Additional Information to Children and Young Peoples Committee Inquiry on Childhood Obesity

Children, Young People and Education Committee

Paper to note 2

1. Professional opinion of standards which are the same for 4 year old children and 11 year old children.

The school meal standards  apply to food and nutrients and are not individual,  they are for the provision of  food . Food based standards define the types of food which have limited nutritional value and those which consumption should be increased to contribute to a healthy diet.

Nutrient-based standards apply to an average school lunch over five consecutive school days, and relate to overall provision rather than individual consumption.  Many schools (especially secondary schools) provide a choice of food and drink at lunchtime, so each pupil consumes a different balance of nutrients.  Also, some pupils need to eat more than others depending on age, body size, metabolism and physical activity. Therefore, it is an average school lunch over 5 school days rather than every lunch consumed that must meet the nutrient standards.

An average school lunch must provide:

• The specified amount of energy (with 5% tolerance)
• no more than the maximum amount for fat, saturated fat, Non-milk extrinsic (NME) sugars and sodium
• at least the minimum amount for carbohydrate, protein, fibre, vitamin A, vitamin C, folate, calcium, iron and zinc

In terms of the different  requirements of a  4 year old and 11 year old , the portion size needs to reflect their different  energy and protein requirements.

There are no current guidelines on differences between age groups in primary schools so portion sizes are  the same for 4 and 11 year olds, however this should be interpreted at local level with support to acknowledge the different age groups. The guidance could contain some visual interpretation of portion sizes. For example,  in practice the portions are governed to some extent by demand i.e. if there is food left over older pupil will have more and younger pupils will choose less. What also needs to be taken into account is waste as children can be served a balanced meal that meet their requirements in the correct portions but it needs to consumed  for the benefit.  

Micro nutrient requirement will be covered for all age groups provided a balanced choice is taken. The nutritional standards have not followed the principle of greatest need to avoid diets with more energy, fat and  salt than recommended for school age children,  but salt intake could be a concern  for the youngest age group if standardisation of  policies on salt in  cooking are not adhered to.

2. What work is being done to spread good practice across Wales, for example from authorities where uptake rates have remained good to those where there has been a drop off.

This has been  led by Welsh Local Government Association – there is a nutrition analysis liaison officer who works with Local authorities and supports the development  of recipes and  nutritional  analysis.  There is documentation and  sharing of recipes on the website. There should be good local partnership working between LA catering, education and health (public health and dietetics) and this is the case in most areas of Wales.

The level  of professional support to implement the standards varies across Wales,  some areas have utilised the central budget to have dietetic support , but there is a risk going forward that this may be lost with the the funding no longer ring fenced. Most areas have multiagency implementation groups.

3. Delivery of the MEND Programme in Wales

The Committee asked for information on where the MEND programme had been delivered in Wales.  The table below provides information for the period from April 2008 until March 2013.

	APRIL 2012 – MARCH 2013	SEP  2011 – MARCH 2012	APRIL 2008- JULY 2011
No of programmes	33 (MEND  7-13) 2 (MEND  5 -7)	29	111 over 33 months
Areas	Abertawe Bro Morgannwy UHB Area: Neath Port Talbot LA Swansea LA Bridgend Aneurin Bevan HB covering 5 LA’s Cardiff and Vale Health Board  Powys Cwm Taf HB - Rhondda Cynon Taff LA Hywel Dda HB Carmarthenshire LA Betsi Cadwaladr UHB Wrexham LA Conwy LA	Abertawe Bro Morgannwy UHB Area  Swansea Neath Port Talbot Powys Cardiff  and Vale Health Board  Cwm Taf Rhondda Cynon Taff LA Hywel Dda HB Carmarthen Betsi Cadwaladr UHB Wrexham Conwy Anglesey	All Health Board areas, but not all Local Authorities were covered during this period

Health Impact Assessment (HIA) and Local Development Planning

Planning Departments and planning decisions can have a huge impact on health and wellbeing and can have an enormous influence on the wider determinants of health.  They can shape the environment we live in, make decisions about the siting and development of housing, green space, retail, leisure and employment facilities and how we access and use these.  Decisions can facilitate physical activity or access to fresh, quality food or limit choices to do so ie supermarkets in out of town retail parks that we drive to versus easy to walk or cycle to local shops; or allocating green space for development or recreation. As obesity and associated ill health increases in Wales there is a need to make these connections more explicit.

