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Live Well: Diet, Physical Activity and Obesity

Profile Information

Profile title Live Well: Diet, Physical Activity and Obesity

Profile owner Knowledge and Intelligence, Public Health, Derby City Council

Profile author(s) Leila Pinder

Profile information reviewed August 2016

Profile endorsed by JSNA Steering Group

Reviewer Andrew Muirhead

Current version 24/08/2016

Replaces version N/A

Section Lifestyle: Live Well

Contents Live Well: Diet, Physical Activity and Obesity ...... 1 The importance of diet, physical activity and a healthy weight ...... 4 Living a healthy lifestyle ...... 4 Recommendations ...... 5 Diet and Nutrition ...... 6 Diet and nutrition introduction...... 6 First 1,000 days of life ...... 6 Reduce sugar, salt and saturated fat intake ...... 6 Sugar ...... 6 Salt ...... 7 Saturated fat ...... 7 Diet and nutrition campaigns and guidance ...... 8 5-a-day ...... 8 Classification: OFFICIAL 1

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Eatwell Guide ...... 8 Food labelling ...... 9 Change4Life healthy living campaign...... 10 School meals ...... 10 Who’s at risk and why? ...... 10 Young adults and Men ...... 10 Particular geographical regions ...... 10 Household food poverty ...... 11 Nutrition during the first 1,000 days of life ...... 11 Local intelligence data ...... 13 5-A-Day consumption ...... 13 Proportion of the population meeting the recommended ‘5-a-day’ ...... 13 Breakdown of fruit and vegetables consumed ...... 14 First 1,000 days of life ...... 14 Further information sources ...... 15 Diet and Nutrition References ...... 15 Physical Activity ...... 17 Importance of physical activity ...... 17 Government priority ...... 17 Public Health England infographics ...... 18 Physical activity campaigns ...... 19 Change4Life...... 19 This Girl Can ...... 19 One You ...... 19 Get Going Together ...... 19 Love Outdoor Play ...... 19 Physical activity guidelines ...... 19 Early Years (under 5s) ...... 19 Children and Young People (5-18 years) ...... 19 Adults (19-64 years) ...... 20 Older adults (65+ years) ...... 20 National physical activity data ...... 20

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Local intelligence data ...... 20 Physical activity in adults ...... 20 Evidence of what works ...... 21 Physical activity for children and young people ...... 21 Physical activity: walking and cycling ...... 22 Physical activity in the workplace ...... 22 Physical Activity References ...... 23 Obesity ...... 25 Obesity introduction ...... 25 Who’s at risk and why? ...... 25 Children and Young People ...... 25 Adult obesity ...... 26 Maternal obesity ...... 27 Evidence of what works ...... 27 Derby’s Childhood Obesity Strategy ...... 28 Obesity References ...... 28

Figure 1. The Eatwell Guide (Public Health England, 2016c)...... 9 Figure 2. Food label example (Public Health England, 2016c)...... 10 Figure 3. Physical activity infographics directly from Public Health England (2016)...... 18 Figure 4. Promising principles for practice (Public Health England, Youth Sport Trust and Association of College and Sport, 2015)...... 22

Table 1. Estimated annual savings from avoiding costs of disease in infants by varying breastfeeding rates (directly sourced from UNICEF UK, 2012)...... 12 Table 2. Maternal benefits and savings from breastfeeding scenarios (directly sourced from UNICEF UK, 2012)...... 13 Table 3. Population meeting the 5-a-day consumption of fruit and vegetables (%) (Source: Sport England Active People Survey, analysed by PHE)...... 13 Table 4. Average number of fruit and vegetables consumed daily by specific populations (Source: Sport Engalnd Active People Survey, analysed by PHE)...... 14 Table 5. Breastfeeding initiation and prevalence at 6-8 weeks after birth (%) 2014-15 (NHS England, cited within PHE, 2016)...... 14 Table 6. The percentage of adults achieving 150 minutes of physical activity per week (Public Health England, 2016)...... 20

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Table 8. The percentage of physically inactive adults in Derby, Derbyshire, East Midlands and England (Public Health England, 2016)...... 21 Table 9. Prevalence of obesity in reception classes (4-5 years old) in 2014/15 (Source: Health and Social Care Information Centre cited within PHE, 2016)...... 26 Table 10. Prevalence of obesity in Year 6 (10-11 years old) in 2014/15 (Source: Health and Social Care Information Centre cited within PHE, 2016)...... 26 Table 11. Overweight and Obese adults (%), 2012-14 (PHE, 2016)...... 27

Full JSNA Report

The importance of diet, physical activity and a healthy weight “Our causes of premature death are dominated by ‘diseases of lifestyle’, where smoking, unhealthy diet, excess alcohol consumption and sedentary lifestyles are contributory factors.” (Department of Health, 2010: p.11).

“Many premature deaths and illnesses could be avoided by improving lifestyles. It is estimated that a substantial proportion of cancers and over 30% of deaths from circulatory disease could be avoided, mainly through a combination of stopping smoking, improving diet and increasing physical activity.” (Department of Health, 2010: p.19).

“Dementia affects around 750,000 people in the UK and numbers are expected to double by 2030.81 The annual costs of dementia in the UK amount to £17 billion.82 Half of dementias have a vascular component; by improving diet and lifestyle in earlier life we can significantly reduce their impact.” (Department of Health, 2010: p.21).

Living a healthy lifestyle A healthy lifestyle for children and young people is central for individuals to reach their potential. Living a full, content and active life for good health includes not only physical health but also mental, social, emotional and spiritual wellbeing. A healthy lifestyle includes factors such as a balanced and healthy diet, physical activity, not participating in harmful activities such as smoking, misusing drugs or consuming more than the recommended quantity of alcohol as is age appropriate and avoiding risky behaviours e.g. practising safe sex, road safety. A healthy lifestyle also comprises positive mental health strategies such as managing stress, effective work-life balance, and opportunities for education, training and development. It also consists of emotional development through positive social relationships and a healthy environment in life surroundings such as within the home, work, education and the wider community.

