been identified as overweight or obese, one intervention had finished in the previous year, one had been implemented after the snapshot day, and a further intervention was excluded because it was not possible to secure an interview with the contact and insufficient information was available from other sources. The eleven interventions have been listed in Table 4.1.below. Further details on individual interventions have been included in the annex.
Table 4.1 Description of interventions
Number Intervention Name 1 The Friday Boy Club
Description Friday Boy (a former Wishing Well volunteer) attends schools on a Friday lunch-time. Pupils are invited to participate in physical activity, healthy snacks are eaten and there is an opportunity to learn about human biology. The club also addresses mental health (bullying), but focuses most on physical activity in the playground. This young people's club aims to promote general good health and to raise the self-esteem of young people. There are informal opportunities for health education and for addressing obesity issues in a supportive environment. Referral is via the school nurse and the focus is on the most vulnerable. A project to encourage physical activity during school time, and out of school hours. The focus is on participation by pupils who dont enjoy the school PE curriculum and on informal non-competitive activities. The Food in Schools programme a joint venture between the DH and DCSF includes a range of nutrition related activities. The School Fruit and Vegetable Scheme is part of the 5 A Day initiative - children in primary schools (LEA maintained) aged 4-6 years are entitled to a free piece of fruit or vegetable each day. This operates across England. Bike2School is a CNBC led project (with Sustrans) linked to Routes2Action a free publication. Individual schools have developed travel policies and funding has been available to support this. There is a local Cycling Champion to encourage and support school-children. Extended Schools are expected to offer quality
Chill and Chat Youth Club
Health Lynx
The National School Fruit Scheme, 5 A Day, and the Food in Schools Programme Bike2Schools/Safe Routes to Schools
Extended Schools
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The Cheshire Healthy Schools Programme
Play Outreach Programme
10
Government Nutritional Standards for School Lunches and other School Food Snack Right
11
Healthy Start
childcare, a menu of activity (including physical activity) and parenting support. Meals provided under Extended Schools are required to meet nutritional guidelines. As a result of ES some children may have the majority of their nutrition at school. Takes a 'whole school' approach to health and addresses issues across the school staff, parents, curriculum and pupils. Healthy Schools have in place projects, policies and education initiatives in relation to both healthy eating, and promotion of physical activity. A child-centred programme to promote play in public spaces with a focus on the most vulnerable communities. This programme also involves parents and offers a wide range of play activities. New government standards initially implemented in primary schools in 2008 (secondary schools by 2009). These are mandatory and cover all eating in school lunches and snacking. In Cheshire, new initiatives include: salad bars, local sourcing, information about healthy packed lunches, and access to fresh water. Snack Right uses a social marketing approach and targets economically inactive parents and their children (including under 19s and teenage parents in Crewe). This project promotes breast feeding, and healthy snacking by under 4s and their parents. There have been 15 Snack Right events at children's centres (2 of which were in Crewe and Nantwich) and a leafleting campaign targeted 113,000 households. Healthy Start aims to tackle health inequalities by providing food vouchers to young mothers (particularly those under 18 years). Vouchers can be exchanged at shops for fruit, vegetables, milk or vitamins. Referral is via ante-natal clinics and Health Visitors.
Source: ECOTEC Research and Consulting, 2008
While some of the interventions were operating in the case study area as part of national schemes and initiatives, others were specific to wards within the borough, the borough as a whole, or were operating across Cheshire (usually across Cheshire schools). Improving childrens health by promoting changes in eating behaviour or encouraging higher levels of physical activity were central aims of the interventions identified, rather than specifying the goal of reducing obesity - although this was an intended outcome. All of the interventions were characterised by partnership and cross-agency working and linked in with regional or national policy initiatives. A majority of the activity took place in the school setting although some of the interventions had a community-wide focus. Four face-to-face interviews were conducted in Crewe and Nantwich with: two stakeholders from the Primary Care Trust (CECPCT), one from the Wishing Well
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Healthy Living Centre; and one from the Health Development Team at Crewe and Nantwich Borough Council. In addition, further local information was provided by key a stakeholder from Cheshire County Council (via email exchanges). 4.2.1 Characteristics of interventions in the case study area
A summary of the eleven case study interventions in Crewe and Nantwich is included in the annex. This section explores the key findings arising from the interventions identified. Several key themes arising from the analysis are then explored: Settings The settings for the eleven identified interventions were either the school or the community; none were based in a healthcare setting. Six of the interventions were school-based, four were community-based and one operated across both the school and the community settings. Typologies Healthy eating followed by physical activity programmes occurred most frequently. Most of the interventions related to more then one typology, providing an indication of the extent to which interventions utilised different activities and actions to address obesity. The Cheshire Healthy Schools programme was aligned with five of the typologies, demonstrating the multi-component nature of its approach. The number of interventions relating to each typology is shown in Table 4.2 below:
Table 4.2. Allocation of intervention typology
Evaluation and monitoring Links with Policy and Strategy Delivery partners Funding and sustainability
Typology Physical activity programme Change to provision of tuck in school Healthy eating Peer support Lifestyle activity Reduce sedentary activity Changes to/ incorporation into curriculum Signposting Postal communication Workshops Use of incentives/rewards Change to school meal content
Source: ECOTEC Research and Consulting, 2008
Number of interventions 5 4 7 1 3 3 1 1 1 1 1 1
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Cheshire County Council had a central role in the development and implementation of interventions in Crewe and Nantwich. Other key players and/or lead authorities were CNBC, and the Central and East Cheshire Primary Care Trust (CECPCT). All three of these authorities were associated with leading on one intervention: the Cheshire Healthy Schools Programme. Five of the interventions were part of initiatives operating at the national level (The National School Fruit Scheme; National Standards for School Lunches and other School Foods; the Extended Schools Programme; Safe Routes to School; and Healthy Start). Two of the interventions were operating as regional programmes (The Cheshire Healthy Schools programme, and Snack Right), and the remaining four were operating at a local level (Friday Boy Club; Chill and Chat Youth Club; Health Lynx; and the Play Outreach Programme). Target groups The target group for all eleven interventions was school-age children or young people 519 years. Within this overall category there was some sub-targeting as follows: Vulnerable school-aged children (secondary level) 2 (Friday Boy Club, Chill and Chat Youth group) School-age children (primary and secondary levels) 3 (Nutritional Standards for School lunches and other school food, Health Lynx, 5 A Day and the Food in Schools programme) School staff, pupils and parents 1 (The Cheshire Healthy Schools Programme) School pupils and parents - 3 (The Extended Schools programme; Safe Routes to School and Bike2Schools; and the Play Outreach Programme) Pre-school children and parents (under 19 years) 2 (Snack Right, and Healthy Start). Evaluation and Monitoring Information regarding monitoring and/or evaluation for each of the 11 interventions was identified. In addition, information about levels of participation in each intervention was sought. For two of the interventions no information regarding monitoring or evaluation was identified, a further two could not provide any evidence of effectiveness, but did report that the interventions had been very well received. The anecdotal feedback was in general very positive. Only one local evaluation was identified, this involved the collection of monitoring information and an invitation to participants to complete feedback forms (see case study 1). Although some future evaluation activity was planned in relation to national level initiatives, there was very little evaluation activity locally. For four of the interventions, evaluation studies may be undertaken or are planned for the future. However this suggests a stronger emphasis on outcome evaluation after project completion. On the basis of the available information more than 1,385 individual school-age children were being targeted by one or more of the interventions and it was possible to conclude that nearly all the
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schools in the CNBC area were involved in one of more of the interventions identified (More than 189 schools were targeted across all 12 interventions). Evaluation associated with the Healthy Schools programme has recently been commissioned by the DH65 for a three year period (to 2010). This will investigate the impact of the programme on young people and will be based around research conducted in 400 English schools. The focus will be on the impact of the programme and will centre on changes in behaviour, knowledge and attitudes.
Case Study 1 Health Lynx promoting physical activity in Crewe and Nantwich schools
Established five years ago, Health Lynx was originally implemented in response to the Healthy Schools programme. The emphasis is on activities not normally available in the school PE curriculum (e.g. dance mats and Pilates) provided during school hours and after the school day has ended. The target group is pupils who tend not to be active at school and who don't enjoy PE. Health Lynx serves six secondary schools and 75% of the primary schools in Crewe and Nantwich, and is funded by CNBC (their Health Development team deliver the project), various grant funding and contributions from the schools themselves. Through project monitoring and feedback CNBC have received information regarding the uptake of Health Lynx, and how it has been received by both the schools and their pupils. Key findings include: Initial take up was slow 68% of Year 9 pupils take part in Health Lynx By mid 2007, 1,110 pupils were taking part Overall a positive response was received from schools who requested return visits from the Health Lynx team. Teachers have reported that some of the more challenging pupils have been taking part 40% of pupils agreed with the statement: "It's fun, different and exciting compared to normal PE" 64% of pupils agreed that they now know more about different ways to be active. The Health Lynx intervention contributes to CNBC's Community and Corporate Strategies and to meeting the government targets to: "increase the number of people who do 30 minutes of physical activity 5 times a week" and "to halt the year on year rise in obesity in children under 11 years by 2010."
Sources: Interview with Crewe and Nantwich Borough Council (Health Development) September, 2008. CNBC (2006/07) CNBC Performance Indicators return CNBC (undated) Health Lynx information sheet CNBC (undated) CNBC Community Development and Social Policy. Health Development Project Monitoring Form.
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Links with Policy and Strategy While the development of the interventions was most often in response to policy and strategic initiatives, only one intervention Snack Right had explicitly been based on the evidence for best practice. The strongest links were in relation to the policy and strategic initiatives at different levels as follows66: Local policy (CNBC, CECPCT, or CCC) 7 interventions (Friday Boy Club, Chill and Chat Youth Club, Health Lynx, Cheshire Healthy Schools programme, the Extended Schools Programme, Safe Routes to Schools, and the Play Outreach Programme). Regional policy/strategy (regional responses to health inequalities) 2 interventions (Healthy Start and Snack Right) National level policy (PSA Obesity Target, government action plans, mandatory provision, implementation of Every Child Matters, Getting Serious About Play (DCMS), national Sure Start programme) 6 interventions (Healthy Lynx; National School Fruit Scheme, National Standards for School Lunches and other School Food, Cheshire Healthy Schools Programme, Extended Schools programme, Healthy Start) It was thus clear that all eleven interventions were embedded in public health policy either at the local, regional or national level. The national policy context was highly influential in shaping and providing the focus of local interventions. This also supports a level of coherence across the interventions and arguably contributes to concerted action across the case study area as a whole. The Role of Social Marketing The Snack Right initiative was a regional campaign that targets economically inactive parents and their children. It uses a social marketing approach to counteract the influence of mainstream advertising and marketing by the food industry. Social marketing has been defined by the Department of Health as follows: "Health-related social marketing is the systematic application of marketing concepts and techniques to achieve specific behavioural goals relevant to improving health and reducing health inequalities."67 Thus social marketing can be used to support changes in health behaviours by using some of the powerful marketing techniques, to make good health an attractive and desirable choice. In response to this the UK government has created the National Social Marketing Centre for Excellence to increase both the use and understanding of social marketing techniques. In relation to obesity recent initiatives have embraced a social marketing approach in particular: the Healthy Towns initiative and the Change4Life campaign. Change4Life is a new movement that is supported by the DH 68 and has the central aim of improving children's diets and levels of physical activity with a particular focus on educating parents about obesity. The campaign works with commercial partners (supermarkets, food manufacturers and the media), develops and disseminates resources, and aims to provide clear and consistent messages. The Healthy Towns initiative 69 is part of the Change4Life movement; it includes nine towns in England that receive government funds to encourage healthy lifestyles. Healthy Towns will provide a range of opportunities for their communities to lead healthier lives, in particular in relation to:
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opportunities for physical activity and making healthier food choices. The approach will address the whole community and the infrastructure of the towns.
Delivery Partners A partnership and cross-agency approach was an important feature of all eleven interventions, suggesting that existing practice is in line with current recommendations, and acknowledging the complexity of the obesity problem. While the interventions were often funded by a number of organisations, delivery did not always involve all of these funders, in some cases it was the responsibility of one organisation. Delivery partners sometimes included beneficiaries, who were regarded as key to effective implementation. For this reason parent/carers and young people themselves were sometimes cited as delivery partners. The key partners and the number of interventions relating to each of these are shown in Table 4.3 below:
Table 4.3 Key partners in the delivery of interventions
Partner Other schools CNBC CCC CECPCT Teachers and other school staff Young people External organisations working with schools e.g. Traveline
Number of interventions 4 3 3 6 3 2 1
Partner Parents/carers School meals provider
Number of interventions 3 1
Other local 2 authorities Health professionals 3 Shops or local supermarkets Other council departments e.g. Highways 2 1
Source: ECOTEC Research & Consulting, 2008
The involvement of partners from the private sector (e.g. supermarkets) and other council departments indicates that to some extent wider environmental factors have been recognised. Young people and parents/carers would appear to have a less prominent role than might be expected. This may be due to the fact that involvement of both of these groups was implicit to approaches and that they have therefore not been identified as delivery partners. Alternatively this may be due to an understanding that partners refers to those with a financial stake in the intervention or to statutory agencies only.
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Case Study 2: The Cheshire Healthy Schools Programme
More than 95% of England's schools are now involved in the national Healthy Schools (HS) programme, and more than 60% have achieved National Healthy School Status (NHSS). A long-term initiative HS aims to improve the health of school-children through healthy behaviours, positive mental health, and safety. Via a whole school approach that involves all of the school community and parents, physical and emotional health is addressed through 4 key themes: personal, social and health education; healthy eating; physical activity; and emotional health and well-being. Cheshire's Partnership Approach Cheshire's Healthy Schools programme is one of the largest HS partnerships in England, including 324 schools (268 primary, 47 high schools, and 9 special schools). Across Cheshire 37 schools have signed up to 'The 1 Million Meals' (healthy eating initiative) and schools have been given resource boxes for the 'Give Me 5' campaign. In Crewe and Nantwich 49 schools have been engaged, of which 40 have achieved NHSS. These schools have been meeting all requirements for healthy meals and snacks, and have food and physical activity policies in place. Most schools have been engaged with the HS programme for in excess of 5 years. The Cheshire Healthy Schools programme supports a strategic approach to increasing physical activity and healthy eating in schools. This involves a multi-agency and partnership approach between health professionals, the local education authorities (CCC and CNBC) and strategic planners. Partnership is central to the approach and in particular involves joint working between Environmental Health Officers (Local Authority), health professionals, and schools.
Sources: Email communication with the Healthy Schools Co-ordinator at Cheshire County Council (November, 2008). Healthy Schools (2008) Healthy Schools web site. http://www.healthyschools.gov.uk/
Funding and sustainability Funding for the eleven interventions was from a range of sources, predominantly the public sector. The main public sector sources were CCC, CNBC, CECPCT and central government funds (e.g. from DCSF and DH). In addition to this, funding for activity also came from individual schools, the Wishing Well Health Living Centre (core funding from CNBC and CECPCT), and to a lesser extent other grant funding. There was little evidence of significant funding from either private or third sector sources. Five of the interventions had been established for one year or more, five for more than three years, and one for less than a year. Five of the interventions (Cheshire Healthy Schools programme, the National School Fruit Scheme, Nutritional Standards for School Lunches and other school foods, Safe Routes to School, and Healthy Start) were well established and therefore likely to continue while political support for them remains. Two interventions were set to continue in the short term and had in place plans for longer term
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sustainability (Chill and Chat Youth Club and Healthy Lynx) but this would depend on the availability of continued local and health authority funding. The Friday Boy Club was based around the input of one individual so may be less likely to be sustainable.
Case Study 3: Healthy Start A National Initiative to Reduce Health Inequalities
Healthy Start replaces the Welfare Food Scheme and operates across the UK providing: fruit and vegetables; vitamin supplements; and milk. The scheme aimed at disadvantaged pregnant and young mothers, also supports breastfeeding. People from disadvantaged groups have significantly higher rates of: infant mortality, low birth weight, smoking in pregnancy and postnatal depression, compared to the general population. Those eligible for the Healthy Start scheme (incomes of less than 15,575 or on benefits) receive vouchers (each voucher is worth 3) through the post every 4 weeks that can be exchanged at registered shops. Compared to other areas of East Cheshire, Crewe has the highest proportion of children and young people, and also has significant levels of poverty and deprivation. Recent evidence from the Cheshire East Joint Strategic Needs Assessment provides an illustration of this (CECPCT, 2008). Compared to Cheshire East, Crewe and Nantwich has a higher infant mortality rate (5.2 per 1,000 compared to 3.8 per 1,000) and the rates of breastfeeding are lower than the national average (62.8% in Crewe and Nantwich compared to 69.2%). In Crewe, estimated adult obesity rates are high (26.1% compared to 22.8% for Cheshire East) and the estimated consumption of 5 portions of fruits and vegetables a day is low (21.2% in Crewe and 25,4% in Cheshire East). The Healthy Start scheme has particular relevance to Crewe, which has significant health inequalities and in particular a high rate of teenage pregnancy. Latest data indicates that there are 43.9 per 1,000 teenage pregnancies in Crewe compared to 31.1 per 1,000 across East Cheshire the highest rate in the area. Prevention of obesity and the promotion of a healthy diet are clearly of importance for this group of young mothers. While these figures suggest that there is a significant target group in the CNBC area for the Healthy Start scheme, the low take up to date suggests further work is needed to ensure it reaches those who will benefit the most.
Source: Interview with Public Health contacts at Cheshire and East Cheshire Primary Care Trust (October, 2008). Healthy Start (2008) Healthy Start web-site. http://www.healthystart.nhs.uk/ Department of Health (2002) Proposals for the reform of the Welfare Food Scheme. http://www.dh.gov.uk/en/Consultations/Closedconsultations/DH_4087874
4.2.2
Overview of the Crewe and Nantwich Approach
The organisation and management of approaches to obesity prevention in Crewe and Nantwich was reflected across England as a whole, with local authorities (CNBC and CCC) and primary care services (CECPCT) taking a lead on activity. There was also
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some third sector activity (voluntary and community sector organisations and non-profit making organisations), but this was often in conjunction with health and/or local authorities. The CNBC has a Health Development team which was established 10 years ago and employs three officers. This offers the local authority an opportunity to take a lead in promoting health and to deliver key interventions e.g. Health Lynx. While the Healthy Communities programme 70 established in 2006 has aimed to promote the role of local authorities in delivering a seamless approach to public services in particular working closely with the health sector, an established health development team within a borough council was still relatively unique. The Health Development Team has helped CNBC to develop and deliver a relatively large scale physical activity intervention in the borough. Interventions did have a strong focus on healthy eating and physical activity often along side other actions, but two in particular aimed to address positive mental health among young people. This approach indicates an acknowledgement of the role that mental health plays in childhood obesity. Being overweight and obese was often accompanied by low self-esteem71 therefore an approach that addresses mental health alongside health behaviour was highly appropriate. The interventions included in this case study were identified because they met predetermined criteria. However, it was evident during the course of the study that a wide range of other initiatives and activities in the borough of Crewe and Nantwich were impacting on obesity and the health of school age children. These included other initiatives specifically focused on school-age children or young people as well as those operating across the locality and affecting the wider population. The multi-level activity operating within the case study area highlights the complex nature of health behaviours and their determinants, and the wider environmental factors that impact on overweight and obesity. The table (1.2) included in the appendix provides an illustration of some of the local activities and other initiatives that have an impact in the CNBC area. None of the interventions identified took place in a healthcare setting. This may be because while childhood obesity was addressed by healthcare professionals in this setting (for example by health visitors, doctors, practice nurses or physiotherapists), such activity tends to occur on an individual basis, or with small groups (usually adults). In addition, it was noted that some general practitioners were not convinced that there was sufficient evidence of effectiveness regarding public health interventions to justify taking on a greater public health role. Nonetheless, a move towards the promotion of wider health and wellbeing within the healthcare setting was evident. In Crewe and Nantwich, the Eagle Bridge Health and Wellbeing Centre (opened in November 2007) embraces the delivery of statutory primary healthcare services alongside provision of health information and a community caf run by the Wishing Well Healthy Living Centre. This centre brings together three GP practices and the centre was also used by community and voluntary sector groups. 4.2.3 Barriers and Facilitating Factors
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Interventions that were effectively implemented and well received were associated with a number of facilitating factors that helped this to happen. Where schools were both receptive and supportive of an intervention this assisted with raising awareness and participation. If schools themselves made a financial contribution towards initiatives this helped to embed interventions and ensure on-going support for them. A flexible approach was also a facilitating factor that assisted in promoting a sense of 'ownership' among those participating. This approach allowed change and a natural evolution due to the input of participants, supported their commitment to the intervention and a level of 'empowerment' among beneficiaries. Interventions delivered as part of wider regional and national programmes (e.g. Healthy Schools) had the advantage of being part of an established initiative, with allocated resources such as regional co-ordinators and health information. This helped to provide them with a high profile and to attract support and commitment from partners e.g. schools and parents. A number of barriers hampered the effective implementation and delivery of interventions. There was a tendency for the prevention of obesity to be seen as primarily the responsibility of the NHS, rather than being a much wider responsibility that included other statutory authorities and the wider community. Joint commissioning and multiagency approaches have been established to encourage a shared approach, but changing the culture may take longer. Partnerships such as the LSP support working together and provide the opportunity for a number of agencies to consider together a single issue such as obesity. Some of the interventions took time to become established and to gain support. Initial participation levels were often low and it was necessary to raise awareness and market interventions to their target group in order to reach anticipated participation levels. Other identified barriers centred around: the reliance on short-term funding; difficulties around attracting external funding for interventions; the high levels of change and re-organisation taking place within both health and local authorities; and a need for higher levels of personal responsibility regarding health. 4.2.4 Examples of good practice
As already noted, the eleven interventions included in this case study had been subject to little local evaluation, and where this occurred it tended to be limited to monitoring data, anecdotal reports and information collated from feedback forms. Monitoring of interventions was often associated with funding requirements and involved reporting back on outputs as part of the funding agreement. The feedback on interventions was generally sought from participants and those delivering the initiatives, often on an ad-hoc basis using self-completion questionnaires. Some of the interventions had been the subject of national evaluation studies, although these had been either baseline or pilot research studies. Although some information was available on intervention costs there has been no cost effectiveness reporting. Without any local evidence it was hard to draw firm conclusions regarding effectiveness.
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However, the identified interventions do offer examples of practice that are in line with current recommendations. The table below reflects on the Crewe and Nantwich approaches in line with current guidance for evidence-based practice:
Table 4.4 Links between case study interventions and current recommendations on delivery.
Current recommendations on delivery72 Community programmes to prevent obesity, increase physical activity and improve diet should address the concerns of local people
Crewe and Nantwich Interventions Consultation with young people was a strong feature of the Play Outreach Programme. The Wishing Well HLC in Crewe reported developing its interventions in response to needs identified by local people (including young people). Local authorities, PCTs and LSPs should The LAA and Sustainable Community ensure that preventing and managing Strategy have identified the health of obesity is a priority for action at strategic young people as priority areas and action and delivery levels through community to address obesity is prominent in local intervention policies and objectives. policy and strategy. No specific evidence Dedicated resources should be allocated for that financial resources have been action. dedicated for action to address obesity in school-aged children. However, a large proportion of the funding for interventions originates from the PCT, the borough council or the county council. Schools: School Travel Plans (Safe Routes to Ensure school policies and the School) and the Cheshire Healthy Schools Programme support implementation of environment encourage physical school policies to encourage physical activity and a healthy diet activity and a healthy diet. Arrange training for teaching, support and catering staff Initiatives that link well with local Establish links with health strategies and partnerships include Health professionals and local strategies Lynx, Play Outreach Programme, and Safe and partnerships to promote sports Routes to School. Promote activities that children enjoy and can take part in outside Active parental involvement in the Food in school and into adulthood Schools intervention, the Extended Introduce sustained interventions to Schools programme, and the Play Outreach Programme. encourage pupils to develop lifelong healthy habits Take pupils' views into account Involve parents
Source: ECOTEC Research & Consulting, 2008
Healthy Lynx, Extended Schools and the Play Outreach Programme promote activities out of school and into adulthood.
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4.2.5
Conclusions
On the basis of findings from the Crewe and Nantwich case study it was evident that partnership underpins the approaches to intervening in relation to childhood obesity and effective partnerships were beginning to emerge in practice. Some interventions through their approach recognise the need for comprehensive action by including both healthy eating and physical activity, extending interventions into the home via parents, and implementing environmental changes. The Healthy Schools programme provides a good example of this. A significant gap was the lack of evaluation associated with interventions or evidence regarding cost effectiveness. The review of the evidence base relating to childhood obesity conducted by NICE73noted that many of the obesity interventions tended to be of short duration with little or no follow-up, and that in general the monitoring of interventions was very low. It also noted a need for longer term follow-up of outcomes with a greater emphasis on rigour (e.g. via randomised controlled trials), and a need to build up a UK evidence base relating to the effectiveness of multi-component interventions. As the national interventions progress it is likely that further evidence on effectiveness and costs will come forwards. In conclusion, the case study demonstrates that actions to address obesity are in place and that as a consequence of the range of activity at all levels this issue was being tackled on a number of different fronts. A significant proportion of identified activity was in line with current recommendations on delivery, although few interventions were explicitly based on evidence for best practice. It remains to be seen if over the medium to longer term there are genuine reductions in childhood obesity. In the absence of evaluation studies it will not be possible to conclude if any future reductions in overweight and obesity are attributable to the identified interventions.
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5 The Dutch case study: Beverwijk in middle and south Kennemerland
5.1
5.1.1
Policy context
National health policy and strategic context
The Dutch government - particularly the Ministry of Health, Welfare and Sport - has a central role in the promotion and protection of the health of Dutch citizens. In its prevention policy 2006-2010, it specified two goals to overcoming overweight and obesity, especially in lower socio-economic groups 74: 1. To maintain (or reduce) the share of adults that are overweight and obese; and 2. To decrease the share of young people who are overweight and obese. The most relevant policies, strategies and programmes that aim to achieve these goals are summarised below. The Ministry of Health, Welfare and Sport's policy brief Choosing for a healthy life (Kiezen voor gezond leven, 2006), overweight and obesity75 are specified as one of the five most important issues76. As a result, the Centre of Healthy Living (Centrum Gezond Leven) was set up in 2007, aiming to stimulate the use of nationally developed interventions among professionals working in relevant fields (health, food, physical movement, etc.)77. An example is the Healthy School method (Gezonde School) that stimulates and enables schools to improve physical, emotional and sexual health of young people (4-18 years old) 78. The Health Care Inspectorate (IGZ, Inspectie voor de Gezondheidszorg) protects and promotes health and healthcare by ensuring that care providers, care institutions and companies comply with laws and regulations 79. It is also responsible for the introduction of performance indicators in the health care sector (by 2010 at the latest). These performance indicators will assist municipalities in developing and improving their local policies and will assist health care providers to improve the quality of healthcare 80. Time for Sport - moving, joining in and achieving (Tijd voor sport bewegen, meedoen, presteren, 2005) aims to stimulate people to undertake more sport and physical activities to improve their health. To achieve this goal, the National Action Plan for Sport and Physical Movement (NASB) (Nationaal Actieplan Sport en Bewegen, 2005) was set up by the Ministry of Health and partners81. This Action Plan includes a subsidy (called Impulse NASB in 2008-2010 and in 2010-2012) for 50 Dutch municipalities with
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the greatest health problems. This focuses on providing advice, and increasing expertise and knowledge regarding effective interventions to encourage Dutch citizens to pursue an active lifestyle. The four year public campaign 30 Minutes of Physical Activity (30 minuten bewegen) was initiated by the NASB in 2007 as part of this Action Plan82,83. A counterpart of the National Action Plan for Sport and Physical Movement is the master plan to prevent obesity, Netherlands in balance (Nederland in Balans). This plan has been set up for 2005-2010 by the Dutch Foodcentre and focuses on healthy eating communication strategies, behavioural programmes and programmes targeting specific groups (for example women and children) 75. The national Overweight Covenant (Covenant Overgewicht) is also important. Set up in 2005 by the Dutch government (Ministries of Health and Education) in cooperation with the food industry, hotel and catering industry, employers, health care providers and sports organisations, the Covenant is particularly focused on the prevention of overweight and obesity among children 82 . In 2008, several priorities were agreed between the stakeholders: to use one logo for healthy food; to make healthy food more visible in supermarkets; to ensure healthier school canteens at secondary level; and to ensure more space and supervisors to stimulate sport and outside playing grounds in 40 identified neighbourhoods (krachtwijken84)83. The initiative includes projects such as the national school action plan 'Go healthy' (Ga voor gezond). This action plan consisted of a learning programme set up by the NISB which involved approximately 1,000 primary schools82. Similarly, the Overweight Partnership Netherlands (PON, Partnerschap overgewicht Nederland) has been set up by the Dutch Government (Ministry of Health) in cooperation with 17 partner organisations (care organisations, patient organisations and care insurance companies). Its aim is to improve care and thus the health and quality of life of people who are overweight or obese85. In addition, the Knowledge Centre Overweight has developed a Masterplan Overweight (Masterplan overgewicht) for the Juvenile Health Care Organisation (JGZ) in cooperation with the Ministry of Health. This plan incorporates firstly, the need for an uniform signalling system of overweight and obesity which has led to the set up of a signalling protocol in 2004 86; and secondly, the need to undertake preventive and other measures has led to the set up of a Bridge Plan (Overbruggingsplan) which describes practice-based interventions87 which can be used until a national evidence based programme has become available. Thirdly, it covers the monitoring of developments in the Electronic Client Record (Electronisch Clienten dossier) of the JGZ. For those regional JGZ centres that lack such a system, an overweight and obesity monitor has been set up in cooperation with TNO 88. The Dutch Health Institute (NIGZ, nationaal gezondheidsinstituut) focuses on stimulating healthy behaviour by offering support to stakeholders directly involved in public health: municipalities, public health services (GGD), home care, GPs and other organizations. It also offers information to the general public. The NIGZ offers courses, publicity material and other information materials regarding how to prevent overweight and obesity in schools, at work, in health care institutions and in neighbourhoods89. Examples of interventions include90:
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Moving buddy (Beweegmaatje.nl) which is a free internet community site for children aged 16 and older to find a friend to undertake sport activities; Toolkit for integrated approach obesity at school (toolkit voor integrale aanpak overgewicht jeugd op school) which offers an overview of prevention projects and material to deal with overweight and obesity at schools. Regional and local activities to combat childhood obesity
5.1.2
At the regional level, the 12 Dutch provinces are able to set up provincial plans or campaigns and allocate provincial funding to these plans to tackle the problem of childhood obesity. To set up and implement these plans they regularly work with regional and/or local organisations such as the public health service, sport service points, regional vocational schools (ROCs) and other stakeholders to ensure an integrated method. Through these provincial plans or campaigns, Dutch municipalities can apply for provincial co-funding to set up a specific activity at local level91. In the region of Kennemerland, municipalities can currently apply for provincial cofunding (referred to as social domain subsidies) by the province of Noord-Holland to undertake and fund preventive interventions to overcome childhood obesity because such interventions fit with provincial social policy. At the regional level, the Public Health Service (GGD 92) plays an important role. This organisation carries out youth health care in cooperation with homecare organisations. They organise regular health checks of children by school GPs, during which the height and weight of children are registered. They also initiate many local and regional projects to overcome overweight and obesity among young people93. In Kennemerland region, the public health service (GGD Kennemerland) is responsible for regular health checks and an important partner in the many regional interventions. At the local level, Dutch municipalities play a crucial role in preventing overweight and obesity. The four important domains for action within the municipality are: public health & welfare; sport & recreation; education; and environment/ traffic and transport. The policy measures can be legal, economic or communicative. Municipalities are responsible, through the Law Collective Preventive Public Health (Wet Collectieve Preventie Volksgezondheid, WCPV), to draw up four yearly policy health plans in which they describe their approach to tackle overweight and obesity94. Within the municipality, the chair responsible for public health can prioritise the prevention of overweight and obesity in local public health policy. The council subsequently decides priority areas and allocates funding to the priority areas 94. In the region of Kennemerland, political attention in the municipality of Beverwijk for interventions to tackle childhood obesity has, until recently, been very low which resulted in a lack of local municipal funding for the set up of preventive interventions. (In two other municipalities located in the region - Heemskerk and Zandvoort - childhood obesity has been placed higher on the political agenda, which resulted in both municipalities
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setting up a multi-annual local campaign Vet Gezond! for which annual resources have been allocated. The local campaigns include various interventions to tackle childhood obesity.) Municipalities receive support and guidelines from the Dutch government and other organisations (e.g. Health Care Inspectorate) to set up local preventive policy to tackle the issue of overweight and obesity. A good example of a guideline is the manual Prevention of overweight in local health policy (Handleiding Preventie van overgewicht in lokaal gezondheidsbeleid). This manual was published in 2007 by the Foodcentre Netherlands (Voedingscentrum Nederland), in cooperation with municipalities, GGD Nederland and several national partners. It reviews key concepts, and contains practical information and examples for local policy makers and other local stakeholders to set up local preventive policy to overcome overweight and obesity94. The LIFELINE (LEEFLIJN) part of the manual offers an online overview of available preventive measures to overcome overweight and obesity for different age groups 95. Besides municipalities, home care organisations, cardiology departments in hospitals, general practitioners, schools, sport associations and associations for welfare etc. are often locally active in setting up preventive interventions to overcome overweight and obesity in their community. These activities are often coordinated by the local or regional GGD to ensure that expertise from the different local organisations dealing with diet, sport and welfare are utilised efficiently 94. One of the most important stakeholders in relation to childhood obesity in Kennemerland is the regional project group Overweight Kennemerland. This involves a partnership between the Sportservice Noord-Holland (regional organisation responsible for sport activities); the GGD Kennemerland (regional public health service); JGZ Kennemerland (regional juvenile health care provider); Zorgbalans and ViVa! Zorggroep (regional health care providers)96.
5.2 Overview of Beverwijk in middle and south Kennemerland