In preparation for a new National Assembly for Wales, Better Health, Better Wales (Welsh Office, 1998) described the need to tackle the social and economic determinants of health and aimed to develop HIA in Wales as a means to support health promotion and prevention initiatives.  At a strategic level, the publication of ‘Making the Connections’ (Welsh Assembly Government, 2004) aimed to support the integration of health across all sectors and a consideration of ‘Health in all Policies’ (WHO, 1999).  A focus on integrating ‘Health in All Policies’ has led to HIA being seen as a key element in raising awareness of health and wellbeing in Wales in other sectors and supporting the health promotion and prevention agendas. 

HIA as practiced in Wales (WHIASU, 2012) considers not just the biophysical and environmental health impacts which can be derived from planning proposals and plans (which are routinely assessed as part of Environmental Impact Assessments (EIAs)) but assesses the impact on the wider determinants of health in a systematic yet flexible way. These determinants such as the physical and built environment, community, transport, housing, employment and access to services all interact to influence our health and mental wellbeing to a greater or lesser extent in conjunction with the lifestyle choices that we make and our genetic makeup.   HIA also considers issues of equity and inequalities by looking at any vulnerable groups who may be affected by a plan or proposal and the distribution of effects on them.  

Conducting an HIA within planning processes, regeneration and housing sectors can confer considerable benefits and contribute to healthy public policy and urban and rural planning.  Not only will HIA assess the potential positive and negative impacts but it will highlight any potential improvements which could be made to maximize health and wellbeing and identify and mitigate for any detrimental impacts or unintended consequences. HIA can make more explicit the links between land use and associated planning decisions, the way that we live and the key health and wellbeing issues today – including obesity, lack of physical activity and the associated risk factors and illnesses.  

It directly involves the local key organizational and community stakeholders and those who have local knowledge and understanding of how the project, plan or proposal will have a direct and indirect impact on local populations.  A HIA can give context to a decision or plan.    This includes how a community interacts with its physical and built environment and can facilitate physical health promotion and health improvement by encouraging cycle paths, pedestrian friendly towns, more active travel, open and green space allocation for recreation and sport in LDPs and housing developments and access to the growth and purchase of fresh and affordable food.

WHIASU is currently working with a number of local authorities on Local Development Plans, regeneration initiatives and housing projects and plans.  Within each of these HIAs, there have been discussions around creating safe, physical activity friendly environments as encouraged by ‘Creating an Active Wales’ (WAG, 2009) and its explicit linkage of planning to health and wellbeing.

Studies have shown that open spaces and well planned integrated people friendly urban centres can contribute to promoting physical activity and well being and can help to reduce being overweight and obesity by encouraging walking and cycling and can improve mental wellbeing for all age ranges.  Well planned and integrated transport links can aid physical activity. It is essential in childhood for social development and in older people for increasing social interaction and mental wellbeing. At a community level, it has also been shown that green space and a well planned urban environment in a neighbourhood can similarly promote and increase social interaction and reduce social isolation.  Green spaces in an urban area offer the opportunity for the community to find calmness, be sociable, take exercise and escape to the pressure of urban life.  (Netherland Institute for Health Services Research Utrecht, 2006; Institute of Occupational Medicine, 2008; Institute of Rural Health and Countryside Council for Wales, 2008; Faculty of Public Health and Natural England, 2010).  The importance of the link between the built and natural environment and being physically active is also recognised within the NICE public health guidance 8 – ‘Promoting and creating built or natural environments that encourage and support physical activity’ (NICE, 2008). 