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Good nutrition, physical activity and positive behaviours in early life provide the building blocks for physical health in adulthood. However, the five core areas - physical, mental, emotional, spiritual and social – produce a healthy lifestyle in individuals.

Recommendations Individuals, families and communities are recommended to review, and where necessary, make improvements to their diet, physical activities levels and to strive to be a healthy weight. Commissioners can help individuals make improvements and to stay living well through prioritising population level interventions that focus on halting and reversing the rising tide of obesity and the associated inactivate sedentary behaviours and poor diets.

There are a few key areas that are particularly important to note:

On the subject of diet, everyone should eat a diet that includes five portions of fruit and vegetables per day. Diets should be healthy and nutritious, with three-quarters of food obtained from fruit, vegetables and starchy carbohydrates. As a nation we need to reduce our average saturated fat, sugar and salt consumption. The Eatwell Guide and food labels are useful tools to help keep diets on track. Pregnant women should be encouraged and supported to exclusively breastfeed their baby’s for the first six months to provide infants with the best nutrition and the associated maternal-infant health benefits.

In Derby, more adults need to become physically active. All children need to be encouraged and given the opportunity to engage in daily physical activity and to avoid prolonged sedentary activities. Specific population groups have been identified as physically inactive and may benefit from targeted interventions: girls and young women; particular ethnic minorities’ e.g. Bangladeshi men and women; most deprived socio-economic group.

Obesity is a major public health problem in the UK: we are now the most obese nation in Western Europe. Obesity is associated with the health problems including diabetes type 2, heart disease, stroke, hypertension and some cancers. One in three children and two in three adults are overweight or obese. It is projected that by 2050 one in two adults will be obese if this obesity trend is not reversed. Individuals and commissioners need to implement changes that will build lifestyle habits that include moving more and eating less in order to live well.

The following sections are organised according to diet and nutrition, physical activity and obesity. However, it is noted that there is frequent overlap and it is helpful to consider these live well areas holistically.

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Diet and Nutrition

Diet and nutrition introduction “Nutrition is the intake of food, considered in relation to the body’s dietary needs. Good nutrition – an adequate, well balanced diet combined with regular physical activity – is a cornerstone of good health. Poor nutrition can lead to reduced immunity, increased susceptibility to disease, impaired physical and mental development, and reduced productivity.” (WHO, 2015b).

Non-communicable disease risk factors include poor diet and physical inactivity, as well as obesity (WHO, 2015a).

First 1,000 days of life The first 1,000 days of life encompasses the time from the beginning of pregnancy through to a child’s second birthday. The first 1,000 days is the most significant time of life as it is the most influential on future life capabilities. For instance, it is associated with the majority of brain development (80% by aged three) (NCT First 1,000 Days).

Nutrition in these first 1,000 days is crucial for growth promotion and laying quality foundations for a healthy life course. The consequences of malnutrition include, iron deficiency anaemia, vitamin A deficiency associated night blindness, weakened immunity, impaired mental and physical development, disability, obesity and infant mortality. Maternal malnutrition of iron deficiency anaemia and short stature increases the risk of delivery mortality and the likelihood of low birth weight babies and mortality. The first 1,000 days of life is crucial for prenatal and early life interventions which promote growth, particularly because the consequences of malnutrition are challenging to reverse later on in life (World Health Organization, 2013).

Strategies focused upon the first 1,000 days include interventions that:

 improve nutrition of women who are trying to conceive, pregnant and breastfeeding  early initiation of breastfeeding and exclusive breastfeeding until infants are 6 months old  continued breastfeeding and complementary feeding between six months and 2 years  vitamin and mineral supplementation where needed (e.g. vitamin A, iron, iodine)

Reduce sugar, salt and saturated fat intake

Sugar High quantities of sugar consumption are associated with poor diet, obesity and non-communicable diseases, as well as dental decay and cavities. Meta-analysis evidence of RCTs have found a relationship between sugar intake and body weight (e.g. high sugar consumption and increased body weight, and conversely, reduced sugar intake and reduced body weight). The World Health Organization recommends a reduction in the intake of sugar across the life span. Specifically it is Classification: OFFICIAL 6

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recommended that adults and children consumption of free sugar is <10% of total energy intake, preferably <5%. Sugar is not only found as additives in foods such as cakes, biscuits and deserts (free sugars), but also sugar is naturally present in honey, syrups and fruit juices (intrinsic sugars) (WHO, 2015a).

In the UK, it is advised that adults and children aged 11 years and over should not exceed 30g of sugar a day, with children aged between 4 and 6 years limited to 19g intake (Public Health England, 2016c).

Salt Most adults consume too much salt in their diet. In Europe it is estimated that adults have a salt intake of 7-18g per day, which is above the WHO recommended daily amount of <5g. Too much salt is associated with health problems such as raised blood pressure and cardiovascular diseases. “Salt reduction is thus a priority policy action and considered one of the most cost-effective approaches to prevent noncommunicable diseases (NCDs). Action is typically built around 3 core pillars: product reformulation; consumer awareness and education including clear and comprehensive labelling; and monitoring of salt consumption in the population. Finland and the United Kingdom were early adopters of effective salt reduction programmes…” (WHO Europe, 2014).

Studies in the UK found an average daily salt intake of 9.5g back in 2001. Interestingly, only 5% of salt was naturally present in the food, and consumers added approximately 15% to their food, however 80% of salt was added to food by the food industry. Since salt reduction public health measures have been implemented, the UK average daily salt intake was reduced by 10% to 8.6g in 2008 (WHO Europe, 2013). The positive trend in salt consumption reduction continued as in 2014 the average daily salt intake in adults was 8.0g. The importance of continuing this positive trend in reducing salt consumption is highlighted in the Public Health England press release: “A reduction in average salt intake from 8g to 6g per day is estimated to prevent over 8000 premature deaths each year and save the NHS over £570million annually.” (Public Health England, 2016b).