5.2.1 Demographics and characteristics of the Beverwijk in middle and south Kennemerland
The municipality of Beverwijk is situated in the region of middle and south Kennemerland97, part of the province North Holland (Noord-Holland), and located 20 km north-west of Amsterdam. Beverwijk is the fourth largest municipality of the region of Middle and South Kennemerland with a total population of 372,816 inhabitants in 2008 of which 65,313 were aged 5-19 (18% of total population). In 2008, Beverwijk had a population of 37,347 inhabitants of which 6,359 were aged 5-19 (17% of total population) 98. The municipality of Beverwijk can be described as large urban and around a fifth of its population come from an ethnic group (19.8%). This percentage is 0.4% higher than the Dutch average. The socio-economic status99 of Beverwijks inhabitants (at 2,116) is 243 points higher than the Dutch average 98.
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5.2.2
Prevalence figures of childhood overweight and obesity in Beverwijk
According to two large scale independent studies among children and young people in primary and secondary schools, Beverwijk has higher levels of overweight and obesity in comparison to the Netherlands and the region of Kennemerland. Results of preventive health research (2005)100 among children of school age (4-15 years old)101 indicate that 15.9% of the examined children in Beverwijk are overweight (11.5% in the region100 , 15.1% in the Netherlands102) and 4.8% are obese (2.9% in the region 100, 3.1% in the Netherlands102,103 ). The so-called EMOVO104 research (2007)105 among school-going children (13-16 years old)106 estimates that 11% of the 6.260 surveyed young people in Beverwijk are overweight compared to 7% in the region. The research suggested that at least part of the high proportion of overweight and obese children in Beverwijk can be explained by the relatively high number of children with a minority ethnic background living in this municipality100. In particular, children with a Turkish background are more likely to be overweight or obese, followed by Moroccan children, Surinam and Antillean children107 . The research also indicated that the problem of overweight and obesity is greater amongst older primary age children (9-10 years old) in the Kennemerland region, while in Beverwijk the problem is greater in younger children (3-4 years old). The results also indicated that the problems of overweight and obesity are more common among girls (almost 16% versus 13% for boys). In Beverwijk, the results are similar (23.6% for girls and 17.7% for boys)100 . 5.2.3 Lifestyle of children in Beverwijk and Kennemerland
Children in Beverwijk generally eat less healthily (i.e., less regular breakfast and dinner, lower vegetable intake) than children in Kennemerland apart from fruit intake (see Table 5.1 below).
Table 5.1 Share of respondents per reply in Beverwijk and Kennemerland Survey question No breakfast at least once a week before going to school Skip diner more often than twice a week Eat vegetables on a daily basis Eat fruit on a daily basis
Source: 105
Beverwijk 23% 5% 25% 34%
Region Kennemerland 19% 3% 35% 23%
Children in Beverwijk have similar physical activity patterns compared to children in the wider region: they are equally as likely to cycle or walk to school (91% versus 93%) and they follow a similar number of hours of physical activity in school (92% 2 to 3 hours weekly versus 93%). Children in Beverwijk are slightly less likely to be a member of a sports club (79% versus 81%) but more likely to undertake other physical activities (16% versus 14%). Children from an ethnic minority are generally less likely to be a member of a sports club
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compared with the picture nationally (66% versus 75%); and this is particularly noticeable for girls. However, regarding other physical activities, children with an ethnic minority background undertake more activities than children with a Dutch background (58% versus 40%). Approximately three quarters (77%) of the children in Beverwijk do not meet the requirement set by the Dutch Standard Healthy Movement to undertake physical activity at least 1 hour per day and 7 days per week; this is also the case in the wider region (78%).
5.3 Prevention of childhood obesity in Beverwijk and middle and south Kennemerland
Six interventions were identified in the municipality of Beverwijk, and across the wider region of middle and south Kennemerland; 18 further interventions were identified that met the study criteria. As noted earlier, the policy of a municipality is determined by the priorities of local politics. Originally, 25 preventive interventions were identified in the region of middle and south Kennemerland. Seven interventions were excluded (2 in Beverwijk) from the case study because they were either: statutory services that address childhood obesity and were not time-limited population-based interventions aimed at prevention (2 out of 7); because it was unclear whether they were still being implemented on the snapshot day; and/or because insufficient information was available (5 out of 7). As part of the case study, six face-to-face interviews were conducted in the region middle and south Kennemerland: two stakeholders from the GGD Kennemerland, one from Zorgbalans, one from the municipality of Heemskerk; one from the municipality of Zandvoort, and one of the Sportservice Noord-Holland. In addition, further local information was provided by the municipality of Beverwijk and Fit4family via phone and email exchange. The 18 interventions are listed in Table 5.2 below. Further details are included in annex 1.
Table 5.2 Interventions to prevent childhood obesity in middle and south Kennemerland- those marked with an * are also taking place in Beverwijk Number 1 Intervention name Course Fit, Food & Fun Description Multidisciplinary course after school time at a school venue: PA programme (1 hour a week, given by a physiotherapist), food lessons and homework (given by a dietician), 2 parent information meetings (evening) regarding healthy eating, physical activity and the up bring of children in general. 2 Kidsclub This is a sport and game hour for children, carried out in a leisure centre or sport association. They get acquainted with different sports and through this they learn necessary sport skills which will increase and facilitate their physical activity in the future.
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Food advice for ethnic women
Existing ethnic minority women groups who already regularly come together, convene at a suitable place (can be a community centre, a mosque, elsewhere) to receive advice and information from a dietician of Zorgbalans in relation to improve the healthy eating and physical activity of their children.
All pupils active (Alle leerlingen actief)
This intervention consists of a mix of activities: children are involved in motivation conversations to spur a behaviour change. The parents also receive counselling to take away any existing obstacles. The children and parents are signposted to diverse sport activities in the neighbourhood or to an intervention like the course Real Fit. The participating schools organise extra sport activities (sport days) and arrange support of a dietician/psychologist or otherwise in relation to healthy eating. The intervention is sometimes combined with other interventions like sporthackers or healthy school canteen (gezonde schoolkantine)
Cruyff court
A playing field is set up/built to offer young people the facilities to undertake diverse sport activities (like football). Diverse physical activities on and around the playing field are coordinated in cooperation with all the involved partners.
Special support* (speciale bijstand)
Families with a low income can apply for municipal funding for their children (and parents) to become a member of a sport association ( 200 per family in Heemskerk, Dutch national average is 100)
School sport programme* (school sport programma)
The school sport programme consists of 10 different physical activities: this can include a sport day; skating lessons, sport tournaments and otherwise. At the start of the school year, children receive a flyer with information regarding the JSP. If their parents register them they can receive 4 lessons of 1 hour each at a sport association (or elsewhere) after school to get acquainted with a sport they find interesting (8 different sport activities are offered). For each period (3 a year) children can participate in 1 sport. After the sport lessons, the children can decide to become a member of the relevant sport association.
Jeugdsportpas (JSP)
Course Real Fit
Multidisciplinary course after school time at school venue including healthy eating lessons, physical exercise (in a fitness centre) and parent information evenings to offer advice on healthy eating (offered by a dietician), raising children and sufficient physical exercise.
10
Sporthackers
Sporthackers tries to stimulate young people to (continue) to be physically active. The basis of this intervention is shaped by the available sport supply of the participating schools; the organisation of sport clinics during holidays; and the sport supply of sport associations. This supply is adjusted to the needs of young people and marketed better to young people.
11
Pilot know your talent (ken je talent)
Services are offered to participating sport association to get young members involved in volunteer work for the sport association: analysis of the situation, workshops and training, tailored support to implement change, education and training of young members (using existing and new techniques)
12
Whoznext
Whozenext is a national campaign which aims to offer young people a voice in sports. A whoznext team consists of 4 to 8 young people in
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combination with a team coach from the participating sport association, school or community centre. The team receives 450 (besides other support and training) to organise at least 3 activities (can be a party, excursion to a sport association during school PE, skate tournament, etc.). The whoznext teams are connected to each other on a national level and they can exchange information. 13 Fit4family* Parents and their children can fitness in the same fitness club: for children lots of fun materials are available. For some children with overweight problems a simple individually-tailored programme is made 14 Project Beter (Zw)eten* Ex ante measurement of length and weight; courses on healthy eating; physical activities; information meetings for parents; individual counselling; advice school policy; post measurement of length and weight 15 Groep 6 on the move The children decide what they want to learn in relation to food and physical movement. Their wishes are shaped through the inputs of teachers and parents. Sportive activities are organised and in the curriculum attention is put on healthy living. Facilities in the neighbourhood are used to stimulate children to move (sport clubs, play grounds, etc.) 16 Parent meetings Participating primary education schools take the initiative to organise this intervention. The parents receive advice in relation to healthy eating (breakfast), physical activity, the cause of overweight and treatment, support in upbringing of the children (behaviour influencing, parent role model, watching TV, computer games). 17 Youth sport subsidy* (jeugdsport subsidie) The youth sport subsidy offers funding to sport associations in Beverwijk for young members. The height of the funding is depending on the annual number of young members. 18 Social card overweight for professionals* (sociale kaart overgewicht)
Source: ECORYS own compilation, 2008
The social card offers an overview of all organisations in the region of middle and south Kennemerland which are active to help prevent and/or treat overweight of children. It offers information regarding preventive activities, websites, sport opportunities, etc.
5.3.1
Characteristics of the identified preventive interventions
Setting The setting of the different interventions varied with a slight majority being embedded in a community setting (9 out of 18) (See Table 5.3 below). The school setting was, however, highly relevant (7 out of 18). Two interventions were embedded equally in a school and community setting because they were partially carried out in participating schools and in sport associations and other neighbourhood organisations. None of the identified interventions was embedded in a healthcare setting.108 The interventions within a community setting were either organised in a leisure centre, a sport association or other neighbourhood centre, or delivered as a subsidy for leisure activities.
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The interventions which were organised in a school setting, either take place after school and then mostly target specific target groups (e.g. children who were already coping with overweight), or were inserted into the school curriculum and then target all schoolchildren of a certain age or in a specific class.
Table 5.3 Number of interventions that fit with identified settings Setting School Community School and community Healthcare setting Total
Number of interventions 7 9 2 0 18
Types of interventions Table 3.2 below provides an overview of the typologies and the number of interventions that fitted with these typologies. Almost all the interventions (13 out of 18) include a multi-component approach, addressing a range of factors influencing childhood overweight and obesity. (In these cases the intervention has been categorised under more than one typology.) Five interventions have a one-component approach of which two focus on subsidising leisure activities.
Table 5.4 Number of interventions that fit with identified typologies Typology Number of interventions in Kennemerland Physical Activity programme Healthy eating Workshops Postal communication Changes to/incorporation into curriculum and use of homework Subsidised leisure activity Reduce sedentary activity Behavioural change therapy Counselling Signposting Interactive communication methods for advice and support
12 7 6 6 5 4 4 3 3 2 2
It was noticeable that the majority of the interventions (12 out of 18) focus on physical activity. Interventions that included a healthy eating component were much less common (7 out of 18). Notably, five of those 7 interventions including a healthy eating component were combined with a physical activity programme component and it was rare to have a health eating component on its own.
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The physical activity component tends to include physical activity programmes offered after school time but on school premises (e.g. the Fit, Food, & Fun or Real Fit courses); physical activities offered by sport associations (e.g. like the youth sport membership card (jeugdsportpas); or other physical activity providers (e.g. like fit4fun in a leisure centre). Five out of the six interventions which include a workshop element include workshops aimed at parents (e.g. parent meetings). Two examples are: the course Fit, Food & Fun which include two parent evenings: and the food advice meetings for ethnic minority women with children. Three interventions explicitly109 include a behavioural change therapy element with, or without, a clear reference to counselling. These interventions were explicitly targeted at children who were either already overweight and/or obese or who failed a physical endurance test (e.g. the All Pupils Active initiative).
Case study 1 The All Pupils Active initiative The initiative All Pupils Active is a good example of intervention including a behavioural change therapy element as it includes motivational conversations 110 between the participating children and a counsellor (e.g. a specially trained teacher). The conversations aim to intrinsically motivate the participating children to undertake more physical activities and to become more responsible for their own behaviour.
The participating children (and their parents) are subsequently signposted to diverse sports activities in their neighbourhood or, if applicable, to another intervention like the course Real Fit. In parallel, the participating schools organise additional sport activities (next to their regular PE programme) including, for example, sports days, or they link the initiative All pupils Active to another intervention like Sporthackers or the national initiative Healthy School Canteen (gezonde schoolkantine).
Source: Interview Sportservice Noord-Holland, October 2008; NISB: Alle leerlingen actief. NISB, 2008.
http://kic.nisb.nl/extern.htm?http://kic.nisb.nl/home/main-nieuws.php?flag=2&page_number=0&site=8&ID=4797
Four interventions could be described as subsidised leisure activities. They either offered an individual subsidy to applicants to become a member of a sport association (e.g. like the special support assistance) or they were aimed at subsidising organisations to organise leisure (e.g. sport) activities (e.g. like the youth sport subsidy or the building of Cruyff courts). Only one intervention (the social card overweight for professionals) exclusively aimed to provide postal communication (i.e. a document) regarding all organisations/services in the case study area that focus on childhood obesity and overweight. It was targeted at professionals who work with young people and their parents to prevent overweight issues. The document offers this information on interventions in the region to stimulate proper signposting and more adequate information provision. Five other interventions, like the course Fit, Food & Fun and the course Real Fit also use postal communication (e.g. newsletters, brochures), but only as an add-on to publicize information about the courses for parents and children: dates, prices, location, etc. Target groups Table 5.5 below offers an overview of the target groups and the number of interventions targeting these specific groups.
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Table 5.5 Identified target groups Target groups All children School going children All children (no age defined) Primary school-going children (4-12 years old) Primary school-going children (8-9 years old) Primary school-going children (9-10 years old) Primary school-going children (9-11 years old) Secondary school-going children (13-18 years old, vocational education) Children problems with overweight Primary school children with overweight 2 Number of interventions 3 1 1 1 1 1
problems (8-12 years old) Secondary school children with overweight problems (13-18 years old) Primary and secondary school children with a lack of physical activity (9-16 years old, vocational education) 1 1
Indirectly targeting children
Parents of children (4-12 years old) Ethnic minority women with children Families with low income Sport associations and their young members Professionals Total
1 1 1 2 1 18
Three interventions were aimed at all children. Typical interventions that targeted all children were subsidised leisure activities like the Cruyff courts, special assistance support, and the Whoznext initiative. Six interventions were aimed exclusively at children (and/or parents) of primary school age with or without overweight and obesity problems compared with only two interventions aimed at children (and/or parents) of secondary school age with or without overweight and obesity problems. Two of the three interventions aimed at secondary school age children particularly target children who follow vocational education. It is arguable that often particularly this target group was less physically active in comparison to other school-going children111 . Four interventions were specifically set up for children who have overweight problems (they were weighed) or clearly lack physical activity (on the basis of a physical endurance test). Six interventions targeted children indirectly. Three of these interventions were targeted at the family; to influence the parents to improve the eating habits and/or physical activity habits of their children. Two other interventions were targeted at sport associations to increase the number of young members and/or to adjust their sport supply to the needs of young members (e.g. for example the Pilot Know Your Talent).
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Evaluation results Only five interventions (out of the 18) had evaluation material readily available112 . For six interventions anecdotal information was available regarding outcomes and possible impact, but no evaluation was carried out. For seven interventions no information could be identified at all. For two of these, this can be explained by the fact that they have only been recently set up. On the basis of available information, more than 6,601 children were directly targeted by the identified interventions and 47 ethnic minority women with children. A considerable number of schools (particularly primary schools) were involved in the identified interventions. The available evaluation results indicate that some interventions seem to lead to positive outcomes.
Evaluation results of the course Fit, Food & Fun The course Fit, Food, & Fun is a multidisciplinary course for children aged 8-12 with overweight and/or obesity problems. They participate voluntarily after registrations to the course by their parents. After school time at a school venue they are weekly (for 10 weeks) involved in a PA programme (1 hour a week, given by a physiotherapist), food lessons and homework (given by a dietician). The parents are invited to attend 2 parent information meetings (evening) to gain useful information regarding healthy eating, physical activity and the up bring of children in general.
The following results have been noted in the region of middle and south Kennemerland:
Heemstede (2007) results: weight difference with age group reduced after the course (6 weeks after the last lesson). Stomach profile was also reduced. Children and parents reacted enthusiastic. Heemskerk (2007) results: weight difference with age group increased after the course. The stomach profile reduced somewhat. The parents participated well but the children were not always very involved: they did not increase their knowledge on the topic of healthy eating although they did their homework. Parents think that many of the children were simply not ready yet to follow this course and this resulted in low participation. They also indicated that the children know what healthy is but just don't carry this out in practice.
Heemstede (2005) results: weight decrease and stomach profile decrease after the course.. Average length increase in 10 weeks of 1.5 cm is not normal: probably due to the fact that the position of the children increased. The parents mentioned that their children play more outside and were more asked by other children to play outside. The children also eat healthier and eat fewer sweets (less asking for sweets).
As can be see from the results, the courses Fit, Food & Fun have been successful in the municipalities Heemstede in 2005 and 2007, but less successful in Heemskerk in 2007.
Source : Zorgbalans: Resultaten FFF Heemstede ; Zorgbalans: Resultaten FFF Heemskerk;

