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Childhood Obesity

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					                                                                           Childhood Obesity


           Outcome:             Childhood Obesity                 Leads:           Natalie Field & Inge Shepherd & John Twigger

           A    Executive Summary
                 In 2007/08, 10.3% of reception age children were obese rising to 19.5% for Year 6 children (10-11 year olds). Nationally 18.3% of year 6 children
                were obese. This does not include the percentage of children who are overweight.
                 The national target (Vital Signs) indicator is to increase the percentage of reception year children with height and weight recorded from 86.0%
                coverage in 2007/08 to 91.5% by 2010/11 and the percentage of year 6 children from 84.0% coverage in 2007/08 to 88.3% by 2010/11 (see B4 and
                B12). This is the process indicator. The key actions are to reduce levels of obesity. The rate of rise in childhood obesity is to be reduced by 50%
                (est. 15,000-20,000 children) by 2010. The target excludes overweight children who would represent an additional 16% (est. 15,000 children) of all
                children.
                 Obesity is more prevalent in specific communities within our population e.g. Pakistani, Black African communities and people with
                learning difficulties.
                 There has been some previous work which has been limited to working in schools on primary prevention e.g. Healthy Schools Programme.
                 Tackling this problem is complex and no developed country has yet succeeded in reversing the trend. Due to the scale of this problem
                this is a multi-faceted, multi agency programme of work that will require additional investment and require more sophisticated modelling
                and evaluation of the impact for each intervention.


                  New short term work includes:
                 Prevention: Includes encouragement of breastfeeding as evidence states that breast fed babies are less likely to be obese. Physical
                 activity, food and health advice to parents in early years settings e.g. childrens centres. A school nurse to support the national childhood
                 measurement programme and healthy weight interventions in a school setting e.g. physical activity, behavioural change and nutritional
                 advice sessions for children at risk of being overweight (these sessions are with their parents) and developing a programme for roll out
                 across the school nursing service. This links very closely with the healthy schools programme. Also, development of programmes aimed at
                 increasing physical activity.
                 Treatment: To provide an obesity treatment programme through 1 clinic at Bristol Childrens Hospital and 2 clinics out in the community (behaviour
                 modification). Providing the MEND programme which is a 12 week targeted programme for children and their families (see delivery plan C).
                  Long term work is part of wider healthy weight and physical activity programmes and work is:
                 Prevention: Bristol is the first city to implement the UNICEF Breastfeeding Baby Friendly Initiative in the community which are standards to ensure the
                 quality and consistency of advice from health visitors, etc; provide peer support, which is evidence based, in the 8 wards with the lowest
                 breastfeeding rates i.e. mothers with significant breastfeeding experience supporting breastfeeding mothers; expanding the interventions (similar to
                 the healthy schools programme) in early years settings (childrens centres) around healthy weight and physical activity e.g. cooking groups, provision
                 of healthy food, active travel plans; healthy schools programme - implementing nutritional guidelines; increasing the number and range of physical
                 activities interventions e.g. 'Bike It', 'Heels and Wheels'; Healthy Kids programme - healthy lifestyle interventions including physical activity and
                 nutrition.
                 Treatment: Implementing the childhood obesity care pathway - training our workforce including primary care and establishment of 4 new clinics in the
                 community (see delivery plan C).
                  Total new investment 2009/10-2012/13 = £400,000 (see delivery plan D).
                  Partnership arrangements: Partnership arrangements with the council are crucial. Links to the Health and Wellbeing group, sub group of
                 the Strategic Partnership (see delivery plan E).

           B    Background

           B1   Brief description of health outcome:
                Prevalence of obesity in Year 6 and Reception primary school age children. Good practice is that PCTs show in their plans a rate of increase in
                prevalence of childhood obesity that is lower than the current national trend, as they work towards the new ambition of returning, nationally, to 2000
                levels of childhood obesity by 2020. The rate of rise in childhood obesity to be reduced by 50% by 2010.

           B2   Please state the rationale for choosing this health outcome:
                In Bristol, approximately 1 in 5 (20%) Year 6 children and 1 in 10 (10%) Reception year children are obese, which is a four fold and two fold increase
                respectively against the initial 5% who exceeded the 95th percentile from the 1990 baseline (1990 UK Growth Reference Charts). Obesity is a key
                factor in short and long term health, in particular fatty liver and Type 2 Diabetes. Obesity in childhood usually leads to obesity in adulthood. Obesity is
                more prevalent in specific communities within our population e.g. Pakistani, Black African communities and people with learning difficulties, which links
                with the PCT's equality agenda.

           B3   Brief description of indicator:
                Tier 2 Vital Sign - VSB09 - (2 targets (1) Reception Year children and (2) Year 6 children). Percentage of children with height and weight recorded
                should increase year-on-year and is expected. Measurements of height and weight for Year 6 children for 2009/10 will take place in autumn 2009 and
                spring 2010 and for Reception age children in the summer of 2010.

