Healthy weight, healthy lives: a cross-Government strategy for England

HealtHy weigHt, HealtHy lives:a cross-government strategyFor englanD

ForeworDBy tHePrime minister

Healthy weight, healthy livesiiiWhen the National HealthService was established 60years ago, its architectswere preoccupied with thelives taken and destroyedby the major infectiousdisease epidemics that hadswept Victorian Britain.Since then, in part as aresult of the contribution ofthe NHS itself, hugeprogress has been made in tackling infectious diseaseand the modern NHS has made common-place, whatjust 50 years ago would have seemed medicalmiracles.These improvements in care and quality of life havesaved millions and transformed our experience ofhealthcare. But they have also exposed a growingproblem of the so-called ‘lifestyle diseases’ of whichobesity is the foremost, creating a future of risingchronic disease and long-term ill-health. Heartdisease, stroke, cancer and diabetes have taken theplace of 19th century diseases as the illnesses thatcurtail life prematurely, cause long-term incapacity,reduce quality of life and on which we focus ourhealthcare resources.These modern ‘lifestyle’ epidemics are now one of thebiggest threats to our health and that of our families.In terms of their impact on our care and healthsystems, they represent as big a threat to ourambitions for world class services as a lack ofinvestment in the NHS did ten years ago.In England alone, nearly a quarter of men andwomen are now obese. The trends for children areeven more cause for concern. Almost a fifth of 2 to 5year-olds are obese, while a further 14 per cent areoverweight. The Foresight report indicated that oncurrent trends nearly 60 per cent of the UKpopulation will be obese by 2050 that is almost twoout of three in the population defined as severelyoverweight. If we do not reverse this, millions ofadults and children will inevitably face deterioratinghealth and a lower quality of life and we facespiralling health and social care costs.Our response as a society to this challenge will be oneof the defining elements in our lives over the next 20years - one of the most powerful influences on thekind of society in which we live and which we pass onto our children. It is why we need a reformed NHS,better able to put information and control in thehands of patients, and better able to prevent illnessbefore it develops.This strategy marks an important shift in our focus tosupport everyone in making the healthy choiceswhich will reduce obesity, especially among children.Our ambition is that by 2020 we will not only havereversed the trend in rising obesity and overweightamong children but also reduced it back to the 2000levels. And whilst our focus is rightly on children, weneed to see progress on rates of obesity in adults aswell. This is an ambitious goal, but achievable if werecognise the desire of people to live healthy lives andrespond to it with the opportunities and informationpeople need and expect.There should be no doubt that maintaining a healthyweight must be the responsibility of individuals first- it is not the role of Government to tell people howto live their lives and nor would this work. Sustainablechange will only come from individuals seeing the linkbetween a healthy weight and a healthy life and sowanting to make changes to the way that they andtheir families live.The responsibility of Government, and wider society,is to make sure that individuals and families haveaccess to the opportunities they want and theinformation they need in order to make healthychoices and exercise greater control over their healthand their lives. This is what Government can do, andit is what will make a real and sustainable differenceto all of us in trying to make healthy choices and leadhealthy lives.And as well as ensuring people have healthy optionswe must ensure that all of us have access to theinformation and evidence we need to adopt healthierlifestyles.

ivWe must do nothing less than transform theenvironment in which we all live. We must increasethe opportunities we all have to make healthy choicesaround the exercise we take and the food we eat.This strategy is a first step in that transformation.It sets out how the government will discharge itsresponsibilities, but also calls on all members ofsociety to act, from individuals and families tobusinesses and charities.As we publish this strategy today I want to issue achallenge to everyone in this country, from NHSprofessionals to parents to businesses to Government,to work towards a society in which everyone canexercise greater control over their diet and levels ofactivity, maintain a healthy weight and lead healthierlives.Prime MinisterGordon BrownJanuary 2008

Our ambition is to be the firstmajor nation to reverse the risingtide of obesity and overweight inthe population by ensuring thateveryone is able to achieve andmaintain a healthy weight. Ourinitial focus will be on children:by 2020, we aim to reduce theproportion of overweight andobese children to 2000 levels.v

introDuction By tHesecretaries oF stateFor HealtH anDcHilDren, scHoolsanD Families

viiBritain is a successful country. The post-war periodhas seen dramatic changes in the way we live: foodis cheaper, more abundant and more convenientthan ever; our working lives are physically far lessdemanding; and technological change has givenus a wealth of new ways to entertain ourselves.However, this success is increasingly coming at acost. In England two-thirds of adults and a third ofchildren are either overweight or obese, and withoutaction this could rise to almost nine in ten adults andtwo-thirds of children by 2050. This trend has asevere impact on the health of individuals, increasingthe risk of diabetes, cancer, and heart and liverdisease. The cost will be felt by every single part ofsociety, not just in headline financial or health termsbut in very personal ways, affecting the lives andopportunities of millions of people.The core of the problem is simple – we eat too muchand undertake too little physical activity. The solutionis more complex. From the nature of the food thatwe eat to the built environment through to the wayour children lead their lives, it is harder to avoidobesity in the modern environment.The eminent scientists who wrote the Foresightreport described obesity as the climate change ofpublic health. And like climate change, action by theGovernment alone is not enough. We will onlysucceed if the problem is recognised, owned andaddressed in every part of society; in particular it willrequire personal responsibility and action amongindividuals, communities, families, teachers,clinicians, industry, and local and nationalgovernment.This strategy is the first step in achieving a newambition of enabling everyone in society to maintaina healthy weight. It sets out a vision of what thismeans for schools, the food industry, employers,health services and others, and commits theGovernment to play our part with concrete action.Schools and children’s centres will continue to becritical to supporting parents in raising their children.That is why we are both committed to going further.On top of the £1.3 billion of extra investment inschool food, schools PE and sport, and playannounced both in The Children’s Plan and theComprehensive Spending Review, this strategy setsout plans to introduce compulsory cooking for all 11to 14 year olds by 2011. This will give all youngpeople the understanding and skills to eat morehealthily, skills that will serve them well throughouttheir life.We also recognise the role that the builtenvironment plays in shaping our lives. Many of thegreat engineering and planning feats of VictorianBritain were driven by the need to improvesanitation, and we want to see planners return totheir public health roots to meet the obesitychallenge of today. Therefore this strategy describeshow the Government will work with planners,architects, health professionals and communitiesto promote physical activity through the builtenvironment. We will also invest £30 million in‘Healthy Towns’ that bring together changes inphysical infrastructure and community action topromote healthy living. This will provide lessons thatall communities can draw on.Having been at least 30 years in the making, the risein the numbers of obese and overweight individualswill not be halted overnight. This strategy is the veryfirst stage of the Government’s response to theForesight report and will be followed by an annualreport back to the public that assesses progress,looks at the latest evidence and trends and makesrecommendations for further action on howeveryone can maintain a healthy weight.Secretary of State for HealthAlan JohnsonSecretary of State for Children, Schools and FamiliesEd Balls

contents

ixExecutive summaryxi1. The challenge 12. Our new ambition – a healthy weight for all 73. Achieving the new ambition 134. Delivering change 275. Investing in our knowledge 31Conclusion33Annex A – Definition of obesity35Endnotes37

executivesummary

xii Healthy weight, healthy livesSeptember 2007 and forms part of theGovernment’s new Public Service Agreement (PSA)on Child Health and Well-being. 3To help fulfil this ambition, the Foresight expertssuggested that Government could best focus itsactions in five main policy areas – to promotechildren’s health; to promote healthy food; to buildphysical activity into our lives; to support health atwork and provide incentives more widely to promotehealth; and to provide effective treatment andsupport when people become overweight or obese.Across all of these domains, the Government’sambition is no less than a radical transformation inthe opportunities that children and adults have tomake healthy choices, supported by significantimprovements in information and, where needed,practical help. Tackling the obesogenic society thatthe Foresight report has described for us will requireus to find ways to give real control and power backto individuals and families in making choices abouttheir lives.Because no country has yet succeeded in reversingthe trend of increasing numbers of obese andoverweight individuals, the evidence on what workseffectively in each of these policy areas to tackle therise in excess weight is less developed than, say,policies to tackle climate change.So this strategy is the beginning of a sustainedprogramme to support people to maintain a healthyweight, and sets out what can only be consideredthe first steps towards achieving the new ambition.We will continue to examine not just what moreGovernment can do based on the best emergingevidence of what works, but also whether everyonein society – employers, communities and individuals– is doing their bit to enable people to makehealthier choices. Helped by a panel of experts,we will publish annually an assessment of theprogress we are making in halting and thenturning around the rise in excess weight,including leading indicators of behaviour change,such as breastfeeding rates, food consumption, ratesof physical activity and children’s health. We willuse this annual assessment to develop andintensify our policy focus, as evidence strengthenson what works and on whether we are beingsuccessful or not.Children, healthy growth andhealthy weightOur vision for the future is one where every childgrows up with a healthy weight, through eating welland enjoying being active. In early years, this meansas many mothers breastfeeding as possible, withfamilies knowledgeable and confident about healthyweaning and feeding of their young children.As children grow, parents will have the knowledgeand confidence to ensure that their children eathealthily and are active and fit. All schools will behealthy schools, and parents who need extra helpwill be supported through children’s centres, healthservices and their local communities.In this strategy we lay out immediate plans to:• identify at-risk families as early as possibleand plans to promote breastfeeding as thenorm for mothers• give better information to parents abouttheir children’s health by providing parentswith their child’s results from the NationalChild Measurement Programme (NCMP)• invest to ensure all schools are healthyschools, including making cooking acompulsory part of the curriculum by 2011for all 11–14 year-olds• ask all schools to develop healthy lunch boxpolicies, so that those not yet taking upschool lunches are also eating healthily• develop tailored programmes in schools toincrease the participation of obese andoverweight pupils in PE and sportingactivities• invest £75 million in an evidence-basedmarketing programme which will inform,support and empower parents in makingchanges to their children’s diet and levels ofphysical activity