In the UK it is recommended that adults should consume 6g or less of salt a day and children should have less than this (Public Health England, 2016c).

Saturated fat It is common in the UK that adults consume too much saturated fat and this is harmful as it contributes to ill-health such as heart disease and high blood cholesterol. It is recommended that women eat <20g of saturated fat a day, men should have no more than 30g and children should consume less than adults. However, children <5 years should not be put on a low fat diet (Public Health England, 2016c).

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Diet and nutrition campaigns and guidance The Government recommends that individuals should eat 5 portions of fruit and vegetables each day for good nutrition and Public Health England published the Eatwell Guide illustrating the proportions of food groups for a healthy diet.

5-a-day The 5 A Day campaign was created following a World Health Organization symposium and recommendation to encourage a daily fruit and vegetable consumption of a minimum of 400g (NHS Choices, 2016b). With one portion of fruit or vegetables equating to 80g, the 5-a-day term was generated. The 400g of fruit and vegetables per day recommendation by the World Health Organization led to the 5-a-day advice implemented in the UK. This campaign occurred at a time where heart disease, stroke and bowel cancer cases were increasing and could be prevented through good nutrition and a healthy diet that included several portions of fruit and vegetables each day.

Fruit and vegetables provide sources of vitamins and minerals required for health, provide dietary fibre for healthy digestion, reduce the risk of some serious health problems like heart disease and some types of cancer, and underpin a healthy, balanced diet.

Eatwell Guide The new Eatwell Guide was published in 2016 by Public Health England (Figure 1). The guide provides a pie chart that depicts quantities in each food group that constitute a healthy and balanced diet.

 39% Fruit and vegetables  37% Starchy carbohydrates (potatoes, bread, rice, pasta, cereal, etc)  12% Proteins (beans, pulses, fish, eggs, meat, etc)  8% Dairy and alternatives (milk, soya, yoghurt, cheese, etc)  1% Oils and spreads  3% Occasional foods

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Figure 1. The Eatwell Guide (Public Health England, 2016c).

Three quarters of a diet should be obtained from vegetables, fruit and starchy carbohydrates. When choosing starchy carbohydrates, it is encouraged that individuals select wholegrain and higher fibre versions, such as wholegrain rice and breakfast cereals, wholemeal and whole grain bread pitta and chapattis, wholewheat pasta and whole oats. Depending on personal dietary choices, proteins should be obtained from sources such as beans, pulses, fish, eggs, nuts, poultry meat. The intake of red and processed meat should be limited to low quantities. It is recommended that two portions of fish are consumed per week, with one portion being oily fish. Milk, dairy food and alternates are also good sources of protein, vitamins and calcium. Some dairy and alternatives can be high in fat and saturated fat so adults can pick reduced fat versions. Oils and spreads should be consumed in limited quantities, and unsaturated fat options such as vegetable, rapeseed and olive oils selected before saturated versions. Alongside the recommended proportions of food groups, it is advised to keep well hydrated with 6-8 glasses of fluid per day (Public Health England, 2016c).

Food labelling Food labels (Figure 2) are often found on pre-packaged foods and provide the consumer the nutritional information per serving with colour coded food labels indicating the high, medium or low quantities of fat, sugars and salt. Low is coloured green and high is coloured red for a quick reference per food serving (Public Health England, 2016c). These food labels can aid the consumer with making healthy choices in their diet.

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Figure 2. Food label example (Public Health England, 2016c). Change4Life healthy living campaign The NHS Change4Life campaign is about following a healthy diet, as well as other factors that form a healthy lifestyle: physical activity; active lives; reduction in alcohol consumption (NHS 2016).

School meals The government provides funding for free cooked meals for children in the first three years of primary education (Reception, Year 1 and Year 2) through the Universal Infant Free School Meals (UIFSM) scheme. The meals have to meet the school food standards that ensures pupils are provided with food that is nutritious and of high quality (Department for Education, 2014).

Who’s at risk and why? Adults are recommended to eat 5-a-day – that is 5 portions of fruit and vegetables a day. However, the majority of adults do not achieve this recommendation.

Young adults and Men Public Health England (2015) reports that 30% of working aged adults (19-64 years) and 41% of older adults (65 years +) meet this recommendation. One portion equates to an 80g serving of fruit or vegetables. From 2001, women have consistently consumed more fruit and vegetables than men. In 2013, women ate 3.7 portions compared to 3.5 portions for men, on average. The highest portions were consumed by women aged 35-44 and 65-74 years old (4.0 portions per day average) and men aged 65-74 years (3.8 portions per day average).

Particular geographical regions There are regional differences in the average portions of fruit and vegetables consumed: London residents report the highest average with 4.0 portions for men and 4.1 portions for women, and the lowest average was found in men in Yorkshire and the Humber with 3.0 portions and women in the North East with 3.2 portions. In the East Midlands, men consumed 3.4 portions and women 3.6 portions (Public Health England, 2013).

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Household food poverty Household income is an indicator of fruit and vegetables purchased. Between 2006 and 2013, lower income households purchased less fruit and vegetables compared to the average. For example, in 2013, 3.2 portions were purchased per day by the lowest income quintile compared to 4.3 portions by the highest income quintile, with 4.0 portions on average for all households in England (Public Health England, 2013).