           B4   Vital Signs Submission:




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                                                                                                            Childhood Obesity


           B5   Definition of Obesity:
                Childhood obesity is defined as having Body Mass Index greater than the 95th percentile (vs 1990 baseline). Overweight is defined as having a BMI
                greater than or equal to the 85th percentile but less than the 95th percentile. Healthy weight is defined as having a BMI lower than the 85th percentile
                for their age and sex. Obesity in children is identified differently to adults, identification is based on growth charts, depending upon the age of the child.
                Current growth charts do not accurately reflect the growth patterns of certain BME groups, and therefore in areas with high BME groups there is a
                danger of over estimating the levels of obesity.

           B6   Causation Analysis and Evidence Base
                The causes of childhood obesity are complex and multifaceted but result in an excess of calorie intake relative to calorie expenditure. The evidence
                base is largely limited to observational data, but Bristol's Healthy Weight Strategy has been designed in line with NICE guidance 2006 and the Faculty
                of Public Health 'Lightening the load' toolkit.

           B7   Summary of Strategy:
                Bristol has three inter-related strategies that tackle overweight and obesity as listed below. The combined strategies are known as Bristol’s Healthy
                Weight strategy. Each strategy has its own action plan that is reviewed every two years.
                • Weight Management Strategy 2007 - 2012 (focuses on treatment of overweight and obesity)
                • Food & Health Strategy 2007 - 2012 (focuses on prevention of overweight and obesity and wider nutritional issues)
                • Physical Activity Strategy 2005 - 2010 (focuses on prevention of overweight and obesity).
                All the three strategies have Children and Young People as a key population group. The National Support Team for Childhood Obesity reviewed
                Bristol's Healthy Weight strategies in March 2008. Their feedback was extremely positive and in particular they noted the robust strategies and action
                plans were in place. They identified many examples of good and exemplar practice.

           B8   Demonstrate the links to the Joint Strategic Needs Assessment (JSNA):
                The Joint Strategic Health Needs Assessment (JSHNA) 2008 for Bristol identifies reducing childhood obesity as a key priority.

           B8   Data from national data set (available to assessment panel):
                Figure 1 shows levels of Year 6 childhood obesity for Bristol PCT, the SHA average and Cluster PCT average for 2007/08.



                                                                                Vital Sign VSB09 - Childhood obesity
                                                                                  Obesity in 10-11 yr olds (2007/08)

                                 25%


                                 20%


                                 15%
                                                                                                                            National Average
                                                                                                                            National upper quartile
                                 10%
                                                                                                                            National low er quartile
                                         5%


                                         0%
                                                        Bristol PCT        Cluster Average         SHA Average
                                                                        PCT and com parators



           B9   Data source:
                Information Centre for Health and Social Care – National Child Measurement Programme (NCMP)

           B10 Is the national data robust? How have we come to this conclusion?
               Year 6 2006/07 data was not robust due to low coverage (44%), Reception was robust and coverage was 89%. 2007/08 data for both is be robust
               (see coverage below). The Year 6 low coverage in 2006/07 was due to the process being an opt-in method and a large proportion of higher BMI
               children did not opt-in, thus skewing the results and underestimating the true level of obesity. Measurement has now changed to an opt-out consent
               policy and this is reflected in a much higher coverage for year 6 in 2007/08. For Year 6 the 2007/08 data has been used as the baseline due to the
               unreliability of Year 6 data in 2006/07, whereas for Reception year 2006/07 data is being used for the baseline.


           B11 Please state current performance against target outcome:


                                                      Figure 1: Reception Year Obesity Prevalence


                                        12%
                   % of children measured that were




                                        10%

                                                8%
                                 obese




                                                6%

                                                4%                                                             Plan
                                                                                                               Actual
                                                2%

                                                0%
                                                      2006/07         2007/08       2008/09     2009/10      2010/11
                                                                                  School Year


                Figures 1&2 show the increasing prevalence of obesity amongst Bristol's children between 2006/07 and 2007/08 (in blue). The
                Vital Signs targets for 2008/09-2010/11 are shown in pink. The apparent increase of obesity in Year 6 children is misleading
                because of the known inaccuracy of the 2006/07 data.




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                                                                                                                           Childhood Obesity


           B12 Do we know the current rate of improvement? If so, please provide details:
               The table below shows Bristol’s National Child Measurement Programme results (the proportion of children weighed & measured and levels of
               childhood obesity. In 2007/08 nearly one out of five Year 6 children was obese. In 2006/07 nearly one out of ten Reception age children was obese.

