Preventative Public Policy and Childhood Obesity Case Studies

Preventive public policy and childhood obesity: case studies in England and the Netherlands

Preventative Public Policyand Childhood Obesity

Case Studies in Englandand the Netherlands

ECORYS Research Programme

Nicola Hall, Kate Crosswaite and Allice Hocking (ECOTEC Research & Consulting)Wija Oortwijn, Emmy Nelissen, Judith Mathijssen (ECORYS)Professor Carolyn Summerbell (University of Durham)

Date of submission: 19th December 2008.


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Table of contents

Executive Summary 51. Introduction 52. Background and Rationale 53. Methodology 64. The UK Case Study 65. Netherlands Case Study 76. Conclusions and Recommendations 7

Glossary 10

1 Introduction 121.1 Aims and Objectives 131.2 Content of this report 13

2 Background and Rationale for the Study 142.1 Definitions 142.2 The Size of the Problem 152.3 Preventive public policy 172.4 The relationship between health behaviours and obesity 172.5 Health consequences 192.6 The role of the environment in obesity 202.7 The European Policy Context 212.8 What works? The evidence for effective practice and policy in preventing

childhood obesity 222.9 Approaches and the theoretical basis 222.10 The Evidence base 23

3 Study Methodology 253.1 Parameters of the Study 253.2 Methodology 27

4 The English case study: Crewe and Nantwich 334.1 Overview of Crewe and Nantwich 334.2 Preventing Childhood Obesity in Crewe and Nantwich: the Interventions 34

5 The Dutch case study: Beverwijk in middle and south Kennemerland 475.1 Policy context 47

5.1.1 National health policy and strategic context 475.1.2 Regional and local activities to combat childhood obesity 49


5.2 Overview of Beverwijk in middle and south Kennemerland 505.3 Prevention of childhood obesity in Beverwijk and middle and south

Kennemerland 52

6 Discussion, Conclusions and Recommendations 686.1 Introduction 686.2 The policy and strategic context for prevention of childhood obesity 686.3 Crewe and Nantwich and Beverwijk and Kennemerland – how do they

compare? 696.4 Preventive public policy: comparative analysis of interventions identified

in England and the Netherlands 69

6.5 Conclusions 74

7 Annex 1: Overview of interventions in the English case study 78

8 Annex 2: Overview of interventions in the Dutch case study 86

9 Annex 3: Selection of Case Study Areas 102

10 Annex 4: Identified typologies for interventions to prevent childhoodobesity 111

11 Annex 5: Topic Guide for Interviews – Childhood Obesity 115

12 Annex 6: References 123

Preventive public policy and childhood obesity: case studies in England and the Netherlands 5

Executive Summary

1. Introduction

This study was supported by the Ecorys Research Programme as part of the preventivepublic policy strand. The aim of the study was to investigate preventive public policy inrelation to childhood obesity in two case study areas in England and the Netherlands,enabling a comparative analysis of the approaches and the wider context for prevention.

2. Background and Rationale

Obesity is a growing problem globally and in Europe. The number of European childrenaffected by overweight and obesity is estimated to be rising by more than 400,000 a year,adding to the 14 million plus of the EU population who are already overweight (includingat least 3 million obese children); across the entire EU25. Being 'overweight' affectsalmost 1 in 4 children across the EU.

Levels of obesity are in higher in the UK than in the Netherlands. Recent data forEngland indicates that 29.7% of children were classed as overweight or obese comparedto only 16% in the Netherlands1. This difference and the reasons behind it are a corefocus for this study. The key question is: are there any differences in the preventativeapproaches each country adopts in tackling childhood obesity?

This study focuses on the aspects that determine an effective public preventive approachto the problem of childhood obesity in two comparable municipalities in the Netherlands(Beverwijk in the region of Kennemerland) and England (Crewe and Nantwich in thecounty of Cheshire). Preventive public policy addresses the physical, social and culturalenvironment in which people live and the way in which people behave. Factors that arefound to have the most significant influence on health are often called determinants ordrivers of health. Although age, sex and hereditary factors are key in influencing health,individual lifestyle factors such as diet and physical activity levels also have a key role toplay in determining health; and these factors along with social and economic factors worktogether in a complex and dynamic manner.

Since many countries are now attempting to implement policy in this area, the EuropeanCommission has called for further investigation and sharing of examples of good practice.

1 Data for 2006 and 2003 respectively.


This study provides such information for two specific case study areas in England and theNetherlands.

3. Methodology

The study focussed on school-aged children aged 5-19 years. The case study areas in theUK and the Netherlands were selected as broadly representative of each country via ananalysis of population data. Using a list of intervention 'typologies' (identified fromrecent guidelines regarding the prevention of childhood obesity) a series of primaryprevention interventions were identified in each case study area that conformed to agreedcriteria.

Data on each of the identified interventions was collated through desk-based research andthrough interviews with key stakeholders in each area. The interviewees were identifiedfrom web-based information and a 'snowballing' process. Intervention data from bothinterviews and desk-based work was used to populate an intervention framework thatsupported cross-national analysis and ensured that consistent information was collectedfor each case study area.

4. The UK Case Study

In the English case study area, Crewe and Nantwich, eleven interventions were identifiedthat met the agreed criteria. In general the interventions aimed to improve child health byincreasing levels of healthy eating and physical activity, and providing support for thisbehaviour change.

Nearly one half of the interventions were part of national programmes and initiatives ,including Healthy Schools and Healthy Start. Healthy eating was given greaterprominence overall than efforts to raise physical activity levels, in particular throughchanges to the food available in school. Partnership and cross agency approaches were aprominent feature of the approaches taken, in the school or the community setting.

The study found that very little evaluation of the interventions had been undertaken, andactivity at the local level tended to be focused on ad-hoc informal feedback fromparticipants and project monitoring data. Some national evaluation activity was relevantto the large scale programmes, but this was restricted to set up and early impact stagesonly.

The Healthy Schools programme provided a good example of a comprehensiveintervention that addressed both healthy eating and physical activity, and thatincorporated the involvement of parents, environmental actions and the wider schoolcommunity. Some of the smaller local interventions linked into the Healthy Schoolsprogramme extending its impact and reach.

The interventions identified in Crewe and Nantwich largely conformed to currentguidance on delivery with partnership approaches featuring prominently. However, due tothe absence of evaluation and cost effectiveness evidence, it was not possible to drawconclusions regarding attributable reductions in childhood overweight and obesity.


5. Netherlands Case Study

In the Netherlands case study, there was extensive national support for regional and localpreventative interventions to address childhood obesity. For example, in the region ofKennemerland a large number of interventions were carried out through national, regionaland local funding. Some of these interventions had already shown encouraging resultswhile for others the (cost) effectiveness was not yet clear.

The setting of the different interventions varied. A small majority were embedded in acommunity setting, but the school setting was also highly relevant. Almost all theinterventions included a multi-component approach, addressing a range of factorsinfluencing childhood overweight and obesity. The majority of interventions focussed onphysical activity and interventions including a healthy eating component were much lesscommon. Interventions tended to target children (and/or parents) of primary school agewith or without overweight and obesity problems, or targeted children indirectly bytargeting the family or sport associations.

Some municipalities within the region of Kennemerland were running more interventionsthan Beverwijk. For example, the municipalities of Heemskerk and Zandvoort fundedmany different interventions due to multi-annual campaigns while the municipality ofBeverwijk was struggling to gain political support to get the subject of childhood obesityon the political agenda. As a result, only a minimum of 6 out of 18 interventionsidentified at regional level were operational in Beverwijk itself.

Partnership approaches also proved a key success factor in the Netherlands. One of themost important stakeholders in relation to childhood obesity in Kennemerland was theregional project group “Overweight Kennemerland” (a partnership of the SportserviceNoord-Holland (regional organisation responsible for sport activities); as well as theGGD Kennemerland (regional public health service for children aged 4-18); JGZKennemerland (regional juvenile health care provider for children aged 0-4); Zorgbalansand ViVa! Zorggroep (regional health care providers). The Dutch concept of “BredeSchool” also proved effective in establishing cooperation between all stakeholders (e.g.schools, childcare, sport associations, libraries) in the upbringing of children and youngpeople.

One weakness of almost all the interventions was a dependence on time-restricted local(municipal funding), regional (provincial funding), and/or national (e.g. Ministry ofHealth) subsidies. This made the sustainability of the interventions highly dependent onthe level of political prioritisation of childhood obesity. Another weakness as in the UKcase study was the lack of (long-term) evaluation and monitoring. None of the identifiedinterventions in either case study could provide a clear overview of the total costsinvolved. As a result, it was impossible to evaluate the costs and cost-effectiveness of theinterventions. This impedes informed decision making regarding what interventions toimplement in the future.

6. Conclusions and Recommendations

Key conclusions emerging from a comparison of the case studies were as follows.


Preventing childhood obesity has been prioritised nationally in both the UK and theNetherlands, and multidisciplinary interventions are being implemented in both countriesto address it. However, the nature of those interventions is distinctly different. While inthe Netherlands more attention was placed on encouraging increased physical activity; inthe UK healthy eating received greater attention. Also, in the Netherlands, interventionswere predominantly integrated in the community while in the UK, interventions tended totake place within schools.

In the UK, interventions tended to target all school-age children, while in the Netherlandsattention was more focussed on specific age bands particularly the 4-13 age groups (i.e.,primary education level) and in the UK, school staff and parents were targeted in additionto school-age children. In addition, in the Netherlands case study, several interventionsspecifically targeted school-age children with overweight problems whereas this kind oftargeting was not in evidence in the UK. In several of the Dutch interventions, othergroups were targeted in addition to school staff and parents (e.g. ethnic minority womenwith children, professionals, low income families and sport associations).

In both countries, a common weakness of the identified interventions was theirdependence on temporary public funding (local, regional and/or national) which meantthe sustainability of the interventions was highly dependent on continued politicalattention on childhood obesity. Partnership approaches were central to the success ofinterventions identified in both countries.

The reliance on schools to deliver interventions is a key issue in both countries. Schoolswere already burdened with delivery of a full educational curriculum and often struggledto take on additional responsibilities and the need to balance a wide range of demands ontheir time and resources.

The dearth of local evaluation and monitoring was a key finding in both of the case studyareas, with only a minority of all the interventions being subject to evaluation. Whereevaluation has been completed this was often only in relation to impact and short termoutcomes (e.g. participant feedback on the intervention or self-reported behaviourchange) rather than the measurement of longer term reductions in overweight/obesity.The lack of evidence for effectiveness has hampered opportunities for evidence-basedpractice.

Generally there was little funding in both case study areas specifically ear-marked forevaluation studies to enable rigorous research to be undertaken. Information regardingcost effectiveness was absent from both case studies suggesting a significant gap ininformation about the extent to which investment in interventions is worthwhile.Therefore, as a consequence, there was a lack of clarity regarding the real costs andeconomic benefits associated with efforts to reduce obesity.

RecommendationsConsiderable efforts in both the UK and the Netherlands at all levels have ensured thatchildhood obesity has a high priority on political agendas, for example through nationalframeworks to shape the delivery of interventions. Policy and strategic approaches at the


EU, country, and local levels emphasise multi-component approaches addressing bothhealthy eating and physical activity delivered via sustainable partnerships.

The importance of partnership working is evident and it is recommended that all futureapproaches continue to emphasise this multi-partnership working. It is also recommendedthat funding bodies allocate resources over a number of years to support costeffectiveness and evaluation research.

Links to national policies and programmes play an important role in securing longer termfunding and thus sustainability. It is thus recommended that in order to support a coherentapproach across localities, links with national and regional strategies are fundamental toapproaches to the prevention of obesity.


Glossary

Below is a glossary of terms used in the report.

Body Mass Index (BMI) A measure of body mass that uses height and weightmeasurements

Covenant A binding agreementEthnicity In the Netherlands, ethnicity is determined on the basis of

the birth country of the caring parent.EU European UnionGeneralPractitioner/GP

A doctor of general practice

GGD In the Netherlands, GGD offices carry out public health carein assignment of municipalities. GGD offices are oftenorganised on a regional level. There are 36 regional GGDs inthe Netherlands.

Health intervention An activity undertaken to prevent, improve or stabilise amedical condition.

IOTF International Obesity Taskforce (IOTF)Inequalities in health Avoidable health inequalities arise because of the

circumstances in which people grow, live, work and age andthe systems put in place to deal with illness. The conditionsin which people live are shaped by political, social andeconomic factors.