Executive summary xiii• invest in improving cycling infrastructureand skills in areas where child weight is aparticular problem, as part of the recentlyannounced package of further funding of£140 million for Cycling England.Promoting healthier food choicesOur vision for the future is one where the food thatwe eat is far healthier, with major reductions in theconsumption and sale of unhealthy foods, such asthose high in fat, salt or sugar, and all individualschoosing to eat levels of fruit and vegetables in linewith recommended amounts consistent with goodhealth. Individuals and families will have a goodunderstanding of the impact of diet on their health,and will be able to make informed choices about thefood they consume, with extra support andguidance for those who need help. The food, drinkand other related industries will support this throughclear and consistent information, doing all they canto make food healthy.In this strategy, we lay out immediate plans to:• finalise a Healthy Food Code of GoodPractice, in partnership with the food anddrink industry, and other relevantstakeholders. This code would challenge thewhole industry to adopt practices to reduceconsumption of saturated fat, sugar andsalt among other measures• promote the flexibilities contained withinplanning regulations, so that localauthorities are able to manage theproliferation of fast food outlets inparticular areas, e.g. near parks or schools• ask Ofcom to bring forward its review ofrestrictions on the advertising of unhealthyfoods to children, to begin in July andreport early findings as soon as possible.Building physical activity intoour livesOur vision for the future is one where all individualsand families are able to exercise regularly and to stayhealthy and well throughout their lives. Individualsand families will understand the links betweenphysical activity, exercise and health, and will be ableto take responsibility for their travel and leisurechoices as well as increasing the amount of physicalactivity they undertake in their everyday lives,especially for children. Government, business, localcommunities and other organisations will supportthis by creating urban and rural environments wherewalking, cycling and other forms of physical activity,exercise and sport are accessible, safe and the norm.In this strategy we lay out immediate plans to:• invest in a ‘Walking into Health’ campaign,aiming to get a third of England walking atleast 1,000 more steps daily by 2012 – anextra 15 billion steps a day

xiv Healthy weight, healthy lives• invest £30 million in ‘Healthy Towns’ –working with selected towns and cities tobuild on the successful Ensemble prévenonsl’obésité des enfants (EPODE) model used inEurope, with infrastructure and other bestpractice models to validate and learn fromwhole-town approaches to promotingphysical activity• Set up a working group with theentertainment technology industry toensure that they continue to develop toolsto allow parents to manage the time thattheir children spend playing sedentarygames and online• review our overall approach to physicalactivity, including the role of Sport England,to develop a fresh set of programmesensuring that there is a clear legacy ofincreased physical activity leading up to andafter the 2012 Games.Creating incentives for better healthOur vision is a future where all employers value theiremployees’ health, and where this is put at the coreof their business plans. The longer-term risks andcosts of ill-health arising from excess weight will beclear to everyone, and there will be strongerincentives for people, companies and the NHS toinvest in health.In this strategy we lay out immediate plans to:• work with employers and employerorganisations to develop pilots exploringhow companies can best promote wellnessamong their staff and make healthyworkplaces part of their core businessmodel• launch a number of pilots of well-beingassessments throughout the NHS in spring2008, where individual staff are offeredpersonalised health advice and lifestylemanagement programmes linked topersonal assessments of their health status.• pilot and evaluate a range of differentapproaches to using personal financialincentives to encourage healthy living, suchas individuals losing weight and sustainingweight loss, eating more healthily or beingconsistently more physically activePersonalised advice and supportOur vision is a future where individuals have easyaccess to highly personalised feedback and adviceon their diet, their weight, their physical activity andtheir health, providing them with personalisedinformation to encourage healthy behaviours.People will also have easy access to authoritativebut clear advice on how to look after themselves,making sense of the competing claims made abouteating, diet, activity and health. When people areoverweight or obese, they will have access topersonalised services that are tailored to their needsand support them in achieving real and sustainedweight loss, leading to the maintenance of ahealthy weight.In this strategy we lay out immediate plans to:• seek to develop the NHS Choices website togive highly personalised advice to all ontheir diet and activity levels, with clear andconsistent information on how to maintaina healthy weight• support the commissioning of more weightmanagement services by providing extrafunding for this over the next three years.

Executive summary xvBeyond this, the Government will invest in researchto deepen our understanding of the causes andconsequences of the rise in excess weight, and theevidence of what works in tackling it. This researchwill be part of wider efforts to develop ourknowledge of what works by the newly establishedObesity Observatory – part of the wider PublicHealth Observatory family, and sitting alongsideexisting Government research and developmentbodies.Success will also depend on ensuring that theprogramme of Government action is fully resourced.To this end, the Government will makeavailable an additional £372 million forpromoting the achievement and maintenanceof healthy weight over the period 2008–11.This is over and above the £1.3 billion investmentin school food, sport and play and the £140 millionfurther funding for Cycling England, alreadyannounced for 2008–11.

cHaPter 1:tHe cHallenge

1THE CHALLENGEIn the first half of the twentieth century it wasuncommon for individuals to be overweight orobese. Since then the number of people withpersistent, severe weight problems affecting theirhealth has risen steadily. Although year-on-year datacan show peaks and troughs, there has been a clearrise in obesity rates, probably accelerating in the late1980s and early 1990s.Obesity prevalence trends from 1993 to 2005adults, and children aged 2–153025WomenMenChildren aged 2–15study found that 55 per cent of obese 6-9 year oldsand 79 per cent of obese 10-14 year olds remainedobese into adulthood. 4Looking to the future, the Foresight expertsestimated that, based on current trends, levels ofobesity will rise to 60 per cent in men, 50 per cent inwomen, and 25 per cent in children by 2050, with afurther 35 per cent of adults and nearly 40 per centof children overweight. 2 *Forecast trend in the proportion of adults andchildren who are overweight and obese, to2050100Actual/EstimatedForecast902080% obese1510501993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005% overweight or obese70605040302010Men aged 21–60Women aged 21–60Boys aged 6–10Girls aged 6–10YearSource: Health Survey for EnglandThis is a trend repeated almost universally indeveloped, and increasingly developing nations.Although it is difficult to draw reliable internationalcomparisons, most experts agree that the UnitedStates has the greatest problem, with England andAustralia not far behind. 2 The rate of increase inEngland is greater than most comparable countriesin Europe. 2019931995199719992001200320052007200920112013201520172019202120232025202720292031203320352037203920412043204520472049YearSource: Foresight Tackling Obesities: Future Choices – ModellingFuture Trends in Obesity and Their Impact on HealthThe trends discussed above apply across society. Obeseindividuals are present in all socio-economic groups,although they are represented to a slightly lesser extentamong the most affluent, particularly for women.The trend of weight problems in children is aparticular cause for concern because of evidencesuggesting a ‘conveyor-belt’ effect in which excessweight in childhood continue into adulthood. A US* This report uses the 85th and 95th percentiles on the 1990 UK Growth Charts to define children as obese andoverweight for existing data, in line with the current conventions for population monitoring within the UK. Wheregiven, Foresight-derived projections to 2050 use the IOTF definition to childhood obesity

2 Healthy weight, healthy livesTrends in Obesity Prevalence 1993–2004 bySocial Class I and V• health effects of excess weight are increasingly35Men social class IMen social class V30Women social class IWomen social class V25201510501993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004YearSource: Foresight Tackling Obesities: Future Choices – ModellingFuture Trends in Obesity and Their Impact on HealthWhy do these trends matter? Both being obese andbeing overweight increase the risk of a range ofdiseases that can have a significant health impact onindividuals, although the risks rise with BMI* and soare greater for the obese:• 10 per cent of all cancer deaths among nonsmokersare related to obesity 5• the risk of Coronary Artery Disease increased3.6 times for each unit increase in BMI 5• 85 per cent of hypertension is associated with aBMI greater than 25 5• the risk of developing type 2 diabetes is about20 times greater for people who are very obese(BMI over 35), compared to individuals with aBMI of between 18 and 25 6• up to 90 per cent of people who are obese havefatty liver. Non-alcoholic fatty liver disease isprojected to be the leading cause of cirrhosis inthe next generation 7% obeseapparent even in children; the incidence of bothtype 2 diabetes and non-alcoholic fatty liverdisease used to be rare in children, but isincreasing 8• obesity in pregnancy is associated with increasedrisks of complications for both mother and baby• social stigmatisation and bullying are commonand can, in some cases, lead to depression andother mental health conditionsThese diseases ultimately curtail life expectancy.Severely obese individuals are likely to die onaverage 11 years earlier (13 years for a severelyobese man between 20 and 30 years of age) 9 **than those with a healthy weight, comparableto, and in some cases worse than, the reduction inlife expectancy from smoking.Given the impact on individual health, it isunsurprising that obese and overweight individualsalso place a significant burden on the NHS – directcosts are estimated to be £4.2 billion and Foresightforecast these will more than double by 2050. 2 Butthese also bring costs to society and the economymore broadly – for example sickness absencereduces productivity. Foresight estimate that weightproblems already cost the wider economy in theregion of £16 billion, and that this will rise to £50billion per year by 2050 2 if left unchecked. Overall,the work of Foresight and others suggests thatweight problems presents society with a greaterchallenge than previously realised, and that, withoutadditional action, the costs to individuals, the NHSand society will be massive.* Body Mass Index (BMI) – see Annex for full description** Applies to individuals with BMI over 45.

Chapter 1: The challenge 3CAUSES OF EXCESSWEIGHTAt heart, excess weight is caused by an imbalancebetween ‘energy in’ – what is consumed througheating – and ‘energy out’ – what is used by thebody, including that through physical activity. Onthat basis, eating more healthily and being moreactive are the solutions to maintaining a healthierweight, decisions that are fundamentally anindividual’s responsibility. Recent evidence fromForesight, however, is clear that a broad set of socialand environmental factors influence these decisions,and are increasingly making healthy decisions thehardest to make and stick to. These broader factorscan be considered under four headings: humanbiology, culture and individual psychology, the foodenvironment and the physical environment.1) Human biologyHumans have evolved to survive in an environmentwhere it was never certain when the next mealmight be – our bodies are programmed to storeenergy when it is available. Genetics play a part inthis: indeed, a number of studies have nowidentified a range of specific genes associated withexcess weight. It is too simplistic to claim that theypre-destine a person to being obese or overweightbut genetic factors do increase the susceptibility ofsome individuals to obesity.The pattern of growth through early life alsocontributes to the risk of excess weight. A baby’sgrowth rate is in part determined by parentalfactors, with the period immediately after birth ofparticular importance. Whether a child is breastfedor not, and at what stage weaning begins, have alsobeen shown to affect the risk of excess weight laterin life.2) Culture and individualpsychologyWeight is a very sensitive issue, especially for parentswho understandably fear their child beingstigmatised at an early age and being judged as badparents.Evidence suggests that many parents:• struggle to assess their children’s weight statusaccurately – research found only 17 per cent ofparents with an obese child were able tocorrectly gauge their child’s weight status 10• overestimate activity levels and underestimatethe amount of high-fat, high-sugar foods thefamily eats• make no connection between poor diet and lowactivity levels in their children and long-termhealth problems.Even when weight is recognised as an issue byindividuals and families, there are many factorswhich means it is often ignored. Once the issue isacknowledged and the need to change somebehaviours recognised there may be a psychologicalconflict which makes it difficult to change the usualbehaviour patterns. For example, the short-termdesire for a fatty snack or the convenience of drivingto the local shops may be more tempting than thelong-term gain linked to choosing the healthieroption.It is harder to make healthy choices where others inthe family or community are also maintainingunhealthy behaviours. This is further compoundedby the welter of competing health claims and quickfixes that can be found in the media daily whichcan make it difficult and confusing to make ahealthier choice.Repetition of everyday behaviours over time cansolidify them into habits that can become verydifficult to change later in life. This is of crucialimportance when considering the impact of parentalbehaviour on their children – significantly only 3 percent of obese children have parents who are neitheroverweight nor obese 11 (65 per cent of men and 55per cent of women are either overweight or obese 1 ).3) The food environmentCompetitive markets coupled with technologicalchange have enabled the food industry to producefood cheaply and in high quantities in response toconsumer demand. This has led to the production ofgrowing volumes of processed foods and ready