                                                                                                             2006/07   2007/08
                Reception                                                 % obese                             9.7%      10.3%
                                                                          % coverage                           89%      86.0%
                Year 6                                                    % obese                             15.2%     19.5%
                                                                          % coverage                           44%      84.0%
                * Year 6 2006/07 prevalence unreliable due to low coverage



           B13 Include benchmarking data where available - comparison with SHA - ONS comparison - 'cluster' comparable cities:
               Figures 3 & 4 shows the percentage of Reception age and Year 6 children who were obese in 2006/07 for some core cities and
               for England as a whole.

                Figure 3: In 2007/08 Bristol had lower levels of obesity among Reception age children compared to the core cities of Manchester
                and Liverpool but higher levels than Sheffield and Leeds. Figure 4: In 2007/08, Bristol had lower levels of obesity among
                Reception age children compared to the core cities of Manchester and Liverpool but higher levels than Sheffield and Leeds.


                                                               Figure 3: 2007/08 Reception Year Prevalence - Core Cities                                                                         Figure 4: 2007/08 Year 6 Prevalence - Core Cities
                   % of children measured that were obese




                                                                                                                                               % of children measured that were obese
                                                            14.0%                                                                                                                       25.0%
                                                            12.0%
                                                                                                                                                                                        20.0%
                                                            10.0%

                                                            8.0%                                                                                                                        15.0%

                                                            6.0%                                                                                                                        10.0%
                                                            4.0%
                                                                                                                                                                                        5.0%
                                                            2.0%
                                                            0.0%                                                                                                                        0.0%




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           B14 Is there an LAA, PCT Strategic Ambition or SHA stretch target? If so, please provide details:
               PCT Strategic Ambition - SA28 - The rate of rise in childhood obesity to be reduced by 50% by 2010 (based on trajectory ref: Health Survey for
               England (1995 to 2004)). The importance of childhood obesity has been recognised within Bristol’s LAA for 2008 – 2010 inclusive. The agreed
               indicator is the level of obesity among Reception age children. There is a breastfeeding stretched target included in the LAA: To increase
               breastfeeding initiation and continuation rates city-wide concentrating on the eight wards with the lowest levels. To achieve initiation rates of 80.8% by
               31 March 2008 (from 72.5% at the year ending 31 March 2006). To achieve continuation rates at 6 to 8 weeks of 53.6% by March 2010 (from 48.5%
               for 2005).

           B15 Are there any links to other WCC health outcomes? If so, please provide details:
               Health inequalities.




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                                                                                              Delivery Plan


  C     Delivery Plan Actions & Indicators

  Please state the main actions to be undertaken in order to improve health outcomes:
  At the present time there is not enough evidence to indicate what impact each action will have on obese children. Therefore, these are process indicators that we will be
  evaluating. However, all the actions come from the evidence base of NICE and the national support team recommendations.

  No                               Actions                                Delivery Date                  Indicators/Data Collection                                 Evidence Base

        Specify the units of activity and exactly what outcome this will  When will the       What data/indicators will be collected/used to               Why will the action be carried out?
                                      lead to.                           action be carried               demonstrate success?
                                                                               out?
                                                                                                    2008/09
        PREVENTION: Children Centre Public Health Work Programme
      1  Finalise consultation and production of childhood Mar-09                            Guidelines in place and dissemination           Current inconsistency of nutritional advice to
        nutrition guidelines for pre-conception, conception                                  & implementation plan developed.                  parents. Evidence shows that establishing good
        and children 0-5 years.                                                                                                                dietary behaviour at a young age prevents obesity.
                                                                                                                                               Aim that all Children's Centres and Health Visitors
                                                                                                                                               are giving quality consistent advice.

      2  Develop proposal to secure recurring funding                 Nov-09                 Proposal submitted into OPP.                    As above.
        through the OPP to develop cooking skills/nutrition
        training and Healthy Weight programmes e.g.
        HENRI in Children's Centres.