Local authority A local authority is an administrative entity composed of aclearly defined territory and its population and commonlydenotes a city, town, or village, or a small grouping of them.A municipality is typically governed by a mayor and a citycouncil or municipal council. Known in the Netherlands as amunicipality.

Motivationalconversations

Motivation conversations are organised using a method ofmotivational interviewing. This is a special technique whichrequires special training. The counsellor does not try toconvince the student, but instead tries to empathise and showthe difference between current behaviour and goals andvalues of the student and support the student to believe theycan change their behaviour themselves.

Municipality A municipality is an administrative entity composed of aclearly defined territory and its population and commonlydenotes a city, town, or village, or a small grouping of them.A municipality is typically governed by a mayor and a city


council or municipal council. Known in the UK as a localauthority.

Obesity An excess of body fat that results in significant impairmentof health

Prevention Activities designed to reduce the incidence of illness in apopulation

Primary Care Trust Type of NHS trust and part of the National Health Service inEngland

Province A territory governed as an administrative or political unit ofa country or empire.

Public Health The approach to medicine that is concerned with the healthof the community as a whole – community health.

Public policy Laws, regulatory measures, courses of action and fundingpriorities covering a given topic.

Region A specified district or territory.SES In the Netherlands, socio-economic status (SES) is measured

on the basis of level of education, income and level ofoccupation. A high outcome indicates a high level ofeducation, income or level of occupation.

WHO World Health Organisation


1 Introduction

ECOTEC Research & Consulting (ECORYS in the UK) and ECORYS NL are delightedto present this research report. The research was kindly supported by the ECORYSResearch Programme. This document contains the results of a twelve month collaborativeresearch study into preventative public policy around childhood obesity.

There is an increasing volume of evidence to indicate that obesity is a significant publichealth problem that requires immediate and appropriate policy responses at the European,national, regional and local levels. As an important area of social policy research, obesityhas been funded in the preventative public policy strand of the 2007-08 ECORYSResearch Programme (ERP) providing an opportunity for in-depth investigation and thecompletion of a comprehensive research study.

The ECORYS Research Programme was designed to bring together researchers fromacross the ECORYS group, to further knowledge and work on collaborative studies.Following the submission of proposals to the ERP in October 2007, ECOTEC’s SocialPolicy Division (UK) and ECORYS’ MSB Division (Netherlands) were awarded fundingof €10,000 by the ERP to deliver an exploratory paper on the subject of obesity, and todevelop a joint proposal for collaborative work in the field of childhood obesity. Findingsfrom the exploratory paper1 highlighted the significant problem that obesity poses forsocial policy. It established that the challenge for policy makers at all levels is, and willbe, to tackle obesity across the range of policy areas including: regeneration,environment, health, education and community. Young people are a particularlyimportant target group; recent statistics suggest that obesity levels are rising amongchildren and that the consequences of this will present major policy challenges for thefuture.

Following the completion of this exploratory paper, subsequent funding of €85,000 wasgranted by the ERP for the proposed childhood obesity research and completion of thefull study to investigate prevention approaches in two case study areas. This reportincludes information on all stages of the study and brings together results from researchteams in the Netherlands and England, offering a cross-national perspective on this areaof preventive public policy. Throughout the study, Professor Carolyn Summerbell,School of Medicine and Health, at the University of Durham, has acted as expert adviser.


1.1 Aims and Objectives

The aim of this study was to investigate preventive public policy interventions in relationto childhood obesity in two case study areas in England and the Netherlands, enabling acomparative analysis of the approaches and context for prevention in both countries.

The study objectives were to:

Undertake literature and policy reviews to provide a review of the evidence foreffectiveness of interventions to prevent obesity, and the wider policy context forintervention.

Use national data to identify a case study area in England and the Netherlandsthat best reflects the overall population of each country.

Develop a profile of each case study area including health, populationdemographics and socio-economic data.

Systematically collect information on preventive interventions taking place on thesnapshot day in each case study area, in line with an agreed interventionframework and using agreed criteria for selection.

Identify stakeholders in case study areas to provide further data on interventionsand address gaps in the intervention framework.

Compare the results of the case studies in line with the evidence base and identifydifferences and commonalities in approach, and the intervention context for eachcountry.

1.2 Content of this report

The report includes the following:

Chapter 2 provides an introduction to the topic and offers an assessment of thesize of the problem; this includes an outline of the significant public healthchallenges posed by the rise in obesity among young people. In addition a reviewis given of recent Policy Context and the Evidence Background with a focuson Europe. This section also provides an overview of the many approaches toprevention and health promotion, and the evidence base associated with these.

Chapter 3 presents the methodological approach used for the study. Two case studies have been developed providing a snapshot of activity in

England and the Netherlands. These are reported in chapters 4 and 5. The discussion and conclusions emerging from the study are presented in

chapter 6. The particular focus in this section is on comparisons betweenEngland and the Netherlands and the conclusions that can be drawn in relationto future social policy initiatives and areas for further investigation.

The annex provides further details on case study interventions, references,interview topic guides used for the study, and further relevant information.


2 Background and Rationale for the Study

This chapter provides the context and background to the study. Firstly it provides anintroduction to overweight and obesity (Section 2.1); then demonstrates the relevance ofrising childhood obesity as a public policy issue and looks at the size of the problem atthe European level and in our two case study countries (Section 2.2). The rationale for thestudy also links to the European policy imperative which is placing tackling obesityfirmly on the agenda. The chapter therefore provides a brief review of the recentEuropean policy context (Section 2.3). Finally, the chapter provides an overview ofapproaches to prevention and health promotion, and the associated evidence base todemonstrate what effective preventative public policy might look like and what types ofintervention will be explored in the case studies (Section 2.4).

2.1 Definitions

2.1.1 Overweight and obesity

The most commonly used indicator of obesity is the Body Mass Index (BMI), a measureof body weight (in kilograms) divided by height (in metres) squared. The World HealthOrganisation (WHO) has defined obesity as a BMI ≥30kg/m2. The threshold for normalweight is set at 18.5kg/m2 –24.9kg/m2, for overweight that is 25kg/m2 - 30kg/m2. Beingobese or overweight is associated with a higher likelihood of suffering numerous chronicdiseases, including amongst others: cardiovascular disease, diabetes and cancers (WHO,2003). This indicator is used across Europe, as well as in England and the Netherlands.

In the UK there is on-going debate regarding the definition of overweight or obesity inchildren, due to a recognition that adult BMI measures do not take into account thecontinuing physical growth and development of children. The following definition isoffered by the Department of Health (2007): “The clinical definition of overweight andobesity in children is based on BMI percentile charts for boys and girls plotted at differentages from 2-16 years. The National Institute for Health and Clinical Excellence (NICE)recommends that tailored clinical intervention should be considered for children with aBMI at or above the 91st centile, depending on the needs of the individual child andfamily, and that an assessment of co-morbidity should be considered for children with aBMI at or above the 98th centile.”2


2.2 The Size of the Problem

Obesity is not a new problem, but it is a growing problem. This section explores the sizeof the problem at EU levels and nationally, exploring some of the key factors that havecontributed to its rising importance on the policy agenda.

The WHO considers obesity has reached epidemic proportions globally. Deaths relatingto obesity are estimated at around 300,000 a year in Europe (Branca, Nikogosian andLobstein, 2007).3 Childhood obesity within this is a large and growing problem. TheInternational Obesity Taskforce (IOTF)4 highlighted that worldwide one in ten children isoverweight, with a total of 30-45 million classed as obese.

The number of European children affected by overweight and obesity is estimated to berising by more than 400,000 a year, adding to the 14 million plus of the EU populationwho are already overweight (including at least 3 million obese children); across the entireEU25, and being 'overweight' affects almost 1 in 4 children. The situation across Europeis illustrated in figure 2.1 below.

IOTF figures indicate that the trend has been towards rising levels of childhoodoverweight and obesity since the mid 1980s. Data suggest a higher prevalence ofoverweight in southern European countries, Spain and Portugal in particular. The easternEuropean (Slovenia, Lithuania, Latvia and Estonia5) and some of the northern Europeancountries (Finland, the Netherlands and Poland) have significantly lower rates ofoverweight children compared to the rest of Europe6.

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

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Source: WHO, Global InfoBase


2.2.1 The Size of the Problem: England

Recent (2008) data from the Health Survey for England indicates that 29.7% of childrenwere classed as overweight or obese in 2006. This includes 30.6% of boys and 28.7% ofgirls7. Since 1995 there has been a 5 percentage point increase in obesity rates amongchildren showing a trend towards higher levels. This trend towards increasing prevalenceof obesity among children has been a concern to UK policy-makers. If obesity is nottackled it has been estimated that by 2050, 50% of boys 6-10 years will be obese and 20%of girls in this age range. Among children aged 11-15 years it has been predicted thatrates of obesity for boys will be 23% and for girls 37%.8.9

Data from the Health Survey for England indicates that in January 2008, boys were morelikely to be obese than girls (17% compared to 15%). The survey also found that boyswere more likely than girls to meet recommended levels of physical activity but that ahigher percentage of girls consumed five or more portions of fruit and vegetablescompared to boys (19% and 22% respectively).10

The cost of obesity to the National Health Service (NHS) in the UK is around £4.2billion, and this figure is forecast to double by 2050. In addition, there are also widercosts to the economy (due to weight problems: e.g. absenteeism and reducedproductivity) estimated to be around £16 billion11.

2.2.2 The Size of the Problem: The Netherlands

Figure 2.1 above shows that the prevalence of overweight and obesity in the Netherlandsremains low compared to the rest of Europe and particularly compared to England.However, the table below reveals that the prevalence of overweight and obesity in theNetherlands is rising, and at an even faster rate than previously.

Table 2.1 Average proportion of girls and boys (aged 4-16) being overweight (including those obese) in the

Netherlands

Gender 1980 1997 2003

Boys 3.9% 9.7% 14.5%Girls 6.9% 13.0% 17.5%Source: Van den Hurk et al., 2007

The prevalence of obesity among girls and boys aged 4-16 also increased in the sameperiod. In 2003, 2.6% of the boys and 3.3% of the girls aged 4-16 years were obesecompared to 1980 (boys 0.2%, girls 0.5%) and 1997 (boys 1.2%, girls 2.0%). At the ageof 4, 12.3% of the boys and 16.2% of the girls were already overweight.


2.3 Preventive public policy

This study focuses on preventive public policy. Prevention operates at three levels(primary, secondary and tertiary); the focus of this study was on primary preventionwhich has been defined by the WHO12 as activities designed to reduce the instances ofillness in a population and to reduce the risk of new cases appearing. For example cancerprevention includes avoiding the identified risk factors such as smoking, obesity and alack of exercise. Public policy is defined in this study as: "a system of laws, regulatorymeasures, courses of action and funding priorities concerning a given topic promulgatedby a governmental entity or its representatives"13.

As such 'preventive public policy' addresses the physical, social and cultural environmentin which people live and the way in which people behave. Factors that are found to havethe most significant influence on health are often called determinants or drivers of healthand are depicted in Figure 2.2 below. This illustrates that although age, sex and hereditaryfactors are key in influencing health (including body mass), individual lifestyle factorssuch as diet and physical activity levels also have a core role to play in determininghealth; and these factors along with social and economic factors all work together in acomplex and dynamic manner.

Figure 2.2: The Determinants of Health

(Adapted from: Ministry of Social Affairs and Health Finland (2006), Health in allpolicies – Prospects and potentials, Finland)

2.4 The relationship between health behaviours and obesity

Obesity is closely related to poor diet and low levels of physical activity. Combinations offactors arising over the past two decades in relation to diet and physical activity havecontributed to increasing the concerns relating to obesity.


The last two decades have seen a number of social and environmental developments thathave changed diet and consumption patterns. These include increased energy intake dueto increased consumption of: fats (particularly saturated fats and trans-fatty acids), sugar,salt, alcoholic beverages and micronutrient poor foods. This is exacerbated by fallingconsumption of fresh fruits, vegetables and other sources of dietary fibre and increasingenergy density of food overall. Also European citizens are, on the whole, not yetconsuming recommended nutrient intake goals suggested by the WHO. For example, inhalf of the EU Member States, the average fruit and vegetable consumption is less than70% of the level recommended by the WHO.