4 Healthy weight, healthy livesmeals, many of which tend to be high in fat, sugarand salt. Fatty and sugary foods and drinks are alsovery heavily marketed and promoted, furtherreinforcing consumer demand, even though it iswidely recognised these should be the smallestproportion of a healthy balanced diet.These trends have contributed to our diet containingtoo much saturated fat, added sugar and salt, andnot enough fruit and vegetables.Consumption of selected nutrients and fruitand vegetables vs recommended levels% contribution to food energy6050 5403020100Target = 11%Target = 11%Target= 50%Target= 5Saturated fat Added sugar Carbohydrates Fruit and VegSource: Family Food Survey 2005/06 and HSE 2005A diet rich in saturated fat is associated with highlevels of blood cholesterol which increases the risk ofheart disease.Alcohol consumption is also a part of an individualscalorie intake, and so the rising trend inconsumption also contributes to excess weight.643210Number of portions per dayof travel have changed, with car use increasingsubstantially since the 1950s.Passenger transport by mode (billionpassenger km, 1952 to 2006)% of passenger kilometres1009080706050403020100195219571962196719721977Year1982Source: Department for Transport statistics1987Cars, vans and taxisBuses and coachesMotor cyclesPedal cyclesRailPhysical activity is a particular issue in children. Forinstance, the last two decades have seen a 10percentage point drop in children walking toschool. 13 Today’s children are also increasinglyspending time in front of a TV or computer screen –an average of five hours and 20 minutes a day, upfrom four hours and 40 minutes five years ago. 14A lack of physical activity contributes to excessweight but also increases the risk of Type 2 diabetesindependent of the effects on body weight.19921996200120064) The physical environmentOver the last few decades new forms of technologyhave started to make a major impact on daily life.Lives that were for most of the population physicallydemanding, are now increasingly sedentary, soreducing average energy expenditure. As last year’sRoyal Commission on Environmental Pollution reporton the urban environment 12 highlighted, modernurban systems can serve to discourage activity,thereby promoting weight gain and other healthrisks. This can be particularly seen in how methods

Chapter 1: The challenge 5TACKLING THE CAUSES OFEXCESS WEIGHTThe above brief discussion of the causes of excessweight demonstrates that, like climate change,tackling this problem is complex and multifaceted,involving individuals, communities and industry aswell as Government. It is clear that Governmentaction alone will not be enough. Success will onlycome from the problem being recognised, ownedand addressed at every level and every part ofsociety.While the causes of excess weight are similar toclimate change in their complexity, the evidence onsolutions is less clear, and indeed no country in theworld has yet succeeded in reversing a rising trendof increasing numbers of obese and overweightindividuals.Foresight recognised this in their report but, basedon the very latest evidence from the NationalInstitute for Clinical Excellence (NICE) and others,they suggested five areas where Government actionto tackle excess weight are likely to succeed.Five areas for tackling excess weight1. Children: healthy growth and healthy weight– early prevention of weight problems toavoid the ‘conveyor -belt’ effect intoadulthood2. Promoting healthier food choices – reducingthe consumption of foods that are high infat, sugar and salt and increasing theconsumption of fruit and vegetables3. Building physical activity into our lives –getting people moving as a normal part oftheir day4. Creating incentives for better health –increasing the understanding and valuepeople place on the long-term impact ofdecisions5. Personalised advice and support –complementing preventative care withtreatment for those who already haveweight problemsThis document sets out the immediate actions forGovernment in these areas, although as the nextsection makes clear, this is only the start of a longtermcommitment to addressing the challenge ofobesity.Map of major sectors that must play a role in tackling excess weight• Food producers• Food retailers• Food manufacturers• Restaurants• School/work canteens• Employers• Educational establishments• Local strategic partnerships• Voluntary sector and NGOs• Institutions (e.g. prisons)• Health service• Local government• MediaIndividualsandfamilies• Public transport• Town planners• Leisure industry e.g. cinemas,holiday venues• In home entertainment –TV, websites, gaming• Hospitality industry• Gyms/sports facilities etc.Underpinning action by central government

cHaPter 2:our new amBition– a HealtHy weigHtFor all

7The number of obese and overweight individuals hasbeen increasing for at least thirty years. In 2004 theGovernment set a clear target for tackling obesity:To halt the year-on-year rise in obesity amongchildren aged under 11 by 2010, in the context of abroader strategy to tackle obesity in the populationas a whole.The target has been effective in stimulating actionacross the country. In 2004 the evidence suggestedthat a focus on children, and on food labelling,promotion and formulation was likely to have thegreatest impact. Policies in these areas havedelivered notable success, including:Children• 86 per cent of school children now do at leastthat school travel plans reduce car use for• Over the past three years, the share of childrenjourneys to and from school in 60 to 90 per centon the School Fruit and Vegetable Schemeof schools and, in a substantial proportioneating ‘5-A-DAY’ has increased from just over a(about 15 to 40 per cent), by over 20 per cent.quarter to just under a half. 15 two hours of physical education and sport a• Tough new food-based standards are now inweek – a significant improvement on theplace for school lunches and other school food.2003–04 figure of 62 per cent and beats theThese will be complemented by nutrient-basedGovernment’s target 85 per cent by 2008. 16standards for school lunches, starting in primaryschools from September this year. By 2011 theGovernment will have invested in excess of£600 million to support the improvement ofschool food in all parts of the school day• At the end of March 2007 more than 14,000schools in England (56 per cent) had anapproved school travel plan as a result of theTravelling to School project. Research has shown• Established in 2005, the NCMP weighs andmeasures children in Reception Year (aged 4–5years) and Year 6 (aged 10–11 years).Significantly improved coverage has producedone of the largest collection of data on children’sheight and weight in the world, and this is nowbeing used to inform local planning and deliveryof services for children and gather population­

8 Healthy weight, healthy liveslevel data to allow analysis of trends in excessweight.Food labelling, promotion andformulationDeveloping a new targetBut while progress has been made, at the same timeour knowledge has developed. The Foresight reporthas provided a much clearer understanding of thecomplexity and scale of the problem. We need to gofurther, faster. A fundamental shift in approach isrequired, one that is firmly based on the latestevidence on the size of the problem, its causes andpotential solutions.Illustrative chart of shifting weight distributionin the population to a healthy weightIn many areas the UK is a global leader in itsapproach to food and health:UnderweightHealthy weightOverweightObese• the Food Standards Agency (FSA) has workedwith the food industry to introduce front of packlabelling – with the aim of making it simpler forfamilies to make healthier food choices. Currentlyour preferred model, developed by the FSA, isbased on a traffic light system which independentresearch show consumers find easy to understandand helps drive behaviour change. This hasalready been adopted by many major retailersand manufacturers (see www.food.gov.uk)BMI• Ofcom has introduced restrictions on broadcastfood and drink advertising to children. Theseapply to advertising of food products high in fat,salt and sugar within programming of particularinterest to children. The restrictions initiallyapplied to programming aimed at under-10s andfrom 1st January 2008 also apply toprogramming aimed at under-16s. Industry,under the Advertising Standards Authority,introduced new content rules for all food anddrink advertising to children in non-broadcastmedia, with exceptions for fruit and vegetablesFewerunderweightMaximise proportionat a healthy weightBMIMinimise proportionof overweight and obeseFeweroverweightFewerobeseReduce average BMIUnderweightHealthy weightOverweightObeseFirst, this means moving away from a focus solely onobesity to one of promoting healthy weight and sohealthy lives. Ultimately, this will need to encompasssupporting individuals who are underweight and soalso at a higher risk of health problems to maintain ahealthy weight. However, the Government’s initialfocus will be on tackling the obese and overweight.

Chapter 2: Our new ambition – a healthy weight for all 9Illustrative chart of potential reduction in average BMI in childrenfrom implementing best practice programmes – indicative trajectoryAverage BMI of 2 to 19 year olds20• The evidence from these programmes has beenused as the basis for setting the government’sambition for promoting health weight in childrenthat is both stretching but achievable• It has also been used to underpin the policyproposals in Chapter 3, although these go furtherto cover all major Foresight areas and to aim atadults tooTrend average BMI growth.Evidence-based methods of promoting healthyweight in childrenProgramme• Breastfeeding• Targeted support for at risk families• Children’s centres (includingactivity and nutrition) to 2yrs• School-based prevention (includingactivity, nutrition, reduced soft drinkconsumption and education toreduce TV viewing)• Reduced consumption of HFSS foods e.g.through reformulation and clear labelling• Reduced HFSS advertising to children• Community interventions all agesForesight areaChildren:healthygrowth andhealthy weightPromotinghealthier foodchoicesPhysical activity182000 2007 2010 20152020Source: Department of Health analysisSecond, a fundamental shift in approach meansrecognising that weight is a problem that affectsadults as well as children. The evidence suggeststhat an initial focus on children is appropriate (seechart): the importance of early years is clear, andchildren’s services provide a variety of avenues forsupporting change. However, because parents andparental behaviour has such a strong influence onchild behaviour, excess weight problems in childrencan only be tackled in concert with tackling them inthe whole family, and society more broadly.Finally, a shift in approach means being moreambitious. It will not be enough to simply halt therise in the numbers of overweight and obese people,it must be reversed if the severe consequences toindividual health are to be avoided.