      3  Nutrition training for early years practitioners             Mar-09                 Number of staff trained and each                As above. Evaluation from the training courses
        including Children Centre staff will have been                                       setting or cluster will appoint a healthy         showed that prior to training there were a varying
        delivered.                                                                           eating champion. A minimum of 1                   degree of knowledge around nutrition, healthy
                                                                                             member of staff per Children's Centre             eating recommendations for 0-5s and healthy
                                                                                             will complete training.                           start.
        PREVENTION: Breastfeeding 2008/09
      4  A stretched target to increase breastfeeding                 Started Apr 08.        Breastfeeding rates at initiation and 6-8       UNICEF BFI standards recommended by NICE
        initiation and continuation rates is included in the           Certificate of        weeks.                                            Guidelines for Postnatal Care(2006), NICE
        Bristol LAA.                                                   commitment to          Results of on-going BFI in house audit.         Guidelines for Maternal and Child Nutrition (DH
         Bristol is implementing UNICEF Breastfeeding                 be achieved by         Evaluation of the BFI project by Bristol        2008), Scientific Advisory Committee on Nutrition
        Baby Friendly Initiative (BFI) in the community (see           Sep 08 and            University                                        (SACN 2008).
        briefing paper for details of the initiative and the           Stage One
        relationship to obesity). There is evidence of                 accreditation by
        improved initiation rates in hospital, but not of              Oct 08.
        widespread coverage of BFI in the community. We
        are likely to be the first PCT to achieve this. Project
        will be completed Dec 09 and will be maintained
        through audit and training thereafter. Project is
        being evaluated by Bristol University to add to the
        evidence.
      5  Funding proposal developed to secure recurring               Nov-08                 Funding secured to develop robust        In a few areas there are voluntary breastfeeding
        funding through OPP for breastfeeding peer support                                   peer support service.                      peer supporters associated with local
        service targeting the wards with the lowest                                                                                     breastfeeding support groups. These peer
        breastfeeding rates.                                                                                                            schemes are on a small scale and they rely
                                                                                                                                        virtually entirely on volunteers. Only a small
                                                                                                                                        proportion of breastfeeding women can attend
                                                                                                                                        such groups. UNICEF BFI standards
                                                                                                                                        recommended by NICE Guidelines for Postnatal
                                                                                                                                        Care(2006), NICE Guidelines for Maternal and
                                                                                                                                        Child Nutrition (DH 2008), Scientific Advisory
                                                                                                                                        Committee on Nutrition (SACN 2008).
      6  Breastfeeding Welcome scheme, working with           Mar-09                         Number of establishments signed up to NICE maternal and child nutrition guidelines
        NCT, breastfeeding groups, peer supporters,                                          the scheme.                                (NICE March 08), Baby Friendly in the Community
        council and local establishments to increase the                                      Phase One of the project will be         guidelines (BFI March 08), D of H Health
        welcome for breastfeeding mothers in the wider                                       internally evaluated and will monitor      Inequalities progress and next steps (DH June
        community - so far around 100 establishments are                                     breastfeeding rates.                       08). Paid peer supporters in Lancashire have
        breastfeeding friendly.                                                               Phase two of the project will be         been shown to increase breastfeeding
         A breastfeeding peer support project to support                                    externally evaluated using qualitative     continuation rates (29% in 3yrs at 6-8 weeks and
        mothers to breastfeed in the 8 wards with the lowest                                 methods and breastfeeding rates. 100% exclusive breastfeeding rates at 6 months by
        rates, will run from Oct 08-09. Bristol PCT is                                       of health visitors will have completed BFI 21%). An action research project is concurrently
        working in partnership with Barnardo's who have                                      training.                                  being carried out to explore parents and staff
        employed the peer support co-ordinator. Aim of the                                                                              views of breastfeeding support within 3 Children's
        project is to strengthen peer support for                                                                                       Centres.
        breastfeeding in local breastfeeding groups to help
        more mothers to breastfeed for longer. Peer
        supporters will have breastfed, live locally and will
        have undertaken peer supporter training.
         Funding needed for second phase of project which
        will build on work of the PS Co-ordinator and also
        employ paid local peer supporters to offer an
        enhanced service to mothers in 3-4 of the wards.
        Paid peer supporters will have enhanced training.
        This part of the project will be externally evaluated.
         If successful, phase three of the project will
        focus on rolling out this project to the 7 areas
        with the lowest rates.

        PREVENTION: Healthy Schools Programme/Healthy Kids 2008/09
      7  Continuation of the Cooking from Scratch  By Feb 09       Evaluation forms will inform evidence                                     Work in progress to be completed.
        Programme - Key worker.                                    base.




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                                                                            Delivery Plan