There is also evidence of decreasing physical activity in the EU. Almost 40% ofEuropean adults do not engage in any moderate activity during the week. In cross-sectional studies, activity levels have been reported to drop by as much as 50 percentduring adolescence.14 Several studies show a marked decline from the age of 12.15 InEurope, only one third of the children achieved the recommended hour of moderateactivity five days per week (especially girls), while between 25-50% watch four or morehours of television per day16. Across all countries and regions internationally, and all agegroups, girls are less active than boys, and the gender gap increases with age. TheEuropean countries with the highest percentages (over 50%) of boys achieving therecommended amount of physical activity are: Ireland, Austria, Slovenia, the UK,Lithuania, Malta and Finland. Those with the highest percentages of girls (over 40%) areIreland, Austria, Slovenia, UK (Scotland), Lithuania, Finland, and the Czech Republic.The poorest levels of physical activity for girls (less than 20%) are found in Belgium(Flanders) and France, and for boys (less than 30%) are in Belgium (Flanders) andFrance17.

Several factors influence the relation among diet, physical activity and obesity. Forexample, socio-economic status plays an important role with respect to diet and physicalactivity. The data available suggests that the more disadvantaged families are in socio-economic terms (e.g. low income, low education), the more they depend on the relativepricing and ready availability of foods.

Figure 2.1 below illustrates the extremely complex relationships that exist betweennutrition, physical exercise and obesity, illustrating that a complex causal web of factorsinfluences people's lifestyle choices about food and exercise at different levels.


Figure 2.1 The causal web of influences on population weight gain

Source: IOTF

At the international level, markets and availability of food is one critical factor; at thenational level the level of education about healthy lifestyles and the role of media are bothvital. At the community level the quality and availability of local health care services isimportant and the availability of local public transport such as safe cycle lanes andfootpaths play a role. Moving to the individual level, individual choices on diet, activityand work situation all play a role. There are thus a variety of different levels ofintervention where public policy may be effective. The issue is how they interrelate andare actioned by different agencies that have a responsibility for obesity levels.

2.5 Health consequences

Obesity is associated with a range of health risks and chronic diseases, including18:

Diabetes, Hypertension (high blood pressure), Coronary Heart Disease and stroke, Cancers (10% of cancer deaths are associated with obesity), Osteoarthritis, Reproductive function, and Liver disease.

It has been estimated that overall, obesity is responsible for more than 9,000 prematuredeaths in England per year and due to the link between obesity and chronic disease placesa tremendous burden on the NHS. Obesity also has an impact on children’s mental healthand the following psycho-social risks have been identified19:

Social stigmatisation,


Poor self-esteem, Depression, Poor social functioning, Bullying, and Social exclusion.

Research has highlighted the need for effective intervention at all levels. Understandingcurrent activity in relation to the prevention of childhood obesity and learning frompractice across Europe can make an important contribution to the knowledge base. Thisresearch study therefore aims to contribute to the current debate and to furtherunderstanding of some of the key issues by drawing on cross-national comparisons.

2.6 The role of the environment in obesity

The environment also has a role to play in rising obesity levels. Despite rises inknowledge and awareness levels regarding healthy lifestyles and significant investment inhealth education, the recent rise in the prevalence of obesity across Europe has beendescribed as a ‘pandemic’20. Over the last decade increasing acknowledgment of thewider influences on health and obesity in particular has informed the concept of the‘obesogenic’ environment, resulting in a move away from a more traditionalunderstanding of obesity primarily as a self-determined state.

The concept of the obesogenic environment views obesity as a normal response to anessentially abnormal environment (“normal physiology within a pathologicalenvironment” Egger, 1997). It is argued this reflects the complex interplay betweenhuman physiological mechanisms and the physical, economic and socio-culturalenvironment operating at the macro level. Therefore as long as the macro-environmentremains ‘obesogenic’, levels of obesity will continue to rise and will be unlikely to fallwithout significant modification of a range of environmental factors. The necessaryenvironmental change needs to be substantial and is likely to be difficult to implement.Required environmental changes, while varied and wide ranging, could include:regulation of the food industry, changes to building design and the built environment, anda shift in the balance between pedestrians and vehicles in favour of the pedestrian.

The Public Health response to obesity and to the obesogenic environment requirescomprehensive policy interventions that address obesity at both the micro and the macrolevel, requiring a multi-agency and partnership approach. This holistic approach isemerging as the model for promoting health and is exemplified by the Healthy Schoolsand Healthy Town initiatives in Europe. The EPODE initiative in France offers oneexample of an intervention that adopts a ‘whole town’ approach21 to tackling obesity.This initiative involves ten French towns and uses a range of community-basedapproaches, is based on social marketing principles, and has partnerships operating at alllevels, with a range of sectors across each of the towns.


2.7 The European Policy Context

In 1997, obesity and overweight were identified as serious threats to global public healthby the World Health Organization (WHO) and the previous section identified the size ofthe problem.22 This major health problem is leading policy makers to explore effectivepolicy interventions.

The WHO followed this by advising the governments of middle- and high-incomecountries to ‘urgently consider’ the steps necessary to manage the risks posed by non-communicable health threats such as obesity in 2002.23

In 2005, the European Commission (EC) launched the EU Platform on diet, physicalactivity and health to “provide a common forum for all interested actors at European levelwhere they can explain their plans to contribute concretely to the pursuit of healthynutrition, physical activity and the fight against obesity, and where those plans can bediscussed; and outcomes and experience from actors’ performance can be reported andreviewed, so that over time better evidence is assembled of what works, and best practicecan be more clearly defined.”24

In 2006, the WHO organised a European Ministerial Conference on CounteractingObesity with the aims25:

to place obesity high on the public health and political agendas;

to foster greater awareness and high-level political commitment to action; and

to promote international and inter-sectoral partnerships.26 27

At the meeting, EU Member States of the WHO’s European Region signed a EuropeanCharter on Combating Obesity.

The following year, the EC set up the High Level Group that consists of representativesof national governments, with the role to:

offer an overview of all government policies in the area of nutrition and physicalactivity;

facilitate effective exchange of policy ideas and practices between Member States;and

improve liaison between the EU Platform for Action on Diet, Physical Activity andHealth and representatives of national governments, enabling relevant public-privatepartnership possibilities to be quickly identified and agreed upon.

The High Level Group and the EU Platform together form a framework that can work tocreate European solutions to the health issues related to obesity and overweight.28

In 2007, the EC, Directorate-General Health and Consumer Protection (DG SANCO)published a White Paper on a comprehensive nutrition and physical activity strategy. Themain strategic objective is to reduce the prevalence and incidence of conditions related todiet and physical activity and to reduce suffering caused by the mortality and morbidityof these conditions (i.e. reverse the trend of rising prevalence of obesity in the EU by2015). The secondary goal is to reduce costs associated with these conditions, improveoverall economic productivity and sustainability throughout the EU and ultimately to


increase the economic, physical and quality-of-life aspects of citizens’ welfare in linewith the Lisbon Strategy.29

From the White Paper it became clear that policy actions are needed with regard to bothphysical activity and food systems to increase positive environmental factors, reduce thenegative factors that promote unhealthy diet and low levels of activity and weaken orsever the ‘positive feedback’ loops by which problems in one aspect contribute toproblems in another. There is general agreement on the need to tackle obesity via a multi-policy or multi-strategy approach, i.e. the integration of policies across several arenas:from food to sport, education and transport.30 These actions have to be conducted at alllevels of decision-making, from local to EU level.

2.8 What works? The evidence for effective practice and policy inpreventing childhood obesity

Policymakers have recognised that all public health issues, including obesity, needpolicies and strategies which are based on sound evidence.

A range of (policy) instruments can be used at different levels, including legislation,networking, public-private approaches, and engaging the private sector and civil society.However, to be effective and cost-effective, action is needed from a wide range of privateorganisations, such as the food industry and civil society, and statutory and voluntaryorganisations at a local level, such as schools and community organisations. For example,the design of a community can influence health status by stimulating physical activitythrough safe cycle paths and the availability of playing fields for children.

There is some available evidence and evaluation of policy interventions, particularly atthe local and regional level , although these are often limited in terms of assessing impacton change in health status. Evidence at European and national levels (e.g. the UK) aremore limited.

2.9 Approaches and the theoretical basis

As depicted in Figure 2.1, the relation between nutrition and physical activity is complex.Variables that influence the balance between energy intake and energy expenditureinclude:

Physiological variables, e.g. blood pressure;

Changes in dietary or physical activity behaviour, e.g. walking to school;

Mediating behavioural, economic and neighbourhood variables where these lead tobehavioural change at an individual level, e.g. price of food;

Knowledge, perceptions or attitudes relating to obesity-relevant factors, where theselead to changes in individual behaviour or policy, e.g. safety of cycle paths;

Factors relating to availability or access, e.g. access to sport facilities.31

Overweight and obesity are thus related to societal, environmental, economic andpersonal factors.32


It is likely that the needs of children and young people differ from the needs of thegeneral population. 33 The causal pathways of obesity-relevant factors may also bedifferent since what diet is influenced by (family-related) preferences, and by our utilityfor available food choices, and by our income, attitudes and behaviours.34 Also, it isknown that physical activity behaviours and leisure-time activities in children and youngpeople differ from adults.35

The approach taken to tackle the rising prevalence of overweight and obesity, as advisedby most public health analysts, is to empower the individual to make healthy decisions.This implies a combination of interventions focusing on individuals’ own responsibilityand their children, but also shaping the environment to making healthy decisions easier.

This so-called holistic approach is applied in different settings (e.g. schools, localcommunities) in several European countries. Examples include free fruit at schools,increasing physical activity in the school curriculum. Also, several governments provideguidance to local areas regarding the tackling of overweight and obesity and achieving ahealthy weight for the local population. In the UK, the government published suchguidance aimed at primary care trusts, local authorities and frontline staff in early 2008.This guidance sets out suggestions for how local partners can develop their own plans, setgoals and choose interventions, and also ensure evaluation.36 In the Netherlands,municipalities receive support and guidance from the government and other organisationsto set up local preventive policy to tackle the issue of overweight and obesity. Anexample of a guideline offered by the Dutch government is the manual Prevention ofoverweight in local health policy (Handleiding Preventie van overgewicht in lokaalgezondheidsbeleid). This manual was published in 2007 by the Foundation Food centreNetherlands (Voedingscentrum Nederland), in cooperation with municipalities, PublicHealth Service Netherlands (GGD Nederland) and several national partners. It containspractical information, concepts, and examples for local policy makers and other localstakeholders to set up local preventive policy to overcome overweight and obesity.37

2.10 The Evidence base

Effective preventative policies need to be based on sound (scientific) evidence. It isknown that the evidence base of the effectiveness of preventative interventions is limitedand not yet fully explored.

The UK's National Institute for Health and Clinical Excellence (NICE) has publishedguidelines regarding the prevention, identification, assessment and management ofoverweight and obesity in both children and adults.38 The guidelines are based on severalsystematic reviews that focus on lifestyle and behavioural interventions, rather than onsocial and environmental interventions.

Little review-level evidence is available on the impact of social and environmentalinterventions for children and young people. Most reviews consider research relating towhole populations. Reviews contain limited evidence from robust prospective studydesigns relating to large-scale macro-level interventions, such as policy change, taxation,or changes to the built environment. There are few systematic reviews of community-based programmes which primarily targeted obesity and measure a range of outcomes.Also, very limited data exist that is relevant to health inequalities or to the cost-effectiveness of interventions.

Since many countries are now attempting to implement policy in this area, guidance tothe mass of available evidence, effective monitoring and evaluation is required. TheEuropean Commission’s obesity white paper (2007) called for further investigation and


sharing of examples of good practice, and in the UK, for example, there is growingpolitical interest in developing a better understanding of preventative policy relating toobesity. The recently published Foresight Report (which generated media interest aroundthe question of whether obesity will be as big a problem as climate change) suggested thatfurther evidence of effective policy interventions will need to be explored in the UK:

“Most of the research we reviewed focused on identifying and defining problems. Wefound insufficient evidence of effective programmes that have reduced obesity, fromwhich learning may be extrapolated and applied to other situations. Indeed we were toldthese do not exist. Finding (or if necessary creating) practical examples of successfulnational-level programmes or structures might be a fruitful area of further work.”39

This suggestion was also highlighted by the EC in its impact assessment that waspublished in 2007. More specifically, the key aims of the EC for the coming three yearswill be to determine the range of policies and actions in place within Member States, aswell as to strengthen monitoring and evaluation of their impact. Sharing of information inthe area of good practice in nutrition and physical activity, and obesity prevention is oneof the main tasks.