Despite this and until recently, not all local authorities have reflected the importance of health in planning decisions re green spaces, recreational areas or person centred built environments but this is now changing as obesity and associated ill health increases.  Indeed in Wales, the use of HIA as a process to consider health and wellbeing has been included the new 2013 Regeneration Framework ‘Vibrant and Viable Places’ (WG, 2012) and although there is no statutory requirement for HIA in Wales (or the UK) HIA is included as a requirement or advocated as best practice in more and more planning documents.  ‘Chapter 2: Development Plans’ (Page 21) of Planning Policy Wales (WG, 2012) states that ‘the several impacts of plans upon health and its determinants should be considered’.  In addition Planning Policy Wales produced a Technical Advice Note 16 in January 2009, Sport, Recreation and Open Space (WG, 2009) which advises on the role of the planning system in making provision for sport and recreational facilities and informal open places in both the urban and rural environment.

At a local level, many HIAs have been completed in conjunction with regeneration, LDPs, planning and housing schemes.  These are published on the WHIASU website – www.whiasu.wales.nhs.uk .   Recent HIA case studies are described below.

HIA Case Studies

Flintshire Local Development Plan (2013 - 2017)

This will be a comprehensive, integrated HIA and take place throughout the lifetime of the preparation of the LDP.  It will be led by a multi-disciplinary, multi-sector Steering Group on behalf of Flintshire County Council, who will take ownership of the HIA.   The HIA will be supported by the Wales HIA Support Unit and Public Health Wales (PHW) Regional Public Health Team.

A  HIA Scoping Report has been written to set out the terms of the HIA and includes an agreed plan for it and how the process can be used to consider health, wellbeing and inequalities and integrate them with planning policy throughout the LDP development.  It will consist of a number of HIA participatory workshops at all the defined, key stages of the Plan (including assessment of the Candidate Sites) and will be fed into the Strategic Environmental Assessment (SEA) and Sustainability Appraisal (SA).  The HIA will ensure the involvement of key health stakeholders, elected members, private citizens and specific communities.

HIA has been embraced by the LA Planning Policy Department and as part of this commitment a section on HIA has been included within the LDP Delivery Agreement and presented to WG.

The HIA will focus on the following:

• Housing
• Economic Development
• Employment (all of which are the primary themes of the SEA and SA)
• Physical health and mental wellbeing (including facilitating physical activity and active travel as part of developments and green space and promoting accessible, cheap and fresh food where possible)

Other important elements to be considered within the context of Flintshire are:

• Inequalities and the impacts on vulnerable groups ie travellers
• Geographical Areas and communities of Interest ie Communities First areas

Evidence will be both quantitative and qualitative. 

An Evidence Document is currently being finalised and this contains all the essential references to key Public Health documents, policies, community health profiles and evidence with regards to health and planning - for example ‘Creating an Active Wales’, TAN 16 and the Active Travel (Wales) Bill (WG, 2013).  This Evidence Document will be updated and help to shape and substantiate any health and wellbeing input or changes made to the LDP as it progresses. This work is currently ongoing but it has already proved highly beneficial – by making Planning Officers more aware of health and health issues and making connections to how what they are planning can have a significant direct and indirect impact on the populations’ health and wellbeing.  This includes the siting of fast food and takeaway outlets (particularly near schools), out of town retail shopping centres – where people have to drive or walk minimally and the importance of the maintenance of green or other recreational space.   

 Cardiff Local Development Plan (At final stage)

This HIA work (Cardiff County Council, 2012; 2013) has now almost concluded but the rapid HIAs have demonstrated the health connections and linkages to planning policy and planners very clearly and explicitly. 

Amendments have been made to the LDP documents throughout the final 2 stages and specific references have been included such as adding in supporting text to Policy C7 Health and linking this to Policy R7 Food and Drink Uses (access to healthy affordable food/care with alcohol accessibility) which make a clear recognition between the links to health from such uses; cross references from policy C6 Provision of Children’s Play to Policy T1 Walking and Cycling; the agreement to prepare a separate Open Space SPG to supplement LDP policies for recreation and physical activity ; and explicit referencing of   Healthy Urban Planning in Policy KP14 Healthy Living.

Rhyl ‘Going Forward’ Regeneration Delivery Plan, Denbighshire (2012)

The HIA was based on a short evidence review and a participatory stakeholder workshop.

It aimed to identify and assess potential health and community impacts and highlight future projects contained within the Delivery Plan to be subject to a HIA. The workshop included a number of ‘non health’ participants including planning, housing and regeneration leads from the local authority, elected members, community and voluntary organisation representatives plus public health practitioners. 