    8  Healthy Schools Programme/Healthy Kids (see          By Mar 09      Project plans from each of the 25           To support schools to build on 41 criteria using
      briefing paper for description of impact on obesity) -               schools involved will be submitted and        local partnerships to facilitate behaviour change
      91% of Bristol Schools have achieved minimum                         monitored at 6 monthly intervals (funding     for those children and families with higher health
      evidence standards. The ‘Transforming Food in                        subject to delivery/progress) to              need therefore tackling health inequalities.
      Schools Project’ has led to improvements in the                      demonstrate progress towards health
      quality of school meals.                                             behaviour change relating to PSA12 and
       To recruit 25 schools to deliver Healthy Schools                   Priorities VSB09 and EX39 and 40.
      Plus programme focusing on vulnerable children in
      areas of high health need; to support local and city
      wide health priorities. Provide first payment
      £750/school.
    9  Funding proposal developed to secure recurring       Nov-08         Funding to be secured to develop the        Evaluation of the pilot Healthy Kids Programme
      funding through OPP for expanding the Healthy Kids                   Healthy Kids Programme to 21 schools          shows positive behaviour change among the
      Lifestyle Programme.                                                 in 2009/10 (with a high proportion of         children participating.
                                                                           children claiming free school meals).
   10  95% of Bristol schools to hold Healthy Schools     By Mar 09        National Healthy Schools Database           Healthy School Programme is a universal health
      status.                                                              Audit Tool.                                   promotion programme which has four aims: To
       To provide training and support to schools to                       Attendance records for training.            support children and young people in developing
      achieve or revalidate Healthy Schools Status -                        All school to have a development plan       healthy behaviours (including physical activity &
      maintaining 100% participation and at least 95%                      in place PSA12 and NI 52,55,56,57,198.        healthy eating), to help raise the achievement of
      achieving status.                                                                                                  children and young people, to help reduce health
                                                                                                                         inequalities and to help promote social inclusion.
   11  Achieve standards for 'Food other than Lunch' in   By March 09      95% of schools to achieve standards.        School food contributes significant proportion of
      primary and secondary schools.                                       Bristol City Council Client Unit              daily macro and micro nutrient intake, ensuring the
                                                                           monitoring visits.                            standards are adhered to will ensure that these
                                                                                                                         meet and do not exceed current recommendations
                                                                                                                         for children and young people.
   12  Achieve the nutrient based standards target,       By Sep 08/By     Menus with supporting nutritional           Current inconsistency in school meals across City,
      compulsory in all primary schools.                   Mar 09          analysis from all school meal providers,      Standards will ensure that 33% or RNIs for various
       Implement a healthy lifestyles programme for                       Bristol City Council Client Unit school       nutrients are provided and that maximum levels
      children and young people targeting schools with                     based monitoring, School Food Trust           for those nutrients known to be detrimental when
      the highest number of children overweight at                         research, school based monitoring by          in excess
      reception and/or year 6.                                             staff and pupils.
                                                                            Identification of first 15 target schools
                                                                           and base line data taken National
                                                                           Weighing and Measuring Programme to
                                                                           the target group via a series of lunchtime
                                                                           and after school session, involving the
                                                                           parent/carers where appropriate.
                                                                            PSA12 and NI55,56,57,198.

   13  Appoint a public health school nurse to work       By Jan 09     To support schools and children's              Early pilot studies and research evidence
      specifically on healthy weight and to link closely                centres to write and implement a whole           suggests that children who have attended a
      with Bristol Healthy Schools Programme.                           school/centre Food Policy covering               Healthy Lifestyles Programme; building on whole
       Appoint Healthy Eating Coordinator for Children                 education and training to promote                school approach to developing healthier lifestyles,
      and Young People as part of Healthy Schools                       healthier eating in line with the Eat Well       involving parents and carers, has resulted in
      Team.                                                             Plate and to ensure food served meets            improved self-esteem, willingness to participate in
                                                                        the National Schools Foods Standards.            physical activity and a better knowledge of the eat
                                                                         To support schools to implement                well plate.
                                                                        Healthy School Programme plans.
      PREVENTION: Active Bristol - Physical Activity Strategy and Active Travel 2008/09
   14  Start implementation of 'Bike It' (see briefing       By Oct 08  2 Bike It officers will be appointed to        Bike It is an intervention developed by the cycling
      paper for details) in Bristol schools.                            start working with 24 Bristol schools by         charity, Sustrans, which has shown to significantly
                                                                        end of October 2008.                             increase cycling to school.
   15  Appoint active travel officer to work with Children's By Jan 09  To be agreed with BCC.
      Centres.
      PREVENTION: Childhood Obesity Care Pathway - Development of Treatment Services 2008/09
   16  Funding proposal to be developed for further          By Oct 08  Funding secured to support the                 Tier 2 Healthy Weight Services Bristol’s Mind,
      funding beyond Apr 09 for the 12 week Bristol’s                   ongoing work of the MEND programme               Exercise, Nutrition and Do It! (MEND) programme
      Mind, Exercise, Nutrition and Do It! (MEND)                       and/or children's healthy weight                 is coordinated by BCC Culture Leisure and Sport.
      programme.                                                        programme based on similar model.                The programme enables overweight children (7-13
                                                                                                                         yrs) and their families access to fun, effective and
                                                                                                                         practical lifestyle solutions to achieving a healthy
                                                                                                                         weight. Each programme lasts for 12 wks and
                                                                                                                         includes sessions on healthy eating and physical
                                                                                                                         activity as well as behaviour change advice.
                                                                                                                         Funding for 21 programmes from Feb 07 to Apr 09
                                                                                                                         has been secured from the Big Lottery Wellbeing
                                                                                                                         fund with dietetic support being funded by Bristol
                                                                                                                         PCT. In 2007/08 107 children received support
                                                                                                                         through the scheme and mean BMI change was -
                                                                                                                         0.73 with a mean weekly increase in physical
                                                                                                                         activity of 4.3 hours and a drop in sedentary
                                                                                                                         activities of 4.7 hours a week. Recruitment from
                                                                                                                         ethnic minorities is good, with an average of 39%
                                                                                                                         from various ethnic origins largely due to the
                                                                                                                         location of the programme in central Bristol.