This study is focusing on identifying good practices in both England and the Netherlandsfor two specific municipalities.


3 Study Methodology

This chapter describes the research parameters set for the study and the methods used.

3.1 Parameters of the Study

3.1.1 Overweight and obesity

This study focuses on the categories of ‘overweight’ and ‘obesity’. These are defined aslabels for ranges of weight greater than what is generally considered healthy for a givenheight. Obesity is an excess of body fat that frequently results in a significant impairmentof health. For children, overweight and obesity are usually measured using age- andgender specific cut-off points for BMI, such as those developed by the IOTF (see ChapterOne for definitions).

3.1.2 Age and gender

Our study focused predominantly on the age range of 5-19 years (male and female). Thefocus on children and young people is linked to the focus on preventative policy, sincethere is evidence that obesity at an early age leads to obesity in older age,40 and therefore,the focus for preventative public policy regarding tackling obesity is to ‘catch peopleearlier’ to prevent problems later in life.

3.1.3 Geographical spread

This study included a comparison of preventative public policy in addressing overweightand obesity in two countries: the Netherlands and England. Our rational for selectingthese two countries is that the Netherlands is an example of a country which has belowEU-27 average mean levels of overweight (BMI >25), whereas England is an example ofa country with above EU-27 average levels of overweight (see Figure 2.1). In addition,while the challenge in England is an absolute reduction in obesity levels, in theNetherlands the challenge is to stop the increasing prevalence in obesity.

3.1.4 Type of intervention

This report does not attempt to explore the biological aspects of weight gain or look atmedical interventions or treatments of obesity (i.e. curative approaches such as surgicalprocedures and drugs) but instead on preventative interventions. It focuses on the


relationship between nutrition/diet and physical activity, behavioural change andoverweight and obesity. This builds on the contention that the trend towards higherprevalence of obesity among children in Europe is driven by increased energy intakerelative to physical activity in the population. The rationale for this focus is that there is averified role for preventative (as opposed to curative) policy interventions in tacklingobesity through diet and exercise (based on WHO evidence). In fact, the WHO suggeststhat government investment in health promotion (preventative policy) can be effective inreducing obesity and in reducing the associated rising costs of morbidity and mortality.

The study therefore focuses on interventions which have been identified by the WHO(2003) as being where evidence is probable or convincing as to its effect on behavioursthat are likely to promote healthy weight:

• regular physical activity;

• high dietary intake of non-starch polysaccharides (dietary fibre);

• intake of fruits; and

• home and school environments that support healthy food choices for children.

In our study, a range of interventions to prevent obesity were identified from backgroundresearch, and specifically the NICE guidance on obesity published in 2006 (appendices 6,7, 8 and 9)41. Each of these documents lists a range of studies / interventions which havebeen used to address or prevent obesity and their results (where available). A full list ofrelevant initiatives was produced, and then identified from this list 20 'typologies'.Definitions for each typology have been included in the annex (see Table 2). Thetypologies were chosen from across the range of provision areas, such as schools,community and healthcare (see Table 3.1 below).

Table 3.1 Identified typologies for interventions to prevent childhood obesity

Typology School Community HealthcareTopic or theme

1Reduce sedentary activity (watching TV andvideos) x x

2 Change to school meal content x3 Healthy eating x x

4Change to provision of tuck in school (i.e. morefruit) x

5 Physical activity programme x x x6 Lifestyle activity x x7 Subsidised leisure services x

Approaches8 Counselling x x x9 Postal communication (i.e. newsletters) x x10 Workshops x x

11Behaviour change therapy / behaviourmanagement therapy x x x

12 Traffic light system x13 Use of incentives / rewards x x14 Changes to / incorporation into curriculum and x


Typology School Community Healthcareuse of homework

15Interactive communication methods for adviceand support (e.g. telephone, website etc) x x

16 Peer support x x x17 Signposting x x x

3.2 Methodology

The study involved a series of different phases: a desk based review of current policy and the evidence base along with other

relevant documents and development of appropriate intervention typologies;

the identification of two comparable case study areas in England and theNetherlands;

the identification of current interventions in both case study areas in line withagreed criteria; and

interviews with key stakeholders.

3.2.1 Theoretical models

Preparing the interview protocols and analysing the preventative interventions identifiedin our case studies involved the use of a combination of two theoretical models:

1. ANGELO framework (Analysis Grid for Environments Linked to Obesity -ANGELO).This is a conceptual model for understanding the obesogenity of environments and apractical tool for prioritising environmental elements.42 This model distinguishesphysical, economic, policy and socio-cultural aspects at the micro and macro levels.These factors are analysed to the extent to which they influence preventativeinterventions (e.g. what is the influence of different cultural backgrounds on healthyeating?).

2. IOTF principles.The International Obesity Task Force (IOTF) emphasizes the importance of acomprehensive public health approach and sets principles to guide national andtransnational action.43 The principles include:

Principle 1. Education alone is not sufficient to change weight-related behaviours.Environmental and social interventions are also required to promote and supportbehavioural change.

Principle 2. Action must be taken to integrate physical activity into daily life, not justto increase leisure time exercise.

Principle 3. Sustainability of programmes is crucial to enable positive change in diet,activity and obesity levels over time.

Principle 4. Political support, inter-sectoral collaboration and communityparticipation are essential for success.

Principle 5. Acting locally, even in national initiatives, allows programmes to betailored to meet real needs, expectations and opportunities.


Principle 6. All parts of the community must be reached – not just the motivatedhealthy.

Principle 7. Programmes must be adequately resourced.

Principle 8. Where appropriate, programmes should be integrated into existinginitiatives.

Principle 9. Programmes should build on existing theory and evidence.

Principle 10. Programmes should be properly monitored, evaluated and documented.This is important for dissemination and transfer of experiences.44

3.2.2 Desk based review

The literature review set the context for gaining an understanding of the evidence base forinterventions aimed at preventing obesity. The literature review also aimed to identifyinformation of relevance to the case study areas, specifically documentation orinformation on local policy and local interventions45. During the initial phase of the studya general review of the literature was conducted in both England and the Netherlands. Asubsequent review was conducted in September 2008 on an agreed 'snapshot day' toensure that information was current and as a means of duplicating the previous search toensure accuracy. The approach to the literature review involved the following:

A series of key search terms were identified, from initial scoping of the literature.These terms were developed and adjusted during the early phases of the studyand were structured into the following categories (full list included in the annex):

► Clinical► Policy► Social► Markets / Commercial► Location.

For the case study in England relevant literature was identified from thefollowing databases:

Idox Google Scholar Database of Abstracts of Reviews of Effects (DARE) and NHS Economic

Evaluation Database (NHS EED) via the Centre for Review andDissemination search facility46

British Medical Journal's web-based search47

Healthy Schools web-site (search by region and local projects)48

For the case study in the Netherlands relevant literature was identified fromthe following databases: Google Scholar Google Cochrane NHS Database of Abstracts of Reviews (English search terms) Cochrane NHS Economic Evaluation Database (English search terms) British Medical Journal database (English search terms)49


Gezonde School (equivalent of Healthy Schools database50

Nederlands Tijdschrift voor Geneeskunde (Dutch Journal for Medicine)51

Centrum Gezond Leven (Centre for Healthy Living) ZonMw (the Netherlands organisation for health research and

development) Rijksinstituut voor Volksgezondheid en Milieu (RIVM) (Institute for

public health and environment)52

Gemeente Beverwijk53

On the 'snapshot day' (3 rd September 2008) the second literature search wascompleted. This was a refined search based on learning from the first literaturesearch, and using the same databases. A limited number of key wordcombinations were used based on the following terms (translated into Dutch forthe Netherlands):

Obesity Overweight Food Healthy eating Nutrition Physical activity Young people Children Crewe and Nantwich/Beverwijk Cheshire/Kennemerland public health policy prevention strategy healthy communities

3.2.3 Selection of case studies

The approach to the case study phase of the research commenced with identification ofcomparable case study areas in England and the Netherlands. The aim was to identify amunicipality or local authority area which was representative of each country and ofsufficient size and population density to support a range of intervention activity inrelation to the prevention of childhood obesity54. Population data (census) was used toinform this process and consideration was given to the following:

Population size

Levels of deprivation

Ethnic populations

Health status of the population


Balance between urban and rural

Representativeness of individual local authorities/municipalities of eachcountry as a whole.

In order to identify each case study town national data was used. In England thisincluded: 2001 census data55; the Index of Multiple Deprivation56 (IMD) (NationalStatistics, 2004); and Rural/Urban classifications57 (DEFRA, 2008). In the Netherlandsdata sources included the data included: census data (Statistics Netherlands, 2007)58;socio-economic status data (Cultural Planning Office of the Netherlands, 2006);Rural/Urban classifications data (Statistics Netherlands, 2007)59; and ethnicity data allacquired from Statistics Netherlands (CBS) for the year 2007.

A shortlist of seven possible case study towns in England was identified and from this listCrewe and Nantwich was initially selected as being close to average for England (close tothe mean and median for each of the indicators considered). In the Netherlands ten townswere shortlisted and Beverwijk was selected as being close to the national average.Further details regarding the methods used to identify case study towns have beenincluded in the annex. The Dutch and English areas relate to each other as follows:

The North West of England was broadly equivalent to Noord-Holland

The County of Cheshire was at a similar level to Kennemerland

Crewe and Nantwich was at a similar level to the municipality of Beverwijk.

3.2.4 Identification of interventions within the case study areas

The case study research involved identifying preventative public policy interventionsoperating at some level on the 'snapshot day' (3rd September, 2008) in the case studyareas. Up to twenty interventions were identified using the following methods:

Internet searches

Resources identified via the literature review

Data from documents sourced from local contacts

Interviews with stakeholders in the case study areas (the topic guide used forinterviews has been included in the annex).

The criteria for the inclusion of interventions in the case studies was informed byliterature searches, consultation with the expert adviser, and evidence of ‘what works’from the NICE guidelines for good practice60. The inclusion criteria were as below:

Preventive (primary level) interventions that aim to reduce or prevent childhoodobesity or overweight by promoting physical activity and/or healthy eatingamong children aged 5-19 years,

Interventions that conform with typologies identified from the NICE Guidelines(all typologies and their definitions are listed in the annex),

Interventions that were operating at some level in the case study area on the'snapshot day'.

Interventions that met these criteria were eligible for inclusion. It was recognised that anumber of health promotional and other activity would also impact on school-age


children and play a role in preventing overweight or obesity, for this reason someinterventions were excluded as follows:

Interventions that involve a medical response and that take place in the secondaryhealthcare setting (e.g. hospital based surgery or drug treatments).

Statutory services that address childhood obesity and that are not time-limited,population-based interventions aimed at prevention (e.g. one-to-one consultationsbetween general practitioners, nurses or dieticians with individuals).

Interventions that target school-age children who have been identified as 'obese'or ‘overweight’ by a clinical specialist e.g. school nurse, health visitor or doctor(secondary level prevention has been excluded).

Interventions that were not taking place on the 'snapshot day' (3rd September,2008).

Interventions that do not include school-aged children (5-19 years) in theirprimary target group or as a target group via interventions aimed at teenageparents.

3.2.5 Interviews

Key stakeholders in the case study areas were initially identified through web-basedinformation for each of the relevant authorities (Primary Care Trusts, Council Councils,Borough Council in the UK, and municipalities; GGD and other public healthorganisations in the Netherlands), and contacts linked to interventions that had beenindentified via internet searches. Thereafter further stakeholders were identified through a'snowballing' process with additional contacts being suggested by interviewees and thosecontacted by phone. The interviews were conducted in a location and at an agreed time tosuit the interviewee.

The interviews focussed on the intervention(s) for which the stakeholder had directresponsibility or the greatest knowledge of. The interview questions were structured inline with the 'intervention framework' in order to capture consistent information regardingeach identified intervention (the full topic guide has been included in the annex). Thefollowing areas were discussed with interviewees:

The policy background with specific reference to local strategies and policies. In depth information on the intervention(s) including the timeframe, target

group(s), delivery and the setting for delivery. Participation in the intervention and related monitoring and evaluation. Financing of the intervention(s) and other information on associated costs. Barriers and facilitators associated with the intervention. Examples of 'good practice' in the case study area.