Nutrition during the first 1,000 days of life In 2010 the UK Infant Feeding Survey reported that the breastfeeding rates were:

• 81% of mothers initially breastfed (83% in England) • 69% of mothers were breastfeeding at one week • 55% of mothers were breastfeeding at six weeks • 34% of mothers were breastfeeding at six months (36% in England)

Exclusively breastfeeding rates in the UK:

• 69% of mothers at birth • 46% of mothers at one week • 23% of mothers at six weeks • 1% of mothers at six months

Older mothers are more likely to breastfeed (87% of mothers aged 30 years +) and teenage mothers least likely (58% of mothers aged under 20 years old). Mothers from all groups of ethnic minority groups were most likely to breastfeed (Asian 95%; Black 96%; Chinese or other ethnic origin 97%; mixed race 89%; White 79%). In addition, women living in the least deprived areas and in professional and managerial occupations are most likely to breastfeed (McAndrew et al., 2012).

The UNICEF UK breastfeeding report (2012) calculated the potential prevention of disease and resources saved through the increase of breastfeeding rates in the UK. An economic analysis was conducted using evidence from published reviews and studies. It was appraised that if the UK experienced a moderate increase in breastfeeding rates, “if 45% of women exclusively breastfed for four months, and if 75% of babies in neonatal units were breastfed at discharge, every year there could be an estimated:

 3,285 fewer gastrointestinal infection-related hospital admissions and 10,637 fewer GP consultations, with over £3.6 million saved in treatment costs annually

 5,916 fewer lower respiratory tract infection-related hospital admissions and 22,248 fewer GP consultations, with around £6.7 million saved in treatment costs annually

 21,045 fewer acute otitis media (AOM) related GP consultations, with over £750,000 saved in treatment costs annually

 361 fewer cases of NEC, with over £6 million saved in treatment costs annually.

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In total, over £17 million could be gained annually by avoiding the costs of treating four acute diseases in infants. Increasing breastfeeding prevalence further would result in even greater cost savings.

If half those mothers who currently do not breastfeed were to breastfeed for up to 18 months in their lifetime, for each annual cohort of around 313,000 first-time mothers there could be:

• 865 fewer breast cancer cases

• with cost savings to the health service of over £21 million

• 512 breast cancer-related quality adjusted life years (QALYs) would be gained, equating to a value of over £10 million.

This could result in an incremental benefit of more than £31 million, over the lifetime of each annual cohort of first-time mothers.” (UNICEF UK, 2012: p.11).

UNICEF UK provided saving estimates (Table 1 & Table 2) based on three policy scenarios:

• Least optimistic policy scenarios – increasing exclusive breastfeeding to 21% at four months, and 35% of babies breastfeeding at discharge from neonatal units • Mid-level policy scenarios – increasing exclusive breastfeeding to 45% at four months, and 75% of babies breastfeeding at discharge from neonatal units • Most optimistic policy scenarios - increasing exclusive breastfeeding to 65% at four months, and 100% of babies breastfeeding at discharge from neonatal units

Table 1. Estimated annual savings from avoiding costs of disease in infants by varying breastfeeding rates (directly sourced from UNICEF UK, 2012).

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Table 2. Maternal benefits and savings from breastfeeding scenarios (directly sourced from UNICEF UK, 2012).

Local intelligence data

5-A-Day consumption The White Paper ‘Healthy Lives, Healthy People’ highlights the role of diet as a major contributor to chronic disease and premature death in England. Poor diet is an important public health issue: it increases the risk of some cancers, CVD and type II diabetes and these diseases are linked to obesity.

Proportion of the population meeting the recommended ‘5-a-day’ Derby has a similar proportion to the England average of the population meeting the recommended 5-a-day guidelines of daily fruit and vegetable consumption (52.4% and 52.3% respectively). In England, the proportions range from 36.5% at the lowest to 62.8% at the highest.

Table 3. Population meeting the 5-a-day consumption of fruit and vegetables (%) (Source: Sport England Active People Survey, analysed by PHE).

2015 Derby 52.4 Derbyshire 53.3

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East Midlands 52.7 England 52.3

Breakdown of fruit and vegetables consumed The average number of portions of fruit and vegetables consumed daily is shown in the table below. These figures would suggest that on average the population is consuming nearly 5 portions of fruit and vegetables per day but this does not correspond to the figures given in Table 3.

Table 4. Average number of fruit and vegetables consumed daily by specific populations (Source: Sport Engalnd Active People Survey, analysed by PHE).

Portions of fruit Portions of vegetables

Derby 2.47 2.28

Derbyshire 2.46 2.36

East Midlands 2.48 2.29

England 2.51 2.27

First 1,000 days of life The breastfeeding initiation in Derby is 70.2% which is lower than 74.3% reported in England. Local data regarding breastfeeding prevalence at 6-8 weeks after birth is not reported (Table 5).

Table 5. Breastfeeding initiation and prevalence at 6-8 weeks after birth (%) 2014-15 (NHS England, cited within PHE, 2016).

Breastfeeding Breastfeeding prevalence at 6-8 initiation weeks after birth

Derby 70.2

Derbyshire 73.4

East Midlands 71.6 44.4

England 74.3 43.8

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Further information sources British Nutrition Foundation https://www.nutrition.org.uk/

Change4Life http://www.nhs.uk/change4life/Pages/change-for-life.aspx

NHS Choices http://www.nhs.uk/livewell/goodfood/Pages/Goodfoodhome.aspx

Diet and Nutrition References Department for Education (2014) Universal infant free school meals: departmental advice for local authorities, maintained schools, academies and free schools. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/408015/Archived- Universal_infant_free_school_meals_departmental_advice_30092014.pdf (Accessed: 23 August 2016).

Department of Health (2010) Healthy lives, healthy people: Our strategy for public health in England. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216096/dh_12742 4.pdf (Accessed: 7 June 2016).

McAndrew, F., Thompson, J., Fellows, L., Large, A., Speed, M. and Renfrew, M. (2012) Infant feeding survey 2010. Available at: http://digital.nhs.uk/catalogue/PUB08694/Infant-Feeding-Survey-2010- Consolidated-Report.pdf (Accessed: 23 August 2016).