   17  Funding proposal to be developed for expansion     By Oct 08        Funding secured to expand the               A consultant led childhood obesity clinic has been
      of community childhood obesity clinics dependent                     ongoing work of community childhood           running in Bristol for 8 years. In Apr 08 2
      on evaluation of existing services.                                  obesity clinics.                              community childhood obesity clinics started in
                                                                            Model dependant on outcome of               Knowle West and Horfield as part of a feasibility
                                                                           feasibility study in Bristol.                 study funded by the DH. These will continue for 18
                                                                                                                         months. Referrals are accepted from GPs and
                                                                                                                         school nurses. It is envisaged that results of the
                                                                                                                         evaluation will inform future service provision. The
                                                                                                                         clinics currently run in only these 2 areas of Bristol
                                                                                                                         but there may be opportunities to expand the
                                                                                                                         service, depending on the outcomes and funding
                                                                                                                         (i.e. weight loss and patient satisfaction).




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                                                                            Delivery Plan


   18  Development of childhood healthy weight care       By Mar 09        Childhood Healthy Weight Care
      pathway for consultation.                                            Pathway produced, agreed and staff
                                                                           trained in its use.
                                                                        2009/10
      PREVENTION: Children Centre Public Health Work Programme 2009/10
   19  Recruit a dietician as an Early Years healthy    Apr-09    Co-ordinator in post.                              Currently healthy eating advice is sought from
      eating co-ordinator/advisor/trainer to work across                                                               various agencies, a dedicated post will ensure a
      PCT & Local Authority.                                                                                           whole settings approach to food policy. Uptake of
                                                                                                                       Healthy Start is low.
      PREVENTION: Breastfeeding 2009/10
   20  Achieve BFI Level 3 accreditation.                 By Oct 09        Bristol PCT will have achieved full BFI   Bristol will be the first city in England to achieve
                                                                           accreditation by October 2009.              UNICEF BFI status if this target is achieved.

   21  Establishment of a Bristol-wide Peer Scheme to     Phase one by    1,000 new mothers in the most
      support mothers to breastfeed in the 10 wards with   Oct 09. Second disadvantaged wards of Bristol will
      the lowest rates.                                    phase (pilot)  receive breastfeeding peer support.
                                                           Oct 09-Apr 11