Information collected via the interviews and desk-based reviews for each interventionwas used to populate an intervention framework, as a means of ensuring a systematicapproach to recording interventions and assessing them against established frameworksbetween both research teams. The intervention framework ensured the collection ofinformation in relation to the following:

Background information on the intervention


Data in response to the ANGELO framework (physical, economic, policy andsocio-cultural data at the micro and macro levels) and the IOTF Framework, asdescribed above.

Any other additional information about the interventions.

The completed intervention frameworks for both case study areas were used for theanalysis stage and to inform development of a table of case study interventions. A tablepresenting the intervention frameworks for the England and Netherlands case studies isincluded in the annex.

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4 The English case study: Crewe and Nantwich

4.1 Overview of Crewe and Nantwich

4.1.1 Demographics and health status in Crewe and Nantwich

The Borough of Crewe and Nantwich has a total population of 111,007 persons61 ofwhom 21,473 (19%) are aged 5-19 years. The borough has been classed as ‘part rural’62

and has two main towns: the more affluent Nantwich, and Crewe which has higher levelsof deprivation. The borough has significant pockets of deprivation and consequent healthinequalities across the district. Neighbourhood Renewal activity is focussed on the fivemost deprived wards in Crewe.

Data from the 2007 and 2008 Crewe and Nantwich Health Profiles63 indicates that withregards to health measures this borough was about average in comparison with Englandas a whole. However, a lower percentage of people rate their health as ‘not good’ thanthe averages for both the North West and England as a whole.

While life expectancy in this borough was similar to both the North West and Englandaverages for men, it was lower for women. However, women in the most deprived areaslive on average for two years less than those from the least deprived areas, while menfrom the most deprived areas have a five year lower life expectancy. Although, over theprevious decade there has been a decrease in early death rates from cancer, heart diseaseand stroke, this has been decreasing at a lower rate compared to the rate for England. Thisindicates a widening gap between Crewe and Nantwich, and England as a whole.

4.1.2 Health and lifestyle of children in Crewe and Nantwich

The 2008 Crewe and Nantwich Health Profile64 indicates that 8.3% of school children inthe reception year (4-5 years) were classed as obese compared to the England average of9.9%. The percentage of young people (5-16 years) in Crewe and Nantwich who spend atleast 2 hours per week on high quality PE and school sport in 2006-07 was 90.5%compared to the England average of 85.7%, suggesting that physical activity levels aresignificantly better than the England average.

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4.2 Preventing Childhood Obesity in Crewe and Nantwich: theInterventions

A total of eleven interventions that met the agreed study criteria were identified in Creweand Nantwich. The eleven interventions were selected from a total of sixteen originallyidentified. Of the five that were excluded: two targeted children/young people who hadalready been identified as overweight or obese, one intervention had finished in theprevious year, one had been implemented after the snapshot day, and a furtherintervention was excluded because it was not possible to secure an interview with thecontact and insufficient information was available from other sources.

The eleven interventions have been listed in Table 4.1.below. Further details onindividual interventions have been included in the annex.

Table 4.1 Description of interventions

Number InterventionName

Description

1 The Friday BoyClub

‘Friday Boy’ (a former Wishing Well volunteer) attendsschools on a Friday lunch-time. Pupils are invited toparticipate in physical activity, healthy snacks are eatenand there is an opportunity to learn about humanbiology. The club also addresses mental health(bullying), but focuses most on physical activity in theplayground.

2 Chill and ChatYouth Club

This young people's club aims to promote general goodhealth and to raise the self-esteem of young people.There are informal opportunities for health educationand for addressing obesity issues in a supportiveenvironment. Referral is via the school nurse and thefocus is on the most vulnerable.

3 Health Lynx A project to encourage physical activity during schooltime, and out of school hours. The focus is onparticipation by pupils who don’t enjoy the school PEcurriculum and on informal non-competitive activities.

4 The NationalSchool FruitScheme, 5 A Day,and the Food inSchoolsProgramme

The Food in Schools programme a joint venturebetween the DH and DCSF includes a range of nutritionrelated activities. The School Fruit and VegetableScheme is part of the 5 A Day initiative - children inprimary schools (LEA maintained) aged 4-6 years areentitled to a free piece of fruit or vegetable each day.This operates across England.

5 Bike2Schools/SafeRoutes to Schools

Bike2School is a CNBC led project (with Sustrans)linked to Routes2Action a free publication. Individualschools have developed travel policies and funding hasbeen available to support this. There is a local ‘CyclingChampion’ to encourage and support school-children.

6 Extended Schools Extended Schools are expected to offer quality

35

childcare, a menu of activity (including physicalactivity) and parenting support. Meals provided underExtended Schools are required to meet nutritionalguidelines. As a result of ES some children may havethe majority of their nutrition at school.

7 The CheshireHealthy SchoolsProgramme

Takes a 'whole school' approach to health and addressesissues across the school – staff, parents, curriculum andpupils. Healthy Schools have in place projects, policiesand education initiatives in relation to both healthyeating, and promotion of physical activity.

8 Play OutreachProgramme

A child-centred programme to promote play in publicspaces with a focus on the most vulnerablecommunities. This programme also involves parents andoffers a wide range of play activities.

9 GovernmentNutritionalStandards forSchool Lunchesand other SchoolFood

New government standards initially implemented inprimary schools in 2008 (secondary schools by 2009).These are mandatory and cover all eating in school –lunches and snacking. In Cheshire, new initiativesinclude: salad bars, local sourcing, information abouthealthy packed lunches, and access to fresh water.

10 Snack Right Snack Right uses a social marketing approach andtargets economically inactive parents and their children(including under 19s and teenage parents in Crewe).This project promotes breast feeding, and healthysnacking by under 4s and their parents. There have been15 Snack Right events at children's centres (2 of whichwere in Crewe and Nantwich) and a leafleting campaigntargeted 113,000 households.

11 Healthy Start Healthy Start aims to tackle health inequalities byproviding food vouchers to young mothers (particularlythose under 18 years). Vouchers can be exchanged atshops for fruit, vegetables, milk or vitamins. Referral isvia ante-natal clinics and Health Visitors.

Source: ECOTEC Research and Consulting, 2008

While some of the interventions were operating in the case study area as part of nationalschemes and initiatives, others were specific to wards within the borough, the borough asa whole, or were operating across Cheshire (usually across Cheshire schools). Improvingchildren’s health by promoting changes in eating behaviour or encouraging higher levelsof physical activity were central aims of the interventions identified, rather thanspecifying the goal of reducing obesity - although this was an intended outcome.

All of the interventions were characterised by partnership and cross-agency working andlinked in with regional or national policy initiatives. A majority of the activity took placein the school setting although some of the interventions had a community-wide focus.

Four face-to-face interviews were conducted in Crewe and Nantwich with: twostakeholders from the Primary Care Trust (CECPCT), one from the Wishing Well

36

Healthy Living Centre; and one from the Health Development Team at Crewe andNantwich Borough Council. In addition, further local information was provided by key astakeholder from Cheshire County Council (via email exchanges).

4.2.1 Characteristics of interventions in the case study area

A summary of the eleven case study interventions in Crewe and Nantwich is included inthe annex. This section explores the key findings arising from the interventions identified.Several key themes arising from the analysis are then explored:

Evaluation and monitoring Links with Policy and Strategy Delivery partners Funding and sustainability

Settings

The settings for the eleven identified interventions were either the school or thecommunity; none were based in a healthcare setting. Six of the interventions wereschool-based, four were community-based and one operated across both the school andthe community settings.

Typologies

Healthy eating followed by physical activity programmes occurred most frequently.Most of the interventions related to more then one typology, providing an indication ofthe extent to which interventions utilised different activities and actions to addressobesity. The Cheshire Healthy Schools programme was aligned with five of thetypologies, demonstrating the multi-component nature of its approach. The number ofinterventions relating to each typology is shown in Table 4.2 below:

Table 4.2. Allocation of intervention typology

Typology Number ofinterventions

Physical activity programme 5Change to provision of tuck in school 4Healthy eating 7Peer support 1Lifestyle activity 3Reduce sedentary activity 3Changes to/ incorporation into curriculum 1Signposting 1Postal communication 1Workshops 1Use of incentives/rewards 1Change to school meal content 1

Source: ECOTEC Research and Consulting, 2008

37

Cheshire County Council had a central role in the development and implementation ofinterventions in Crewe and Nantwich. Other key players and/or lead authorities wereCNBC, and the Central and East Cheshire Primary Care Trust (CECPCT). All three ofthese authorities were associated with leading on one intervention: the Cheshire HealthySchools Programme.

Five of the interventions were part of initiatives operating at the national level (TheNational School Fruit Scheme; National Standards for School Lunches and other SchoolFoods; the Extended Schools Programme; Safe Routes to School; and Healthy Start).Two of the interventions were operating as regional programmes (The Cheshire HealthySchools programme, and Snack Right), and the remaining four were operating at a locallevel (Friday Boy Club; Chill and Chat Youth Club; Health Lynx; and the Play OutreachProgramme).

Target groups

The target group for all eleven interventions was school-age children or young people 5-19 years. Within this overall category there was some sub-targeting as follows:

Vulnerable school-aged children (secondary level) – 2 (Friday Boy Club, Chilland Chat Youth group)

School-age children (primary and secondary levels) – 3 (Nutritional Standards forSchool lunches and other school food, Health Lynx, 5 A Day and the Food inSchools programme)

School staff, pupils and parents – 1 (The Cheshire Healthy Schools Programme) School pupils and parents - 3 (The Extended Schools programme; Safe Routes to

School and Bike2Schools; and the Play Outreach Programme) Pre-school children and parents (under 19 years) – 2 (Snack Right, and Healthy

Start).

Evaluation and Monitoring

Information regarding monitoring and/or evaluation for each of the 11 interventions wasidentified. In addition, information about levels of participation in each intervention wassought. For two of the interventions no information regarding monitoring or evaluationwas identified, a further two could not provide any evidence of effectiveness, but didreport that the interventions had been very well received. The anecdotal feedback was ingeneral very positive. Only one local evaluation was identified, this involved thecollection of monitoring information and an invitation to participants to completefeedback forms (see case study 1).

Although some future evaluation activity was planned in relation to national levelinitiatives, there was very little evaluation activity locally. For four of the interventions,evaluation studies may be undertaken or are planned for the future. However this suggestsa stronger emphasis on outcome evaluation after project completion. On the basis of theavailable information more than 1,385 individual school-age children were being targetedby one or more of the interventions and it was possible to conclude that nearly all the

38

schools in the CNBC area were involved in one of more of the interventions identified(More than 189 schools were targeted across all 12 interventions).

Evaluation associated with the Healthy Schools programme has recently beencommissioned by the DH65 for a three year period (to 2010). This will investigate theimpact of the programme on young people and will be based around research conductedin 400 English schools. The focus will be on the impact of the programme and will centreon changes in behaviour, knowledge and attitudes.

Case Study 1Health Lynx – promoting physical activity in Crewe and Nantwich schools

Established five years ago, Health Lynx was originally implemented in response to theHealthy Schools programme. The emphasis is on activities not normally available in theschool PE curriculum (e.g. dance mats and Pilates) provided during school hours andafter the school day has ended. The target group is pupils who tend not to be active atschool and who don't enjoy PE. Health Lynx serves six secondary schools and 75% ofthe primary schools in Crewe and Nantwich, and is funded by CNBC (their HealthDevelopment team deliver the project), various grant funding and contributions from theschools themselves.

Through project monitoring and feedback CNBC have received information regardingthe uptake of Health Lynx, and how it has been received by both the schools and theirpupils. Key findings include:

Initial take up was slow 68% of Year 9 pupils take part in Health Lynx By mid 2007, 1,110 pupils were taking part Overall a positive response was received from schools who requested return

visits from the Health Lynx team. Teachers have reported that some of the more challenging pupils have been

taking part 40% of pupils agreed with the statement: "It's fun, different and exciting

compared to normal PE" 64% of pupils agreed that they now know more about different ways to be

active.

The Health Lynx intervention contributes to CNBC's Community and CorporateStrategies and to meeting the government targets to: "increase the number of peoplewho do 30 minutes of physical activity 5 times a week" and "to halt the year on year risein obesity in children under 11 years by 2010."