A number of practical recommendations were made including;

• continuing to encourage physical activity with the extension of cycle paths;
• filling in the flood defences in order to minimise accidents and injuries;
• recommending to the Supplementary Planning Guidance (SPG) group that they liaise with the architects who will be designing new buildings/areas in Rhyl in order to take a creative approach to planning and creating a balanced community and healthier built environment ;
• attempting to enhance social capital and physical activity through community development projects such as ‘The Cut’ (Community green space);
• trying to attract more families to live in areas with a high number of current HMO’s by providing high quality family orientated housing and attractive green spaces. 

Many of these have been followed.  As part of this HIA, the West Rhyl Housing Improvement Project was highlighted as a significant project which would need to have a separate HIA completed as part of its development and execution.  This work is currently taking place - with the first phase focussing primarily on the creation of a community green space at the centre of the Housing Project.

The HIAs have demonstrated how health is affected by all policies and plans and certainly those that have attended or have been part of the HIAs have reflected that it is a very beneficial and positive process which had made them understand health much more broadly,  made connections to their work much more explicit and rethink some plans and decisions.

Liz Green

Principal HIA Development Officer, WHIASU

January 2014

References

Cardiff County Council (2012). Health Impact Assessment of the Local Development Plan Preferred Strategy.

Cardiff County Council (2013). Health Impact Assessment of the Deposit Local Development Plan

Faculty of Public Health and Natural England (2010). Great Outdoors: How our natural health service uses green space to improve wellbeing.

Institute of Occupational Medicine and Greenspace Scotland (2008). Health Impact assessment of green space: A Guide. 

Institute of Rural Health and Countryside Council for Wales (2008).  Natural Heritage: a pathway to health.

National Institute for Clinical Excellence (NICE) (2008).  Public health guidance 8 - Promoting and creating built or natural environments that encourage and support physical activity

Netherland Institute for Health Services Research Utrecht, Wageningen (2006). Green Space, urbanity and health: how strong is the relation? Journal of Epidemiology and Community health.

Wales Health Impact Assessment Support Unit (WHIASU) (2012).  Health Impact Assessment; A Practical Guide

Welsh Office (1998)        Better Health, Better Wales.  Cardiff: Welsh Office

Welsh Assembly Government (2004). Making the Connections: Delivering better services for Wales.

Welsh Assembly Government. (2006) Draft Ministerial Interim Planning Policy Statement 02

Welsh Assembly Government (2007).  One Wales - A progressive agenda for the government of Wales.

Welsh Assembly Government (2008).  Welsh Transport Appraisal Guidance (WelTAG) http://cymru.gov.uk/topics/transport/publications/weltag/;jsessionid=fnjGMmfTYXVKrZJN5vydzHDtplLXQS3txpm6LhhK8Tx9tzxZyyTx!-971712554?lang=en (accessed July 20th 2013)

Welsh Assembly Government.  (2002) Technical Advice Note 21

http://wales.gov.uk/splash;jsessionid=yXtwTgTRdxvvhSzj9plTrnbFr1hSMh0V23vbMKbWQhTJJnmC0CmB!-1123340228?orig=/topics/planning/policy/tans/tan21/    (accessed July 20th 2013)

Welsh Assembly Government.  (2009)  Minerals Technical Advice Note 2

Welsh Assembly Government (2009) Creating an Active Wales http://wales.gov.uk/docs/phhs/publications/activewales/100121activewalesen.pdf

Welsh Government (2009) Planning Policy Wales Technical Advice Note (TAN) 16 Sport Recreation and Open Space

Welsh Government (2012). ‘Chapter 2: Development Plans’ (Page 21) of Planning Policy Wales (Edition 5, November 2012) http://wales.gov.uk/topics/planning/policy/ppw/?lang=en (Accessed 6/11/2013).

Welsh Government (2013).  Active Travel (Wales) Bill

Welsh Government (2013) ‘Vibrant and Viable Places: New Welsh Regeneration Framework’

World Health Organisation (1999).  Health 21: The health for all policy framework for the WHO European Region. European Health for All Series No.6. Copenhagen: World Health Organisation