   22  Expansion of the Breastfeeding Welcome Here        Ongoing and     All 28 libraries and 6 museums will
      Scheme.                                              focused around participate in the scheme.
                                                           Breastfeeding
                                                           Awareness
                                                           Week in May
                                                           09
      PREVENTION: Food and Health Strategy 2009/10
   23  Expansion of the Cooking from Scratch               Mar-10          Statistics on numbers and age groups To increase fruit & vegetable consumption.
      Programme. Continue to develop and expand the                        will be collected, follow up evaluation will
      Cooking from Scratch project to include other                        gauge success.
      community food initiatives.
   24  Cooking skills training for parents in Children’s   Mar-10          Develop cooking skills / nutrition
      Centres. The aim is to improve the nutritional status                training for parents in 6 children's
      of children under 5 by equipping parents with                        centres.
      practical cooking skills.
   25  Development of Food Cooperatives to improve         Mar-10          Number of food cooperatives in Bristol.
      access in disadvantaged areas to healthy food (in                    Number of people accessing fruit &
      particular fruit and vegetables).                                    vegetables through schemes.
       Establish a food cooperative in North and Inner                     Evaluation to be commissioned.
      city Bristol and expand the existing food cooperative                 Monitored annually through Bristol
      in South Bristol.                                                    Quality of Life Survey for fruit &
                                                                           vegetable consumption.
      PREVENTION: Healthy Schools Programme/Healthy Kids 2009/10
   26  Achieve the nutrient based standards target,       2009          Menus with supporting nutritional            Current inconsistency in school meals across City.
      compulsory in all secondary schools.                              analysis from all school meal providers,       Standards will ensure that 33% of RNIs for various
                                                                        Bristol City Council Client Unit               nutrients are provided and that there are maximum
                                                                        monitoring, School Food Trust research,        levels for those nutrients known to be detrimental
                                                                        school based monitoring by staff and           when in excess.
                                                                        pupils.
   27  To develop the Healthy Kids Programme in 21        Dependent of  Dependent on securing recurring OPP          See 19.
      Bristol schools.                                     funding. If  funding. Programme will be implemented
                                                           secured by   in 21 schools.
                                                           March 2010
   28  To provide training and support to schools to      By Mar 10     National Healthy Schools Database            See 7.
      achieve or revalidate Healthy Schools Status -                    Audit Tool.
      maintaining 100% participation and at least 95%                    Attendance records for training.
      achieving status.                                                  School Development Plans PSA12 and
       To complete Healthy Schools Plus projects with                  NI 52,55,56,57,198.
      first wave 25 schools demonstrating healthier                      Project plans from each school
      behaviours for vulnerable children in areas of high               involved will be monitored at 6 monthly
      health need; to support local and citywide health                 intervals (funding subject to
      priorities. second and final payments made - £1250                delivery/progress) to demonstrate
      /project.                                                         progress towards health behaviour
       To recruit second wave of 25 schools to Healthy                 change relating to PSA12 and Priorities
      Schools Plus Programme. Healthy Eating                            VSB09 and EX39 and 40.
      coordinator for Children and Young People as part                  Second wave of schools will repeat
      of Healthy Schools Team.                                          process.
                                                                         To support schools and Children's
                                                                        Centres to write and implement a whole
                                                                        school/centre Food Policy covering
                                                                        education and training to promote
                                                                        healthier eating in line with the Eat Well
                                                                        Plate and to ensure food served meets
                                                                        the National Schools Food Standards.
                                                                         To support schools to implement
                                                                        Healthy School Programme plans.
      PREVENTION: Active Bristol - Physical Activity Strategy and Active Travel 2009/10
   29  25% of phase 1 and 2 Children Centres will have Mar-10
      a travel plan in place.
   30  Implement 'Bike It' in selected Bristol schools (8 Jul-10        Bike It to be implemented in 8
      additional schools).                                              additional schools.
      TREATMENT: Childhood Obesity Care Pathway - Development of Treatment Services 2009/10
   31  Implementation of childhood healthy weight care    Start Dec 09  Childhood Healthy Weight Care                Children weighed and measured as part of the
      pathway.                                                          Pathway produced, agreed and GPs,              National Child Measurement Programme need
                                                                        Practice Nurses and School Nurses              options for referral. Existing and possible
                                                                        trained in its use.                            treatment options require identifying and mapping
                                                                                                                       in the form of a care pathway and referral criteria
                                                                                                                       developed in order to prioritise patients for
                                                                                                                       treatment.




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                                                                                   Delivery Plan


      32  Deliver 18 healthy weight programmes: 9        Mar-10                  18 programmes delivered. Each
         programmes for 5-8 years and 9 programmes for an                        programme is for 12 children a with one
         older age group (9-13 years). Assuming funding                          parent.
         secured through OPP.
      33  Four new childhood obesity clinics will be     Start Nov 09            12 families will be seen per week.
         established in the community.                    Fully                  Once set up this would consist of approx
                                                          established Mar        6 new patients and 6 follow up per week
                                                          10                     per clinic.
      34  Development of a new obesity prevention        01/03/2010              Deliver a Healthy Weight programme
         programme for children aged 2-4 years and their  Dependent on           in 10 out of 24 Children's Centres.
         families . E.g. HENRI programme.                 OPP funding
                                                                                       2010/11
           PREVENTION: Children Centre Public Health Work Programme 2010/11
      35    Cooking skills training for parents in Children’s   01/03/2011      Develop a weekly programme of             Indications are that parents/carers would welcome
           Centres. The aim is to improve the nutritional status Dependent on cooking skills / nutrition training in 8      support around dietary behaviour change.
           of children under 5 by equipping parents with         OPP funding    additional children centres (16 childrens
           practical cooking skills.                                            centres in total for 2010/11).
           PREVENTION: Breastfeeding 2010/11
      36    Maintenance of UNICEF Breastfeeding Friendly        Reassessment  BFI status will be maintained in the
           status in the community and in acute trusts.          within 2 years hospital and community.
                                                                 2010            100% of health visitors will be BFI
                                                                                trained.
      37    Expansion of Peer Supporter scheme & evaluation Mar-11              2,100 out of 5,800 new mothers will
           from year 1.                                                         receive breastfeeding peer support.
      38    Expansion of Breastfeeding Welcome Here             Mar-11          An additional 20 cafes will become
           Scheme.                                                              involved in the scheme.
           PREVENTION: Food and Health Strategy 2010/11
      39    Mainstream Cooking from Scratch project by          Mar-11          Funding secured to develop robust         Difficulty in hiring suitable kitchens determines
           funding a mobile cooking kitchen. Dependent on                       peer support service.                       where courses can be delivered.
           funding.
      40  Expand the number of Healthy Weight               Mar-11         Deliver Healthy Weight programmes in
         Programmes being delivered in Children's Centres.                 an additional 10 children's centres.
      41  Continue to expand the food cooperatives in North Mar-11         Increase in numbers of people
         and inner city Bristol.                                           accessing schemes.
         PREVENTION: Active Bristol - Physical Activity Strategy and Active Travel 2010/11
      42  50% of phase 1 and 2 Children Centres will have By Mar 11        12 Children's Centres will have a travel
         a travel plan in place.                                           plan in place.
         TREATMENT: Childhood Obesity Care Pathway - Development of Treatment Services 2010/11
      43  Implementation of childhood healthy weight care   By Mar 2011    Childhood obesity clinics and MEND
         pathway. Dependent on securing recurring OPP                      programme well established. 50% of
         funding.                                                          families with an overweight/obese child
                                                                           will be offered a healthy weight
                                                                           intervention.
      44  Continue to run 4 community childhood obesity     Mar-11         Assuming clinics are operational for 46
         clinics and Bristol Children's Hospital clinic.                   weeks of the year, a total of 276 new
                                                                           patients and 276 follow-up patients
                                                                           would be seen per clinic per year.
      45  Expand Healthy Weight programme (MEND). 36           Mar-11            18 programmes for 5-8 years and 18
         programmes to be delivered: 18 programmes for 5-                        programmes for 9-13 years.
         8 years and 18 programmes for 9-13 years.