Zorgbalans: Metingen AVB 2007: voedingsvoorlichting, FFF. 2007;. Heming H, Jansen R: Evaluatie fit, food & fun, pilot voorjaar/zomer 2005, Nieuw Groenendaal sport & revalidatie, 2005.
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Evaluation results of the initiative Group 6 on the move In relation to this intervention, participating children (aged 9-10) decide what they want to learn in relation to food and physical movement. Their wishes are shaped through the inputs of teachers and parents. Sport activities are organised and in the curriculum attention is put on healthy living. Facilities in the neighbourhood are used to encourage children to be more active (e.g. sport clubs, play grounds, etc.).
Preliminary evaluation results of the school year 2005-2006 indicate an increased intake of fruit among the children, increased intake of light carbonated drinks, less candy eating, and an increase of outside physical activity (can be seasonal).
Almost all of the participating schools have also registered in parallel- to receive the taste lesson chest (smaakleskist) provided by the Ministry of Agriculture. This chest contains a lot of fun materials for children to experiment with food. The intervention is also sometimes combined with other interventions for example the Jeugdsportpas and the National School Breakfast initiative (Nationaal Schoolontbijt). The evaluation indicated that the participants especially liked the introduction to new forms of physical activity. Parents liked to participate in the children's activities and several schools have, as a result, adjusted their snack policy (pauzehapjes). The evaluation shows that several schools wanted to keep certain elements of the intervention in the upcoming years: the marathon around the school, the taste lessons (smaaklessen), the assignments in physical activity diary Hupla and the cooking activities.
This intervention has been included as good practice in the Leeflijn of the manual prevention of overweight in local health policy developed by the Ministry of Health.
Source: Interview GGD Kennemerland, October 2008
Delivery partners A partnership and cross-agency approach was an important feature throughout the 18 identified interventions: 15 out of the 18 interventions were carried out by different partnership. The funding organisations were mostly not included in the delivery of the interventions because funding was usually offered in the shape of a subsidy. The table below offers an overview of the key delivery partners involved in the 18 identified interventions. The Sportservice Noord-Holland was involved in 12 out of 18 interventions and primary schools rank second with involvement in 9 interventions.
Table 5.6 Key delivery partners Delivery partner Sportservice Noord-Holland Primary schools (including staff) GGD Kennemerland Sport association or leisure centre Zorgbalans Secondary schools (including staff) Neighbourhood organisations and other local organisations Municipalities Cruyff foundation Parents
Number of interventions 12 9 8 6 6 5 4
3 1 1
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5.3.2
Success factors
Partnership approaches Partnership approaches involving the appropriate stakeholders were a key success factor. One of the most important stakeholders in relation to childhood obesity in Kennemerland was the regional project group Overweight Kennemerland. This project group was a partnership of the Sportservice Noord-Holland (regional organisation responsible for sport activities); the GGD Kennemerland (regional public health service for children aged 4-18); JGZ Kennemerland (regional juvenile health care provider for children aged 0-4); Zorgbalans and ViVa! Zorggroep (regional health care providers)113. The aim of this group was to increase the cooperation and linkages between the various activities of participating organisations and to exchange expertise. In 2005, the project group Overweight Kennemerland set up a regional plan Signalling, approach and prevention of overweight of children aged 0-19 in the region Middle and SouthKennemerland114. The plan includes a combination of interventions that have previously been developed either by one or several of the partners or by for example, the Knowledge Centre Overweight or the Food Centre Netherlands. The interventions were organised in such a way that they were coordinated by one partner (Real Fit was for example coordinated by the Sportservice Noord-Holland and the course Fit, Food & Fun was coordinated by Zorgbalans) while the various sub-activities of the intervention were carried out by the partner with the most relevant expertise (for example Zorgbalans always takes care of any healthy eating element) and also financed (if possible) by the most relevant partner.
Case study 2 Food advice meetings for ethnic minority women An example of successful cooperation within the regional project group overweight Kennemerland is the collaboration between the two organisations Zorgbalans and Sportservice Noord-Holland providing food advice meetings for ethnic minority women to feed their children more healthily.
These meetings are organised by Zorgbalans and originally included only advice on healthy eating for the parents. Due to the cooperation with the sport service in relation to other interventions, this advice has been broadened and now also includes a physical activity element for the parents to take into account.
Source: Interview Sportservice Noord-Holland, October 2008; Interview Zorgbalans, October 2008
The interviews highlighted the importance of an institutional partnership such as the project group Overweight Kennemerland. However, interviewees commented that its success was completely dependent on the contributions of the individuals - not of the organisations - in the partnership. Embedding interventions in into regional and local policy When interventions were embedded into regional and local policy and subsequently into multi-annual regional and local programmes they can engage important regional and local stakeholders and lever in the necessary funding. Eight interventions receive essential cofunding from the province of Noord-Holland because they relate to provincial priorities set in social domain115.
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Fourteen interventions were implemented using (co-)funding of the relevant municipalities without which they would not be able to take place. For example, in the municipalities of Heemskerk and Zandvoort a considerable number of interventions were (co-) financed by the respective municipalities because they fit with local campaigns (for instance the Vet Gezond! intervention for which annual resources were allocated). The limited number of interventions carried out in the municipality of Beverwijk (6 out of 18) was due to the small amount of municipality (co-)funding116 (and therefore also limited co-funding of the province). The lack of municipal funding was related to the fact that childhood obesity has received - so far - little or no political attention in the local council of Beverwijk. However, it seems that the municipality of Beverwijk was slowly trying to overcome the lack of political attention as it was tendering to build a Cruyff court. This was a playing field to offer young people the facilities to undertake outside sport activities (such as soccer). The Cruyff foundation acts as a co-financing organisation and was particularly interested in offering sport facilities to young people with an ethnic minority background: these being the group of children who run the highest risk of overweight or obese in the municipality of Beverwijk (and the region Kennemerland). Wider impact possible through involvement of schools Nine out of the 18 interventions were carried out in primary and secondary schools either during school hours (e.g. incorporation in the school curriculum) or after school (with school premises made available). The after-school interventions typically fall in the Dutch concept of Brede School which stands for cooperation between all stakeholders involved in the upbringing of children and young people like schools, childcare, sport associations, libraries, etc. Until now, schools predominantly took a central role in this cooperation.
Course Real Fit The course Real Fit is a good example of an after school interventions which falls in the Brede School concept as it includes cooperation between multiple partners in which the schools play a central role.
The participating school arrange the venue after school time and publicise the course among its pupils; the local sport service (Sportservice Noord-Holland) subsequently arranges the sport element and a healthcare organisation (Zorgbalans) arranges the healthy eating element.
Source: Interview Zorgbalans, October 2008
Course Beter (Zw)Eten The intervention Beter (Zw)Eten is a good example of an intervention incorporated in the school curriculum. It is carried out in primary schools in the region of Kennemerland (Beverwijk, Heemskerk, Zandvoort) for 8 -9 year olds and includes a multi-component approach of 4 weeks offering healthy eating classes, physical activities, consultation meetings, parent meetings, stimulation of healthy food in the school canteen and where needed individual support for children who are likely to become/are overweight. The evaluation of the intervention shows that many teachers are enthusiastic about the fact that they can include the discussed subjects in their regular learning programme after the project period of 4 weeks (facilitated by a project map) 117 .
Source: Interview GGD Kennemerland, October 2008
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Embedding the interventions in a school environment has multiple advantages. First, the interventions were more easily accessible for children because they typically take place within their school which tends to be close to their home118 . Secondly, the interventions generally target a large audience (all school-going children or children of a specific class) which increases the likely impact of the intervention. Third, when the intervention was embedded in the school curriculum, there were few barriers (such as administrative paperwork, negative stigma, participation fee) attached to registration and participation because all school-going children automatically participate. Integration into a school-environment however also contains a potential weakness: since the cooperation of schools was essential but many organisers of the various interventions have reported problems convincing local schools to cooperate. Currently, many schools were overwhelmed by new responsibilities (as part of the Brede School concept) alongside their essential task of providing education119 and - as a result - they were faced with budgetary and personnel constraints. Adjusting the offer of sport associations to the needs of young people leads to increased membership of young people Young people (particularly between the age of 13 and 18 years) often give up their membership of a sport association because the offer does not appeal to them and because other activities (like employment) become more important for them120 . As a result, several interventions in the region of Kennemerland/ Beverwijk (4 out of 18) aim to adjust the offer of sport associations to make membership more attractive for young people. The results vary but overall seem to indicate that young people become - as a result of the interventions - more aware and interested in the offer of sport associations. Two good examples of reasonably successful interventions were the jeugdsportpas en sporthackers.
Jeugdsportpas The jeugdsportpas offers children in primary school (aged 4-12) the chance to become acquainted with different sports without immediately becoming a member of a sport association. In four lessons of 1 hour each after school in a sport association or elsewhere- they learn the basics of a sport which interests them. The parents contribute for 1 sport and the involved municipalities contribute the rest of the budget. The Sportservice 5 Noord-Holland coordinates the intervention. Evaluation in the municipality of Heemskerk121 shows that in 1 year 800 children have participated - which is a considerable number in comparison to other intervention - and it is estimated that approximately 10% of the participating children decide to become a member of a sports association.
Source: Interview gemeente Heemskerk, October 2008; Interview Sportservice Noord-Holland, October 2008
Sporthackers An evaluation of the intervention Sporthackers- which aims to adjust the sport offer of vocational secondary schools (VMBO) and sport associations and includes the organisation of sport clinics during holidays and in schools- shows that after participation, the membership of a sport s association increased by 12% (only measures in Zaanstad) en the number of young people involved in any sport increased on average with 3.3%. Four VMBO schools participated in the interventions in combination with 31 sport associations. In total, 497 young people participated in sport clinics during the holidays and 3,269 young people participated in sports
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clinics in schools. In total 42 sport associations received support to adjust their sport offer to the needs and interests of young people 129.
Source: Interview Sportservice Noord-Holland, October 2008
A weakness with interventions aiming to adjust the offer of sport associations to the needs and interests of young people was that they generally only interest young people who were already involved in sport activities. The hard-to-reach group of young people not undertaking physical activity has a more limited engagement with such interventions. Another problem was the difficulty getting sport associations interested due to a lack of available staff to offer the sport clinics to the young people122 . The introduction of combined functions for professional sport teachers can, however, solve this issue (see Section 5.3.3 for more information). 5.3.3 Barriers to success
Reliability on temporary funding A weakness of almost all examined interventions (17 out of 18) was their dependence on time-restricted local (municipal funding), regional (provincial funding), and/or national (e.g. Ministry of Health) subsidies. The sustainability of the interventions was highly dependent on national, regional and/or local political attention for childhood obesity. If political attention reduces, subsidies can be partially or completely cut leading to the cancellation of interventions. In addition, the duration of the subsidies was often fixed (ranging between approximately 1 to 3 years). This implies that those organisations that were implementing the interventions need to (re-)apply for subsidies to guarantee continuation of the interventions.
Fit, Food & Fun The Fit, Food and Fun course depends heavily on available subsidies and is financed through multiple channels: (1) provincial and local co-financing agreements through the municipal campaign Vet Gezond! (See before); (2) other co-financing from the province and the municipalities through the regional plan of the project group Overweight Kennemerland (such as the BOS-impuls); and (3) ZonMw funding
123 124
. A subsidy is
requested by different partners involved in the intervention: ZonMw funding is for example requested by Zorgbalans, while the Sportservice Noord-Holland is responsible for acquiring provincial and municipal cofunding.
Source: Interview Zorgbalans, October 2008
Lack of monitoring and long-term evaluation of interventions As mentioned before, a weakness of almost all of the examined interventions was the lack of evaluation. From the 18 interventions examined in our research, only five have readily available evaluation results.125 However, none of the examined interventions provided evidence of long-term results and impacts. This was due to several factors. First, the effectiveness of preventive measures was extremely difficult to measure. The evaluation of the intervention beter (zw)eten124 for example shows some promising results: it has led to an increasing number of children eating breakfast, undertaking more physical activities and watching less television and sitting behind the computer; also, the knowledge of the children regarding healthy eating has increased. However, it is unknown whether these effects will continue to exist on a
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long-term basis and whether these effects will change behaviour and reducing overweight and obesity in the future. Second, evaluations were frequently not carried out or not completed due to a lack of funding and/or evaluation capacity. Third, attention tended to focus on process-evaluation (beneficiary satisfaction etc.) instead of measuring (longterm) effects. As a result of a lack of monitoring and (long-term) evaluation, our interviews highlighted that the offer of interventions was not always timely and adequately adjusted for the needs of the target groups. It is, for example, suggested by multiple interviewees, that the project group overweight does not always take sufficient time to invest in researching the needs for interventions; the content of their interventions; and to learn from their previous interventions. In addition, they sometimes seem to hold on to their specific methods of working instead of being open to new methods. The cause of the above was partially rooted in the fact that funders (like municipalities) do not always value building the evidence base nor formulate their research question and requirements in the most helpful way. For example more of a focus on a demand study, measurable targets, monitoring and (long-term) evaluations would help build a picture of what works, where and when. The lack of a sufficient evidence base makes it - so far difficult to define acceptable and realistic targets. Lack of impact due to short duration of interventions Many of the examined interventions were of limited duration. The intervention 'Beter (Zw)Eten' for example lasts 4 weeks, the intervention course 'Fit, Food & Fun' lasts 10 weeks; and the course 'Real Fit' lasts 12 weeks. As a result, these interventions will most likely obtain short-term effects such as raising awareness; more physical activity; etc. It has been proven that these effects slowly subside over time leading to no long-term effect126 . Lack of participants caused by socio-cultural environment and other factors The interventions aimed at children who were overweight and/or obese generally seem to lack participants. The research suggested a variety of possible causes. First, parents who were responsible for subscribing their children to such a course often do not recognize that their children were overweight and/or obese. Second when the parents acknowledge their child has a problem, they often experience the administrative paperwork, the individual participant fee127 or the negative connotation (stigma) surrounding obesity as barriers. Third, families who have the highest risk of becoming obese or overweight were those with a relative low income and/or with an ethnic minority background (particularly those with a Turkish, Moroccan or Surinam/Antillean background) who may need a specific approach to engage them. This group tends to be more difficult to reach through information and advice meetings, information leaflets, folders and other publicity material. Fourth, it was mentioned that organisations responsible for referring overweight and/or obese children (such as the GGD) often do not refer to courses such as 'Fit, Food & Fun' and 'Real Fit' because they were either unaware of the existence of these courses or they were not persuasive enough to convince the parents to register their child. Large-scale interventions which were integrated in the school curriculum can potentially generate much greater impact128.
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Lack of sport specialists in schools and sport associations To stimulate children to undertake physical activity our interviewees identified the importance of schools having access to a 'sport' specialist (professionele gym leraar of vakleerkracht). Dutch schools were required to employ a sport specialist, but the Dutch government since removed this requirement. This had led to a reduction in the quality of the sport offer of schools (non-specialists would take over the task) and also led to reduced communication with other sport suppliers due to a lack of knowledge, interestraising and a lack of referral. Since 2004 however, the Dutch government has been stimulating the employment of sport specialists and since 2008, municipalities can apply for funding for a combination measure impuls brede school129 . This measure enables schools to employ a sport specialist (target of 2,500 to be hired) with a remit of combining their school based responsibilities with other sport activities in a sport association or elsewhere. The municipality of Heemskerk in the region Kennemerland was applying for funds and hopes that the employment of a sport specialist will increase the quality of the sport offer in their schools and stimulate linkages, communication and proper referral between the various sport suppliers within the municipality. Lack of knowledge regarding the costs None of the identified 18 interventions could provide a clear cost overview. Only a handful of interventions could provide even partial information. As a result, it was as yet impossible for stakeholders to gain useful insights into the costs and cost effectiveness of available interventions. This impedes good decision making regarding what interventions to implement in future. Table 5.7 below provides the information regarding costs that was available. The amount allocated to interventions ranged between 224.246 for an intervention targeting many school children simultaneously (all pupils active interventions) and 27.890 for an intervention targeted a small number of participating children (intervention project beter (zw)eten).
Table 5.7 Cost information Intervention Ministry of Health Course fit, food, & fun --Between 40- 56 annually Kidsclub -- per 25 meeting 224.246 (2007) 128 annually Food advice for ethnic women All pupils active ----Not available --Not available ---Not available Not available Not available Not available Not available Participating organisation Parents ZonMW funding Municipality funding Provincial funding
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Jeugdsportpas Course real fit
---
---
per sport 5 100 (refund of if 50 participation is sufficient
---
Not available Not available
-Not available
Sporthackers
- 267.250
--
--
--
83.200130 (2007)
73.523 (2007)
Pilot know your talent Project Beter (Zw)eten Group 6 on the move Parent meetings
Not available
--
--
42.7 % of the total budget ( 625.500) 27.890 (10 schools in 1 municipality) 52.136 (7 schools: 10 groups)
--
--
--
--
--
- for 50 material costs
--
--
--
--
Not available
--
--
5.3.4
Conclusions
In the Netherlands, national support for regional and local interventions was extensive. This translates in the region of Kennemerland into a vast number of interventions carried out through national, regional and local funding - of which some have already shown encouraging results while for others the results were not yet clear. The setting of the different interventions varied. A slight majority was embedded in a community setting, but the school setting was also highly relevant. Almost all the interventions include a multi-component approach, addressing a range of factors that influences childhood overweight and obesity. It was noticeable that the majority of the interventions focus on physical activity. Interventions that include a healthy eating component were much less common. Most interventions either target children (and/or parents) of primary school age with or without overweight and obesity problems or they target children indirectly by targeting the family or sport associations. Clearly some municipalities within the region of middle and south Kennemerland were running more interventions than in Beverwijk. For example, the municipalities of Heemskerk and Zandvoort fund many different interventions due to their multi-annual campaigns Vet Gezond! while the municipality of Beverwijk was as yet struggling with gaining political support to get the subject of childhood obesity on the political agenda. As a result, only a minimum of 6 out of the 18 identified interventions in the region of middle and south Kennemerland have yet been carried out in Beverwijk. Partnership approaches were a key success factor for implementing preventative interventions. One of the most important stakeholders in relation to childhood obesity in Kennemerland was the regional project group Overweight Kennemerland which was a partnership of the Sportservice Noord-Holland (regional organisation responsible for
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sport activities); the GGD Kennemerland (regional public health service for children aged 4-18); JGZ Kennemerland (regional juvenile health care provider for children aged 0-4); Zorgbalans and ViVa! Zorggroep (regional health care providers). Another successful partnership relates to the Dutch concept of Brede School which stands for cooperation between all stakeholders involved in the upbringing of children and young people like schools, childcare, sport associations, libraries, etc. A clear weakness of almost all examined interventions was their dependence on timerestricted local (municipal funding), regional (provincial funding), and/or national (e.g. Ministry of Health) subsidies. This makes the sustainability of the interventions highly dependent on national, regional and/or local political attention for childhood obesity. Another weakness was the lack of (long-term) evaluation and monitoring. In addition, none of the identified interventions could provide a clear overview of the total costs involved. As a result, it was as yet impossible for stakeholders to gain useful insights into the costs and cost-effectiveness of available interventions. This impedes good decision making regarding what interventions to implement in the future.
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6 Discussion, Conclusions and Recommendations
6.1 Introduction
This chapter provides comparisons regarding findings from the English and Dutch case studies. Specific attention was paid to the policy and strategic context for both case study areas, demographic comparisons, and comparisons regarding the identified interventions in each country. Below, conclusions and some recommendations for research and policy and practice were presented.
6.2 The policy and strategic context for prevention of childhood obesity
Both the Netherlands and the UK have in place a range of policy initiatives that address overweight and obesity among school-age children. At the national level both countries seek to reduce the prevalence of overweight and obesity particularly among young people, and have in response to this set goals and targets. This highlights the high priority given to this matter by both countries, with obesity being recognised as an important health issue. Both countries target areas with the greatest problems in the Netherlands by targeting lower socio-economic groups and in the UK through action to address health inequalities. Via national policy outlining action to address obesity, (Healthy Weight, Healthy Lives and Choosing a Healthy Life) both countries have recognised that efforts to influence the food industry and the advertising and marketing sectors should be included. There were similarities between the policy and strategic approaches of both countries. The emphasis on partnership was outlined in the PON and Covenant in the Netherlands and in England via the NICE guidelines. Also the Dutch leeflijn directly compares to the National Service Framework for Children, Young People and Maternity Services in the UK. At the local level, community public health takes a lead role in both countries, via the local health care organisations; the PCT in England and via the equivalent organisation in the Netherlands, the GGD. One notable difference was that the UK does not have a database providing information on all the available preventive measures to address obesity. In addition, evidence from the case studies suggests that General Practitioners (doctors) and hospitals play a more prominent role in the delivery of Dutch interventions. The presence of the Gezonde Schools in the Netherlands and the Healthy Schools programme in the UK demonstrates a shared vision and approach, as well as a recognition
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of the importance of the school as a setting for addressing health behaviour among children. The value of the school in providing an accessible cross-section of the total population of children and young people was recognised in both countries and interventions were generally implemented through the framework of these programmes. These also ensure that school-based interventions were consistent across each country, were embedded in shared philosophies and policies, and in addition these established national programmes can provide a channel for resourcing activity and directing government funding.
6.3 Crewe and Nantwich and Beverwijk and Kennemerland how do they compare?
In terms of prevalence figures of obesity among children, the rate for Crewe and Nantwich (8.3% of 4-5 years old) was lower than the England average of 9.9% (4-5 year olds)131 . The prevalence of childhood obesity in Beverwijk (4.8% of 4-15 years old102 ) was higher compared to the Dutch average (3.1% of those aged 4-15 years104). Overall, the prevalence of childhood obesity was in the UK was high when compared to the Netherlands. With regard to physical activity patterns, a higher share of the children in Crewe and Nantwich (5-16 years) were active in physical exercise and school sports (at least 2 hours a week) compared to England as a whole. However, this share was still slightly less than in Beverwijk (4-15 years old were physically active during 2 to 3 hours weekly i.e., 92% compared to 90.5% in Crewe and Nantwich). In Beverwijk, 91% of the children cycle or walk to school. In England, traditionally much more reliance was put on taking children to school by car although actions to encourage cycling and walking to school are now being promoted.
6.4 Preventive public policy: comparative analysis of interventions identified in England and the Netherlands
6.4.1 The balance between physical activity and healthy eating
The majority of the interventions identified in the Dutch case study were primarily focussed on physical activity with healthy eating featuring to a lesser extent overall, although a proportion of the Dutch interventions addressed both of these typologies. This also reflects the balance towards physical activity evident in the country's national policy. This finding implies that the approach to preventing obesity in the Netherlands was seen primarily to be about increasing levels of physical activity. In the context of the infrastructure of Dutch towns and cities (including cycleways and facilities for cycling) and the culture of cycling and walking that was in place this seems to be a an appropriate approach. The majority of the interventions identified in Crewe and Nantwich were clearly focussed on healthy eating and on the improvement of children's diets. However, two of these also included a physical activity element alongside promotion of healthy eating. This may be due to the fact that interventions which were generally led by health authorities tend to focus more initially on changing eating behaviours; an area in which it was possible to
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legislate (e.g. in relation to the nutritional content of school meals) and to implement interventions with relative ease. In terms of physical activity there needs to be suitable facilities available and wider issues such as safety require consideration (e.g. in promoting walking and cycling to school). In the UK the infrastructure to encourage cycling and walking was not in place to the extent that it was in the Netherlands. The Dutch case study was highly focused on physical activity, healthy eating and behavioural change strategies were available but to a lesser extent. The number of interventions in the region, and the diversity of the interventions show a scattered pattern of interventions. Also, interventions in Beverwijk (and Kennemerland) were not well connected to national interventions focused on tackling childhood obesity. 6.4.2 Setting of the interventions
In the UK case study, preventive interventions to tackle childhood obesity were predominantly embedded in a school setting (6 out of 11 interventions) while in the Netherlands, there was stronger emphasis on a community setting was evident (9 out of 18 interventions). No preventive interventions to tackle childhood obesity were embedded in a healthcare setting in either one of the case studies. This latter finding can be partially explained by the exclusion criteria of our study. For example, regular controls of children by school GPs organised by the Public Health Services in both the UK and the Netherlands (organised by GGD Kennemerland in the Dutch case study area and organised by Central and East Cheshire Primary Care Trust (CECPCT) in the UK case study) were excluded. In the Netherlands, when schools were involved, school involvement was always voluntary, which explains the different levels of involvement. It can for example consist of minimal involvement, e.g. schools make their school facilities available (e.g. classrooms) or more involvement, e.g. allocating time of teachers to be involved in interventions to tackle childhood obesity. In principle, the Dutch case study suggests that individual schools do not allocate direct funding (instead of staff time) to an intervention. In the UK case study however, interventions were sometimes funded by individual schools. This funding was either sourced through schools' own budgets (via the Local Education Authority, Cheshire County Council allocations) or via grant funding applied for by the schools themselves. 6.4.3 Targeting of the interventions
In both the UK and the Dutch case study areas, the interventions were mainly (in the UK all) targeted at school-age children at primary and secondary education levels. However, in the UK case study all school-age children were targeted while in the Dutch case study the attention was more focussed on specific age groups of school-age children, particularly the 4-13 age group (i.e., primary education level applicable to 6 out of 18 interventions). In addition, in the Dutch case study area, several interventions (4 out of 18 interventions) specifically targeted school-age children with overweight problems. The voluntarily participating children were weighed and measured before they were included in the intervention or - in one specific case (the All Pupils Active intervention) - the
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children were asked to participate in a physical endurance test to identify whether they fit in the target group. In the UK case study area, school staff and parents were targeted in addition to the school-age children. In several of the Dutch interventions (5 out of 18 interventions), also other groups were targeted in addition to school staff and parents. This includes for example ethnic minority women with children, professionals, families with a low income and sport associations and their young members. These interventions were all targeted at preventing childhood obesity and thus focus more indirectly- on combating childhood obesity. In the Netherlands it was therefore clear that much more attention was placed on specific targeting while in the UK general targeting was the standard. In the UK it was generally accepted that primary level interventions should be targeted at general population groups e.g. the whole school community. Interventions that target overweight/obese children were less common (one example was the MEND intervention in Crewe and Nantwich, a secondary level intervention) this may be due to a desire to avoid labelling among young people and to avoid the stigma attached to being obese. 6.4.4 Factors that influence the implementation of the interventions
Link to national policy and strategies In the UK, the national policy context was highly influential in shaping and providing the focus of local interventions. Overall, the interviewees in the UK indicated a very strong linkage of their local interventions to national programmes. Five out of 11 interventions in Crewe and Nantwich were directly related to national programmes (for example Healthy Start and the Food in School initiative). Two out of the 11 interventions in Crewe and Nantwich were directly related to regional policy (for example Snack Right, Bike2School). In the Netherlands, the link with national strategies clearly exists but it was less obvious. It was evident that guidelines were followed, policy advice was used in shaping interventions (e.g. partnership) and best practice examples of effective interventions were translated to particular local contexts. Also, national funds were available to implement interventions at the local level. 132 The Dutch interviewees explained the local and regional policy context instead of providing a direct linkage to national policy. An explanation for this can be that Dutch governance was generally decentralised. Dutch municipalities were given much independence and decision power to set up their own political programme and action points. This can result in large differences between municipalities with regard to their attention for childhood obesity. For example, the municipality of Beverwijk has - until now - hardly given any attention to the topic of childhood obesity, which resulted in the implementation of few preventative interventions. On the contrary, the municipality of Heemskerk (located in the same region of Kennemerland) has set up a multi-annual local campaign (Vet Gezond!) to specifically tackle the issue of childhood obesity. This has resulted in a large number of interventions being carried out in this municipality.
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Due to the decentralised structure in the Netherlands, regional policy seems much more influential in shaping and implementing interventions to tackle childhood obesity in the Netherlands: 8 out of 18 interventions in the case study were carried out with co-funding from the province of Noord-Holland 133 Dependence on public resources Both in the UK and the Netherlands, a considerable weakness of the identified interventions was their dependence on temporary public funding (local, regional and/or national) with a duration between 1 to 3 years. The social domain co-funding subsidies offered by the province of Noord-Holland for example have a maximum duration of 3 years134 . In the UK case study, for example a considerable number of interventions were funded through either Cheshire County Council (CCC) and/or the Central and East Cheshire PCT (CECPCT). In the Dutch case study, a considerable number of interventions were funded through co-funding arrangements between the Province of North-Holland and relevant municipalities in the region of middle and south Kennemerland. As a result, the sustainability of the interventions was highly dependent on the continued political attention for childhood obesity. If political attention fades away, subsidies can be partially or completely cut, leading to the necessary cancellation of interventions. Interviewees in the UK and the Netherlands emphasised that they intend their relevant interventions to last for a longer period in time, but none could specify for how long because they were dependent on securing further funding in the future. Involvement of partners Partnership was central to the approaches of interventions identified in both countries. The approach at the local and regional level to joint working (for example the joint needs assessment process and the Local Strategic Partnership) in England has shaped the partnership approach characteristic of interventions. All eleven of the English interventions included two or more partners, however such partnerships usually had a lead delivery partner, seen in some instances to dominate at the expense of other partners. The practice of partnership working was regarded by some to still be developing and thus not as effective as might initially be assumed. In the Netherlands the partnership organisation 'Overweight Kennemerland' was a key stakeholder that operates to build and strengthen the partnership approach. Here, as in England successful partnership was dependent upon the commitment of individuals and the sense of involvement that each partners has in the intervention. A key barrier identified in the Dutch case study was the constraints upon schools already burdened with delivery of a full educational curriculum to take on additional responsibilities. While this was not an outcome identified in the case study it was nonetheless likely that this was to some extent also an issue for English schools, which have to balance a wide range of demands on their time and resources. Although the award system associated with the Healthy Schools programme in England supports achievement of high standards and was reflected in how schools perform in the inspection process. For this reason it is advantageous for schools to achieve NHSS and to demonstrate this on their promotional and literature.
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6.4.5
Brede school/extended schools
The Extended Schools concept introduced in England in 2004 has supported the introduction of initiatives to promote healthy eating and increase levels of physical activity among school-aged children at either side of the school day. Both of the case studies identified a large number of interventions based in the school setting and the Dutch 'Brede School' in particular compares very favourably with the Extended School concept, involving physical activity and healthy eating interventions out of school time and between different schools. The involvement of external organisations and the wider community was also a key feature of this approach in both countries. 6.4.6 Finance for interventions
Statutory organisations and authorities were the main sources of funding for interventions in both case study areas and funds were closely tied in with local policy and strategic goals. A common problem for both case study areas was the time limited nature of available funding, with the continuity of interventions depending upon further funding coming forwards. This posed significant problems for planning in the medium to long term. The need to secure external funding was an on-going issue for interventions, in England attempts to 'mainstream' interventions that aim to prevent obesity was regarded as one solution. Furthermore, five of the interventions included in the English case study were part of national initiatives and as such were more likely to be subject to evaluation and have longer term funding allocated. 6.4.7 Evaluation and cost effectiveness
The dearth of local evaluation and monitoring was a key finding in both of the case study areas, with only a minority of all the interventions being subject to evaluation study. Where evaluation has been completed this was often only in relation to impact and short term outcomes (e.g. participant feedback on the intervention or self-reported behaviour change) rather than the measurement of longer term reductions in overweight/obesity. The review of the evidence base relating to childhood obesity conducted by NICE135 noted that many of the obesity interventions tended to be of short duration with little or no follow-up, and that in general the monitoring of interventions was very low. It also noted a need for longer term follow-up of outcomes with a greater emphasis on rigour (e.g. via randomised controlled trials), and a need to build up a UK evidence base relating to the effectiveness of multi-component interventions. The lack of evidence for effectiveness has hampered opportunities for evidence-based practice. Generally there was little funding in case study areas specifically ear marked for evaluation studies to enable rigorous research to be undertaken. Information regarding cost effectiveness was absent from both case studies suggesting a significant gap in information about the extent to which investment in interventions was worthwhile. Therefore, as a consequence, there was a lack of clarity regarding the real costs and economic benefits associated with efforts to reduce obesity.
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While policy documentation frequently highlights the need for the evaluation of new interventions and initiatives, the importance attached to this research activity was usually quite low and this was often reflected in the minimal levels of government funding attached to evaluation activities. However, the recent Healthy Towns initiative provides an example of good practice, by placing a strong emphasis on evaluation from the outset and a significant research budget to support this activity.
6.5 Conclusions
Key conclusions emerging from the case studies and cross national comparison have been listed below: The case study results indicate that shared learning between both countries has already taken place and that this has influenced policy-making and the approaches adopted in the school and community settings. Evidence from both countries indicates the value of 'whole school' approaches that were part of national programmes e.g. the Healthy School in England and the Gezonde Schools in the Netherlands. These programmes offer an opportunity for longer term intervention and were more likely to secure funding to continue and be sustainable. Prevention of childhood obesity works best at the local level provision of organisations in the borough (close to the parents and children)136 Policy (in UK at national level and in Netherlands at the local level) is highly influential in shaping and providing the focus of local interventions Preventive interventions should include three components to achieve success: healthy eating, physical activity and behavioural change Funding for preventive interventions is very scattered and this hampers success Provision of preventive strategies is scattered and sometimes very targeted. This may be one of the reasons that very little local evaluation has been done.
The cultural differences with regards to physical activity have been highlighted. Dutch infrastructure supports cycling and walking and may contribute towards the lower levels of obesity in the Netherlands Comparing the two countries has highlighted that where there were cultural differences, responses to prevention may differ. In the UK the social stigma attached to obesity and a recognition of the psychological impact of being labelled as 'obese' have led to a general approach that targets the whole population of school-aged children. However, in the Netherlands there is generally a more targeted approach focussed on those regarded as overweight or unfit. National interventions can confer significant benefits as they were more likely to attract funding in the longer term and to be subject to evaluation. Where efforts to improve the health of children (and address obesity) were strongly incorporated into the school curriculum and strengthened by other actions in the school including contributing to its ethos, barriers around implementing intervention may be overcome. Environmental influences on obesity were being given a higher priority and now feature in policy at all levels and in intervention approaches. However, there is still
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scope for environmental factors to have a greater emphasis in approaches to intervention. 6.5.1 To what extent do the findings suggest that European policy is being implemented in both countries and resulting in shared approaches?
As stated in Chapter 1 of this report, there is an increasing volume of evidence to indicate that obesity is a significant public health problem that requires immediate and appropriate policy responses at the European, national, regional and local levels. Both the UK and the Dutch case study show considerable efforts have been done on the national, regional and local level to include the issue of childhood obesity on the political agenda. Both in the UK and the Netherlands, frameworks have been developed at a national level to provide guidance on the level and types of interventions (including examples of best practices) that could be offered at the national, regional and local level (i.e., National Service Framework for Children, Young People and Maternity Services in the UK and the manual Prevention of overweight in local health policy (including the LEEFLIJN in the Netherlands). In these frameworks and other policy documents and strategies considerable emphasis is put on the EU agreement to tackle obesity via a multi-policy or multi-strategy approach, i.e., the integration of policies across several arenas: from food to sport, education and transport. The case studies make clear that the majority of the interventions that were found in the case study areas consist of multiple components, e.g. emphasis was put on healthy eating and physical activity and behavioural change. Besides the multi-component approach, the Dutch and UK case studies were also similar with respect to the importance of partnership. At a national level, the NICE guidelines in the UK emphasise partnership. In the Netherlands the Covenant Overweight (Covenant Overgewicht) and Partnership Overweight Netherlands (PON, Partnerschap overgewicht Nederland) were clear examples of a (public-private) partnership approach. At the local level, the Sustainable Community Strategy for Crewe and Nantwich 2000-2016, including the Local Strategic Partnership (LSP) of local and health authorities was a good example of using partnership to combat childhood obesity. In the Dutch case study, the regional project group Overweight Kennemerland was active as a regional partnership tackling the issue of childhood obesity. Still lacking in both the UK and the Netherlands was the lack of evidence of effective interventions. Because of the urgency of tackling obesity it is important to continue implementing serious initiatives, while ensuring that they a culture of independent evaluation is developed. Partially as a result of the availability of several, sometimes very targeted interventions at national and local level and the scattered nature of time-limited funding (national, regional and local), long-term evaluation of interventions - particularly implemented at a local level - were also lacking. For both the UK and the Dutch case study, local (longterm) evaluation results were missing due to either a lack of capacity in terms of