NCT First 1,000 Days (2013) First 1, 000 days: What it means. Available at: http://www.first1000days.org.uk/p/first-1000-days_2.html (Accessed: 8 June 2016).

NHS (2016) Change4Life. Available at: http://www.nhs.uk/change4life/Pages/change-for-life.aspx (Accessed: 23 August 2016).

NHS Choices (2016a) The Eatwell guide. Available at: http://www.nhs.uk/Livewell/Goodfood/Pages/the-eatwell-guide.aspx (Accessed: 7 June 2016).

NHS Choices (2016b) Why 5 A DAY? Available at: http://www.nhs.uk/Livewell/5ADAY/Pages/Why5ADAY.aspx (Accessed: 29 July 2016).

Public Health England (2015) Adult diet data factsheet. Available at: http://www.noo.org.uk/securefiles/160607_1401//Adult-dietfactsheetDec2015.pdf (Accessed: 7 June 2016).

Public Health England (2016a) Eatwell Guide Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/528193/Eatwell_g uide_colour.pdf (Accessed: 13 June 2016).

Public Health England (2016b) New PHE data on salt consumption levels. Available at: https://www.gov.uk/government/news/new-phe-data-on-salt-consumption-levels (Accessed: 23 August 2016).

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Public Health England (2016c) The Eatwell Guide: Helping you eat a healthy, balanced diet. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/528200/Eatwell_g uide_booklet.pdf (Accessed: 26 July 2016).

UNICEF UK (2012) Preventing disease and saving resources: The potential contribution of increasing breastfeeding rates in the UK. Available at: http://www.unicef.org.uk/Documents/Baby_Friendly/Research/Preventing_disease_saving_resourc es.pdf (Accessed: 8 June 2016).

WHO (2015a) Guideline: sugars intake for adults and children. Available at: http://apps.who.int/iris/bitstream/10665/149782/1/9789241549028_eng.pdf?ua=1 (Accessed: 9 June 2016).

WHO (2015b) Nutrition. Available at: http://www.who.int/topics/nutrition/en/ (Accessed: 8 June 2016).

WHO Europe (2013) Mapping salt reduction initiatives in the WHO European region. Available at: https://issuu.com/whoeurope/docs/mapping-salt-reduction-initiatives-in-the-who- euro?e=185028/7078128 (Accessed: 9 June 2016).

WHO Europe (2014) Reducing salt consumption. Available at: http://www.euro.who.int/en/health- topics/disease-prevention/nutrition/news/news/2014/09/reducing-salt-consumption (Accessed: 9 June 2016).

World Health Organization (2013) Essential Nutrition Actions: Improving maternal, newborn, infant and young child health and nutrition. Available at: http://apps.who.int/iris/bitstream/10665/84409/1/9789241505550_eng.pdf?ua=1 (Accessed: 8 June 2016).

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Physical Activity

Importance of physical activity Physical activity promotes a healthy physical and mental wellbeing. Regular exercise protects against diseases such as diabetes and particular cancers, and conditions such as obesity, hypertension and depression. Physical activity has wider reaching benefits as well, for instance brain development and educational attainment in children, better workplace productivity and reduced sickness absence, and a reduction in antisocial behaviour (Public Health England, 2014).

Government priority Physical inactivity is associated with one in six deaths in the UK which is comparable to the harm from smoking (Public Health England, 2014). One in four adults do not even meet the minimum of 30 minutes of physical activity a week.

Following on from the momentum generated during the London 2012 Olympic and Paralympic Games, the Government aimed to capitalise on this legacy to make the nation much more physically active.

Physical activity can prevent some cases of:

 Type II diabetes

 Depression

 Vascular dementia

 Breast cancer

 Cardiovascular disease

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Public Health England infographics

Figure 3. Physical activity infographics directly from Public Health England (2016).

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Physical activity campaigns There are many campaigns associated with physical activity. Here are some of the well-known campaigns.

Change4Life The NHS Change4Life campaign is about more than just physical activity, it is about overall health in the family unit involving a healthy diet, active lives, reduction in alcohol consumption and activities to take part in.

This Girl Can The national campaign by Sport England encourages all women and girls to become and stay active without fear of judgement of their appearance, weight and ability. There is a large disparity between the amount of physical activity undertaken by men and women in the UK.

One You The One You national campaign by Public Health England is targeted at 40 to 60 year olds and encourages the adoption of a healthier lifestyle in order to avoid ill-health consequences later on it life.

Get Going Together Age UK encourage older people to take part in physical activity through the Get Going Together campaign.

Love Outdoor Play The Play England campaign encourage children to play outdoors more frequently.

Physical activity guidelines In 2011, the Department of Health released guidelines relating to the level of physical activity recommended for good health across various age groups.

Early Years (under 5s) For infants, the time should be minimised in sedentary restrained positions for extended periods and infants should be encouraged to be physical active from birth (e.g. tummy time and swim sessions).

Pre-school children should be physically active for at least 3 hours a day.

Children and Young People (5-18 years) Moderate to vigorous physical activity for at least 60 minutes a day and time spend being sedentary should be minimised.

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Adults (19-64 years) Be moderately physically active for a minimum of 150 minutes a week and minimise time spend being sedentary for extended periods.

Older adults (65+ years) 150 minutes of physical activity a week and minimised time spent being sedentary for extended periods.

National physical activity data In England, 1 in 3 men and 1 in 2 women are not active enough for good health. This is determined by adults achieving the recommended guidelines of 150 minutes of physical activity a week (Public Health England, 2014). The guidelines for children are 60 minutes of physical activity a day. Sadly, only 21% of boys and just 16% of girls aged between 5 and 15 years reach the recommended levels of physical activity. Merely one in 10 very young children, those aged between 2 and 4 years, meet the physical activity guidelines (HM Government, 2014).