10 Healthy weight, healthy livesThe new ambition and indicatorsThe government’s new ambition on excess weight,announced in the Comprehensive Spending Review2007 is to be the first major country: to reverse therising tide of obesity and overweight in thepopulation, by ensuring that all individuals are ableto maintain a healthy weight. Our initial focus is onchildren: by 2020 we will have reduced theproportion of overweight and obese children to2000 levels.The Department of Health is responsible for overallpolicy on obesity and is jointly responsible with theDepartment for Children, Schools and Families(DCSF) for tackling child obesity. Although theambition covers a period of 12 years, progress forthe first three years 2008-11 will be monitoredthrough the inclusion of child obesity as one of theindicators in the Child Health PSA 3 . This will providea solid platform upon which to expand efforts toreduce the proportion of overweight children, aswell as the proportion of obese children in order tofulfil the 2020 ambition.While accountability for meeting the ambition willbe based on indicators of BMI in Reception and Year6, we want to ensure that action is not solelyfocused on these age groups. The Government istherefore committing to publishing an annual reportsetting out performance against these and otherBMI indicators:• children in Reception Year: overweight andobesity levels• children in Year 6: overweight and obesity levels• young adults: overweight and obesity levels(based on Health Survey for England data)• adults: overweight and obesity levels (based onHealth Survey for England data).However, because changes to population measuresof BMI can take some time to become apparent, theGovernment will complement these with a range ofearly indicators of success. These will be based onthe evidence of what causes or is correlated toweight problems. As with the indicators on youngadults and adults, they will not form additionalreporting requirements for primary care trusts (PCTs)and local authorities, outside of the NationalIndicator Set but will as far as possible be based onexisting data, or use centrally-led surveys. Followingthe publication of this strategy the Government willfinalise these indicators, but they are likely toinclude:• Childhood– Proportion of mothers breastfeeding at sixmonths– Take-up of school meals– Portions of fruit and vegetables consumeddaily per child– Number of school children doing at least twohours of school sport a week– Progress against new ambition for eachyoung person to have access to five hoursof PE and sport• Promoting healthier food choices– Nutrient intake data– Consumption (and/or sales) of high in fat,salt and sugar foods– Proportion of the adult populationconsuming their ‘5 A Day’• Building physical activity into our lives– Hours of sedentary leisure activity(e.g. TV viewing)– Numbers of people doing recommendedlevels of physical activity (e.g. number ofdays on which people have walked or cycledfor at least 30 minutes)

Chapter 2: Our new ambition – a healthy weight for all 11• Personalised advice and support– Use data on the onset of Type 2 diabetesin adults to model adult obesity rates in apopulation– Proportion of people maintaining weight lossor BMI reduction on completion of weightmanagement programme.Some of these measures already exist as part of theNational Indicator Set, others will need to bedeveloped in consultation with key stakeholders.Performance against the leading indicators will alsobe published annually, as they will provide us withan early sense of whether we are making realprogress in changing the behaviours that underpinthe rise in the number of overweight and obesechildren and adults, in advance of changes in thetrends for BMI. We will also use progress on thesemeasures to assess whether and where we need tointensify our policy focus, in order to meet ourambition to be the first nation to reverse the obesityepidemic.Experience gained from monitoring performanceagainst the new ambition and early indicators will beused to develop specific goals for other parts of thepopulation in future years.

CHAPTER 3:ACHIEVING THENEw AmbITIoN

Chapter 3: Achieving the new ambition 13Achieving the ambition set out in the previouschapter will not be easy. Success will not lie in theGovernment taking a heavy-handed approach,dictating what people should eat and how activethey should be. Rather, success lies in everyone insociety playing a part in making and supportinghealthier choices. Individual behaviour andresponsibility are critical but it is also about theresponsibility of the private and voluntary sectors– a food industry, for example, that takes seriouslyits responsibility to supply foods that promotehealth; employers that make the health of theirworkforce part of their core responsibility.The vision for all of us must be a society where:• every child grows up eating well and enjoyingbeing active. Parents will have the knowledgeand confidence to make this happen – includingas many mothers breastfeeding as possible – andwill be supported by schools, children’s centres,health and other services, all promoting healthyweight• the food that we eat is far healthier, with majorreductions in the consumption and sale of foodshigh in fat, salt and sugar, and everyone eatingtheir ‘5 A Day’. Individuals and families will makedecisions on their diet based on a goodunderstanding of the impact on their health, andthe food, drink and other related industries willsupport this through clear and consistentinformation, doing all they can to help parentsraise healthy children• everyone is as active as they feel able andunderstands the impact of this on their health,taking responsibility both for how they traveland how they spend their spare time.Government, businesses, local communities andothers will create urban and rural environmentsthat make activity accessible, safe and the norm• individuals have easy access to information andadvice on healthy eating and activity that is clear,consistent and personal to them. Obese andoverweight individuals will be able to accessservices that are tailored to help them achieveand sustain a healthy weight.The Government has a clear role to play in providingleadership for society to achieve this vision. However,this does not mean that the Government should acteverywhere and every time, much less tell people tolive their lives in a certain way or tell parents how toraise their children. Instead, the role of theGovernment is to give people the information andopportunity to make the right choices for themselvesand their families, to ensure that they have clear andtransparent information about food and exercise,and to put in place the right incentives and facilitiesto support people to make healthier choices ineveryday life.1. Children: healthy growthand healthy weightPregnancy and the early yearsInformation on child health is most important toparents during pregnancy and the first years of life.The evidence shows that breastfeeding, delayingweaning until babies are six months old, introducingchildren to healthy foods, controlling portion sizeand limiting snacking on foods high in fat and sugarin the early years can all help to prevent childrenbecoming overweight or obese.There is also much that the Government is doing tosupport parents in this: the Child Health PromotionProgramme (CHPP) is the overarching programmethat covers health reviews, immunisations andadvice to parents. It is led by health professionals butother professionals working early years such aschildren’s centre staff are also involved. Indeed manyCHPP services are delivered in children’s centres,which will be greatly enhanced by the roll-out of3,500 Sure Start Children’s Centres by 2010 – achildren’s centre for every community, fulfilling theGovernment’s commitment in its 10-year childcarestrategy, Choice for parents, the best start forchildren (December 2004).The Government will do more to support parents topromote the healthy growth of their child throughthe following.

14 Healthy weight, healthy livesEarly identification of at-risk familiesThroughout the CHPP, a series of health reviewsprovide an opportunity for health professionals toidentify families that are most at risk from childweight issues and least able to tackle them.In particular, the assessment by the 12th weekof pregnancy allows health professionals toidentify mothers who are already obese oroverweight, and to give them advice onhealthy weight gain in pregnancy. This is crucialfor their baby’s development, safety and alsoto ease delivery.The forthcoming update of National ServiceFramework (NSF) Standard One (CHPP) willprioritise the promotion of healthy weight inearly life, and specify the monitoring andinterventions that are to be offered to allchildren and families.Making breastfeeding the normfor parentsThere is evidence that those who breastfeed notonly provide their child with protection againstinfectious disease, they also reduce the risk of excessweight in later life. Babies at an early age who areexposed to a variety of flavours from their mothers’diet, develop a taste for a greater variety of foodswhile being weaned. Because of the importance ofbreastfeeding in promoting healthy childdevelopment, the Child Health PSA includes anindicator for breastfeeding prevalence at six to eightweeks, which will come into use from April 2008.In addition to this, the Government will:• invest in an information campaign topromote the benefits of breastfeeding aspart of a wider programme of campaignson healthy development (see page 17)• support a National Helpline forbreastfeeding mothers at local rates,providing mothers with access toprofessional advice in times of need• create an environment in maternity unitsthat promotes breastfeeding byencouraging them to adopt UNICEF’s Baby-Friendly Hospital Initiative• pilot and then roll out the new WorldHealth Organization (WHO) growthstandards – based on breastfed infants upto the age of two years• develop a code of best practice foremployers and businesses on how toencourage, support and facilitate employeesand customers who breastfeed.Ensuring that nurseries, children’s centresand childminders support the healthyearly development of all childrenThe Early Years Foundation Stage, which iscompulsory from September 2008, ensures thatchildren’s physical well-being and health arepromoted through opportunities for physical activityand the requirement that all meals, snacks anddrinks that are provided for children must be healthy,balanced and nutritious. Success will be measuredusing the NCMP data for Reception Year pupils,among other indicators.

Chapter 3: Achieving the new ambition 15Going beyond this, the Government willdevelop guidance for professionals workingwith young children so that they can championbreastfeeding in their areas and establishgroups for mothers and fathers to supporteach other.Developing high-quality intensivesupport for the families that are at thegreatest risk of poor child developmentThe Healthy Start programme already provideslow-income families with vouchers to exchange forfresh fruit and other products. But a smallpercentage of families need more direct help – forexample in the form of the Family Nurse Partnership,a nurse-led, intensive programme of home visits thathas been successful in encouraging breastfeedingand other healthy behaviours among families thatneed this intensive support. 17 The Government hascommitted to invest a further £30 million toenable more areas to pilot this approach, andwill evaluate how to provide the most effectivesupport to the most vulnerable children andfamilies.Children and young peopleSchools have a responsibility to provide a healthyenvironment in which children and young peoplecan learn and develop, and to maximise theopportunity for them to live healthy lives. This is nowunderpinned by a duty on schools to promote thewell-being of pupils (guidance will be issued early in2008). In addition, The Children’s Plan 18 committedto developing strong school level indicators thattaken together measure a school’s contribution topupil well-being, and suggested that child obesitybe included.Recent years have seen a step change in schoolfood, travel to school and ensuring that pupils arephysically active. The Government will continue tosupport these reforms as well as introducing otherspecific programmes.Building on its £220 million transitional support forschools and local authorities over the last threeyears, the Government is investing further in schoolfood during 2008–11, including:• a £240 million subsidy for schools and localauthorities towards the direct cost of schoollunches, to help with issues of affordability• £150 million in targeted capital funding forthose local authorities with the highest need forinvestment in school kitchens• development by the School Food Trust (SFT) of anetwork of centres – known as ‘School FEAST’(Food Excellence And Skills Training) centres –to boost the skills of school cooks and caterers• action by the SFT to maximise take-up of schoollunches, notably through its ‘Million Meals’campaign which focuses on the engagementand commitment of schools, and a new mediacampaign focused on winning the hearts andminds of teenagers, in particular, to encouragethem to embrace healthy eating.To promote a culture of healthy eating, theGovernment now expects all schools – inconsultation with parents, pupils and staffto adopt whole-school food policies.*In particular, schools will be expected to:• develop healthy lunchbox policies, so that thosenot yet taking up school lunches are also eatinghealthily. The SFT website(www.schoolfoodtrust.org.uk) provides guidanceto schools on how to go about this• assess the adequacy of their lunchtimemanagement arrangements. They need to beable to determine whether current arrangementsare conducive to healthy eating or not.In particular, schools should consider the lengthof time available for lunch, and whetheradopting a stay-on-site policy at lunchtimewould be helpful in ensuring that all children areeating healthy food.* covering the promotion of school lunches; all food provided by or brought into school; and what is taught aboutfood in the curriculum.