Sources: Interview with Crewe and Nantwich Borough Council (Health Development) September, 2008.

CNBC (2006/07) CNBC Performance Indicators return

CNBC (undated) Health Lynx information sheet

CNBC (undated) CNBC Community Development and Social Policy. Health Development Project

Monitoring Form.

39

Links with Policy and StrategyWhile the development of the interventions was most often in response to policy andstrategic initiatives, only one intervention ‘Snack Right’ had explicitly been based on theevidence for best practice. The strongest links were in relation to the policy and strategicinitiatives at different levels as follows66:

Local policy (CNBC, CECPCT, or CCC) – 7 interventions (Friday Boy Club,Chill and Chat Youth Club, Health Lynx, Cheshire Healthy Schools programme,the Extended Schools Programme, Safe Routes to Schools, and the Play OutreachProgramme).

Regional policy/strategy (regional responses to health inequalities) – 2interventions (Healthy Start and Snack Right)

National level policy (PSA Obesity Target, government action plans, mandatoryprovision, implementation of Every Child Matters, ‘Getting Serious About Play’(DCMS), national Sure Start programme) –6 interventions (Healthy Lynx;National School Fruit Scheme, National Standards for School Lunches and otherSchool Food, Cheshire Healthy Schools Programme, Extended Schoolsprogramme, Healthy Start)

It was thus clear that all eleven interventions were embedded in public health policyeither at the local, regional or national level. The national policy context was highlyinfluential in shaping and providing the focus of local interventions. This also supports alevel of coherence across the interventions and arguably contributes to concerted actionacross the case study area as a whole.

The Role of Social Marketing

The Snack Right initiative was a regional campaign that targets economically inactiveparents and their children. It uses a social marketing approach to counteract the influenceof mainstream advertising and marketing by the food industry. Social marketing has beendefined by the Department of Health as follows: "Health-related social marketing is thesystematic application of marketing concepts and techniques to achieve specificbehavioural goals relevant to improving health and reducing health inequalities."67 Thussocial marketing can be used to support changes in health behaviours by using some ofthe powerful marketing techniques, to make good health an attractive and desirablechoice. In response to this the UK government has created the National Social MarketingCentre for Excellence to increase both the use and understanding of social marketingtechniques. In relation to obesity recent initiatives have embraced a social marketingapproach in particular: the Healthy Towns initiative and the Change4Life campaign.

Change4Life is a new movement that is supported by the DH68 and has the central aim ofimproving children's diets and levels of physical activity with a particular focus oneducating parents about obesity. The campaign works with commercial partners(supermarkets, food manufacturers and the media), develops and disseminates resources,and aims to provide clear and consistent messages. The Healthy Towns initiative69 is partof the Change4Life movement; it includes nine towns in England that receive governmentfunds to encourage healthy lifestyles. Healthy Towns will provide a range ofopportunities for their communities to lead healthier lives, in particular in relation to:

40

opportunities for physical activity and making healthier food choices. The approach willaddress the whole community and the infrastructure of the towns.

Delivery Partners

A partnership and cross-agency approach was an important feature of all eleveninterventions, suggesting that existing practice is in line with current recommendations,and acknowledging the complexity of the obesity problem. While the interventions wereoften funded by a number of organisations, delivery did not always involve all of thesefunders, in some cases it was the responsibility of one organisation. Delivery partnerssometimes included beneficiaries, who were regarded as key to effective implementation.For this reason parent/carers and young people themselves were sometimes cited asdelivery partners. The key partners and the number of interventions relating to each ofthese are shown in Table 4.3 below:

Table 4.3 Key partners in the delivery of interventions

Partner Number ofinterventions

Partner Number ofinterventions

Other schools 4 Parents/carers 3CNBC 3 School meals

provider1

CCC 3CECPCT 6 Other local

authorities2

Teachers and otherschool staff

3 Health professionals 3

Young people 2 Shops or localsupermarkets

2

Externalorganisationsworking withschools e.g.Traveline

1 Other councildepartments e.g.Highways

1

Source: ECOTEC Research & Consulting, 2008

The involvement of partners from the private sector (e.g. supermarkets) and other councildepartments indicates that to some extent wider environmental factors have beenrecognised. Young people and parents/carers would appear to have a less prominent rolethan might be expected. This may be due to the fact that involvement of both of thesegroups was implicit to approaches and that they have therefore not been identified asdelivery partners. Alternatively this may be due to an understanding that ‘partners’ refersto those with a financial stake in the intervention or to statutory agencies only.

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Case Study 2: The Cheshire Healthy Schools Programme

More than 95% of England's schools are now involved in the national Healthy Schools(HS) programme, and more than 60% have achieved National Healthy School Status(NHSS). A long-term initiative HS aims to improve the health of school-children throughhealthy behaviours, positive mental health, and safety. Via a whole school approach thatinvolves all of the school community and parents, physical and emotional health isaddressed through 4 key themes: personal, social and health education; healthy eating;physical activity; and emotional health and well-being.

Cheshire's Partnership Approach

Cheshire's Healthy Schools programme is one of the largest HS partnerships in England,including 324 schools (268 primary, 47 high schools, and 9 special schools). AcrossCheshire 37 schools have signed up to 'The 1 Million Meals' (healthy eating initiative) andschools have been given resource boxes for the 'Give Me 5' campaign.

In Crewe and Nantwich 49 schools have been engaged, of which 40 have achievedNHSS. These schools have been meeting all requirements for healthy meals andsnacks, and have food and physical activity policies in place. Most schools have beenengaged with the HS programme for in excess of 5 years.

The Cheshire Healthy Schools programme supports a strategic approach to increasingphysical activity and healthy eating in schools. This involves a multi-agency andpartnership approach between health professionals, the local education authorities (CCCand CNBC) and strategic planners. Partnership is central to the approach and inparticular involves joint working between – Environmental Health Officers (LocalAuthority), health professionals, and schools.

Sources: Email communication with the Healthy Schools Co-ordinator at Cheshire County Council

(November, 2008).

Healthy Schools (2008) Healthy Schools web site. http://www.healthyschools.gov.uk/

Funding and sustainabilityFunding for the eleven interventions was from a range of sources, predominantly thepublic sector. The main public sector sources were CCC, CNBC, CECPCT and centralgovernment funds (e.g. from DCSF and DH). In addition to this, funding for activity alsocame from individual schools, the Wishing Well Health Living Centre (core funding fromCNBC and CECPCT), and to a lesser extent other grant funding. There was littleevidence of significant funding from either private or third sector sources.

Five of the interventions had been established for one year or more, five for more thanthree years, and one for less than a year. Five of the interventions (Cheshire HealthySchools programme, the National School Fruit Scheme, Nutritional Standards for SchoolLunches and other school foods, Safe Routes to School, and Healthy Start) were wellestablished and therefore likely to continue while political support for them remains. Twointerventions were set to continue in the short term and had in place plans for longer term

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sustainability (Chill and Chat Youth Club and Healthy Lynx) but this would depend onthe availability of continued local and health authority funding. The Friday Boy Club wasbased around the input of one individual so may be less likely to be sustainable.

Case Study 3: Healthy Start – A National Initiative to Reduce HealthInequalities

Healthy Start replaces the Welfare Food Scheme and operates across the UK providing:fruit and vegetables; vitamin supplements; and milk. The scheme aimed atdisadvantaged pregnant and young mothers, also supports breastfeeding. People fromdisadvantaged groups have significantly higher rates of: infant mortality, low birth weight,smoking in pregnancy and postnatal depression, compared to the general population.Those eligible for the Healthy Start scheme (incomes of less than £15,575 or on benefits)receive vouchers (each voucher is worth £3) through the post every 4 weeks that can beexchanged at registered shops.

Compared to other areas of East Cheshire, Crewe has the highest proportion of childrenand young people, and also has significant levels of poverty and deprivation. Recentevidence from the Cheshire East Joint Strategic Needs Assessment provides anillustration of this (CECPCT, 2008). Compared to Cheshire East, Crewe and Nantwichhas a higher infant mortality rate (5.2 per 1,000 compared to 3.8 per 1,000) and the ratesof breastfeeding are lower than the national average (62.8% in Crewe and Nantwichcompared to 69.2%). In Crewe, estimated adult obesity rates are high (26.1% comparedto 22.8% for Cheshire East) and the estimated consumption of 5 portions of fruits andvegetables a day is low (21.2% in Crewe and 25,4% in Cheshire East).

The Healthy Start scheme has particular relevance to Crewe, which has significant healthinequalities and in particular a high rate of teenage pregnancy. Latest data indicates thatthere are 43.9 per 1,000 teenage pregnancies in Crewe compared to 31.1 per 1,000across East Cheshire – the highest rate in the area. Prevention of obesity and thepromotion of a healthy diet are clearly of importance for this group of young mothers.While these figures suggest that there is a significant target group in the CNBC area forthe Healthy Start scheme, the low take up to date suggests further work is needed toensure it reaches those who will benefit the most.

Source: Interview with Public Health contacts at Cheshire and East Cheshire Primary Care Trust (October,

2008).

Healthy Start (2008) Healthy Start web-site. http://www.healthystart.nhs.uk/

Department of Health (2002) Proposals for the reform of the Welfare Food Scheme.

http://www.dh.gov.uk/en/Consultations/Closedconsultations/DH_4087874

4.2.2 Overview of the Crewe and Nantwich Approach

The organisation and management of approaches to obesity prevention in Crewe andNantwich was reflected across England as a whole, with local authorities (CNBC andCCC) and primary care services (CECPCT) taking a lead on activity. There was also

43

some third sector activity (voluntary and community sector organisations and non-profitmaking organisations), but this was often in conjunction with health and/or localauthorities. The CNBC has a Health Development team which was established 10 yearsago and employs three officers. This offers the local authority an opportunity to take alead in promoting health and to deliver key interventions e.g. Health Lynx. While theHealthy Communities programme70 established in 2006 has aimed to promote the role oflocal authorities in delivering a seamless approach to public services in particularworking closely with the health sector, an established health development team within aborough council was still relatively unique. The Health Development Team has helpedCNBC to develop and deliver a relatively large scale physical activity intervention in theborough.

Interventions did have a strong focus on healthy eating and physical activity often alongside other actions, but two in particular aimed to address positive mental health amongyoung people. This approach indicates an acknowledgement of the role that mental healthplays in childhood obesity. Being overweight and obese was often accompanied by lowself-esteem71 therefore an approach that addresses mental health alongside healthbehaviour was highly appropriate.

The interventions included in this case study were identified because they met pre-determined criteria. However, it was evident during the course of the study that a widerange of other initiatives and activities in the borough of Crewe and Nantwich wereimpacting on obesity and the health of school age children. These included otherinitiatives specifically focused on school-age children or young people as well as thoseoperating across the locality and affecting the wider population. The multi-level activityoperating within the case study area highlights the complex nature of health behavioursand their determinants, and the wider environmental factors that impact on overweightand obesity. The table (1.2) included in the appendix provides an illustration of some ofthe local activities and other initiatives that have an impact in the CNBC area.

None of the interventions identified took place in a healthcare setting. This may bebecause while childhood obesity was addressed by healthcare professionals in this setting(for example by health visitors, doctors, practice nurses or physiotherapists), such activitytends to occur on an individual basis, or with small groups (usually adults). In addition, itwas noted that some general practitioners were not convinced that there was sufficientevidence of effectiveness regarding public health interventions to justify taking on agreater public health role. Nonetheless, a move towards the promotion of wider healthand wellbeing within the healthcare setting was evident. In Crewe and Nantwich, theEagle Bridge Health and Wellbeing Centre (opened in November 2007) embraces thedelivery of statutory primary healthcare services alongside provision of healthinformation and a community café run by the Wishing Well Healthy Living Centre. Thiscentre brings together three GP practices and the centre was also used by community andvoluntary sector groups.

4.2.3 Barriers and Facilitating Factors

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Interventions that were effectively implemented and well received were associated with anumber of facilitating factors that helped this to happen. Where schools were bothreceptive and supportive of an intervention this assisted with raising awareness andparticipation. If schools themselves made a financial contribution towards initiatives thishelped to embed interventions and ensure on-going support for them.

A flexible approach was also a facilitating factor that assisted in promoting a sense of'ownership' among those participating. This approach allowed change and a naturalevolution due to the input of participants, supported their commitment to the interventionand a level of 'empowerment' among beneficiaries.