  D        Total Investment

  D1 Please provide details of the total new investment between 2009/10-2012/13:
     £400,000

  D2 Please include comments if funding is subject to Operational Planning Process (OPP) approval:
     Weight Management Treatment Initiatives: Recurring funding required 2009/10 = £540,000 Additional recurring funding 2010/11 = £106,000
     Breastfeeding: Recurring funding required 2009/10 = £201,600 Additional recurring funding required 2010/11 = £122,000
     Food and Health Strategy: Recurring funding required 2009/10 = £857,140 Additional recurring funding required 2010/11 = £464,000 Additional funding required
     2010/11 = £475,000
     Active Bristol: Recurring funding required 2009/10 = £525,000 Additional recurring funding required 2010/11 = £270,000 Additional recurring 2011/12 = £240,000.
     Please note: The Food & Health Strategy and Active Bristol costs could be proportioned between the CVD Delivery Plan and Childhood Obesity Delivery
     Plan.
     Costs for Childhood Obesity Delivery Plan only:
     Food & Health Strategy: 2009/10 = £401,000 Additional recurring funding required 2010/11 = £304,000 Additional recurring costs 2011/12 = £350,000
     Active Bristol: 2009/10 = £125,000 Additional recurring funding required 2010/11 = £55,000 Additional recurring costs 2011/12 = £62,500


  E        Partnership Arrangements

  E1       Which organisations will help us deliver this plan? If key posts are part of another organisation please provide details:
           An ‘obesogenic’ environment has developed in this country over many years. This environment must change if significant progress is to be made in tackling the
           obesity problem. Achieving significant change depends on highly effective collaboration between stakeholders.
           The existing stakeholders in the above strategies are primarily Bristol PCT, acute trusts and some departments of Bristol City Council.
           To be effective in addressing childhood obesity, a much wider range of stakeholder participation is required.
           Stakeholders should include local authorities, town planning, public transport, education, leisure services, acute NHS trusts, primary care, businesses, employers,
           food producers, food retailers, media, hospitality industry underpinned by support from national government.
           Partnership arrangements with the council are crucial. The Health and Wellbeing Delivery group, sub group of the Bristol Strategic Partnership, was responsible for
           performance management of Bristol's healthy weight strategies and Active Bristol. The Health and Wellbeing Delivery Group has recently been disbanded and there
           will be no further meetings. The Health and Wellbeing Partnership Board is to be formed shortly, and will take over the HWDG's role.




04a0c151-218d-48f4-b361-b1053df8faec.xls                                                 7                                                                                 7/4/2011
                                                                      Triangle of Tiers


                                 Figure 1: Hierarchy of the Childhood Obesity Care Pathway




                                                                                Tier 4:
                                                                                Surgery



                                                                    Tier 3:
                                                                    Hospital Obesity Clinic



                                                                Tier 2:
                                                                Community Childhood Obesity Clinics




                                                 Tier 1:
                                                 1. Group sessions for overweight children (Exercise, nutrition,
                                                 behavioural intervention) / School Nurse Brief Interventions
                                                 Or 2. School Nurse Support




                                                   Initial Referral
                                                   (self referral, GP / practice nurse / school nurse / health visitor)


                                           Prevention Programmes
                                           e.g. Healthy Schools Programme, Children Centre Work Programme




04a0c151-218d-48f4-b361-b1053df8faec.xls                                        8                                         7/4/2011

				
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