16 Healthy weight, healthy livesSchools which have achieved most on healthy eatinghave typically been those which have adopted awhole-school approach. Healthy Schools arerequired to have a whole-school food policy.Now all schools are expected to develop them.Compulsory cooking in schoolsA further significant boost for cookery andfood awareness among young people is theGovernment’s plan to make cooking acompulsory part of the key stage 3 curriculumin schools, from 2011. Practical cooking is alreadymuch strengthened in the recently revised secondarycurriculum, which is being introduced in September2008.The ‘Licence to Cook’, beginning at the sametime, means that all pupils aged 11–16 areentitled to learn to cook nutritious dishes frombasic ingredients, whether or not their schooloffers cooking as part of the curriculum.Separately, the SFT, supported by £20 million oflottery funding, is establishing a network of ‘Let’sGet Cooking’ cookery clubs, aimed at engagingboth parents and children in healthy eating and theenjoyment of cookery.Further investment in the Healthy Schoolsprogramme, with the impact on childhealth assessed by Ofsted inspectionsThe Government will provide furtherinvestment to help all schools to reach HealthySchool standards and make a difference to thehealth of their pupils. The Children’s Planproposed that child obesity should be one ofa new basket of indicators that will measureprimary schools’ wider contribution to pupilwell-being.Extended schools£1.3 billion over 2008-2011 to support the on-goingdevelopment of extended schools. All schools areexpected to offer access to extended services by2010, providing a core range of activities from 8am– 6pm, all year round, which can include breakfastclubs, parenting classes, cookery classes, foodco-ops, sports clubs and use of leisure facilities.Ensuring that pupils who are overweightor obese increase their participation inphysical activityAs part of the commitment to five hours of PEand sport for young people, and with supportfrom Government and the Youth Sport Trust,schools are working to develop programmes ofPE and sporting activities to support fullparticipation by all children and young people.Where needed these will be tailored specificallyfor obese and overweight young people.Where there are particularly good examplesof good practice, these will be promoted to allschools in a new on-line resource to beintroduced early in 2008.Extended schools, working with the local authorityand their PCTs, offer ideal opportunities forpromoting healthy weight through a whole-schoolapproach involving health professionals, school staffand parents. In July we announced a further

Chapter 3: Achieving the new ambition 17We want children to enjoy an active childhood, withmore opportunities for active play. The Children’sPlan announced new investment of £225 millionbetween 2008 and 2011 to allow up to 3,500playgrounds to be rebuilt or renewed and madeaccessible to children with disabilities. The fundingwill also support 30 play pathfinders indisadvantaged areas and new volunteering schemesto support play in local communities. To back upthis new investment we will publish a newnational strategy on play in the first half of2008.More children cycling – especially in areaswhere child weight is a particular problemThe recent announcement of a further£140 million in funding for Cycling Englandincludes funding for improving the cyclinginfrastructure and cycling skills in selected areaswhere child weight is a particular problem. Thisbolsters the commitment for all schools to havetravel plans by 2010, and the Government’s aimof enabling 500,000 children to take part inBikeability cycle training by 2012.Information to support parentsWhile the Government can support parents inensuring that their children are physically active andeat healthily by promoting these in schools andchildren’s centres, children only spend a minority oftheir time in these settings. Research by theGovernment into parental attitudes has highlightedthat many parents would value clear and consistentmessages on the risks to children from not eatinghealthily and being inactive, and advice on how toreduce these risks.Many organisations already provide such advice, butto ensure that all parents have access to a core set ofconsistent information, the Government will do thefollowing.Providing parents with their child’s results,on a routine basis, from the NCMPWe will ensure that parents routinely receivetheir child’s results from the NCMP, whichweighs and measures schoolchildren inReception and Year 6. All parents of children whoare weighed and measured (unless they choose toopt out of receiving results) will receive their child’sresults as well as help and signposting to supportthem in addressing any concerns about their child’sweight. Increased numbers of school nurses andschool-based parent support advisers will be amongthose available to help.Investing £75 million in an integratedmarketing programme over 2008–11The Government will invest £75 million in anintegrated marketing programme to inform,support and empower parents to make changesto their children’s diets and levels of physicalactivity. More details about the programme canbe found in Chapter 4, but it will include simpleuniversal messages for all families as well as tailoredmessages for at-risk families. There will be anemphasis on highlighting opportunities to take partin activities in the local area – everything fromfruit-tasting sessions to ‘walking buses’ and safeplay areas.2. Promoting healthier foodchoicesThe food and drink industryAs parents change their behaviour to improve theirown health and to help secure a healthier future fortheir children, so too must the food industry changeto support everyone in making healthier choicesabout food. Some manufacturers, retailers andcaterers have been very active in encouraginghealthier eating but, given the scale of theprospective crisis in excess weight, more needs to bedone. The progress made by the FSA and differentsectors across the food industry towards reducingsalt intake provides a model for successfulengagement.

18 Healthy weight, healthy livesThe Government expects companies in every foodsector to demonstrate their commitment bypledging action to promote healthy eating.The Government will therefore work withindustry leaders and other relevantstakeholders to finalise a Healthy Food Code ofGood Practice, based on the good work thatthey are already undertaking. Ministers andindustry leaders would then establish the Codeas a challenge to the industry as a whole.Healthy Food Code of Good Practice1. A single, simple and effective approach tofood labelling used by the whole foodindustry, based on the principles that will berecommended by the FSA in light of theresearch currently being undertaken.2. Smaller portion sizes for energy-dense andsalty foods.3. Rebalance marketing, promotion, advertisingand point of sale placement, so that wereduce the exposure of children to thepromotion of foods that are high in fat, saltor sugar, and increase their exposure to thepromotion of healthy options.4. Reductions in the consumption of and levelsof saturated fat and sugar in food – inparticular the consumption of drinks withadded sugar, along the lines of thecontinuing action on salt.5. Increased consumption of healthy foods,particularly fruit and vegetables.6. All food businesses to work with the FSA,DH and other stakeholders to deliver a singleset of key healthy eating messages.7. Information on the nutritional content offood in a wide range of settings (forexample, theme parks, visitor attractions,restaurants, take away foods) to be clear,effective and simple to understand.Where the Government is able to work closely withindustry, there are clear advantages to a voluntaryapproach, and this Code of Good Practice will seekto realise these. However, the Government willclearly continue to examine the case for amandatory approach where this might producegreater benefits, particularly for children’s health.There is good evidence that the FSA’s traffic lightlabelling system is understood by consumers. It hasbeen shown to be effective in changing consumerbehaviour, and we therefore want the FSA tocontinue to work with the industry to see it adoptedmore widely. However, there are a number ofdifferent labelling systems currently in operation.The FSA has commissioned an evaluation of thesejointly with the industry – when complete, we willexpect industry to adopt a single labelling systembased on its recommendations.Additionally, the FSA will shortly publish aprogramme of work with industry to reducesaturated fat and added sugar levels in foods, and toreduce portion sizes where appropriate. We expectbusinesses to participate constructively in thisprogramme.As food eaten outside the home becomes moreimportant, it is essential for the Code to incorporatethe catering industry. We have asked the FSA toextend its work with the sector to develop aprogramme with clear outcomes coveringprocurement, menu planning, kitchen practice andconsumer information.One of the challenges that we face in promotinghealthy eating is the availability of foods high in fat,salt and sugar in local neighbourhoods, includingthe prevalence of fast food restaurants andtakeaways in some communities. Local authoritiescan use existing planning powers to control morecarefully the number and location of fast foodoutlets in their local areas. The Government willpromote these powers to local authorities andPCTs to highlight the impact that they can haveon promoting healthy weight, for instancethrough managing the proliferation of fastfood outlets, particularly in proximity to parksand schools.Finally, it will be important to work with the reviewof food commissioned by the Prime Minister fromthe Strategy Unit, Cabinet Office, to determine whatfurther action can be taken to encourage healthier

Chapter 3: Achieving the new ambition 19and more sustainable diets within the context of theentire food supply chain.Food advertising and marketingThe advertising and marketing of food to children isimportant, since the widely held view of publichealth experts is that this has a powerful influenceon children’s food habits – and so on excess weightin childhood. The Government has worked withOfcom and the Advertising Standards Authority(ASA) towards the introduction of tough newrestrictions to reduce significantly the amount andimpact of the promotion to children of foods high infat, salt and sugar. These restrictions are alreadyhaving an impact.However, the position needs to be kept underreview. We have therefore asked Ofcom to bringforward its review of the current restrictions,beginning in July (once six months worthof data have been collected) and reporting itsearly findings as soon as possible.New restrictions are also already in place fornon-broadcast media. The ASA objective, likeOfcom’s, has been to ensure that children are notexposed to excessive advertising of foods high in fat,salt and sugar – a proportionate response to theevidence as analysed by the FSA and Ofcom. TheASA is reviewing all of its advertising codes in 2008and will put out revised codes for public consultationlater this year. The findings of Ofcom’s review intothe effectiveness of the latest HFSS food advertisingcodes will be taken into account in formulating andenforcing revised broadcasting codes.However, these codes do not cover advertiser-ownedwebsites. The Institute of Standards in BritishAdvertising (ISBA) has published best practiceprinciples in this area to ensure a responsibleapproach to marketing to children. Indeed, somecompanies have gone further and committed to takedown their child-oriented websites and eliminategames aimed at children under 12. We welcome thisaction but, as with advertising, the impact of theseprinciples will need to be kept under review toensure that they keep pace with evolving practices.Overall, the combination of healthy eating messagesand restrictions on advertising foods high in fat, saltand sugar should together serve to help make thehealthier choice the easier one for individuals andfamilies.3. Building physical activityinto our livesPromoting participation in physicalactivityMany individuals already participate in physicalactivity through walking or cycling for shortjourneys, gym memberships, dance sessions, andformal sport. The private sector provides a wealth ofopportunities, and the Government supplementsthese through the work of Big Lottery – which fundsthe £155 million Children’s Play initiative and thedevelopment of healthier lifestyles through the£165 million Well-being programme, and willcontribute £50 million to the Sustrans Connect2initiative.In addition to this, Sport England will receive £392million from the Government and an estimated£324 million from Lottery funding over the period2008–11, to deliver community sport. Sport Englandis developing a new strategy to build a world classcommunity sport infrastructure to sustain andincrease participation in sport and allow everyonethe chance to develop their sporting talents.

20 Healthy weight, healthy livesDance has huge potential for both young and old incontributing to healthier lifestyles. It is an artformwhich can truly engage people both mentally andphysically and is particularly appealing to girls andthose who are turned off by competitive sports.Dance Links is an important part of the NationalSchool Sport Strategy, and should of course featurein the Youth Sport Trust’s work with Healthy SchoolCo-ordinators to help pupils who are overweight orobese increase their participation in physical activity.In terms of dance in the community, theGovernment and Arts Council England (ACE) haveworked closely to promote the health benefits ofdance. We will continue to explore what more canbe done to maximise the health benefits of dance.However, being physically active does not requirepeople to be on the move all the time – it is aboutgetting the balance right between physical activityand less active pursuits. People can be helped to getthis balance right. For instance a family timer isincluded or can be downloaded for a range oftechnologies (e.g. Xbox 360 and Nintendo Wii),which allows parents to limit the amount of timethe console can be used.A lot is already happening, but the Governmentbelieves that more must be done if we are topromote healthy weight across the wholepopulation. To go further faster in promotingparticipation in physical activity, the Government will:• support a ‘Walking into Health’ programmeof innovative campaigns (e.g. encouragingwalking to and at work) with the aim ofgetting a third of England walking at least1,000 more steps daily by 2012 – an extra 15billion steps a day• Set up a working group with theentertainment technology industry toensure that they continue to develop toolsto allow parents to manage the time thattheir children spend playing games andonline. To underpin this, we will alsocommission research to review the evidence onthe impact of this ‘screen time’ on children’soutcomes – including their physical health andactivity levels – and will consider the case foroffering guidance to parents• review its overall approach to physicalactivity, through the HM Treasury-leddevelopment of a new physical activitystrategy. This strategy will be clearlyaligned to the new ambition on healthyweight, and will include consideration of:– ensuring that Sport England develops arobust strategy to focus on building anddelivering a truly world-class sportsinfrastructure, maximising the impact ofGovernment investment into sport– seizing the opportunity of the London2012 Olympic Games and ParalympicGames to develop a number of physicalactivity initiatives that will inspirepeople to be more active in the run upto the 2012 Games and beyond– establishing a potential new body, ‘ActiveEngland’, to drive forward theGovernment’s commitments relating towider physical activity, complementingSport England’s work. The review willconsider the scope and funding of anysuch body before reaching a final decision.A supportive built environmentThere is significant potential for promoting ‘activetravel’, particularly given that 55 per cent of trips bycar are under 5 miles, with 25 per cent under 2miles. 11 Promoting walking and cycling as viablealternatives to car use for such journeys could havesubstantial benefits – not only for promoting healthyweight, but also for climate change, congestion andthe wider environment. The methods used bycommunities that successfully promote active travelinclude traffic calming, and building more cycleinfrastructure. The most successful areas galvanisethe whole community, including local businesses,so that everyone contributes.Chapter 1 described how many communities arealready putting in place measures to encouragephysical activity, often to meet environmental, safetyor congestion goals. Local authorities have animportant contribution to make in their ‘placeshaping’role, as planning authorities and working inlocal partnerships with other agencies. Through localarea agreements, they can set specific objectives fortheir communities.