Interventions delivered as part of wider regional and national programmes (e.g. HealthySchools) had the advantage of being part of an established initiative, with allocatedresources such as regional co-ordinators and health information. This helped to providethem with a high profile and to attract support and commitment from partners e.g. schoolsand parents.

A number of barriers hampered the effective implementation and delivery ofinterventions. There was a tendency for the prevention of obesity to be seen as primarilythe responsibility of the NHS, rather than being a much wider responsibility that includedother statutory authorities and the wider community. Joint commissioning and multi-agency approaches have been established to encourage a shared approach, but changingthe culture may take longer. Partnerships such as the LSP support working together andprovide the opportunity for a number of agencies to consider together a single issue suchas obesity.

Some of the interventions took time to become established and to gain support. Initialparticipation levels were often low and it was necessary to raise awareness and marketinterventions to their target group in order to reach anticipated participation levels. Otheridentified barriers centred around: the reliance on short-term funding; difficulties aroundattracting external funding for interventions; the high levels of change and re-organisationtaking place within both health and local authorities; and a need for higher levels ofpersonal responsibility regarding health.

4.2.4 Examples of good practice

As already noted, the eleven interventions included in this case study had been subject tolittle local evaluation, and where this occurred it tended to be limited to monitoring data,anecdotal reports and information collated from feedback forms. Monitoring ofinterventions was often associated with funding requirements and involved reporting backon outputs as part of the funding agreement. The feedback on interventions was generallysought from participants and those delivering the initiatives, often on an ad-hoc basisusing self-completion questionnaires.

Some of the interventions had been the subject of national evaluation studies, althoughthese had been either baseline or pilot research studies. Although some information wasavailable on intervention costs there has been no cost effectiveness reporting. Withoutany local evidence it was hard to draw firm conclusions regarding effectiveness.

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However, the identified interventions do offer examples of practice that are in line withcurrent recommendations. The table below reflects on the Crewe and Nantwichapproaches in line with current guidance for evidence-based practice:

Table 4.4 Links between case study interventions and current recommendations on delivery.

Current recommendations on delivery72 Crewe and Nantwich InterventionsCommunity programmes to preventobesity, increase physical activity andimprove diet should address the concerns oflocal people

Consultation with young people was astrong feature of the Play OutreachProgramme. The Wishing Well HLC inCrewe reported developing itsinterventions in response to needsidentified by local people (including youngpeople).

Local authorities, PCTs and LSPs shouldensure that preventing and managingobesity is a priority for action at strategicand delivery levels through communityintervention policies and objectives.Dedicated resources should be allocated foraction.

The LAA and Sustainable CommunityStrategy have identified the health ofyoung people as priority areas and actionto address obesity is prominent in localpolicy and strategy. No specific evidencethat financial resources have beendedicated for action to address obesity inschool-aged children. However, a largeproportion of the funding for interventionsoriginates from the PCT, the boroughcouncil or the county council.

Schools: Ensure school policies and the

environment encourage physicalactivity and a healthy diet

Arrange training for teaching,support and catering staff

Establish links with healthprofessionals and local strategiesand partnerships to promote sports

Promote activities that childrenenjoy and can take part in outsideschool and into adulthood

Introduce sustained interventions toencourage pupils to developlifelong healthy habits

Take pupils' views into account Involve parents

School Travel Plans (Safe Routes toSchool) and the Cheshire Healthy SchoolsProgramme support implementation ofschool policies to encourage physicalactivity and a healthy diet.

Initiatives that link well with localstrategies and partnerships include HealthLynx, Play Outreach Programme, and SafeRoutes to School.

Active parental involvement in the Food inSchools intervention, the ExtendedSchools programme, and the Play OutreachProgramme.

Healthy Lynx, Extended Schools and thePlay Outreach Programme promoteactivities out of school and into adulthood.

Source: ECOTEC Research & Consulting, 2008

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4.2.5 Conclusions

On the basis of findings from the Crewe and Nantwich case study it was evident thatpartnership underpins the approaches to intervening in relation to childhood obesity andeffective partnerships were beginning to emerge in practice. Some interventions throughtheir approach recognise the need for comprehensive action by including both healthyeating and physical activity, extending interventions into the home via parents, andimplementing environmental changes. The Healthy Schools programme provides a goodexample of this.

A significant gap was the lack of evaluation associated with interventions or evidenceregarding cost effectiveness. The review of the evidence base relating to childhoodobesity conducted by NICE73noted that many of the obesity interventions tended to be ofshort duration with little or no follow-up, and that in general the monitoring ofinterventions was very low. It also noted a need for longer term follow-up of outcomeswith a greater emphasis on rigour (e.g. via randomised controlled trials), and a need tobuild up a UK evidence base relating to the effectiveness of multi-componentinterventions. As the national interventions progress it is likely that further evidence oneffectiveness and costs will come forwards.

In conclusion, the case study demonstrates that actions to address obesity are in place andthat as a consequence of the range of activity at all levels this issue was being tackled ona number of different fronts. A significant proportion of identified activity was in linewith current recommendations on delivery, although few interventions were explicitlybased on evidence for best practice. It remains to be seen if over the medium to longerterm there are genuine reductions in childhood obesity. In the absence of evaluationstudies it will not be possible to conclude if any future reductions in overweight andobesity are attributable to the identified interventions.

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5 The Dutch case study: Beverwijk in middleand south Kennemerland

5.1 Policy context

5.1.1 National health policy and strategic context

The Dutch government - particularly the Ministry of Health, Welfare and Sport - has acentral role in the promotion and protection of the health of Dutch citizens. In itsprevention policy 2006-2010, it specified two goals to overcoming overweight andobesity, especially in lower socio-economic groups74:

1. To maintain (or reduce) the share of adults that are overweight and obese; and2. To decrease the share of young people who are overweight and obese.

The most relevant policies, strategies and programmes that aim to achieve these goals aresummarised below.

The Ministry of Health, Welfare and Sport's policy brief Choosing for a healthy life(Kiezen voor gezond leven, 2006), overweight and obesity75 are specified as one of thefive most important issues76. As a result, the Centre of Healthy Living (CentrumGezond Leven) was set up in 2007, aiming to stimulate the use of nationally developedinterventions among professionals working in relevant fields (health, food, physicalmovement, etc.)77. An example is the Healthy School method (Gezonde School) thatstimulates and enables schools to improve physical, emotional and sexual health of youngpeople (4-18 years old)78.

The Health Care Inspectorate (IGZ, Inspectie voor de Gezondheidszorg) protects andpromotes health and healthcare by ensuring that care providers, care institutions andcompanies comply with laws and regulations79. It is also responsible for the introductionof performance indicators in the health care sector (by 2010 at the latest). Theseperformance indicators will assist municipalities in developing and improving their localpolicies and will assist health care providers to improve the quality of healthcare80.

Time for Sport - moving, joining in and achieving (Tijd voor sport – bewegen,meedoen, presteren, 2005) aims to stimulate people to undertake more sport and physicalactivities to improve their health. To achieve this goal, the National Action Plan forSport and Physical Movement (NASB) (Nationaal Actieplan Sport en Bewegen, 2005)was set up by the Ministry of Health and partners81. This Action Plan includes a subsidy(called Impulse NASB in 2008-2010 and in 2010-2012) for 50 Dutch municipalities with

48

the greatest health problems. This focuses on providing advice, and increasing expertiseand knowledge regarding effective interventions to encourage Dutch citizens to pursue anactive lifestyle. The four year public campaign 30 Minutes of Physical Activity (30minuten bewegen) was initiated by the NASB in 2007 as part of this Action Plan82,83.

A counterpart of the National Action Plan for Sport and Physical Movement is the masterplan to prevent obesity, Netherlands in balance (Nederland in Balans). This plan hasbeen set up for 2005-2010 by the Dutch Foodcentre and focuses on healthy eatingcommunication strategies, behavioural programmes and programmes targeting specificgroups (for example women and children)75.

The national Overweight Covenant (Covenant Overgewicht) is also important. Set up in2005 by the Dutch government (Ministries of Health and Education) in cooperation withthe food industry, hotel and catering industry, employers, health care providers and sportsorganisations, the Covenant is particularly focused on the prevention of overweight andobesity among children82. In 2008, several priorities were agreed between thestakeholders: to use one logo for healthy food; to make healthy food more visible insupermarkets; to ensure healthier school canteens at secondary level; and to ensure morespace and supervisors to stimulate sport and outside playing grounds in 40 identifiedneighbourhoods (krachtwijken84)83. The initiative includes projects such as the nationalschool action plan 'Go healthy' (Ga voor gezond). This action plan consisted of a learningprogramme set up by the NISB which involved approximately 1,000 primary schools82.

Similarly, the Overweight Partnership Netherlands (PON, Partnerschap overgewichtNederland) has been set up by the Dutch Government (Ministry of Health) in cooperationwith 17 partner organisations (care organisations, patient organisations and care insurancecompanies). Its aim is to improve care and thus the health and quality of life of peoplewho are overweight or obese85.

In addition, the Knowledge Centre Overweight has developed a Masterplan Overweight(Masterplan overgewicht) for the Juvenile Health Care Organisation (JGZ) incooperation with the Ministry of Health. This plan incorporates firstly, the need for anuniform signalling system of overweight and obesity which has led to the set up of asignalling protocol in 200486; and secondly, the need to undertake preventive and othermeasures has led to the set up of a Bridge Plan (Overbruggingsplan) which describespractice-based interventions87 which can be used until a national evidence basedprogramme has become available. Thirdly, it covers the monitoring of developments inthe Electronic Client Record (Electronisch Clienten dossier) of the JGZ. For thoseregional JGZ centres that lack such a system, an overweight and obesity monitor has beenset up in cooperation with TNO88.

The Dutch Health Institute (NIGZ, nationaal gezondheidsinstituut) focuses onstimulating healthy behaviour by offering support to stakeholders directly involved inpublic health: municipalities, public health services (GGD), home care, GPs and otherorganizations. It also offers information to the general public. The NIGZ offers courses,publicity material and other information materials regarding how to prevent overweightand obesity in schools, at work, in health care institutions and in neighbourhoods89.Examples of interventions include90:

49

Moving buddy (Beweegmaatje.nl) which is a free internet community site forchildren aged 16 and older to find a friend to undertake sport activities;

Toolkit for integrated approach obesity at school (toolkit voor integrale aanpakovergewicht jeugd op school) which offers an overview of prevention projects andmaterial to deal with overweight and obesity at schools.

5.1.2 Regional and local activities to combat childhood obesity

At the regional level, the 12 Dutch provinces are able to set up provincial plans orcampaigns and allocate provincial funding to these plans to tackle the problem ofchildhood obesity. To set up and implement these plans they regularly work with regionaland/or local organisations such as the public health service, sport service points, regionalvocational schools (ROCs) and other stakeholders to ensure an integrated method.Through these provincial plans or campaigns, Dutch municipalities can apply forprovincial co-funding to set up a specific activity at local level91.

In the region of Kennemerland, municipalities can currently apply for provincial co-funding (referred to as social domain subsidies) by the province of Noord-Holland toundertake and fund preventive interventions to overcome childhood obesity because suchinterventions fit with provincial social policy.

At the regional level, the Public Health Service (GGD92) plays an important role. Thisorganisation carries out youth health care in cooperation with homecare organisations.They organise regular health checks of children by school GPs, during which the heightand weight of children are registered. They also initiate many local and regional projectsto overcome overweight and obesity among young people93.

In Kennemerland region, the public health service (GGD Kennemerland) is responsiblefor regular health checks and an important partner in the many regional interventions.

At the local level, Dutch municipalities play a crucial role in preventing overweight andobesity. The four important domains for action within the municipality are: public health& welfare; sport & recreation; education; and environment/ traffic and transport. Thepolicy measures can be legal, economic or communicative. Municipalities areresponsible, through the Law Collective Preventive Public Health (Wet CollectievePreventie Volksgezondheid, WCPV), to draw up four yearly policy health plans in whichthey describe their approach to tackle overweight and obesity94.

Within the municipality, the chair responsible for public health can prioritise theprevention of overweight and obesity in local public health policy. The councilsubsequently decides priority areas and allocates funding to the priority areas 94.