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evaluation skills and resources. The answer here may be to encourage a culture of using external independent evaluators to assess the impact of interventions. As a result, much of the results of interventions implemented locally in both the Netherlands and the UK remain - as yet - anecdotal in nature. In this sense, it is difficult to share best practices as recommended by the European Commission. However, this case-study analysis provides valuable information about the barriers and factors for successful implementation of preventative interventions to tackling childhood obesity. 6.5.2 Recommendations for research
Effective preventative policies need to be based on sound (scientific) evidence. The evidence base of the cost-effectiveness of preventative interventions is limited and not yet fully explored. Little review-level evidence is available regarding the impact of social and environmental interventions for children and young people. It is therefore recommended that funding organisations ear mark multi annual funding to cost-effectiveness studies in the field of childhood obesity. In addition, future research in the area of preventive interventions to tackle the issue of childhood obesity should predominantly focus on developing an appropriate and common evaluation approach for evaluation, focusing specifically on cataloguing the long-term impact. For this purpose, monitoring systems should be developed and put in place. As cost-effectiveness studies of public health interventions were still in their infancy, future research should also focus on how the capacity to undertake independent evaluations with regard to childhood obesity could increase. 6.5.3 Recommendations for policy and practice
Obesity is a complex health problem. It has been acknowledged that a multi-faceted, environmental approach is needed for effective prevention. It is therefore recommended to tackle obesity in partnership, involving all relevant stakeholders. Both in the Netherlands and in the UK effective partnerships were beginning to emerge in practice, and this should be further stimulated. As prevention of childhood obesity works best at the local level, interventions should be provided by organisations in the locality (close to the parents and children). The national policy context is highly influential in shaping and providing the focus of local interventions. To support coherence across the interventions it is recommended to link local and regional initiatives to national initiatives. Linking to national initiatives is also an important factor for sustainable funding that is needed to evaluate the impacts of the intervention. The findings of the case studies show that the sustainability of the interventions is highly dependent on the continued political attention for childhood obesity. If political attention fades away, subsidies can be partially or completely cut, leading to the necessary cancellation of interventions. Interventions delivered as part of wider regional and national programmes (e.g. Healthy Schools in the UK) had the advantage of being part of an established initiative, with allocated resources such as regional co-ordinators and health information. This helped to provide them with a
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high profile and to attract support and commitment from partners e.g. schools and parents. Sharing of information in the area of good practice in nutrition and physical activity, and obesity prevention should be further stimulated at a national level as it provides valuable insight of barriers and facilitators of tackling childhood obesity. In addition, sharing information should be done on a European level as it will reduce overlap and duplication of efforts in addressing the issue of childhood obesity.
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7 Annex 1: Overview of interventions in the English case study
Table 1.0: Obesity among school age children in Crewe and Nantwich: Case Study Interventions
Intervention name 1 The Friday Boy Club Typology Partners Funding & Costs WW funded No information on intervention costs Duration Target Group Vulnerable young people Setting Evaluation or monitoring Monitoring against outcome data. Well attended (up to 250 each Friday). School staff supportive and benefits for pupils noted. Policy context Meeting the Healthy Schools agenda & CEPCT and CNBC policy Intervention Description
Physical WW activity (delivery) programme CNBC Healthy schools Eating. Change to provision of tuck in school.
September 2007 -
School
Friday Boy (former WW volunteer) attends schools on a Friday lunch-time. Pupils invited to participate in physical activity, healthy snacks required and to learn about human biology. Also addresses mental health (bullying). Strongest focus on physical activity in the playground. Club that aims to promote
2 Chill and Chat Peer
WW
WW funded
September
Vulnerable
Community
None. Reports
Healthy
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Youth Club (Healthy Living Centre)
support
(delivery) Schools and CECPCT
2007 No information on intervention costs
young people
of significant benefits for individuals. Club has 20-25 members
Schools Agenda
general good health and in particular to raise the selfesteem of young people. Opportunities for health education and for addressing obesity issues in a supportive environment. Referral is via the school nurse and focus is on the most vulnerable. Emphasis on peer support for good
3 Healthy Lynx
Physical CNBC, activity Health programme Development Team Lifestyle (delivery) activity and schools
CNBC and contribution from schools and grants 25 per Health Lynx Session (1-2 hours)
2003-
School-aged School children
Monitoring data collected and feedback forms completed by pupils participating
Healthy Schools agenda, Sustainable Community Strategy, CNBC Corporate Strategy
health. Project to encourage physical activity in school time, and out of school. Focus on pupils who dont enjoy the school PE curriculum and on informal non competitive activities.
4 The National School Fruit Scheme, 5 A Day & The
Healthy eating. Change to
CCC (delivery) and CECPCT
Funded by DH and 42 million from the National
2001 -
Primary school children
School
National
Local and
The Food in Schools programme is a joint venture between the DH and DCSF includes a
evaluation regional evidence (pilot policy and schools) 44% Every Child
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Food in Schools Programme
provision of tuck in school
Lottery
of schools reported increased fruit consumption, improvements in knowledge levels and ethos of school. Positive response from parents
Matters; Food range of nutrition related and Health activities. The School Action Plan Fruit and Vegetable Scheme is part of the 5 A Day initiative - children in primary schools (LEA maintained) 4-6 years are entitled to a free piece of fruit or vegetable each day. Operates across England. CNBCs Sports Strategy and NW Plan for Sports and Physical Activity National recommendations for the development of Travel Plans that encourage walking and cycling to school are implemented by local authorities. Bike2School is a CNBC led project (with Sustrans) linked to Routes2Action a termly publication that is free. Individual schools develop travel policies and funding is available to support this. There is a local Cycling Champion to
5 Bike2School/ Safe Routes to School
Lifestyle activity. Reduce sedentary activity.
Cheshire Healthy Schools Coordinator (delivery) and Schools
The Travel Plans are funded via either local or national govt grant funding
2002-
School-aged School and children and Community parents
No information available regarding evaluation. New School Travel Plans have been developed for 30 schools in Crewe and Nantwich.
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encourage and support school-children. 6 Extended Schools out of school sports and physical activities, and breakfast clubs. Healthy eating. Physical activity programme Extended Schools Officer (CCC) delivery, CECPCT & parents DCSF funded programme Programme School-aged School commenced children and at 2003/04 parents and at 200405 C&N had 1 full service extended school. Some evidence regarding impact at national level. Benefits for young people include: increased motivation and self-esteem. Also behavioural improvements and new skills or interests. Behaviour change (national) is monitored via the HRBS Survey. Cheshire Every Child Matters and the Healthy Schools Agenda. Govt. has set targets for all schools to extend from 8am 6 pm by 2010 Extended Schools are expected to offer quality childcare, a menu of activity (including physical activity) and parenting support. Meals provided under Extended Schools are required to meet nutritional guidelines. As a result of ES some children may have the majority of their nutrition at school.
7 The Cheshire Healthy Schools Programme
Changes
CCC, CNBC, Funded by CCC and CECPCT
Established
School-aged Schools
CCC Health
Takes a 'whole school'
to/incorpora CECPCT tion into the (delivery) curriculum Healthy eating. Physical activity
in England in children, 1999 staff and parents.
Scrutiny Sub- approach to health and Committee, addesses issues across Healthy the school staff, parents, Weight, Healthy Lives, Every curriculum and pupils. Multi-agency approach in Cheshire which utilises the 'Lightening the Load' toolkit. 49 C&N schools participate and 40 have
results indicate Child Matters an increase in & NW physical Framework.
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programme . Changes to provision of tuck in school. Reduce sedentary activity. 8 Play Outreach Physical CNBC Programme activity (delivery), programme parents and young Lifestyle people activity Signposting Reduce sedentary activity Healthy eating. Change to school Funded by CNBC 2007School-aged Community children
activity and reports of lower consumption of sweets and crisps. Case Studies from Cheshire also completed.
achieved full status. These schools have projects and education initiatives in relation to both healthy eating in encouraging participation in physical activity.
No formal evaluation but feedback forms are given to children and parents - these inform service development
CNBC Sports & Physical Activity Strategy, NW Plan for Sport and Physical Activity, CCC's Health Scrutiny subcommittee
Child-centred programme to promote play in public spaces with a focus on the most vulnerable communities. Also involves parents and signposts to other services. Offers wide range of play activities.
9 Government Nutritional Standards for school lunches and
DCSF and CCC (delivery)
CCC funding structures
2008-
School-aged Schools children
No information. Healthy Schools and In Crewe 7 primary schools Public Sector Food procurement
New government standards initially implemented in primary schools in 2008 (secondary schools by
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other school food
meal content Change to provision of tuck in school.
involved in new Initiative lunch-time menus provided by County Business Services (the trading arm of CCC).
2009). These are mandatory and cover all eating in school lunches and snacking. Specific guidelines on nutritional content have to be met: levels and amounts of fats, sugars, fruit and vegetables etc. In Cheshire new initiatives include: salad bars, local sourcing, information about healthy packed lunches and access to fresh water.
1 Snack Right 0
Healthy eating. Postal communication. Workshops
CECPCT, Children's Centres, parents/ carers and Aldi (supermarket )
DH (Communities for Health Fund). Total funding 213,000 approx.
May 2007 -
Parents under 19 years
Community
Planned (evaluation by John Moores University). Baseline data has been collected. Operates across Cheshire and Merseyside and focuses on the most
Runs alongside the national Healthy Start scheme.
Uses a Social Marketing approach (to counter mainstream food advertising). Targets economically inactive parents and their children (including under 19s and teenage parents in Crewe). The project promotes breast feeding and healthy snacks in under 4s and their parents. There have been
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deprived areas.
15 Snack Right events at children's centres (2 of which were in Crewe and Nantwich) and a leafleting campaign targeted 113,000 households.
1 Healthy Start 1
Healthy eating. Use of incentives/ rewards
CECPCT and local shops
DH funded
Launched in Parents 2004 across under 19 the UK years (replaces the Welfare Food Scheme)
Community
Other UK National evaluations but Service not in Cheshire Frameworks, Sure Start programme.
Aims to tackle health inequalities (high infant mortality rate amongst the poorest) and provides food vouchers to young mothers (particularly those under 18 years). Pregnant women and young mothers are eligible (income less than 15,575) for vouchers (3 each) that can be exchanged at shops for fruit, vegetables, milk or vitamins. Referral is via ante-natal clinics and Health Visitors.
Key:
WW Wishing Well Healthy Living Centre CNBC Crewe and Nantwich Borough Council CECPCT Central and East Cheshire Primary Care Trust CCC Cheshire County Council
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Table 1.2: Crewe and Nantwich projects and activities that impact on the health of school-age children
Local project and activities that are promoting/ impacting on the health of school-age children School travel plans Crewe and Nantwich at Play School environment and physical layout (play space, sport facilities, stairs, dining hall layout) School crossing patrols The school curriculum (e.g. biology, PHSCE, PE) MEND Statutory health services (dietician, health visitors, GPs, school nurses etc) National Child Measurement Programme Other service, initiatives and projects that impact on the health of the whole community (including school-age children) Step-by-Step walking programme Local urban planning and regeneration strategies (addressing 137 the 'obesogenic' environment) Local transport policies and existing transport infrastructure (e.g. traffic management in favour of the pedestrian) Leisure and sports facilities (availability, variety, cost and accessibility) Green infrastructure (parks, open spaces, and access to the countryside) The availability of supermarkets, markets (e.g. farmers markets) and fresh fruit and vegetables. Affordability is also a factor Provision of and accessibility of play grounds and play facilities. Everybody Health and Fitness (CNBC's fitness brand) Food advertising and food processing and manufacture (the UK government is currently working with the food industry on salt, fat, sugar and portion sizes) Crewe and Nantwich Community Sport and Physical Activity Network (CNSPAN) The Wishing Well Healthy Living Centre. Weigh2Go intervention Eagle Bridge Centre health and wellbeing centre
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8 Annex 2: Overview of interventions in the Dutch case study
Table 1.0: Interventions to prevent childhood obesity in middle and south Kennemerland- those marked with an * taking place in Beverwijk
Nr. Intervention name 1 Course Fit, Food & Fun Workshops (inc parent meetings)/Reduce sedentary activity/Healthy eating/ PA programme/ Behavioural change therapy/Postal communications (brochures) ZonMW subsidy to fund manpower of Zorgbalans Municipal and provincial coSchool Parent contribution (between 40 annually 56 depending on membership of service passport) Set up: The intervention has been set up in 2005 and is currently still running. Typology Setting Funding Duration and timescale Duration: The intervention has a duration of 10 weeks Delivery: project group overweight Kennemerland: sportservice Noord-Holland carries out the PA programme while Zorbalans carries out the healthy eating component. In 2008/09 9 children participated in Haarlem (6 parents); 5 children in Heemskerk (4 parents); 8 children in Zandvoort (10 Coordination: Zorgbalans Children aged 8-12 with overweight and/or obesity problems Multidisciplinary course after school time at a school venue: PA programme (1 hour a week, given by a physiotherapist), food lessons and homework (given by a dietician), 2 parent information meetings (evening) regarding healthy eating, physical activity and the up bring of children in general Three evaluations (2 in Heemskerk and 1 in Heemstede) have been carried out. Different results: in 1 course weight difference with age group reduced after the course and 1 course weight difference with age group increased after the course; in 3 courses stomach profile reduction after course; 1 course children and parents enthusiastic Partners Target group Description Evaluation results
86
funding (BOS impulse)
Also involvement of primary schools.
parents); 10 children in Heemstede (9 parents)
about the course; 1 course children did not participate very well (not ready for it according to the parents); 1 course noticeable that the children play more outside and are also asked by other children more often to play outside; 1 course more healthier eating after the course (less asking for candy)
Kidsclub
PA programme, postal communication (brochures)
Community
Parent contribution ( 128 annually)
Duration: Annually
Coordination and delivery: Sportservice
Children aged 8-12 with overweight and/or obesity problems
It is a sport and game hour for children, carried out in a leisure centre or sport association. They get acquainted
No evaluation results yet, this intervention is newly introduced.
Set up: The Municipal and provincial cofunding intervention has been set up in 2008 and is still running.
Noord-Holland
Intermediary results so far in Heemskerk (anecdotic): participation is low (due to the high parent contribution) and the switch from physiotherapy in a school facility (during
Also delivery organised by participating leisure centres and/or sport associations The participating children already participated in the Fit, Food & Fun course
with different sports and through this they learn necessary sport skills which will increase and facilitate their physical activity in
87
the future.
the course fit, food, & fun) to sports in a leisure centre/sport association is too large.
Food advice for ethnic women
Workshops (inc parent meetings)/Healthy eating/ Signposting
Community
Contribution of the participating ethnic women organisations ( per 25 meeting)
Duration: One-off meetings
Coordination: Zorgbalans
Ethnic minority women with
Existing ethnic minority women groups who already regularly come together, convene at
No evaluation results available.
Delivery in Set up: The intervention has been set cooperation with project group overweight Kennemerland
children
Intermediary results so far in Heemskerk and Velsen (anecdotic): these meetings are reasonably successful and have enough participants because they are organised for existing groups of ethnic minority women. So there is no need to search for participants. Of the 47 participants, 13 have b een signposted to interesting sport activities for their children.
So far 47 participants in Heemskerk and Velsen
a suitable place (can be a community centre, a mosque, elsewhere) to receive advice and information from a dietician of Zorgbalans in relation to improve the healthy eating and physical activity of their children.
ZonMW subsidy to fund manpower of Zorgbalans
up in 2006 and is still running.
All pupils active (alle leerlingen actief)
Counselling/ Behavioural change therapy/ Workshops (parent
School
Municipal and provincial cofunding
Duration: Unclear
Coordination: Sportservice Noord-Holland
School-going (vocational education)
This intervention consists of a mix of activities: children
No evaluation results yet, this intervention is newly introduced. The
88
meetings)/ Signposting/ Changes to / incorporation into curriculum and use of homework/ healthy eating/ PA programme
(provincial contribution in 2007: 224.246)
Set up: The intervention has been set up in 2008 after 2 years of piloting in 6 places throughout the Netherlands. It is currently still running. Delivery: Sportservice Noord-Holland, GGD Kennemerland and participating primary and secondary schools (vocational)
children aged 9-16 who did not pass a physical endurance test (including measurement of fat percentage)
are involved in motivation conversations to spur a behaviour change. The parents also receive counselling to take away any existing obstacles. The children and parents are signposted to diverse sport activities in the neighbourhood or to an intervention like the course Real Fit. The participating schools organise extra sport activities (sport days) and arrange support of a dietician/psychologist or otherwise in relation to healthy eating. The intervention is sometimes combined with other
evaluation results of the pilots show however promising results.
89
interventions like sporthackers or healthy school canteen (gezonde schoolkantine) 5 Cruyff court Subsidised leisure activity/ PA programme Community Cruyff foundation Duration: Ongoing Delivery: Cruyff foundation, municipality and Municipal funding Set up: Set up nationally in 2003 and in 2007 in the region of Kennemerland (Heemskerk). Currently still running cooperating of diverse partners (neighbourhood, sport associations, schools, sometimes also SMEs) Young people (particularly with an ethnic minority background) A playing field is set up/built to offer young people the facilities to undertake diverse sport activities (like football). Diverse physical activities on and around the playing field are coordinated in cooperation with all the involved partners. 6 Special support (sociale bijstand)* Subsidised leisure activity Community Municipal funding Duration: Annually Coordination and delivery: municipality Set up: Unclear. Currently still running. Families with a low income Families with a low income can apply for municipal funding for their children (and parents) to become a member of a sport association ( 200 per family in Heemskerk, Dutch Intermediary results so far in Heemskerk(anecdotic): Participation so far has been low. It seems that not many people are No evaluation results available. No evaluation results available.
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national average is 100)
acquainted yet with this support programme or they fear the bureaucracy.
School sport programme (school sport programma)*
Changes to / incorporation into curriculum and use of homework/ PA programme
School
Municipal funding
Duration: Unclear
Delivery: participating primary
Children aged 9-11 in primary school education (group 6 and 7)
The school sport programme consists of 10 different physical activities: this can include a sport day; skating lessons, sport
Set up: Unclear. Currently still running.
education school
Intermediary results so far in Heemskerk (anecdotic): The number of participating schools and children has been very high. The impact of this is unclear. What can be said is that the school tournaments mostly only stimulate children already physically active, as a result the impact to prevent obesity is likely to be low.
In Heemskerk 13 primary education schools were involved leading to the participation of 2500 children.
tournaments and otherwise.
Jeugdsportpas (JSP)
PA programme/ postal communication (brochures)
Community and school
Parent contribution ( 5 per sport)
Duration: Annually
Coordination: sportservice Noord-Holland
Children aged 4-12 in primary school education
At the start of the school year, children receive a flyer with information regarding
Evaluation results in Heemskerk show that the participating children like to work
Set up:
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Municipal funding
Unclear. Currently still running.
Delivery: sportservice Noord-Holland, sport associations, and primary schools
(groups 1-8)
the JSP. If their parents register them
with new and unfamiliar sport equipment and to receive sport clinics of professional sportsmen. The impact according to the evaluation has been that many of the young participants have become a member of participating sport association (approximately 10% of the participants).
In Heemskerk 15 primary education schools participated (of which 1 in Beverwijk located). In total 800 children participated.
they can receive 4 lessons of 1 hour each at a sport association (or elsewhere) after school to get acquainted with a sport they find interesting (8 different sport activities are offered). For each period (3 a year) children can participate in 1 sport. After the sport lessons, the children can decide to become a member of the relevant sport association.
Course Real Fit
Workshops (inc parent meetings)/Reduce sedentary activity/Healthy eating/ PA programme/
School
Parent contribution ( 100 from which they receive back
Duration: 12 weeks
Young people aged 13-18 with overweight
Multidisciplinary course after school time at school venue including healthy eating lessons,
Nationally an evaluation has been carried out by the House of Sport (Limburg) in cooperation with the
Set up: Unclear. Delivery: project
and/or obesity
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Behavioural change therapy/Postal communications (brochures)
in case of 50 sufficient participation)
Currently still running.
group overweight Kennemerland and secondary
problems
physical exercise (in a fitness centre) and parent information evenings to offer advice on healthy eating (offered by a dietician), raising children and sufficient physical exercise.
University of Maastricht. In the region of Kennemerland no evaluation has been carried out yet.
Municipal and provincial cofunding
schools
Intermediary results so far in (anecdotic): Parents are not keen to register their child for this programme. Probably because they don't find their children overweight and/or also due to the stigma attached to being overweight. Another mentioned reason is the lack of signposting (and persuasion to register) to this intervention by the public health authorities (GGD).
10
Sporthackers
PA programme/ Changes to / incorporation into curriculum and use of homework/ Postal
Community & Schools
Municipal and provincial cofunding (In 2006/07 Province
Duration: Unclear
Young people aged 13-18 in vocational education
Sporthackers tries to stimulate young people to (continue) to be physically active. The basis of
According to a process evaluation the number of young people involved in sports increased on average
Set up: Unclear. Delivery:
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communication/ Interactive communication methods for advice and support
subsidy entailed 138.571 and in 2007/08: 73.523 and 83.200 came from other contributors
Currently still running.
Consortium of Sportservice Noord-Holland, RTV NoordHolland (radio and TV) vocational secondary schools
4 schools participated and 31 sport associations. In total 497 young people participated in the sport clinics during the holidays and 3269 participated in school sport clinics.
this intervention is shaped by the available sport supply of the participating schools; the organisation of sport clinics during holidays; and the sport supply of sport associations. This supply is adjusted to the needs of young people and marketed better to young people.
with 3,3% after theyve participated and membership of youth clubs increased with 12% (only measured in Zaanstad). A weakness of the project has been the low participation number of sport associations and their lack of capacity. In addition, the idea to reach young people who are not physically active did not succeed: 81% of the participants were already involved in sport activities before the intervention. Enthusiasm was high among the participants and participating schools.
11
Pilot know your talent (ken je talent)
Workshops
Community
National funding138 of the Ministry of Health, 267.250
Duration: Unclear
Coordination and delivery: Sportservice
Sport associations and their young members
Services are offered to participating sport association to get young members involved in volunteer
No evaluation results yet, this intervention is newly introduced.
Set up: 2008. Currently still
Noord-Holland
It is recommended to
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running Contributing of participating sport clubs
Also delivery organised by sport associations
work for the sport association: analysis of the situation, workshops and training, tailored
organise an effect measurement 1 year after the intervention to see whether the number of young volunteers has increased and also to check up whether their is any need for postsupport. Unfortunately Sportservice NoordHolland did not include this element in their project and leave it to
Co-funding of participating municipalities and sportservice.net pay the remaining 42.7%. Total 625.500
139
support to implement change, education and training of young members (using existing and new techniques)
the responsibility of the participating youth clubs to organise this.
12
Whoznext
PA programme, subsidised leisure activities, interactive communication
Community
Municipal funding and sometimes small contribution of participating sport associations
Duration: 1218 months
Delivery: Sportservice Noord-Holland,
Young people
Whozenext is a national campaign which aims to offer young people a voice in sports. A whoznext team consists of 4 to 8 young people in combination with a team coach from the participating sport
Intermediary results so far (anecdotic): Available evaluations do not examine impact: it is already great if the teams still exist after 1 or 2 years
Set up: Unclear. Currently still running
sport assocations, schools and community centres
95
association, school or community centre. The team receives (besides other 450 support and training) to organise at least 3 activities (can be a party, excursion to a sport association during school PE, skate tournament, etc.). The whoznext teams are connected to each other on a national level and they can exchange information. 13 Fit4family
140
PA programme
Community
Private incentive of the Fit4family foundation
Delivery: Annually
Delivery: Fit4family foundation
Young people and their parents
Parents and their children can fitness in the same fitness club: for children lots of fun materials are available. For some children with overweight problems a simple individuallytailored programme is made
Set up: Unclear
96
14
Project Beter (Zw)eten*
Reduce sedentary activity/ healthy eating/ PA programme/ Counselling/ Changes to / incorporation into curriculum and use of homework/ Reduction sedentary activities
School
Provincial141 and municipal co-funding
Duration: 4 weeks
Coordination: GGD Kennemerland
Primary school children aged 8-9 (group 5)
Ex ante measurement of length and weight; courses on healthy eating; physical
This intervention has been evaluated in Haarlem during the pilot phase in 2007 (10 schools in total) Yes. A new evaluation including all participating primary schools in middle and south Kennemerland (16 schools of which 1 in Beverwijk in 2007/2008) is expected to be published in November 2008.
Set up: 2006. For 10 schools in 1 municipality (2008/2009): 27.890 Currently still running Delivery: project group overweight Kennemerland and primary schools Of which 7.800 for GGD, 5.215 for Zorgbalans, 2.750 for local sport provider and 5.000 for material costs. 308 hours provided by JGZ 4-19 (GGD); 139 hours provided by Zorgbalans; and 50 hours provided sportservice NH
16 primary education schools participated in 2007/2008 of which 1 in Beverwijk.
activities; information meetings for parents; individual counselling; advice school policy; post measurement of length and weight
Results from the evaluation in Haarlem: the intervention is appreciated by its participants. Increased percentage of pupils taking breakfast; no changes regarding consumption of fruit and vegetables; knowledge of nutrition has increased; and
97
reduction in sedentary activities.
Anecdotic information: The above mentioned positive evaluation effects are likely to be only temporary and will likely reduce over time. 15 Groep 6 on the move Reduce sedentary activity/ Healthy eating/ PA programme/Incorporation into curriculum and use of homework For 7 schools (10 groups): 52.136 School Provincial
142
Duration: Unclear
Coordination: GGD Kennemerland
Primary school children aged 9-10 (group 6)
The children decide what they want to learn in relation to food and physical movement. Their
Evaluation in preparation, to be finalised end of 2008.
and municipal co-funding
Set up: in 2007. Currently still running Delivery: GGD Kennemerland, Sportservice Noord-Holland, Of which 25.068 to fund activities of the GGD and 270.68 for activities of the Sportservice Noord-Holland Per individual group: input of 104 hours by the GGD and Sportservice Noord-Holland. primary schools and parents
Preliminary evaluation results of the school year 2005-2006 indicate an increased intake of fruit among the children (in %), increased intake of light carbonated drinks, less candy eating, increase of outside physical activity (can be seasonal).
8 Primary education schools participated
wishes are shaped through the inputs of teachers and parents. Sportive activities are organised and in the curriculum attention is put on healthy living. Facilities in the neighbourhood are used to stimulate children to move (sport clubs, play
Anecdotic information: Almost all of the
For an
grounds, etc.)
98
additional group: 26 hours extra
schools have also registered for the smaakleskist of the Ministry of Agriculture. It contains a lot of fun materials to experiment with food. The intervention is also combined with for example the Jeugdsportpas and Nationaal Schoolontbijt. The children especially like the introduction to new forms of physical activity. Parents like to participate in the activities of the children. Several schools have adjusted their snack policy (pauzehapjes). Several schools want to keep certain elements of the project in the upcoming years: marathon around the school, smaaklessen, assignments in physical
99
activity diary Hupla and cooking activities.
This intervention has been included as good practice in the Leeflijn of the manual prevention of overweight in local health policy developed by the Ministry of Health. 16 Parent meetings Workshops/ Healthy eating/ Signposting School Participating primary education schools pay to fund 50 costs of materials. Set up: Unclear. Currently still running. ZonMW subsidy to fund manpower of Zorgbalans Duration: One-off meetings Delivery: Zorgbalans, GGD Kennemerland and participating primary education schools Coordination: Zorgbalans Parents of children aged 4-12 Participating primary education schools take the initiative to organise this intervention. The parents receive advice in relation to healthy eating (breakfast), physical activity, the cause of overweight and treatment, support in upbringing of the Provincial funding to fund manpower children (behaviour influencing, parent role model, watching No evaluation results available
100
provided by GGD Kennemerland 17 Youth sport subsidy (jeugdsport subsidie)* Set up: Unclear. Currently still running Subsidised leisure activity Community Municipal funding Duration: Annually Coordination and delivery: municipalities Youth sport associations
TV, computer games).
The youth sport subsidy offers funding to sport associations in Beverwijk for young members. The height of the funding is depending on the annual number of young members.
18
Social card overweight for professionals (sociale kaart)143 *
Interactive communication methods for advice and support (website)/ Postal communication
Community
Unknown, possibly municipal funding
Duration: Not applicable
Coordination and delivery: : project group
Professionals who work with young children and their parents to prevent overweight
The social card offers an overview of all organisations in the region of middle and south Kennemerland which are active to help prevent and/or treat overweight of children. It offers information regarding preventive activities, websites, sport opportunities, etc.
Set up: Published in 2006. Currently still available.
overweight Kennemerland
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9 Annex 3: Selection of Case Study Areas
Overview
An equivalent area in each country (UK, NL) was selected using agreed criteria such as population size etc - for comparison in the case studies. The method for the UK takes into account population size, dispersion (rural-urban classification), Index of Multiple Deprivation (IMD), ethnicity and health as contextual factors. The method for NL takes into account population size, social economic status (SES), dispersion and ethnicity.2 A staged process was adopted whereby population was used first to provide a list of 'average' local authorities, then IMD (UK) or SES (NL) was cross referenced against these to narrow it down further, then ethnicity, and finally dispersion were compared against this narrowed down selection to come up with a final shortlist. In the UK the selected area was also cross referenced to the level of health status.
Given the timescale of the project, the remit for the selection of a case study area was also partly driven by practical considerations. The selected area would have to be:
Methodologically representative of the UK and NL this was
achieved through establishing an 'average' location through the use of a series of indicators such as population, deprivation, and ethnicity. Of a size suitable for study i.e. an area where there will be a range of interventions taking place. An area too small or too rural would limit the scope of the study in terms of the range and volume of interventions selected and the likely scale of evaluation. Accessible given economic constraints and the very hands on research approach envisaged, a secondary consideration was the time 3 and expense of case study visits .
All the data (population, rural-urban classification, ethnicity) used for the selection process, is obtained via CBS and are all from 2007. The data used for the calculation of the SES is a lso obtained via CBS, but these numbers are from 2006. This paragraph for internal use only
102
The devised method took into account two main indicators and used another three to provide a contextual background. The two key indicators were: 1. Population Size (UK: Census 2001, NL: CBS 2007) 2. Index of Multiple Deprivation (UK: National Statistics 2004) Social Economic Status (SES) (NL: CBS 2006) With contextual indicators of: 3. Dispersion characteristics (urban and rural classification information) (NL: CBS 2007) 4. Ethnicity (UK: Census 2001, NL: CBS 2007) 5. Health4 (UK only) 9.1.1 Population size (UK)
The population size of local authorities in England and Wales were considered from information available from the 2001 census. Information from the census was downloaded from national statistics and cleaned to ensure that it was only local authorities which were included (e.g., regions and counties were excluded otherwise people would be counted twice). An average population size was then calculated from data from the column '2001 population of all people', from this data5, the average size was identified to be 142,9786. We considered using urban areas, as a measure to identify the most average 'town' (as previously suggested) but when the average town size was calculated, this was 30,111. We also considered then removing the smallest urban areas to calculate an average of those over 50,000 but decided against this. However, whilst providing a good sample of urban areas (following initial proposals to use a 'town') we felt that it would be difficult when most other data is collected at administrative level. We also had concerns about how this would stand up methodologically and therefore, on reflection, decided that a local authority approach would be the most practicable. All of those local authorities with close to average (143,000) populations were identified. This provided a shortlist of around 20, with 10 locations above and 10 below the average. Population size (NL) The population size of local authorities in the Netherlands was considered from information available from Statistics Netherlands (CBS) for the year 2007. In the population statistics compiled by Statistics Netherlands the inhabitants of a given
4 5
Note health deprivation already forms part of the IMD composite score and this may need to be referenced accordingly. Table KS01 Usual resident population ONS copyright 2003 saved as size of local authorities 2001 in demographics folder unique number 149_D.
area are the people registered in the population register, whose address is located in that area. Information on population size was downloaded from Statistics Netherlands. An average population size was then calculated, the average size was identified to be 36,925. All of those local authorities with close to average (36,925) populations were identified. This provided a shortlist of around 10, with 5 locations above and 5 below the average.
9.1.2 Index of Multiple Deprivation (UK)
Index of Multiple Deprivation (IMD) data which is available for 2004 was used to identify areas which are deemed 'average' when a range of factors were considered. The IMD provides a composite figure and rank for:
Income Employment Health Deprivation Disability Education and Skills Barriers to Housing and Services Crime Living Environment
The IMD therefore provides a useful indicator of overall deprivation, providing an insight into the multiple factors at play in an area, particularly relevant when studying health. It is therefore a useful measure of overall deprivation (NB although we understand there may not be an equivalent measure in NL). The median IMD rank was calculated to be 177. Those local authorities close to this average were then highlighted. By calculating the difference between the local authority rank, and the median national rank, it was possible to establish which local authorities were closest to the average, and which were above, or below average. These ranks were then cross referenced against the population short list. Those authorities with an average population size were then compared against each other using IMD ranks, and from this, a new short list was developed. Socio-economic status (NL) The closest Dutch equivalent to IMD used in the UK is the socio-economic status (SES), which is calculated by postal code area. Data, which is available for 2006 from the Social and Cultural Planning Office (CPO) of the Netherlands, was aggregated to local authority level and used to identify local authorities which are deemed average when a range of factors were considered. The IMD provides a composite figure and rank for:
Welfare Education
104
Income Type of buildings Housing price Family stage Number of babies
Unlike the IMD the SES provides no indication for the health status of an area. The average (national) SES rank was calculated to be 1873. Those local authorities close to this average were then highlighted. A couple of local authorities were excluded from the final short list, because no SES data was available. By calculating the difference between the local authority rank, and the average national rank, it was possible to establish which local authorities were closest to the average, and which were above, or below average. These ranks were then cross referenced against the population short list. Those authorities with an average population size were then compared against each other using SES ranks, and from this, a new short list was developed.
9.1.3 Urban Rural Classification (UK)
DEFRA classification of local authority districts was then also used to ensure that the population of the selected local authority was not too dispersed. DEFRA population trends suggest that at the time of the census, 71.5% of England's population lived in an 'urban area' and therefore we decided that if possible, we wanted to ensure that our selected local authority largely reflected this trend. The DEFRA classifications are7:
very rural - 80% or more of their population live in either rural settlements or market towns, where a 'rural settlement' is any settlement of less than 10,000 people and a 'market town' is a settlement of between 10,000 and 30,000 people which provides certain functions and services to its wider rural hinterland mostly rural - if between 50% and 80% of their population live in rural settlements or market towns. part rural - if not any of the above but either between 26% and 50% of their population live in rural settlements or market towns or more than 37,000 of their population live in rural settlements or market towns. 5 major urban - not any of the above but either at least 50% or at least 100,000 of their population live in an urban area with a total population of 750,000 or more.
Defra Classification of Local Authority Districts and Unitary Authorities in England A Technical Guide : http://www.defra.gov.uk/rural/ruralstats/rural-defn/LAClassifications_technicalguide.pdf
large urban - if not any of the above but either at least 50% or at least 50,000 of their population live in an urban area with a total population of 250,000 or more other urban - if not any of the above.
We identified part rural, major urban, or other urban as possible areas, as these classifications would allow for a roughly average distribution of the population, with potentially a quarter living in rural areas. These classifications were cross-referenced against other Local authorities which had been identified through the analysis of the first two indicators.
Urban Rural Classification (NL)
Statistics Netherlands (CBS) uses the following classification for the concentration of human activities, which is based on the average environment density8:
very urban: average environment density of 2,500 or more addresses per km2 ; strong urban: average environment density of 1,500 to 2,500 addresses per km2; moderate urban: average environment density of 1,000 to 1,500 addresses per km2; little urban: average environment density of 500 to 1,000 addresses per km2 ; not urban: average environment density of less than 500 addresses per 2 km .
9.1.4
Ethnicity (UK)
As another contextual measure, ethnicity data was taken from the 2001 census by local authority area, to ensure that the area selected could be said to be representative of the country as a whole. Using 2001 census information, we looked at the rank given to each local authority based upon its proportion of white population. As with the IMD rank, the difference from the 'middle' rank was calculated to give an idea of how far the local authority diverged from the median rank. This data was then cross referenced against the short list of local authorities which helped provide information in addition to population and IMD. A couple of local authorities were excluded from the final short list, because their ethnicity rank differed so far from the median. In NL ethnicity data was taken from the Statistic Netherlands for the year 2007. Ethnicity is defined by the origin of inhabitants which is determined by the country of birth and that of their parents. Statistic Netherlands distinguishes inhabitants of Western and non-
http://www.cbs.nl/nl-NL/menu/methoden/begrippen/default.htm?ConceptID=658
106
Western origin. Data from both categories were added up to calculate the total ethnic population percentage by local authority. As with the SES rank, the difference from the average was calculated to give an idea of how far the local authority diverged from the average. This data was then cross referenced against the short list of local authorities which helped provide information in addition to population size and SES. Health (UK only)
9.1.5
Short listing process
From this point, a short list of potential local authorities was produced. Possible 'average' case study areas in the UK based on series of variables were:
Local / Unitary Authority name Populati on Difference in population from the average for England UrbanRural classificat ion Ethnicity rank (2001 census with 1= highest proportion 9 white) Difference between ethnicity rank and England average (376/2 = 188) 121 IMD rank Difference in IMD from the median for England
Northampto n Reading
190,000
47,000
'other urban' 'large urban' 'other urban' 'other urban' 'other urban' 'major urban' 'part rural'
309/376
135
42
143,096
-96
330/376
142
153
24
Swindon
181,000
38,000
259/376
71
171
Thurrock
143,000
258/376
70
122
55
Telford
158,000
-15,000
270/376
82
112
65
Solihull
199,000
-56,000
273 /376
85
183
-6
Crewe and Nantwich
111,000
32,000
178/376
-10
164
13
http://www.statistics.gov.uk/census2001/profiles/rank/ewwhite.asp
In terms of the composite IMD measure, Solihull and Swindon are the closest to the average for England, followed by Crewe and Nantwich and then Reading.
The closest to average in terms of population size is Thurrock, followed by Reading, Crewe and Nantwich and Swindon. The closest to average in ranking of white populations (2001) were Crewe and Nantwich, Thurrock and Swindon Therefore to provide a shortlist of three: Reading Crewe and Nantwich Thurrock
Bearing in mind that location for fieldwork and accessibility is an issue, we have identified Crewe, Northampton and Telford and the most accessible.
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Local / Unitary Authority name
Populati on (CBS 2007)
Difference in population from the average for the Netherland s
UrbanRural classificat ion (CBS 2007)
Ethnicity percentag e by local authority (CBS 2007)
Difference between ethnicity percentag e in local authority and Dutch average (19.4) -12.6
SES (SCPO 2006)
Difference in SES from the average for the Netherland s (1873)
RijssenHolten Goes
36,584
-342
little urban moderate urban little urban little urban large urban little urban not urban moderate urban strong urban little urban
6.8
1,601
-272
36,600
-325
13.0
-6.4
1,629
-244
Moerdijk
36,645
-280
8.4
11.0
2,235
+362
Veghel
36,732
-193
14.8
-4.6
1,669
-204
Beverwijk
36,835
-90
19.8
0.4%
2,116
+243
Raalte
37,311
385
6.0
-13.3
1,949
+75
Bronckhorst GeldropMierlo Heemskerk
37,788 37,823
863 +897
5.2 14.0
-14.2 -5.3%
1,582 1,877
-291 +4
38,006
1,080
17.4
-2.0
1,414
-459
Dronten
38,182
1,257
14.0
-5.4
2,127
254
Possible 'average' case study areas in NL based on series of variables:

The closest to average in terms of population size is Beverwijk, followed by Veghel and Moerdijk. The closest to Dutch average in terms of SES measure, Geldrop-Mierlo is the closest, followed by Raalte and Veghel. The closest to average ethnicity percentage (2007) is Beverwijk, followed Heemskerk and Veghel.
Therefore to provide a shortlist of three: Beverwijk Veghel Geldrop-Mierlo 9.1.6 Crewe and Nantwich
Crewe and Nantwich was selected to be the case study area. It scored close to the mean and median of each of the indicators which were looked at as part of the selection process. In particular, it scored close to average in terms of population size and IMD as well as the contextual characteristics, particularly being part rural and with close to average health statistics. Beverwijk Beverwijk was selected to be the case study area. It scored close to the mean of each of the indicators which were looked at as part of the selection process. In particular, it scored close to the average in terms of population size, and ethnicity.
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10 Annex 4: Identified typologies for interventions to prevent childhood obesity
Table 2 Identified typologies for interventions to prevent childhood obesity Typology School Community Topic or theme Reduce sedentary activity (watching TV and 1 videos) x x 2 Change to school meal content x 3 Healthy eating x x Change to provision of tuck in school (i.e. more 4 fruit) x 5 Physical activity programme x x 6 Lifestyle activity x x 7 Subsidised leisure services x Approaches 8 Counselling x x 9 Postal communication (i.e. newsletters) x x 10 Workshops x x Behaviour change therapy / behaviour 11 management therapy x x 12 Traffic light system x 13 Use of incentives / rewards x x Changes to / incorporation into curriculum and 14 use of homework x Interactive communication methods for advice 15 and support (e.g. telephone, website etc) x 16 Peer support x x 17 Signposting x x Setting
Healthcare
x x x
The setting refers to the actual location for delivery (not who funded it or delivers the service). School setting = Embedded in a school environment Community setting = A setting that is used by a wide range of people (including children and young people) for a range of community-based activities e.g. community centres,
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children's centres, church halls, leisure centres (private and public), sport associations, and parks and green spaces. Healthcare setting = Provisions provided in a health care centre by a health care professional (e.g. GP, obstetrics, paediatrics, internal medicine, physiotherapy, etc.) Typology Five interventions are defined according to the NICE-guidelines. See footnotes. Other interventions are defined according to other academic and in case not present, nonacademic sources. See footnotes. Seven interventions have been defined on the basis of our research into existing interventions tackling childhood obesity, both in the UK and in the Netherlands. 1. Reduce sedentary activity = A clear and universal definition of a sedentary lifestyle is currently still lacking. Some authors have tried to determine the prevalence of sedentary lifestyles analysing the number of hours that individuals spend sitting down in a typical day (behind a computer or television), or the number of hours expended walking or in other specific physical activities. Other researchershave investigated the energy expended climbing stairs, or how many times a week they participated in an activity that induced sweating144 . For this study, the reduction of sedentary activity is defined as a reduction in sedentary behaviour (e.g. sitting behind the television, computer, using a car for short journeys or otherwise) 2. Change to school meal content = changes to the nutritional content of school meal to improve their nutritional value and support healthier eating behaviours e.g. higher levels of fruits and vegetables, reduced fats and sugars in meals145 ,146. 3. Healthy eating = interventions to promote and increase the levels of healthy eating in line with current government and/or other guidelines e.g. five fruits and vegetables a day. A healthy diet contains plenty of fruit and vegetables; is based on starchy foods such as wholegrain bread, pasta and rice; and is low in fat (especially saturated fat), salt and sugar142 . 4. Change to provision of tuck in school (i.e. more fruit) = interventions that aim to increase levels of healthy eating in line with government and/or guidelines with a particular reference to snacks at school e.g. fruit and fruit juices sold in the tuck shop and healthy snacks 147 only available from the vending machine 148. 5. Physical activity programme = the full range of human movement, from competitive sport and exercise to active hobbies, walking, cycling or activities of daily living (excluding physical activity as part of the regular school curriculum, e.g. PE). Physical activity varies by: volume or quantity (total quantity of physical activity over a specified period, usually expressed as kcal or METs149 per day or week). Frequency of participation, typically expressed as number of sessions per day or week. Intensity, usually expressed as light, moderate or vigorous. Commonly used approximations are: light intensity = less than 4 METs, for example, strolling; moderate = 4 6 METs, for
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example, brisk walking, vigorous = 7+ METs for example, running. Duration time spend on a single bout of activity142 . 6. Lifestyle Activity = Activities that are performed as part of everyday life, such as climbing stairs, walking (for example, to work, school or shops) and cycling. They are normally contrasted with programmed activities such as attending a dance class or fitness training session 142. 7. Subsidised leisure services = the funding of leisure services. This could range from local funding for the establishment of a leisure centre to the supply of a subsidy to a family to become a member of a sport association 150. 8. Counselling = Different definitions of the term counselling exist. It generally means: the offering of individual advice or guidance, especially as solicited from a knowledgeable person (e.g. individual conversations - including advice - with children regarding their activities, life-style etc.)151 ,152. 9. Postal communication = individual information provision to children and/or parents in the shape of a newsletter, flyer, brochure or otherwise. The provision is one-way from the information provider to the receiver 153. 10. Workshops = Different definitions of the term workshop exist. It generally means: an educational seminar or series of meetings emphasizing interaction and exchange of information among a usually small number of participants (e.g. parent information meetings in the evening) 154,155. 11. Behaviour change therapy / behaviour management therapy = Behavioural treatment (or behaviour therapy) draws on the principles of learning theory (stimulusbehaviour contingencies or behaviourreward contingencies). Consists of assessment (identifying and specifying problem behaviours and the circumstances in which they are elicited), treatment (including setting specific, measurable and modest goals that are continually revised) and monitoring. Behaviour change processes include stimulus control, graded exposure, extinction and reward 142. 12. Traffic light system = this is a calorie-based food-exchange system created by Epstein and co-workers. Foods are divided into five groups (fruits and vegetables, grains, proteins, dairy and other foods), and the foods in each group are colour coded according to nutrient density: green for go, yellow for eat with care, and red for stop. Green foods are foods containing less than 20 calories per serving, yellow foods are the staple of the diet and provide most of the basic nutrition and red foods are those foods high in fat and simple carbohydrates. All sweets and sugared beverages are classified as red foods. Families are then instructed to count calories and cannot have more than four red foods a week142 . 13. Use of incentives / rewards = system of rewards to promote behaviour change e.g. vouchers for participating in physical activity interventions 156
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14. Changes to / incorporation into curriculum and use of homework = includes interventions that lead to changes of the school curriculum and/or homework (e.g. a project week around a certain theme, a healthy eating component in biology class or the adjustment of PE in school)157 . 15. Interactive communication methods for advice and support = individual information provision to children and/or parents in the shape of a telephone conversation or website. The provision is not necessarily one-way from the information provider to the receiver158. 16. Peer support = peer support is a system of giving and receiving help founded on key principles of respect, shared responsibility and mutual agreement on what is useful 159. It is derived from social cognitive theory. It is not based on psychiatric models and diagnostic criteria. 17. Signposting = support in the shape of signposting (e.g. indicating, signing, guiding) to appropriate services (e.g. could be a certain activity, programme, health service, or otherwise) 160.
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11 Annex 5: Topic Guide for Interviews Childhood Obesity
Introduction Introduce researcher and thank interviewee for agreeing to take part. Provide brief overview of background to study, if necessary (NB already covered in introductory letters sent out in w/c 25 Aug): ECOTEC is a research and consulting company working mainly in social and economic policy research for public sector clients. ECOTEC is part of an international company called ECORYS who are working with us on this research project. This project is being carried out as part of the ECORYS research programme.. The research focuses on the effectiveness of interventions aimed at preventing childhood obesity in a selected area in the UK and Netherlands. Crewe and Nantwich was selected as our study area in the UK, and our colleagues in the Netherlands have also chosen an equivalent area to study. The project will look at a number of specific interventions within each chosen area to establish their success, and to try to establish what works and what does not in order to inform public policy debate. The purpose of talking to you today is to get more information about the interventions underway in Crewe and Nantwich and to find out how successful they have been at preventing obesity in children. Our partners in the Netherlands will do the same. Our results will then be combined and a final paper will be written for academic publication. The interview should last around 60 minutes, and with your agreement, we would like to record the interview. Before the interview, you should have already established:
The nature of the policy context (but also explore this further in interviews) The nature of the intervention(s): whether the intervention(s) aim(s) to reduce sedentary activity (about physical activity interventions) or aim(s) to improve health (diet etc) How the intervention fits our typology.
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Throughout the interview try to establish whether these typologies provide a good representation of reality. Please refer to the intervention framework to familiarise yourself with the structure of the analysis / information required to fill this in. The topic guide is designed around this framework, but is also intended to gather a wider range of information. This discussion will cover a number of key areas, including background information about [the policy context / intervention], the delivery and implementation, the impacts or outcomes and any lessons learnt. The first few sections are background, but we would really like to concentrate on finding out more about the outcomes and impacts of the intervention(s). SECTION 1 POLICY BACKGROUND IN YOUR AREA AND GENERAL BACKGROUND INFORMATION ON THE INTERVENTIONS In this first section, we would like to collect some background information about the intervention(s). (Only ask the below questions 1-18 if additional background is required to that collected prior to interviews. i.e. you may not need to ask all questions depending on the quality of data collected prior to interviews). 1 What is the policy context for the prevention of childhood obesity in Crewe and Nantwich? Establish the key policies and policy drivers. NB Only ask if data not already available or not clear. Who are the main organisations active in the policy area, and how are they working together? Probe on how they collaborate, their roles, funding streams and ask for examples of collaboration covering health, nutrition, diet, sports, cycle paths, exercise, schools etc. NB Only ask if data not already available or not clear. What specific programmes, projects and interventions are/were you involved in or are you aware of? Prompt with list of things identified in desk review and list of things that ought to be happening but not sure if they are taking place. Ask them to list the interventions, then if list is very long focus on the 3-5 most important. If necessary prompt through exploring the basis on which funding was received. In what capacity were/are you involved in the interventions?
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Why were these interventions established? Explore the need which is being addressed by the intervention / rationale. How do these interventions link to local/ national policy on childhood obesity?
Explore national, regional, local level policies Does it work alongside, or does it fill a gap? 7 What are the timings of the intervention how long has it been running, and what is the future timetable? Ask about each intervention identified. Who are the target groups of the intervention? Ask about each intervention identified. Probe with:
Behaviour does the intervention target any specific attitudes or behaviours Environment where are the target group living / attending school etc Populations explore age range, sex, ethnicity, deprivation, levels of overweight or obese Clarify the level of targeting size of group, and how selected (i.e. is it all children, or all overweight/obese children / all overweight etc) 9 Please could you explain what level the intervention is operating at e.g. at community level, school, county, regional / local level N.B. this to establish 'environment size' whether at Micro or Macro level e.g. an area, a community, a neighbourhood, the whole local authority, the whole county / region
10 And where and when is the intervention delivered? (ask about each intervention identified) E.g. in a school (probe where, classroom, hall), in a community centre, in a GP surgery. Explore time of year, time of day and why were these timings chosen. 11 How was/is the intervention(s) publicised or marketed to target groups?
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12 How many beneficiaries (i.e. children/young people/parents/families) attend/take part? Explore regularity of attendance, how many attend on a regular basis etc 13 Could you explain how [the intervention] is funded and how the funding works?
Establish who the intervention is funded by How much funding is received in total Over what period has the funding been received / is the intervention running If a consortium funds the intervention try to establish how much is contributed by who, either get a % or figures 14 Are there any financial constraints upon delivery? Explore issues around funding how well funded the intervention is, and how costs compare with predicted costs, do attendees need to pay out-of-pocket expenses to attend?
15 Please could you explain a bit more about the management structure of [the intervention], who is responsible for :
The management of the intervention The delivery of services The monitoring (if done) explore this to establish who is monitoring, how data is collected and who it is provided to The evaluation (if any)
16 If partners are being worked with, who are they and what are their roles? How well is this going? Explore how responsibility is shared for delivery, monitoring, evaluating. 17 How does the intervention fit with other mainstream services? Explore links - Is this intervention filling in for deficiencies/gaps in mainstream services?
Are there any staff links, for example cross working, staff working for multiple initiatives, agencies? Targets aims / objectives is the intervention working towards the same targets?
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Measuring / monitoring links does the intervention share information, measurement, monitoring with other services? Evaluation links is the intervention part of a bigger evaluation (e.g. part of a national programme, process evaluation?) 18 Are any innovative techniques or delivery methods used?
SECTION 2 IMPACT AND OUTCOMES We would like to know how effective the intervention(s) have been at preventing or controlling childhood obesity. For each question ask, if necessary about each of the interventions identified. 19 What are target outcomes, or outcome measures used?
Probe for concrete outcomes - for e.g. a 10% reduction in obese girls from different BMI groups (25-30, 30-35, >35). Alternatively, probe for information on the type and nature of data being collected to inform progress Explore any planned, or expected outcomes and any unexpected outcomes
20 Has the intervention been evaluated? a. If yes