Chapter 3: Achieving the new ambition 21The Government has a range of policies andprogrammes in place that aim to support theseefforts.• Our continued sponsorship of the Green Flagaward scheme and voluntary sector programmessuch as British Trust for Conservation Volunteers(BTCVs). Green Gyms provide opportunities forcommunities to increase their levels of activity inopen spaces.• The three Sustainable Travel Towns haveincreased walking by around 20 per cent andcycling by almost 50 per cent in two years, 19providing lessons for other communities toemulate (see case study).• The ‘Manual for Streets’ gives advice on effectivestreet design that encourages people to walkand cycle to local destinations.Peterborough Sustainable TravelDemonstration Town 19Peterborough is one of three towns taking partin the Government’s Sustainable TravelDemonstration Town programme. PeterboroughCouncil has used part of the £3.2 million infunding that is available to implementIndividualised Travel Marketing, which workswith households to offer tailor-madeinformation and support to enable them toconsider alternatives to the car.ImpactResults from the first phase of the programmeinclude:• a 13 per cent reduction in car use• a 21 per cent increase in walking• a 25 per cent increase in cycling• a 13 per cent increase in public transport use.New guidance from NICE sets out the firstrecommendations – based on evidence of effectivenessand cost-effectiveness – on how to improve thephysical environment in order to encourage andsupport physical activity. It complements previous NICEguidance on obesity and is intended to guide futureinvestment in urban design, transport routes, buildingsand school playgrounds. The new guidance is aimed atthe NHS and other professionals who have a role in thebuilt or natural environment, including those workingin local authorities and the education, community,voluntary and private sectors. NICE’s recommendationsinclude ensuring that:• any planning applications for new developmentsprioritise the need for people to be physicallyactive as a routine part of their daily life• pedestrians, cyclists and users of other modes oftransport that involve physical activity are giventhe highest priority when developing ormaintaining roads• public open spaces and public paths can bereached on foot or by bicycle, and aremaintained to a high standard• any new workplaces are linked to walking andcycling networks• during building design or refurbishment,staircases are designed and positioned toencourage use, and are clearly signposted• school playgrounds are designed to encouragevaried and physically active play.NICE has also developed tools to help organisationsto implement this guidance.But if the fabric of our urban and rural spaces is tochange so that they encourage healthy living, thenwe need to go further. A fundamental shift in ourbuilt environment will not happen overnight, butthere is more that can be done to ensure that healthis built more robustly into the fabric of our lives. Inparticular, the Government will:• invest in training for planners (urban, ruraland transport), architects and designers onthe health implications of local plans(e.g. spatial plans and planning applications)

22 Healthy weight, healthy lives• develop and promote a toolkit that drawstogether all the ways in which planningpolicy and powers can be applied topromote physical activity, showcasingexamples of good practice wherecommunities have achieved success.This will build on the NICE guidelines.• ensure that the Thames Gateway and theGrowth Areas and Growth Points areexemplars of best practice• encourage local planning authorities, whenconsidering planning applications relatingto all types of outdoor space, includingopen space and playing fields, to supportthe vision of a more physically active society• include options for strengthening the roleof assessing health impacts within thecurrent consultation on the New Approachto Transport Appraisals• use the planning policy review announcedin the Planning White Paper to identifywhere changes can be made or additionalguidance produced, to help tackle obesityand support healthy communities. This willbuild on the agenda already set out in TheChildren’s Plan to improve the usability ofpublic spaces for playThe Government will also work with a numberof interested local authorities to sign up to aHealthy Community Challenge Fund. This willtest and validate holistic approaches topromoting physical activity. Towns and citiesthat sign up – badged ‘healthy towns’ – will beexpected to invest in infrastructureimprovements that implement the lessons ofa variety of programmes (e.g. Homezones andCycling Demonstration Towns). Theseimprovements will need to be combined withefforts to galvanise local members of thecommunity to take action to change both foodand activity habits, following the example setby the EPODE model in Europe (see below). Thefund will total £30 million during 2008–11, withthe expectation that signatories willsupplement these funds with their own.EPODE case study 20EPODE (‘Ensemble prévenons l’obésité desenfants’, or ‘Together, let’s prevent obesity inchildren’) is a community -based, family -orientednutrition and lifestyle education programme. Itaims to prevent child obesity by bringing togetherinfluential individuals and groups in thecommunity – including education and healthprofessionals, retailers and the media – in acampaign of local physical activity and healthyeating initiatives aimed at both children and theirparents. Since the programme was launched in2004, more than 100 French towns have joinedthe 10 pilot communities. The programme is alsobeing rolled out into Belgium and Spain.The official results from the 10 EPODE pilottowns will be published in 2009. However, earlyresults seem promising. For example, in 2004,19 per cent of the children in Saint Jean, a townin the Midi Pyrénées region, were overweight.A year later this figure was down to 13.5 per cent.4. Creating incentives forbetter healthEmployer incentivesThe workplace can have a significant impact onemployee health, and can present an opportunity topromote healthy living. Employers have a role to playin supporting working adults to make healthychoices. Many well-run organisations already addresshealth and well-being at work as an essential part ofbusiness improvement.Employers can support their staff in a number ofways: making healthy options available in staffcanteens, providing fitness facilities and investing infacilities for cyclists. Employers will reap the benefitsin improved productivity, high staff morale andretention, and reduced sickness absence costs.

Chapter 3: Achieving the new ambition 23Much good work is already happening acrossGovernment to improve the health of working-agepeople and to encourage employers to protect andpromote the health of their workforces – mostnotably through the health, work and well-beingstrategy. The FSA has also recently announced plansto work with employers, catering providers and theirsuppliers to develop practical ways to deliverhealthier workplace catering.However, we want to build on this to achieve a realcultural change. The benefits of work to health needto be understood by all, and the potential of theworkplace to boost health and fitness should bemaximised. To support all this, the Government will:• consider how the findings of theforthcoming review of the health of theworking-age population (being carried outby Dame Carol Black, National Director forHealth and Work) can contribute to meetingour new ambition on healthy weight• work with employers and employerorganisations to develop pilots exploringhow companies can best promote wellnessamong their staff, and make healthyworkplaces part of their core businessmodel• explore with the fitness and leisureindustries how to boost the use of theirfacilities during off-peak times by bothfamilies and staff under flexible workingconditions. Such initiatives could includeemployers fostering relationships with localleisure facilities, and variable charging ratesfor peak and off-peak hours• launch a number of pilots of well-beingassessments throughout the NHS in spring2008, where individual staff are offeredpersonalised health advice and lifestylemanagement programmes linked topersonal assessments of their health status.These programmes have been shown to boostemployee health and to bring benefits toemployers through fewer absences and a moreengaged workforce.Case study examples from‘Well@Work’ pilots‘Cold Turkey‘ and ‘Biggest Loser’ were twoweight loss competitions offered to employeesthrough two Well@Work projects. Bothdemonstrated rapid success in achieving weightloss and in the future will need to show that thiscan be sustained.Cold Turkey was a team-based competition runover 11 weeks. The team that achieved thegreatest weight loss was the winner andreceived a trophy. Also, fruit baskets wereawarded to the team with the greatestpercentage loss each week during thecompetition. In total, 14 teams lost an averageof 8kg each (the range was from 0 per cent to6.9 per cent) – equivalent to 0.7kg per week.Biggest Loser was an eight-week individualweight loss competition. The man and womanwho achieved the greatest percentage weightloss received £130 in gift experience voucherseach, while the man and woman who lost themost waist circumference received £30 invouchers each. Weight loss ranged from 0.4 percent to 6.4 per cent.Incentives across societyMore broadly, the benefits to individuals and publicbodies of taking action to reduce the prevalence ofweight problems often come many years in thefuture, while the costs are immediate. We need torework the incentives for individuals and publicbodies to encourage actions now, thereby avoidingthe often much larger costs in later years. In theUSA, for example, there is some evidence that smallfinancial payments, as part of broader programmesto tackle obesity, have proven particularly effective inincentivising individuals to both achieve andmaintain weight loss.