This shows that the youngest generations are the worst group for meeting physical activity guidelines and this is concerning because physical activity is a lifestyle behaviour and activity levels tend to decline with age. Poor lifestyles adopted in childhood are challenging to reverse in adulthood. Preventative measures that promote good lifestyle habits from the early years are easier to maintain rather than attempts to reverse poor habits and address any associated health issues from physical inactivity.

The degree of physical inactivity is highest amongst the lowest economic group, specific ethnic minorities (e.g. Bangladeshi men and women) and girls. Internationally, British adults and teenagers are more physically inactive than the international averages (HM Government, 2014).

The harmful levels of physical inactivity is unsustainable and costing the UK approximately £7.2bn per year (Public Health England, 2014).

Local intelligence data

Physical activity in adults Almost 60% of Derby adults achieve the government guideline of 150 minutes of physical activity per week. However, nearly 30% of Derby adults are physically inactive. Unfortunately, levels of physical inactivity have increased in more recent years.

Table 6. The percentage of adults achieving 150 minutes of physical activity per week (Public Health England, 2016).

Derby Derbyshire East Midlands England

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2012 55.9 56.7 56.3 56 2013 56.8 55.6 55.9 56 2014 58.9 56.1 57.6 57 Table 7. The percentage of physically inactive adults in Derby, Derbyshire, East Midlands and England (Public Health England, 2016).

Derby Derbyshire East Midlands England

2012 28.5 28.3 28.7 28.5 2013 28.6 29.7 28.6 28.3 2014 29.2 28.4 27.5 27.7

Evidence of what works The methods commonly used to increase the population’s physical activity levels include: brief interventions in primary care, exercise referral schemes, pedometers and community-based walking and cycling programmes.

Physical activity for children and young people WHAT WORKS IN SCHOOLS AND COLLEGES TO INCREASE PHYSICAL ACTIVITY? A briefing for head teachers, college principals, staff working in education settings, directors of public health and wider partners

The report by Public Health England, Youth Sport Trust and Association of College and Sport (2015) outlines eight principles for practice for increasing physical activity among children and young people in schools and colleges. The principles are evidence based, linked to Ofsted and National Institute for Health and Care Excellence (NICE) guidance and include practice examples.

The promising principles for practice are illustrated in Figure 4 and include:

1. Deliver multi-component interventions - whole school/college approach relating to curricular learning, the culture, ethos and environment providing a support of physical activity and engagement with the wider community and families. 2. Ensure a skilled workforce - trained, skilled and knowledgeable workforce responsible for delivering physical activity across schools and colleges 3. Engage student voice - consulting students to allow them ownership of physical activity delivery 4. Create active environments - access to spaces for physical activity such as playgrounds, parks, forests, equipment 5. Offer choice and variety – selection of physical activity opportunities including fun games, traditional sports and competitive activities 6. Embed in curriculum, teaching and learning – increased time allocated for physical activity, excellent physical education syllabus and support the development of physical development, confidence and values.

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7. Promote active travel - increasing physical activity levels through active travel plans and options 8. Embed monitoring and evaluation – self-monitoring devices such as pedometers enable students to measure physical activity levels and encourage goal setting e.g. 10,000 steps per day.

Figure 4. Promising principles for practice (Public Health England, Youth Sport Trust and Association of College and Sport, 2015). Physical activity: walking and cycling SYSTEMATIC REVIEW AND NARRATIVE SYNTHESIS OF THE EFFECTIVENESS OF LOCAL INTERVENTIONS TO PROMOTE CYCLING AND WALING FOR RECREATIONAL AND TRAVEL PURPOSES

Blank et al. (2012) conducted a review for NICE with the purpose to produce guidance on walking and cycling local interventions. The interventions reviewed were structured as: media campaigns; health information; multi component interventions; walking sessions; pedometer interventions; motivational interventions. Overall, mass media health promotion information was effective at increasing walking: more so effective in specific settings with targeted messages. Although multi- component interventions were effective at increasing walking and cycling, it was not apparent which contributing parts were effective or if it was the sum of all parts. Walking sessions in specific settings were found to be effective; however the use of pedometers meant that walking sessions were effective in all settings.

Physical activity in the workplace A REVIEW OF EFFECTIVENESS OF WORKPLACE HEALTH PROMOTION INTERVENTIONS ON PHYSICAL ACTIVITY AND WHAT WORKS IN MOTIVATING AND CHANGING EMPLOYEE’S HEALTH BEHAVIOUR Classification: OFFICIAL 22

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Dugdill, et al. (2007) reviewed the effectiveness of workplace physical activity interventions and organised them into the following groups:

 Workplace stair walking interventions  Walking interventions  Active travel  Other (e.g. health checks, activity sessions, health promotion, motivational interviewing)  Systematic reviews

The evidence was conflicting for the use of posters encouraging stair walking. There were positive results in the instances of pedometers in the public sector for increasing step counts. Some evidence indicated that a campaign using written health materials increased walking to work in women of economically advantaged backgrounds. The separate interventions of health screening and counselling in the workplace produced positive results for improving physical activity.

Physical Activity References Age UK (2016) Get going together. Available at: http://www.ageuk.org.uk/health-wellbeing/fit-as-a- fiddle/getgoingtogether/ (Accessed: 23 August 2016).

Blank, L., Jones, R., Woods, H.B. and Payne, N. (2012) Systematic review and narrative synthesis of the effectiveness of local interventions to promote cycling and walking for recreational and travel purposes. CONTENTS ABBREVIATIONS 5 EXECUTIVE SUMMARY 6 EVIDENCE STATEMENTS 13. Available at: https://www.nice.org.uk/guidance/ph41/evidence/effectiveness-revew-430261597 (Accessed: 26 July 2016).

Children’s Food Trust (2016) Free school meals for all infants FAQs. Available at: http://www.childrensfoodtrust.org.uk/childrens-food-trust/schools/school-food-plan/uifsm/infant- fsm-faqs/ (Accessed: 2 August 2016).