When was it undertaken? Dates and when in the course of the intervention? Is it something that will occur frequently? Why was it undertaken? What method was used to measure, process, impact or outcomes? What were the key findings? (How) has the evaluation been used? Has any follow up work taken place? Are the results published? If yes, collect copy
b. If no
Is an evaluation planned? Why/why not? Formal or informal? What will be measured / monitored?
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Are you measuring anything to report back to funders/partners?
SECTION 3 OUTCOMES, BARRIERS AND FACILITATORS (If multiple interventions, ask for specific details for each) 21 Overall, in your judgement, how successful has the intervention been to date at achieving its intended outcomes? If possible refer to any background material, or to earlier in the interview to probe using specifics. 22 In your view, what has worked well in terms of implementation, and why? What have been the facilitators? 23 What, if any difficulties/barriers have there been in implementing the intervention(s)?

Explore support from colleagues/funders and partner organisations? Support from health / other experts any linkages with other services? Probe Barriers posed by parents/children? Probe social, cultural, economic barriers within organisations and with target groups? Any others?
24 How successfully have you been able to engage with the intervention's target group? If very, how has this been achieved, and if not why?
Prompt if necessary around interest in the intervention, attendance, drop out rate, barriers to certain groups getting involved, access, parental attitudes, children's attitudes, timing, transport etc
25 How much interest / support have you received from complementary or mainstream services, or voluntary sector? 26 What, if any feedback have you received from beneficiaries / attendees about the intervention? Probe: What have they found most/least beneficial?
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27 Have you, or your colleagues, noticed any changes in the individuals attending the intervention? * Find out what research based or statistical findings or evidence exists *
Have there been changes in behaviour explore, physical activity, food, diet / nutrition Clinical changes weight gain or loss? Noticeable / measured health improvements? Quality of life SECTION 4 GOOD PRACTICE AND FINAL CONCLUSIONS 28 Are there any examples of 'good practice' within the intervention(s)? Explore both in terms of design, delivery and monitoring / evaluating. NB Good practice is when something is working well and can be used elsewhere. 29 Similarly, can you think of any examples of promising, effective or best practice in the case study area? Promising practice When practice is in the early stages of development and has yet to be evaluated Effective practice When something is working well but can only be achieved under similar conditions Best practice When something is working at the highest standard and is working 'better' than good practice. 30 Finally, what would you say are the key factors which impact on the success of an intervention to prevent obesity and overweight in children? SECTION 5 CLOSING REMARKS 31 One of the ways in which we are analysing the interventions in this research is through allocating 'typologies'. We used these typologies to inform judgements on the spread of work taking place and in choosing and selecting case studies. Can we check with you, to see if you agree with the typology that we have given to [insert intervention name] Take list of possible options to interviewee to check against.
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32 Can you think of anything else we should look at, or anyone else who you think that we should speak to, any final comments? Record details. Thank and close.
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12 Annex 6: References
Hall, N and Oortwijn, W: Preventative public policy and childhood obesity. Initial exploratory paper Department of Health: Definitions of overweight and obesity, 2007
submitted to ECORYS Research Programme, ECORYS Research and Consulting, 2007.