24 Healthy weight, healthy livesHowever, we are a long way from understandingwhat kinds of incentives work, which groups mightbe most affected by them, and how cost-effectivethese interventions are.• At the individual level, we will build up ourknowledge of which interventions are mosteffective in encouraging individuals andfamilies to change their behaviour. We willprovide resources to pilot and evaluate arange of different approaches toencouraging healthy living. For example,we will look at using financial incentives,such as payments, vouchers and otherrewards, to encourage individuals to loseweight and sustain that weight loss, to eatmore healthily, or to be consistently morephysically active.• At the commissioner level, we will also lookat whether we can better structure healthfunding flows (including Practice BasedCommissioning (PBC) financial flows) topromote effective upfront investments inhealthy living. We will consider whether wecan use health resources more flexibly,building on the Commissioning for Healthand Well-being flexibilities.5. Personalised advice andsupportPersonalised advice for allThe recently launched ‘NHS Choices’ websiteprovides advice to everyone on making the choicesthat lead to a healthier life. The website alreadyincludes some advice on nutrition and exercise, butat present it is generic and not tailored to the needsof individuals.The Government will seek to further developthe NHS Choices website so that it provideshighly personalised advice on diet, activity andhow to maintain a healthy weight. TheGovernment will work with the FSA and otherrelevant bodies to ensure that this advice isbased on the best available evidence, so thatindividuals can make sense of often conflictingadvice from other sources. We will also explorethe potential to include information on whichcompanies meet which aspects of the codes ofgood practice in food and entertainmenttechnology.Personalised care for obese andoverweight individualsWhile prevention measures across the wholepopulation will in time lead to a healthier nation,the situation of those who are already overweight orobese also needs to be considered as a crucialelement of our strategy. The number of overweightand obese individuals is forecast to continue rising,and it is essential that effective services are availableto help these people to meet the personal challengeof reducing their BMI and maintaining a healthyweight.Many people currently choose to face that challengealone, or with the assistance of commercial weightmanagement organisations. Given the health risksassociated with being overweight or obese, the NHSneeds to take an increasingly proactive role inproviding advice on and access to weightmanagement services.The Government has already published a clinical carepathway and guidance for GPs on the managementof excess weight problems, recommending that GPsagree personal weight plans with patients.Additionally, the Quality and Outcomes Frameworkincentivises GPs to keep a register of all adultsregistered to their practice with a BMI of over 30.The NICE guidance of 2006 has also laid a firmfoundation for the NHS to commission weightmanagement services.Many PCTs are increasing their provision for bothchildren and adults with weight problems, andknowledge of what works is growing. However,depending on their particular needs, many localareas will need to accelerate their provision to matchthe growing demand. The Government willsupport the commissioning of more weightmanagement services by providing extrafunding for this over the next three years.The Government will also take a number of steps tosupport PCTs in commissioning and implementing

Chapter 3: Achieving the new ambition 25weight management services. These steps will focuson weight management services for children, in linewith the new ambition’s initial focus, and theyinclude:• developing a toolkit for PCTs and localauthorities to assist with the effectivecommissioning of weight managementservices• considering how best to support local areasin widening the numbers and types of staffand professions that can play a role insensitively identifying and referringoverweight and obese children intoappropriate services• funding research into effective weightmanagement for under-fives.In addition, we recognise the vital role played by thecommercial sector, the third sector, social enterpriseand other providers in ensuring that more peoplecan access effective services and in increasingnational understanding of what works. We willcontinue to engage with these providers to exploreways in which the sector can be developed torespond to future demand.Although the initial focus of this strategy is onchildren, it is also important that, in time, the needsof adults who are overweight or obese areconsidered. More support needs to be provided tothose who wish to move towards a healthier weight.Many of the steps set out above will help local areasto improve the provision of services for adults as wellas children. But in addition to weight managementservices, primary care professionals – including GPsand practice nurses – will remain a trusted first portof call for people seeking advice about healthierlifestyles.However, the Government has received somefeedback that suggests that GPs are not making fulluse of the clinical care pathway, nor their BMIregisters. To address this, the Government willevaluate and, if needed, update the existingclinical care pathway for the management ofweight problems. It will ensure that healthprofessionals are able to use this importantresource effectively.The Government will also ensure that healthcareprofessionals are equipped to support adults whomay wish to work towards maintaining a healthierweight, for example by:• developing a ‘Let’s Get Moving’ resourcepack for GPs and practice nurses based onlessons from the London pilots. This willhelp sedentary adults (and those at riskof adverse health outcomes associatedwith low activity levels) to become moreactive – for example by helping to setindividual goals, signposting patients tolocal opportunities and keeping track oftheir progress as part of personal weightplans• exploring further opportunities foridentifying adults who would benefit frommoving towards a healthier weight, andmaking them aware of opportunities forsupport. For example, as announced by thePrime Minister, the Government will soon bebringing forward proposals for the systematicassessment of adults in England for the risksof heart disease, stroke, kidney disease,hypertensive disease and diabetes.The NHS Next Stage Review is developing a visionfor world-class primary and community services,which will focus ever more strongly on promotinghealth, preventing illness and managing long-termconditions – not least in response to lifestyle riskfactors such as obesity. This is likely to meanreaching out to the harder-to-reach groups amongour diverse population rather than waiting for themto present at the GP surgery. The review willconsider the contractual and commissioningarrangements for primary medical care, includinghow to reshape incentives to provide a strongerfocus on health outcomes and continuous qualityimprovements.And finally, it is of course important that local healthservices also meet the needs of those individuals forwhom pharmaceutical or surgical interventions maybe appropriate. NICE has set clear guidelines on theappropriate use of such interventions.

CHAPTER 4:DELIVERING CHANGE

Chapter 4: Delivering change 27Chapter 3 described some concrete steps that allmembers of society can take to contribute to meetingthe new ambition, and set a clear direction for whatneeds to be done in the medium and long-term.Facilitating a national dialogueAs we know, tackling the rise in unhealthy weight isnot something Government could or should do on itsown. Everyone needs to play their part – individualsand families, teachers and schools, doctors, nursesand the wider health service, the food, leisure,advertising and broadcasting industries, and manymore – all will need to play a role. To develop astronger sense of our respective responsibilities totackle unhealthy weight, and to build a Coalition forBetter Health, the Government will facilitate anational dialogue on society’s response to theepidemic of excess weight. So over the comingmonths the Government will work with theGovernment Offices, strategic health authorities(SHAs), PCTs and local authorities to engage citizens,businesses and others in events across the country,including:• deliberative events• citizens’ juries• regional summits including business, thevoluntary sector, trade unions and GovernmentBy their very nature these events will cover a vastrange of issues, including those where Governmenthas no role but which are important to citizens inaddressing how they can maintain a healthy weight.Engaging parents will be a priority.A comprehensive marketingprogrammeTo tackle unhealthy weight, it’s clear we need awider cultural shift in the way we nourish and raiseour children, resulting in fundamental changes tothose parenting behaviours that lead to childhoodoverweight and obesity. As a catalyst for this culturalchange, we have developed a £75 million marketingprogramme based on extensive research andaudience insight.To be effective, we will create a mix of simpleuniversal messages with broad impact, tailoredmessages for different at-risk families and targetedproducts developed for those who have the greatestneed. This will not be a Government campaign tellingpeople how to raise their children; rather, aGovernment-encouraged movement, to whicheveryone – parents, service providers, third sector andcommercial partners – can belong and contribute.The evidence tells us that it is easier for individuals tomaintain a healthy weight than it is to shed pounds,and easier to establish good patterns of activity andgood eating habits than it is to change habits that havebecome ingrained. Accordingly, the primary emphasisof the marketing programme is on preventativemeasures and the establishment of good dietary habitsand activity levels from early infancy. This willencompass several themes, including: breastfeeding,healthy weaning, encouraging uptake of ‘5 A Day’,improving understanding of the components of ahealthy diet and encouraging everyday activity. Thesecondary focus is on the promotion of interventionsthat change behaviours in older children.National prioritisation and clearaccountability within GovernmentThe Government has sent a clear signal thatenabling individuals to maintain a healthy weight isimportant through the inclusion of obesity as anational priority within the NHS OperatingFramework and the Children’s Plan. The NHSOperating Framework requires all PCTs to developplans to tackle child obesity, and to agree local planswith SHAs. It is the Government’s expectation thatPCTs will seek to work with local authorities todevelop these plans, using the Joint Strategic NeedsAssessment process that will become a requirementfrom April 2008. If the PCT and local authority agreethat there is a sufficient local need to promotemaintaining a healthy weight then they can seek tojointly develop a target within their Local AreaAgreement (LAA) that sets out what they will do toachieve this goal, including funding commitments.Additionally, any plans on child obesity must beclosely aligned to the Children and Young People’sPlans (CYPPs) which set out how local authoritiesand their Children’s Trust partners will meet theneeds of children and young people in their area.PCTs and SHAs have a duty (under section 10 of theChildren Act 2004) to co-operate with local

28 Healthy weight, healthy livesauthorities at every level in making arrangements toimprove children’s well-being. This means that localauthorities must work together with PCTs and SHAsin drawing up and implementing their CYPP.Performance against any targets included with an LAAwill be assessed through the Comprehensive AreaAssessment, which will include publication ofperformance data against the set of national indicatorsand an area risk assessment identifying risks tooutcomes and the effectiveness of their management.NHS performance will also be monitored on an annualbasis through the Vital Signs indicator set. The obesityindicator based on Reception Year and Year 6 NCMPdata, which is proposed for use in both the Vital Signsand the National Indicator Set, complements the annualreporting of performance on childhood obesity for thenational Child Health PSA, based on data from the HealthSurvey for England. This demonstrates that accountabilityfor delivery of the new obesity ambition is closely aligned,both across local areas, and locally and nationally.Extra resourcesAs a demonstration of the Government’scommitment to tackling obesity and beingoverweight, we will make a total of£372 million available for the programmes setout in this strategy document over the period2008–11. This is over and above the £1.3 billioninvestment in school food, sport and play, andthe £140 million further funding for CyclingEngland, already announced for 2008–11.Staff skills and capabilitiesIt will be important for staff in a wide range oforganisations to understand the role that they playin addressing activity and nutrition. This will includestaff in the NHS, schools, built environment, thefood industry and many more.Therefore training will need to address the differentneeds of these staff groups but, importantly, it must alsorecognise how sensitive the issue of weight is and buildboth the confidence of staff to be able to raise the issue,and the know-how to influence behaviour change.A number of training programmes already exist, orare in development, that aim to provide staff withskills and knowledge in nutrition and physicalactivity. These include:• The South East Teaching Public Health Networkprogramme to improve teachers’ attitudes andknowledge about diet and healthier lifestyles• The National Personal, Social Health EducationContinuing Professional Development Programmefor teachers, which includes a module onemotional health and well-being covering issuesto do with body image and food choices• Southampton University’s work to develop ane-nutrition teaching programme• The Association for the Study of Obesity has anannual training course on tackling obesityfocused on the needs of healthcare professionalsThe Government will seek to build on theseprogrammes and spread this good practice intothe curricula for other professions, workingwith the relevant training bodies.Extensive support and guidanceGiven the complexity of tackling weight issues, whereit is identified as a problem, local authorities, PCTs andother organisations will have to work closely together,co-ordinating their activities if they are to successfullytackle it. The funding provided to PCTs as part of theNHS national bundle will allow them to increase theircentral capabilities to manage and co-ordinate actionto tackle excess weight. One option is for PCTs andlocal authorities to jointly fund a local coordinator tobring together the relevant groups which influence thelocal environment (e.g. the planning committee,housing associations, transport companies).In addition to this, the Government will shortlypublish guidance for PCTs, local authorities andother local organisations, describing whatprogrammes and policies they can put in placeto set and meet their own local ambitions onhealthy weight, contributing to delivering thenational ambition. This guidance will also clarify thelinks between promoting healthy weight and otherlocal policy aims (e.g. reducing congestion, tacklingcarbon emissions). The guidance will recognise thatif they want to make a difference on obesity,agencies will need to ensure that they have