Department for Education (2016) School food in England: Departmental advice for governing boards. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/537625/20141209 -School_food_in_England-July2016.pdf (Accessed: 2 August 2016).

Department of Health (2011) UK physical activity guidelines. Available at: https://www.gov.uk/government/publications/uk-physical-activity-guidelines (Accessed: 21 July 2016).

Dugdill, L., Brettle, A., Hulme, C., McCluskey, S. and Long, A. (2007) Physical activity in the workplace NICE evidence: A review of effectiveness of workplace health promotion interventions on physical activity and what works in motivating and changing employees’ health behaviour. Available at: https://www.nice.org.uk/guidance/ph13/evidence (Accessed: 22 July 2016).

HM Government (2014) Moving more, living more: the physical activity Olympic and Paralympic legacy for the nation. Available at:

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https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/279657/moving_li ving_more_inspired_2012.pdf (Accessed: 21 July 2016).

NHS (2016a) Change4Life. Available at: http://www.nhs.uk/change4life/Pages/change-for-life.aspx (Accessed: 23 August 2016).

NHS (2016b) One You. Available at: https://www.nhs.uk/oneyou#tJB5d4B1mdxh2Z5I.97 (Accessed: 23 August 2016).

NHS Change4Life (2016) About change4Life. Available at: http://www.nhs.uk/Change4Life/Pages/why-change-for-life.aspx (Accessed: 26 July 2016).

Play England (2016) Love outdoor play. Available at: https://loveoutdoorplay.net/ (Accessed: 23 August 2016).

Public Health England (2014) Everybody active, every day: an evidence-based approach to physical activity. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/374914/Framewo rk_13.pdf (Accessed: 21 July 2016).

Public Health England (2016) Physical activity benefits for adults and older adults what should you do? Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/541233/Physical_ activity_infographic.PDF (Accessed: 23 August 2016).

Public Health England, Youth Sport Trust and Association of College and Sport (2015) What works in schools and colleges to increase physical activity? A briefing for head teachers, college principals, staff working in education settings, directors of public health and wider partners. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/469703/What_wo rks_in_schools_and_colleges_to_increas_physical_activity.pdf (Accessed: 22 July 2016).

Sport England (2016) This girl can. Available at: http://www.thisgirlcan.co.uk/ (Accessed: 23 August 2016).

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Obesity

Obesity introduction Obesity results from an energy imbalance whereby more food is consumed than is used and is stored in the body as excess body fat. Body Mass Index (BMI) is used to measure obesity and is calculated using a weight-for-height formula. People with very muscular bodies may have an overweight BMI score. In this instance, waist circumference measurements are helpful to distinguish between muscular physiques and body fat mass (Health and Social Care Information Centre, 2016).

BMI = weight (kg) / height² (m²)

Being overweight (BMI between 25 and 29) and obese (BMI 30 and over) is associated with diabetes type II, coronary heart disease, stroke, cancer and hypertension, to list the most common conditions. One fifth of primary school children in Year 6 and one quarter of adults in England are categorised as obese (Public Health England, 2016).

The UK now has the highest level of obesity in Western Europe. In the last 30 years the obesity levels have trebled and it is projected that if this trend continues, half of the UK population could be obese by 2050 (NHS Choices, 2015).

Who’s at risk and why? Since the 1990s, the prevalence of obesity has significantly increased in England.

There were 14% of overweight children aged 2-15 years old in 2014, and a further 17% were obese. The highest proportion of children who were overweight and obese had low household income backgrounds.

In 2014, 41% of males and 31% of females were overweight and a further 24% of males and 27% of females were obese. The mean BMI for adults in England was 27.2kg/m² which equates to an excess weight of 6.9kg for males and 5.6kg for females of average height (Health & Social Care Information Centre, 2015).

Children and Young People The National Child Measurement Programme (NCMP) collects data on the height and weight of children in the first year of primary school (Reception class aged 4-5 years) and last year (Year 6 class aged 10-11 years) to provide data on the prevalence of childhood obesity.

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Table 8. Prevalence of obesity in reception classes (4-5 years old) in 2014/15 (Source: Health and Social Care Information Centre cited within PHE, 2016).

Obesity rates increase over childhood. Obesity in reception children in Derby is 9.1% which is the same as England (Table 8), however it is 20.8% in Year 6 children (Table 9) which is larger than England (19.1%) and the East Midlands region (18.5%).

Obesity is 7.7% in reception children in Derbyshire and 17% in Year 6 children, which is lower than is reported for Derby, East Midlands and England.

Table 9. Prevalence of obesity in Year 6 (10-11 years old) in 2014/15 (Source: Health and Social Care Information Centre cited within PHE, 2016).

Adult obesity The percentage of adults classified as obese (BMI 30 and above) was 24% in England and slightly higher in Derby at 25.8% between 2012 and 2014 (Table 10). Classification: OFFICIAL 26

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Table 10. Overweight and Obese adults (%), 2012-14 (PHE, 2016).

Derby Derbyshire East Midlands England

Overweight 64.8 68.8 66.7 64.6

Obese 25.8 27 25.5 24

Maternal obesity Maternal obesity is measured as a BMI of 30kg/m² and above at the first antenatal consultation. In England 1 in 2 women of childbearing age are overweight or obese. Maternal obesity poses health risks to both the pregnant women (e.g. gestational diabetes) and the baby in utero and after birth (e.g. macrosomia, still birth) (Public Health England, 2016).

Evidence of what works OBESITY: IDENTIFICATION, ASSESSMENT AND MANAGEMENT OF OVERWEIGHT AND OBESITY IN CHILDREN, YOUNG PEOPLE AND ADULTS

NICE commissioned the National Clinical Guideline Centre to produce ‘Obesity: Identification, assessment and management of overweight and obesity in children, young people and adults’ in 2014 which detailed methods, evidence and recommendations.