2
http://www.dh.gov.uk/en/Publichealth/Healthimprovement/Obesity/DH_4133948 3 Branca F, Nikogosian H, Lobstein T (eds):The Challenge of obesity in the WHO European Region and the strategies for response. Copenhagen: WHO Regional Office for Europe, 2007. http://www.euro.who.int/document/E90711.pdf
4 5 6
The International Obesity Task Force (IOTF) http://www.iotf.org This may be based on an underestimate of prevalence as it is self-reported data IOTF: Childhood overweight in the European Union (EU27) and Switzerland. 2008 Department of Health: Obesity general information, 2008.
http://www.iotf.org/database/documents/ECO08ChildEU27Final.pdf
7
http://www.dh.gov.uk/en/Publichealth/Healthimprovement/Obesity/DH_078098
8
McPherson K, Marsh T, Brown M: Foresight- Tackling Obesities: future choices modelling future trends in obesity and their impact on health (2 nd edition). Government Office for Science, 2007.
9
McPherson K, Marsh T, Brown M: Foresight - Tackling Obesities: Future Choices Modelling future ONS The Information Centre: Statistics on obesity, physical activity and diet: England, January 2008.
trends in obesity and their impact on health. Government Office for Science, 2007.
10
http://www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles-related-surveys/health-survey-forengland
11
Department of Health: Obesity general information, 2008.
http://www.dh.gov.uk/en/Publichealth/Healthimprovement/Obesity/DH_078098
12
World Health Organisation: Health promotion: A discussion document on the concepts and principles. WHO Regional Office for Europe, Copenhagen, 1984. 13 Kilpatrick D.G: Definition of public policy and the law. National Violence Against Women Prevention Research Centre, 2000. www.musc.edu/vawprevention/policy/definition.shtml
14
Kimm SYS, Glynn NW, Kriska A.M: Decline in physical activity in black girls and white girls during
adolescence. New England Journal of Medicine, 2002, 347 (10): 709-715. 15 Stubbe J H, Boomsma D I, De Geus E J C: Sport participation during adolescence: a shift from environmental to genetic factors. Medicine & Science in Sports & Exercise, 2005: 563-570.
16
Oortwijn, Lankhuizen, Tsang, Cave, 2007.
17
European Environment and Health Information System: Percentage of Physically Active Children and Adolescents. Fact Sheet No. 24. 2007. http://www.euro.who.int/Document/EHI/ENHIS_Factsheet_2_4.pdf
18 19
Dr Foster Research: Weighing up the burden of obesity, 2008 Department of Health, Department of Education and Schools, and Department if Culture Media and Sport: Egger G: An Ecological Approach to the Obesity Pandemic: BMJ 1997; 315:447-480
Choosing Health, Obesity Bulletin. Issue1,Undated.