Chapter 4: Delivering change 29considered how best to engage and support theneeds of diverse local populations and ensure thatthere is targeted action where required.The implementation of this local guidance will besupported by the Obesity National Support Team,established in September 2007 to provide intensivesupport to those PCTs and local authorities withparticular challenges. This will be delivered in thecontext of central Government and local partnershipsworking together to support excellence as set out inthe Government’s National Improvement andEfficiency Strategy. Regional Directors of Public Health(RDsPH) will also be critical to ensuring that localareas understand and are able to deliver the new PSAambition. They will continue to receive fundingto ensure that they are able to provide supportto local areas on this issue.Clear Whitehall decision-makingTo provide leadership across Whitehall the Governmenthas established a new Cabinet Committee on Healthand Well-being. The remit of this committee includestackling obesity and promoting healthy weight, andthe membership includes all of the lead departments.The Cabinet Committee on Families, Children andYoung People will also monitor progress with respectto child weight problems.Reporting to the new committee is a new cross-Government obesity unit. This is based in theDepartment of Health but led jointly by theDepartment of Health and the Department forChildren Schools and Families, and includes staff andresources from across Government. The majorresponsibilities of the new unit will include:• taking forward the commitment outlined in thisstrategy• producing the annual report• leading across Government in developing furtherproposals as necessary to fulfil our ambition toreverse the rising tide of obesity and overweight• acting as the focal point for knowledge onhealthy weight in Government• managing relationships between Government,industry and other stakeholders – the unit willact as the secretariat to the new stakeholdergroups (see below)• building the evidence base on tackling obesity(see Chapter 5).The unit is supported in its responsibilities by:1. An Expert Panel of academics, building on theForesight science advisers2. A Delivery Reference Group composed ofexperienced representatives from across thedelivery chain and across the country.The Government remains committed to assessingthe impacts, through the Impact Assessmentprocess, including the health impacts, of its policiesupon the public, private and third sectors.Additionally the Government is committed toassessing the impact on equality, including race,disability and gender and has undertaken an EqualityImpact Assessment which will be published on DH’swebsite. The policies set out in this strategy arebased on the best available evidence and expertopinion. Full impact assessments on these policieswill be carried out as these policies are takenforward. The new unit will also work to align policieswith the forthcoming Cross-Government GlobalHealth Strategy.Reinvigorated stakeholder engagementTo support stakeholders in business and the thirdsector in engaging with each other on how theycan meet the challenge of tackling excess weight inthe population, the Government will seek to workwith stakeholders on how to strengthen existingarrangements. Our aim is to build a Coalition forBetter Health, which would:• reach agreements on joint programmes• disseminate knowledge on what works, andwhat doesn’t• challenge each other to go furtherThis development work will take place over thecoming months with a view to launching the newarrangements in the summer.

CHAPTER 5:INVEsTING IN oURKNowLEDGE

Chapter 5: Developing our knowledge 31Good data and a strong evidence base on what workswill be fundamental to successful action to promotehealthy living and reduce the number of overweightand obese individuals. However, we are still in relativelyearly days in terms of our understanding of trends inexcess weight, the reasons for these, and effectiveways of preventing weight gain, maintaining healthyweight and treating overweight and obese individuals.So this final chapter sets out how the Governmentwill improve the available data and continue todevelop the evidence base on what works.Better data to identify at-riskindividuals and familiesThe previous chapter set out how NCMP data will beused to hold PCTs and local authorities to account fortheir performance in tackling obesity where it formspart of LAAs. But since these cover children at theages of 5 and 11, there is a gap in locally availabledata for early years, teenagers and adults. Over timewe will develop comprehensive data that allowsus to track the trends in weight of people at allages. To fill current gaps the Government will explorea number of options, including:• using existing data on maternal weight toidentify at-risk families• weighing and measuring children in the first twoyears of life where there is parental orprofessional concern regarding a child’s growth• collecting height and weight data on youngpeople and adults• obtaining better information from primary careon obese and overweight patients• other cost-effective methods of collecting heightand weight data on adults• participation in the WHO European childhoodobesity surveillance initiative to provideinternationally comparable data• making full use of data from the Expenditureand Food Survey, and the National Diet andNutrition Survey.It is important that any measurements arecomplemented with clear training on how toproperly interpret them, especially in relation to achild’s growth potential. The Government willinclude consideration of this in efforts to improvestaff skills and capabilities.Building the evidence baseOne of the responsibilities of the new cross-Government obesity unit will be to commission newresearch into the causes of weight problems andprogrammes to tackle it. The exact nature of theresearch programme will be developed over thecoming months but will relate to specific policy needs.It will be based on the work of the Foresight obesityprogramme and build on current research andresearch infrastructure funded by other departmentsand organisations. As a first step a meeting of ChiefScientific Advisers from across Government hasalready been held to determine how to take forwardwork on healthy weight collaboratively, including theimportant role of the Research Councils.Beyond this, the Government will invest in researchto deepen our understanding of the causes andconsequences of the rise in unhealthy weight, andthe evidence of what works. Critical to the deliveryof this is the new Obesity Observatory. Established inDecember 2007 as part of the wider Public HealthObservatory family, it will work alongside theexisting research and development infrastructure.The Obesity Observatory will be commissioned to:• provide an authoritative source of data andevidence on obesity, overweight and theirdeterminants• co-ordinate surveillance on obesity andoverweight, including working towards thecommitment to monitoring made in the WHOEuropean Charter on Counteracting Obesity• analyse surveillance and indicator data andreporting on progress against the new ambition• provide guidance on assessing and evaluatingpilots and demonstration sites in England• gather information on international best practiceand develop links to the International ObesityTask Force, WHO, and other supranationalbodies – including the new EU nutrition andphysical activity strategy• provide technical support to the Expert Panel.One of the first tasks of the Obesity Observatorywill be to assess the strengths and weaknessesof using the International Obesity Task Forcecut-offs for defining BMI against the 1990 UKGrowth Reference Standards currently used.

CoNCLUsIoN

Conclusion 33Being obese or overweight are problems that at firstsight seem easy to solve – individuals should just eatless and exercise more. But while this view hasalways been too simplistic on reflection, the latestresearch evidence allows us to understand just howmuch of what drives individual choices on food andphysical activity is influenced by modern society. Forthis reason, excess weight can genuinely bedescribed as the most significant public and personalhealth challenge facing us today.This strategy recognises that the challenge that weface is greater than previously realised, and respondsby setting out both the immediate Governmentactions and the future direction of travel to meet thenew ambition of ensuring that everyone is able tomaintain a healthy weight and so lead a healthierlife. The annual progress report that this strategycommits to will encourage and support a continuingdialogue – enthusing everyone in society to find thelong-term, sustainable answers so that together wecan meet our ambition.

ANNEX A –DEFINITIoN oFobEsITY

Definition of obesity 35Obesity and being overweight are well-knowndescriptions and everyone has a rough idea of theirmeaning, but they are also technical terms with cleardefinitions defined by the WHO based on the BodyMass Index (BMI – see box for an explanation).BMI is an effective measure of weight status at apopulation level but can be less accurate forassessing healthy weight in individuals, especially forcertain groups (e.g. athletes, the elderly) where aslightly higher BMI is not necessarily unhealthy.BMI is therefore often supplemented by measuringwaist circumference and by considering individualcircumstances. However, these complexities meanthat, while BMI is well understood by clinicians andprofessions related to nutrition, it does not alwaysprovide a clear guide for the majority of people.For children the situation is more complicated. Thereis no fixed BMI to define being obese or overweightsince this varies with gender and with growth anddevelopment. Parents can get an indication of theirchild’s weight status by checking their position on astandard growth chart but should seek expertguidance before acting on such information.Although not perfect, leading experts haveconcluded that BMI is the best measure we have.However, we will keep this under review as part ofour commitment to invest in our knowledge.Body Mass Index (BMI)BMI is measured by dividing a person’s weight (in kilograms) by the square of their height (in metres).The calculation produces a figure that can be compared to various thresholds that define whether aperson is overweight or obese. For adults these thresholds are:BMI below 18.5BMI between 18.5 and 25BMI between 25 and 30BMI between 30 and 40BMI over 40UnderweightHealthy weightOverweightObeseMorbidly obese

ENDNoTEs

Endnotes 371. NHS Information Centre (2006) Health Survey for England 2005 Latest Trends. NHS Information Centre2. Foresight (2007) Tackling Obesities: Future Choices – Project Report. Government Office for Science3. HM Government (2007) PSA Delivery Agreement 12: Improve the health and well-being of children andyoung people. HM Treasury. www.hm-treasury.gov.uk4. Whitaker R.C., Wright J.A., Pepe M.S., et al (1997) Predicting obesity in young adulthood from childhoodand parental obesity. The New England Journal of Medicine; 337:869–735. Kopelman P, (2007) Health Risks Associated with Overweight and Obesity. Short Science Review.Foresight Tackling Obesities: Future Choices. Obesity Reviews; 8 (s1): 13-176. Field AE, Coakley EK, Must A, Spadano JL, Laird N, Dietz WH, et al (2001) Impact of overweight on therisk of developing common chronic diseases during a 10-year period. Arch Intern Med; 161: 1581–15867. Targher G (2007) Non-alcoholic fatty liver disease, the metabolic syndrome and the risk of cardiovasculardisease: the plot thickens. Diabetic Medicine; 24(1):1–68. Diabetes UK. www.diabetes.org.uk9. Fontaine, K.R., Redden, D.T., Wang, C. et al (2003) Years of Life Lost Due to Obesity. Journal of theAmerican Medical Association; 289:187–9310. Carnell S., Edwards C., Croker H., Boniface D. and Wardle J (2005) Parental perceptions of overweight in3–5 year olds. International Journal of Obesity; 29: 353–5511. Zaninotto P, Wardle H, Stamatakis E, Mindell J, Head J (2006) Forecasting Obesity to 2010. NationalCentre for Social Research12. Royal Commission on Environmental Pollution (2007) Twenty-sixth Report: The Urban Environment:Royal Commission on Environmental Pollution13. Department for Transport – National Travel Survey www.dft.gov.uk14. Childwise (2007) The Childwise Monitor Trends Report 2007. Childwise15. Blenkinsop S, Bradshaw S., Cade J, Chan D, Greenwood D, Ransley J, Schagen S, Scott E, Teeman D andThomas, J. (2007). Further Evaluation of the School Fruit and Vegetable Scheme. Department of HealthSchagen S, Blenkinsop S, Schagen I, Scott E, Teeman D, White G, Ransley J, Cade J. and Greenwood D.(2005) Evaluation of the School Fruit and Vegetable Pilot Scheme: Final Report. Big Lottery Fund.16. Department for Children, Schools and Families (2007) School Sports Survey 2006/07. Department forChildren, Schools and Families17. Olds D (2002) Prenatal and Infancy Home Visiting by Nurses: From Randomised Control Trials toCommunity Replication. Prevention Science; Vol 3, No 3.18. Department for Children, Schools and Families (2007) The Children’s Plan: Building Brighter Futures.Department for Children, Schools and Families19. Department for Transport (2005) Sustainable travel demonstration towns www.dft.gov.uk20. Wesley H (2007) Thin Living. British Medical Journal; 335–1236–1237

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