The obesity interventions reviewed included:

 Lifestyle interventions  Behavioural interventions  Physical activity  Dietary  Pharmacological interventions  Continued prescribing and withdrawal  Surgical interventions  Bariatric surgery in people with recent onset type 2 diabetes

IMPACT OF PHYSICAL ACTIVITY AND DIET ON HEALTH

The House of Commons Health Committee published the ‘Impact of physical activity and diet on health’ report in 2015. It highlighted that physical activity alone can substantially improve health, although the trio of diet, obesity and physical activity all have important impacts on health. The combinations of individual and population level interventions were most effective at tackling obesity and improving diet and physical activity levels. The role of clinicians in offering brief advice during GP appointments was underlined as a cost effective measure to encourage physical activity.

EVIDENCE STATEMENTS FOR ‘OVERWEIGHT AND OBESE ADULTS – LIFESTYLE WEIGHT MANAGEMENT’

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NICE gathered evidence concerning ‘overweight and obese adults – lifestyle weight management’ and categorised the programmes according to:

1. Mid-term weight loss in BWMPs 2. Long term weight-loss in BWMPs 3. Weight loss in programmes available in the UK 4. Effectiveness for different population groups: gender 5. Effectiveness for different population groups: age 6. Effectiveness for different population groups: ethnicity 7. Effectiveness for different population groups: other categories 8. Diet and physical activity outcomes 9. Weight loss in programmes involving diet and exercise versus diet-only or exercise-only programmes 10. Weight loss by programme delivery type 11. Weight loss by professional background of therapist 12. Weight loss by supervised versus recommended exercise 13. Weight loss by energy intake prescription 14. Weight loss by programme length 15. Weight loss by number of sessions 16. Association of behavioural change techniques with weight loss 17. Applicability of available data (weight regain) 18. Rate of weight-loss regain after Multicomponent behavioural weight management programmes 19. Effect of Multicomponent behavioural weight management programme characteristics on the rate of weight regain after programme end 20. Effect of ease of activity during a behavioural weight management programme on the rate of weight regain after programme end 21. Effective weight-loss maintenance interventions

The NICE document provided the weight of evidence for the effectiveness of each programme/intervention.

Derby’s Childhood Obesity Strategy The Health and Wellbeing Board updated the Derby Strategy for Childhood Obesity in 2015. The report stated the “aim to reduce excess weight amongst Derby’s children by 5% in 5 years and reduce inequalities in childhood obesity.” (Derby City Council Health and Wellbeing Board, 2015: p.1).

Obesity References Derby City Council Health and Wellbeing Board (2015) Derby’s Childhood Obesity Strategy. Available at:

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https://cmis.derby.gov.uk/CMIS5/Document.ashx?czJKcaeAi5tUFL1DTL2UE4zNRBcoShgo=2%2FIrZXI B8zk1eUfoP50YFvMELu%2Bcj%2FCEA7arxHXv6svC8k6GD9b1mQ%3D%3D&rUzwRPf%2BZ3zd4E7Ikn8 Lyw%3D%3D=pwRE6AGJFLDNlh225F5QMaQWCtPHwdhUfCZ%2FLUQzgA2uL5jNRG4jdQ%3D%3D&m CTIbCubSFfXsDGW9IXnlg%3D%3D=hFflUdN3100%3D&kCx1AnS9%2FpWZQ40DXFvdEw%3D%3D=hFfl UdN3100%3D&uJovDxwdjMPoYv%2BAJvYtyA%3D%3D=ctNJFf55vVA%3D&FgPlIEJYlotS%2BYGoBi5ol A%3D%3D=NHdURQburHA%3D&d9Qjj0ag1Pd993jsyOJqFvmyB7X0CSQK=ctNJFf55vVA%3D&WGewm oAfeNR9xqBux0r1Q8Za60lavYmz=ctNJFf55vVA%3D&WGewmoAfeNQ16B2MHuCpMRKZMwaG1PaO =ctNJFf55vVA%3D (Accessed: 23 August 2016).

Health & Social Care Information Centre (2015) Health Survey for England, 2014. Available at: http://www.hscic.gov.uk/catalogue/PUB19295 (Accessed: 27 May 2016).

Health and Social Care Information Centre (2016) Statistics on obesity, physical activity and diet. Available at: http://digital.nhs.uk/catalogue/PUB20562/obes-phys-acti-diet-eng-2016-rep.pdf (Accessed: 23 August 2016).

House of Commons Health Committee (2015) Impact of physical activity and diet on health sixth report of session 2014–15. Available at: http://www.publications.parliament.uk/pa/cm201415/cmselect/cmhealth/845/845.pdf (Accessed: 24 August 2016).

National Clinical Guideline Centre (2014) Obesity: identification, assessment and management of overweight and obesity in children, young people and adults. Available at: https://www.nice.org.uk/guidance/cg189/evidence/obesity-update-full-guideline-193342429 (Accessed: 24 August 2016).

NHS Choices (2015) Britain: ‘The fat man of Europe’. Available at: http://www.nhs.uk/Livewell/loseweight/Pages/statistics-and-causes-of-the-obesity-epidemic-in-the- UK.aspx (Accessed: 24 August 2016).

NICE (2016) Evidence statements for: Overweight and obese adults: Lifestyle weight management services 1 of 28. Available at: https://www.nice.org.uk/guidance/ph53/evidence/evidence- statements-431709229 (Accessed: 24 August 2016).

Public Health England (2016a) Health: Public health England obesity knowledge and intelligence team. Available at: http://www.noo.org.uk/LA/impact/health (Accessed: 13 June 2016).

Public Health England (2016b) Prevalence: Public health England obesity knowledge and intelligence team. Available at: http://www.noo.org.uk/NOO_about_obesity/maternal_obesity_2015/prevalence (Accessed: 23 August 2016).

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