20
123
21 22
EPODE: EPODE: A standard for the prevention of childhood obesity and associated issues, 2006. Commission of the European Communities: Commission Staff Working Document. Impact Assessment
Report accompanying the White Paper from the Commission to the Council, the European Parliament, the European Economic and Social Committee and the Committee of the Regions. A strategy for Europe on nutrition, overweight, and obesity related health issues. Brussels, European Commission, 2007.
23
Woodman J, Lorenc T, Harden A, Oakley A: Social and environmental interventions to reduce childhood
obesity: a systematic map of reviews. EPPI-Centre report 1610. London: EPPI-Centre, 2008. 24 EU Platform on Diet, Physical Activity and Health: Diet, Physical Activity and Health A European Platform for Action, March 15 2005. http://ec.europa.eu/health/ph_determinants/life_style/nutrition/platform/docs/platform_charter.pdf
25
WHO: The Challenge of obesity in the WHO European Region and the strategies for response. http://www.euro.who.int/document/E90711.pdf
26
WHO Europe: The WHO ministerial conference on counteracting obesity, 2006. http://www.euro.who.int/obesity/conference2006
27
Branca F, Nikogosian H, Lobstein T (eds):The Challenge of obes ity in the WHO European Region and the
strategies for response. Copenhagen: WHO Regional Office for Europe, 2007. http://www.euro.who.int/document/E90711.pdf
28
WHO Europe: High level group on nutrition and physical activity, 2007
http://ec.europa.eu/health/ph_determinants/life_style/nutrition/nutrition_hlg_en.htm 29 Oortwijn WJ, Lankhuizen M, Tsang F, Cave J: An analysis of the economic, social and environmental impact of the rising prevalence of overweight and obesity in the European Union. Final report. TR-466-EC. Santa Monica: RAND, 2007. 30 Oortwijn WJ, Lankhuizen M, Tsang F, Cave J: An analysis of the economic, social and environmental impact of the rising prevalence of overweight and obesity in the European Union. Final report. TR-466-EC. Santa Monica: RAND, 2007. 31 Woodman J, Lorenc T, Harden A, Oakley A :Social and environmental interventions to reduce childhood obesity: a systematic map of reviews. EPPI-Centre report 1610. London: EPPI-Centre, 2008.
32
Swinburn B, Egger G, Raza F: Dissecting obesogenic environments: the development and application of a framework for identifying and prioritizing environmental interventions for obesity. Preventive Medicine, 1999; 29: 563-570.
33
Woodman J, Lorenc T, Harden A, Oakley A: Social and environmental interventions to reduce childhood obesity: a systematic map of reviews. EPPI-Centre report 1610. London: EPPI-Centre, 2008.
34
Commission of the European Communities: Commission Staff Working Document. Impact Assessment
Report accompanying the White Paper from the Commission to the Council, the European Parliament, the European Economic and Social Committee and the Committee of the Regions. A strategy for Europe on nutrition, overweight, and obesity related health issues. Brussels, European Commission, 2007.
35
Woodman J, Lorenc T, Harden A, Oakley A: Social and environmental interventions to reduce childhood obesity: a systematic map of reviews. EPPI-Centre report 1610. London: EPPI-Centre, 2008.
36
Woodman J, Lorenc T, Harden A, Oakley A: Social and environmental interventions to reduce childhood
obesity: a systematic map of reviews. EPPI-Centre report 1610. London: EPPI-Centre, 2008. 37 Voedingscentrum Nederland, Handleiding Preventie van overgewicht in lokaal gezondheisbeleid
38
National Institute for Clinical Excellence: Obesity: Full guideline, section 1 - Introduction, methods and
recommendations, 2006. 39 Foresight: Trends and Drivers of Obesity: A Literature Review for the Foresight project on obesity, 2007. www.foresight.gov.uk
40
Millstone et al 2006
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41
National Institute for Clinical Excellence: Obesity: Full guideline, section 1 - Introduction, methods and recommendations, 2006.
42 43
Swinburn B, Egger G, Raza F: Preventive Medicine 1999; 29 (6Pt1): 563-70.
International Obesity Task Force: PHAPO working group causal web, 2008. http://www.iotf.org/groups/phapo/causalweb.htm
44
King L, Turnour C, Wise M: Analysing NSW state policy for child obesity prevention: strategic
policy versus practical action . Australia and New Zealand Health Policy 2007, 4:22; 10.1186/1743-8462-422.
45
A method for cataloguing and storing data was devised to ensure a methodical approach to the storing of
relevant data and to assist in analysis Documents were uniquely coded and details about them stored in a common reference directory. Further details on this system are available in the annex.
46
NHS Centre for Reviews and Dissemination: Centre for reviews and dissemination (York University)
CRD databases, 2008. http://www.crd.york.ac.uk/crdweb/ 47 British Medical Journal: British Medical Journal on-line, 2008. http://www.bmj.com/
48
Healthy Schools: The Healthy Schools web-site, 2008. www.healthyschools.gov.uk
49 50
British Medical Journal: BMJ online, 2008. http://www.bmj.com Gezond School: The Gezond Schools web-site, 2008. http://www.gezondeschool.nl 51 NTVG: Nederlands Tijdschrift voor Geneeskunde web-site, 2008. www.ntvg.nl 52 RIVM: RIVM web-site, 2008. www.rivm.nl 53 Gemeente Beverwijk: Gemeente Beverwijk web-site, 2008. www.beverwijk.nl 54 In order to ensure the viability of the case study area as a unit for analysis.
55 56
National Statistics: 2001, Census Results, 2008. http://www.statistics.gov.uk/census2001/census2001.asp Department for Communities and Local Government: Indices of Deprivation, 2007.
http://www.communities.gov.uk/documents/communities/xls/576504.xls
57
DEFRA: Defra Classification of Local Authority District and Unitary Authorities in England A Technical Guide, 2008. http://www.defra.gov.uk/rural/ruralstats/rural-defn/LAClassifications_technicalguide.pdf
58
Statistics Netherlands: 2007, Census Results, 2008.
http://www.cbs.nl/en-GB/menu/themas/bevolking/nieuws/default.htm?Languageswitch=on 59 Statistics Netherlands: 2006, Rural/Urban classification data, 2008. http://www.cbs.nl/nl-NL/menu/methoden/begrippen/default.htm?ConceptID=658

60
NICE and the National Collaborating Centre for Primary Care: Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children, 2006.
61
Office for National Statistics: Results from the 2001 Census, 2008.
http://www.neighbourhood.statistics.gov.uk 62 DEFRA: Defra Classification of Local Authority District and Unitary Authorities in England A Technical Guide, 2008. http://www.defra.gov.uk/rural/ruralstats/rural-defn/LAClassifications_technicalguide.pdf
63
Department of Health and NHS: Crewe and Nantwich Health Profile 2007, 2008. www.communityhealthprofiles.info
64
Association of Public Health Observatories (APHO), DH and NHS: Health Profile 2008 Crewe and
Nantwich, 2008. http://www.apho.org.uk/resource/view.aspx?RID=50215&SEARCH=C*

65
National Centre for Social Research: National Healthy Schools Programme Evaluation: a summary, 2007. http://www.healthyschools.gov.uk/Uploads/Resources/cb74f78a-0fd3-4935-a73b0c041d81c615/NHSP%20Evaluation%20Summary.pd f 66 The policy links and context were identified by interviewees and contacts but also from documentation and web-based information on sources in relation to the interventions included in the case study.
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67
Yorkshire and the Humber Public Health Observatory: social marketing a definition, 2008. http://www.yhpho.org.uk/social_marketing.aspx 68 Department of Health: Letter from the Chief Medical Officer and the Chief Nursing Officer introducing Change4Life, 2008. www.dh.gov.uk/en/publicationsandstatistics 69 Department of Health: Department of Health news item, November, 2008. www.dh.gov.uk/en/news 70 The Improvement and Development Agency: The healthy Communities Programme, 2008.
http://www.idea.gov.uk/idk/core/page.do?pageId=4820461
71 72
DH, DfES and DCMS: Choosing Health: Obesity Bulletin 2006, Issue 1. NICE: Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children, 2006. 73 National Institute for Health and Clinical Excellence (NICE): Obesity: guidance on prevention, identification, assessment and management of overweight and obesity in adults and children. NICE Clinical Guideline 43, 2006. 74 Voedingscentrum Nederland: The Netherlands in balance, Preventing Obesity Masterplan 2005 2010. Den Haag, Voedingscentrum Nederland, 2005. 75 Ministerie van Volksgezondheid, Welzijn en Sport (VWS): Preventienota kiezen voor gezond leven. Den Haag, 2006. http://www.minvws.nl/kamerstukken/pg/2006/preventienota -kiezen-voorgezond-leven.asp 76 Every four years the Dutch government needs to set up national priorities with regard to collective prevention as required by the law collective preventive public health (Wcpv, collectieve pre RIVM: Wat doet het Centrum Gezond Leven? 77 RIVM: Wat doet het Centrum Gezond Leven? RIVM, 2008. http://www.rivm.nl/gezondleven/centrum-gezond-leven/ 78 RIVM: De Gezonde Schoolmethode. RIVM, 2008. http://www.rivm.nl/gezondleven/werkwijze/werkplaats-gezonde school/gezondeschoolmethode/ 79 IGZ: Organisatie, Missie. IGZ. http://www.igz.nl/organisatie/missie 80 Beter voorkomen, Kwaliteitsprogramma preventie: Maatschappelijke verantwoording in een breder perspectief. http://www.betervoorkomen.nl/index.php/archive/26/ 81 In cooperation with the sport association NOC*NSF, the Dutch Institute for Sport and Physical Activity (NISB), the association of Dutch municipalities (VNG) and the Association of Sport and Municipalities (VSG). 82 NASB: Impuls NASB. NASB. http://www.nasb.nl/cat/1337/Impuls_NASB 83 Convenant Overgewicht: Energie in balans 2007. Harder lopen. Den Haag, Koninklijke De Swart, 2007 84 Identified neighborhoods by the Dutch government which will receive extra attention to overcome the social, physical and economic problems in the neighborhoods to ensure they become a better place to live in the near future. 85 Halberstadt J, Seidell J, HiraSing R, Renders C, van Bolhuis A: Partnerschap Overgewicht Nederland: ketenzorg voor overgewicht en obesitas. Uitgangspunten en positionering ten opzichte van andere ontwikkelingen in de publieke en curatieve zorg. Amsterdam, VU Medisch Centrum, 2008.
86
Bulk-Bunschoten AMW, Renders CM, van Leerdam FJM, HiraSing RA: Signaleringsprotocol
Overgewicht in de Jeugdgezondheidszorg. Amsterdam, VU Medisch Centrum, 2004.
126
87
The BOFT principle takes up a central position: stimulation of breast feeding, stimulation of breakfast, stimulation of playing outside, reduction of soft drink intake and reduction of watching television and sitting behind the computer. 88 Bulk-Bunschoten AMW, Renders C, van Leerdam FJM, HiraSing RA: Overbruggingsplan voor kinderen met overgewicht. Methode voor individuele primaire en secundaire preventie in de jeugdgezondheidszorg. Amterdam, VU Medisch Centrum, 2005. 89 This prevention note was preceded by the prevention nota Living longer healthy (Langer gezond leven) in which overweight was already identified to be an important issue. 90 NIGZ: Overgewicht. NIGZ. http://www.nigz.nl/index.cfm?act=dossiers.inzien&vardossier=53
91
92
Bakker PP: Leren van de BOS-koplopers. Utrecht, Landelijk Ondersteuningsnetwerk BOS-impuls, 2007.
In the Netherlands, GGD offices (gemeentelijke gezondheidsdienst) carry out public health care in assignment of municipalities. GGD offices are often organised on a regional level. There are 36 regional GGDs in the Netherlands. 93 GGD Nederland: TNO-onderzoek: Jeugd steeds sneller dikker. GGDen pakken overgewicht jeugd aan. GGD Nederland. http://www.ggd.nl/ggdnl/uploaddb/downl_object.asp?atoom=34989&VolgNr=333 94 Voedingscentrum Nederland: Handleiding preventie van overgewicht in de nota lokaal gezondheidsbeleid. Voedingscentrum Nederland, 2008. http://www.voedingscentrum.nl/NR/rdonlyres/09FF459C-2E2C-4A94-8840A3A9AF873F9C/0/Handleidingpreventievanovergewichtinlokaalgezondheidsbeleidupdatemaart20 08.pdf 95 Voedingscentrum Nederland: De LEEFLIJN. Ingredinten voor de aanpak van overgewicht. Voedingscentrum Nederland, 2008. http://www.voedingscentrum.nl/NR/rdonlyres/870F6BE09538-4FF4-93E4-61B9F86F0C2B/0/LEEFLIJN.pdf 96 The last two organisations have recently merged and we will refer to Zorgbalans in the rest of this document. 97 This region consists of 10 municipalities of which the city Haarlem is the largest: Bennebroek, Beverwijk, Bloemendaal, Haarlem, Haarlemmerlied & Spaamwoude, Heemskerk, Heemstede, Uitgeest, Velsen and Zandvoort 98 CBS Statline: Population statistics per region and municipality. CBS. http://statline.cbs.nl/statweb/ 99 In the Netherlands, socio-economic status (SES) is measured on the basis of level of education, income and level of occupation. A high outcome indicates a high level of education, income or level of occupation. 100 Nijbroek W, Cluitmans R: Overgewicht onder de jeugd in Kennemerland. Haarlem, GGD Kennemerland, 2005 101 11.502 children in group 2 and group 7 of primary education and class 2 of lower secondary education. Special education is excluded from this research.
102
103 104
Convenant overgewicht. Een balans tussen eten en bewegen. Den Haag, 2005.
4-15 years old, no exact date provided. Elektronische Monitor en Voorlichting Electronic Monitor and Counselling
Robroek S, Cluitmans R: Gezondheid, welzijn en leefstijl van scholieren in Beverwijk. Resultaten van het
105
Emovo-onderzoek. Haarlem, GGD Kennemerland, 2007.

106
Participants of the EMOVO project were 6.260 young people in class 2 and 4 of secondary education. 107 Ethnicity is determined on the basis of the birth country of the caring parent.
127
108
It is important to note here that this is partially logical due to the exclusion criteria of our study (the research excluded statutory services that address childhood obesity and that are not timelimited, population-based interventions aimed at prevention, e.g. one-to-one consultations between general practitioners, nurses or dieticians with individuals). For example, regular checks of children by school GPs organised by the Public Health Services (GGD Kennemerland) in Beverwijk and the region of middle and south Kennemerland are as a result excluded. 109 Several other interventions implicitly include a behavioural change therapy element through their activities. 110 Motivation conversations are organised according to the method of motivational interviewing. This is a special technique which requires special training. The counsellor does not try to convince the student, but instead tries to empathize and show the difference between current behaviour and goals and values of the student and support the student to believe they can change their behaviour themselves. 111 Sportservice Noord-Holland: Alle Leerlingen Actief. Sportservice Noord-Holland en VMBOscholen starten met nieuw beweegproject Alle Leerlingen Actief!. Sportservice Noord -Holland, 2007. http://www.sportservicenoordholland.nl/so_jeugd_alleleerlingen.htm 112 Most funders set the requirement to include an evaluation component. 113 The last two organisations have recently merged and we will refer to Zorgbalans in the rest of this document.
114
Projectgroep Overgewicht: Signalering, aanpak en preventie van overgewicht bij kinderen van 0-19 jaar
in de regio Midden- en Zuid Kennemerland. GGD Kennemerland, 2005.

115 116
Also referred to as social domain subsidies (sociaal domein subsidies) The municipality of Beverwijk did for example not tender to gain BOS-impuls subsidy which could have been used to undertake an intervention in relation to physical activity in the municipality.
117
Schraven M, Venemans A, Poort E: Evaluatierapport Beter (Zw)eten. Over gezonde voeding en
beweging. Haarlem, GGD Kennemerland, 2007.

118
It is important to note that some after-school interventions are also open for school children from other schools. 119 Which fits in the previously explained brede school concept.
120
Sporthackers: Sporthackers. Sports service Noord-Holland.
http://www.sporthackers.nl/news_svmbo.htm 121 September 2008

122
Sportservice Noord-Holland: Eindrapportageformulier projecten sociaal beleid, sporthackers. Sportservice
Noord-Holland.
123
ZonMw is a Dutch organisation which aims to improve prevention, care and health by stimulating and funding research, development and implementation. Its main funders are the Ministry of Health and the Dutch organisation for academic research (NWO, Nederlandse Organisatie voor Wetenschappelijk Onderzoek). 124 ZonMw:Missie.ZonMw, 2008. http://www.zonmw.nl/nl/organisatie/over-zonmw/missies/ 125 Some interventions have only recently been implemented and therefore lack evaluation material. 126 Interview Sportservice Noord-Holland, October 2008 127 The fee of the Kidsclub intervention ( annually) for example has proven to be far too high 128 to attract sufficient participants. 128 Interview municipality of Heemskerk, October 2008
128
129
Funded by the Ministry of Education and Health and co-funding organized by the participating municipalities (after 1 year). 130 Unclear whether this is all municipal funding
131
APHO: Health Profile 2008. Crewe and Nantwich. APHO, 2008.
http://www.apho.org.uk/resource/item.aspx?RID=52240 132 For example, a part of the salary costs of a staff member of the Sportservice Noord-Holland (one of the most important partners in implementing interventions in the region of middle and south Kennemerland) is paid out of national funding directly related to the national programme National Action Plan for Sport and Physical Movement(Nationaal Actieplan Sport en Bewegen). 133 Also referred to as social domain subsidies (sociaal domein subsidies) 134 Provincie Noord-Holland: Subsidieverordering 100. Provinciaal blad, 2006. http://www.noordholland.nl/zoeken/get_url.asp?page=/provstukken/OPENBAAR/AVV/AVV-PB2006-100.pdf
135
National Institute for Health and Clinical Excellence: Obesity: guidance on prevention, identification, assessment and management of overweight and obesity in adults and children. NICE, Clinical Guideline 43, 2006. http://www.nice.org.uk/nicemedia/pdf/CG43FullGuideline1.doc
136
Kliphuis L: Preventie in de eerste lijn moet de herkenbaarheid van een meubelboulevard krijgen. Pre Post 2008; 10: 33: 10-11.
137
Term referring to the environment's role in promoting obesity, the 'obesogenic' environment promotes high energy intake and low energy expenditure. As such obesity is a natural response to the environment - the human body has good physiological defences against the depletion of its energy stores but poor defences against the accumulation of excess energy stores when food is abundant. 138 Tijdelijke stimulerings regeling 139 The municipalities can in turn apply for other national subsidies like BOS impuls subsidy and breedtesport impuls subsidy to gain funding for this intervention 140 Fit4family: Over fit4family. Fit4family, 2008. http://www.fit4family.nl/index.php?option=com_content&task=view&id=30&Itemid=46 141 BOS impuls subsidy and social domain subsidies 142 BOS impuls subsidy and social domain subsidies
143
Projectgroep Overgewicht: Sociale kaart Overgewicht voor de regio Midden- en Zuid-Kennemerland.
Projectgroep Overgewicht, 2007.

144
Varo J, Martinez-Gonzalez M, de Irala-Estevez J, Kearney J, Gibney M, Martinez J: Distribution and determinants of sedentary lifestyles in the European Union. International Journal of Epidemiology 2003; 32: 138-147. http://ije.oxfordjournals.org/cgi/content/full/32/1/138 145 the Caroline Walker Trust (CWT) Guidelines for School Meals guidelines provide figures for the recommended nutrient content of an average school meal provided for children over a oneweek period. The values are based on the recommendations contained in the COMA report Dietary Reference Values for Food Energy and Nutrients for the United Kingdom.
146
Nelson M, Bradbury J, Poulter J, Mcgee A, Msebele S, Jarvis, L: School meals in secondary schools in
England. Research report nr557. London, Kings College London National Centre for Social Research, 2004.
http://www.food.gov.uk/multimedia/pdfs/secondaryschoolmeals.pdf 147 No specific definition. Foods consumed between meals or instead of a main meal. 148 Defined by ourselves. 149 1 MET = a persons metabolic rate (rate of energy expenditure) when at rest. MET values are assigned to activities to denote their intensity and are given in multiples of resting metabolic rate. For example, walking elicits an intensity of 36 METs, depending on how brisk the walk is, and more strenuous activity such as running would have an intensity of 710 METs.
129
150 151
Defined by ourselves The Free Dictionary by Farlex: definition counseling. The Free Dictionary by Farlex, 2008. http://www.thefreedictionary.com/counselling 152 No academic definition available. 153 Defined by ourselves 154 Answers.com: definition workshop. Answers.com, 2008. http://www.answers.com/topic/workshop 155 No academic definition available. 156 Defined by ourselves 157 Defined by ourselves 158 Defined by ourselves
159
Mead S, Hilton D, Curtis L: Peer support: a theoretical perspective. Psychiatric Rehabilitation Journal,
2001;25:134-141
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Defined by ourselves
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Child Obesity

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Preventative Public Policy and Childhood Obesity Case Studies in England and the Netherlands

ECORYS Research Programme

Date of submission: 19th December 2008.

111 115 123

Data for 2006 and 2003 respectively.

Below is a glossary of terms used in the report.

1.1 Aims and Objectives

1.2 Content of this report

2 Background and Rationale for the Study

Overweight and obesity

2.2 The Size of the Problem

Figure 2.1 Mean Body Mass Index in EU-27 adults, 2005

Source: WHO, Global InfoBase

The Size of the Problem: England

The Size of the Problem: The Netherlands

2.3 Preventive public policy

2.4 The relationship between health behaviours and obesity

Figure 2.1 The causal web of influences on population weight gain

2.5 Health consequences

2.6 The role of the environment in obesity

2.7 The European Policy Context

Approaches and the theoretical basis

2.10 The Evidence base

3.1 Parameters of the Study

Identification of interventions within the case study areas

4 The English case study: Crewe and Nantwich

4.1 Overview of Crewe and Nantwich

4.2 Preventing Childhood Obesity in Crewe and Nantwich: the Interventions

Number Intervention Name 1 The Friday Boy Club

Chill and Chat Youth Club

The Cheshire Healthy Schools Programme

Play Outreach Programme

Source: ECOTEC Research and Consulting, 2008

Partner Parents/carers School meals provider

Source: ECOTEC Research & Consulting, 2008

Case Study 2: The Cheshire Healthy Schools Programme

Case Study 3: Healthy Start A National Initiative to Reduce Health Inequalities

Overview of the Crewe and Nantwich Approach

5 The Dutch case study: Beverwijk in middle and south Kennemerland

5.2 Overview of Beverwijk in middle and south Kennemerland

Prevalence figures of childhood overweight and obesity in Beverwijk

Beverwijk 23% 5% 25% 34%

Region Kennemerland 19% 3% 35% 23%

Food advice for ethnic women

All pupils active (Alle leerlingen actief)

Special support* (speciale bijstand)

School sport programme* (school sport programma)

Course Real Fit

Pilot know your talent (ken je talent)

Characteristics of the identified preventive interventions

Indirectly targeting children

Source: ECORYS own compilation, 2008

Source : Zorgbalans: Resultaten FFF Heemstede ; Zorgbalans: Resultaten FFF Heemskerk;

Jeugdsportpas Course real fit

per sport 5 100 (refund of if 50 participation is sufficient

Not available Not available

- for 50 material costs

Source: ECORYS own compilation, 2008

6 Discussion, Conclusions and Recommendations

Brede school/extended schools

7 Annex 1: Overview of interventions in the English case study

2 Chill and Chat Peer

Youth Club (Healthy Living Centre)