In the region of Kennemerland, political attention in the municipality of Beverwijk forinterventions to tackle childhood obesity has, until recently, been very low which resultedin a lack of local municipal funding for the set up of preventive interventions. (In twoother municipalities located in the region - Heemskerk and Zandvoort - childhood obesityhas been placed higher on the political agenda, which resulted in both municipalities

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setting up a multi-annual local campaign Vet Gezond! for which annual resources havebeen allocated. The local campaigns include various interventions to tackle childhoodobesity.)

Municipalities receive support and guidelines from the Dutch government and otherorganisations (e.g. Health Care Inspectorate) to set up local preventive policy to tackle theissue of overweight and obesity. A good example of a guideline is the manual Preventionof overweight in local health policy (Handleiding Preventie van overgewicht in lokaalgezondheidsbeleid). This manual was published in 2007 by the Foodcentre Netherlands(Voedingscentrum Nederland), in cooperation with municipalities, GGD Nederland andseveral national partners. It reviews key concepts, and contains practical information andexamples for local policy makers and other local stakeholders to set up local preventivepolicy to overcome overweight and obesity94. The LIFELINE (LEEFLIJN) part of themanual offers an online overview of available preventive measures to overcomeoverweight and obesity for different age groups95.

Besides municipalities, home care organisations, cardiology departments in hospitals,general practitioners, schools, sport associations and associations for welfare etc. areoften locally active in setting up preventive interventions to overcome overweight andobesity in their community. These activities are often coordinated by the local or regionalGGD to ensure that expertise from the different local organisations dealing with diet,sport and welfare are utilised efficiently 94.

One of the most important stakeholders in relation to childhood obesity in Kennemerlandis the regional project group “Overweight Kennemerland”. This involves a partnershipbetween the Sportservice Noord-Holland (regional organisation responsible for sportactivities); the GGD Kennemerland (regional public health service); JGZ Kennemerland(regional juvenile health care provider); Zorgbalans and ViVa! Zorggroep (regionalhealth care providers)96.

5.2 Overview of Beverwijk in middle and south Kennemerland

5.2.1 Demographics and characteristics of the Beverwijk in middle and south Kennemerland

The municipality of Beverwijk is situated in the region of middle and southKennemerland97, part of the province North Holland (Noord-Holland), and located 20 kmnorth-west of Amsterdam.

Beverwijk is the fourth largest municipality of the region of Middle and SouthKennemerland with a total population of 372,816 inhabitants in 2008 of which 65,313were aged 5-19 (18% of total population). In 2008, Beverwijk had a population of 37,347inhabitants of which 6,359 were aged 5-19 (17% of total population)98.

The municipality of Beverwijk can be described as “large urban” and around a fifth of itspopulation come from an ethnic group (19.8%). This percentage is 0.4% higher than theDutch average. The socio-economic status99 of Beverwijk’s inhabitants (at 2,116) is 243points higher than the Dutch average98.

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5.2.2 Prevalence figures of childhood overweight and obesity in Beverwijk

According to two large scale independent studies among children and young people inprimary and secondary schools, Beverwijk has higher levels of overweight and obesity incomparison to the Netherlands and the region of Kennemerland.

Results of preventive health research (2005)100 among children of school age (4-15 yearsold)101 indicate that 15.9% of the examined children in Beverwijk are overweight (11.5%in the region100, 15.1% in the Netherlands102) and 4.8% are obese (2.9% in the region100,3.1% in the Netherlands102,103). The so-called EMOVO104 research (2007)105 amongschool-going children (13-16 years old)106 estimates that 11% of the 6.260 surveyedyoung people in Beverwijk are overweight compared to 7% in the region.

The research suggested that at least part of the high proportion of overweight and obesechildren in Beverwijk can be explained by the relatively high number of children with aminority ethnic background living in this municipality100. In particular, children with aTurkish background are more likely to be overweight or obese, followed by Moroccanchildren, Surinam and Antillean children107.

The research also indicated that the problem of overweight and obesity is greater amongstolder primary age children (9-10 years old) in the Kennemerland region, while inBeverwijk the problem is greater in younger children (3-4 years old). The results alsoindicated that the problems of overweight and obesity are more common among girls(almost 16% versus 13% for boys). In Beverwijk, the results are similar (23.6% for girlsand 17.7% for boys)100.

5.2.3 Lifestyle of children in Beverwijk and Kennemerland

Children in Beverwijk generally eat less healthily (i.e., less regular breakfast and dinner,lower vegetable intake) than children in Kennemerland apart from fruit intake (see Table5.1 below).

Table 5.1 Share of respondents per reply in Beverwijk and Kennemerland

Survey question Beverwijk Region Kennemerland

No breakfast at least once a week before going to school 23% 19%

Skip diner more often than twice a week 5% 3%

Eat vegetables on a daily basis 25% 35%

Eat fruit on a daily basis 34% 23%Source: 105

Children in Beverwijk have similar physical activity patterns compared to children in thewider region: they are equally as likely to cycle or walk to school (91% versus 93%) andthey follow a similar number of hours of physical activity in school (92% 2 to 3 hoursweekly versus 93%).

Children in Beverwijk are slightly less likely to be a member of a sports club (79% versus81%) but more likely to undertake other physical activities (16% versus 14%). Childrenfrom an ethnic minority are generally less likely to be a member of a sports club

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compared with the picture nationally (66% versus 75%); and this is particularlynoticeable for girls. However, regarding other physical activities, children with an ethnicminority background undertake more activities than children with a Dutch background(58% versus 40%).

Approximately three quarters (77%) of the children in Beverwijk do not meet therequirement set by the Dutch Standard Healthy Movement to undertake physical activityat least 1 hour per day and 7 days per week; this is also the case in the wider region(78%).

5.3 Prevention of childhood obesity in Beverwijk and middle and southKennemerland

Six interventions were identified in the municipality of Beverwijk, and across the widerregion of middle and south Kennemerland; 18 further interventions were identified thatmet the study criteria. As noted earlier, the policy of a municipality is determined by thepriorities of local politics.

Originally, 25 preventive interventions were identified in the region of middle and southKennemerland. Seven interventions were excluded (2 in Beverwijk) from the case studybecause they were either: statutory services that address childhood obesity and were nottime-limited population-based interventions aimed at prevention (2 out of 7); because itwas unclear whether they were still being implemented on the snapshot day; and/orbecause insufficient information was available (5 out of 7).

As part of the case study, six face-to-face interviews were conducted in the region middleand south Kennemerland: two stakeholders from the GGD Kennemerland, one fromZorgbalans, one from the municipality of Heemskerk; one from the municipality ofZandvoort, and one of the Sportservice Noord-Holland. In addition, further localinformation was provided by the municipality of Beverwijk and Fit4family via phone andemail exchange.

The 18 interventions are listed in Table 5.2 below. Further details are included in annex 1.

Table 5.2 Interventions to prevent childhood obesity in middle and south Kennemerland- those marked with an *

are also taking place in Beverwijk

Number Intervention name Description

1 Course Fit, Food & Fun Multidisciplinary course after school time at a school venue: PA

programme (1 hour a week, given by a physiotherapist), food lessons and

homework (given by a dietician), 2 parent information meetings (evening)

regarding healthy eating, physical activity and the up bring of children in

general.

2 Kidsclub This is a sport and game hour for children, carried out in a leisure centre

or sport association. They get acquainted with different sports and through

this they learn necessary sport skills which will increase and facilitate their

physical activity in the future.

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3 Food advice for ethnic

women

Existing ethnic minority women groups who already regularly come

together, convene at a suitable place (can be a community centre, a

mosque, elsewhere) to receive advice and information from a dietician of

Zorgbalans in relation to improve the healthy eating and physical activity

of their children.

4 All pupils active (Alle

leerlingen actief)

This intervention consists of a mix of activities: children are involved in

motivation conversations to spur a behaviour change. The parents also

receive counselling to take away any existing obstacles. The children and

parents are signposted to diverse sport activities in the neighbourhood or

to an intervention like the course Real Fit. The participating schools

organise extra sport activities (sport days) and arrange support of a

dietician/psychologist or otherwise in relation to healthy eating. The

intervention is sometimes combined with other interventions like

sporthackers or healthy school canteen (gezonde schoolkantine)

5 Cruyff court A playing field is set up/built to offer young people the facilities to

undertake diverse sport activities (like football). Diverse physical activities

on and around the playing field are coordinated in cooperation with all the

involved partners.

6 Special support*

(speciale bijstand)

Families with a low income can apply for municipal funding for their

children (and parents) to become a member of a sport association (€200

per family in Heemskerk, Dutch national average is €100)

7 School sport

programme* (school

sport programma)

The school sport programme consists of 10 different physical activities:

this can include a sport day; skating lessons, sport tournaments and

otherwise.

8 Jeugdsportpas (JSP) At the start of the school year, children receive a flyer with information

regarding the JSP. If their parents register them they can receive 4

lessons of 1 hour each at a sport association (or elsewhere) after school

to get acquainted with a sport they find interesting (8 different sport

activities are offered). For each period (3 a year) children can participate

in 1 sport. After the sport lessons, the children can decide to become a

member of the relevant sport association.

9 Course Real Fit Multidisciplinary course after school time at school venue including

healthy eating lessons, physical exercise (in a fitness centre) and parent

information evenings to offer advice on healthy eating (offered by a

dietician), raising children and sufficient physical exercise.

10 Sporthackers Sporthackers tries to stimulate young people to (continue) to be physically

active. The basis of this intervention is shaped by the available sport

supply of the participating schools; the organisation of sport clinics during

holidays; and the sport supply of sport associations. This supply is

adjusted to the needs of young people and marketed better to young

people.

11 Pilot know your talent

(ken je talent)

Services are offered to participating sport association to get young

members involved in volunteer work for the sport association: analysis of

the situation, workshops and training, tailored support to implement

change, education and training of young members (using existing and

new techniques)

12 Whoznext Whozenext is a national campaign which aims to offer young people a

voice in sports. A whoznext team consists of 4 to 8 young people in

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combination with a team coach from the participating sport association,

school or community centre. The team receives€450 (besides other

support and training) to organise at least 3 activities (can be a party,

excursion to a sport association during school PE, skate tournament,

etc.). The whoznext teams are connected to each other on a national level

and they can exchange information.

13 Fit4family* Parents and their children can fitness in the same fitness club: for children

lots of fun materials are available. For some children with overweight

problems a simple individually-tailored programme is made

14 Project Beter (Zw)eten* Ex ante measurement of length and weight; courses on healthy eating;

physical activities; information meetings for parents; individual counselling;

advice school policy; post measurement of length and weight

15 Groep 6 on the move The children decide what they want to learn in relation to food and

physical movement. Their wishes are shaped through the inputs of

teachers and parents. Sportive activities are organised and in the

curriculum attention is put on healthy living. Facilities in the

neighbourhood are used to stimulate children to move (sport clubs, play

grounds, etc.)

16 Parent meetings Participating primary education schools take the initiative to organise this

intervention. The parents receive advice in relation to healthy eating

(breakfast), physical activity, the cause of overweight and treatment,

support in upbringing of the children (behaviour influencing, parent role

model, watching TV, computer games).

17 Youth sport subsidy*

(jeugdsport subsidie)

The youth sport subsidy offers funding to sport associations in Beverwijk

for young members. The height of the funding is depending on the annual

number of young members.

18 Social card overweight

for professionals*

(sociale kaart

overgewicht)

The social card offers an overview of all organisations in the region of

middle and south Kennemerland which are active to help prevent and/or

treat overweight of children. It offers information regarding preventive

activities, websites, sport opportunities, etc.Source: ECORYS own compilation, 2008

5.3.1 Characteristics of the identified preventive interventions

SettingThe setting of the different interventions varied with a slight majority being embedded ina community setting (9 out of 18) (See Table 5.3 below). The school setting was,however, highly relevant (7 out of 18). Two interventions were embedded equally in aschool and community setting because they were partially carried out in participatingschools and in sport associations and other neighbourhood organisations. None of theidentified interventions was embedded in a healthcare setting.108

The interventions within a community setting were either organised in a leisure centre, asport association or other neighbourhood centre, or delivered as a subsidy for leisureactivities.

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The interventions which were organised in a school setting, either take place after schooland then mostly target specific target groups (e.g. children who were already coping withoverweight), or were inserted into the school curriculum and then target all school-children of a certain age or in a specific class.

Table 5.3 Number of interventions that fit with identified settings

Setting Number of interventions

School 7

Community 9

School and community 2

Healthcare setting 0

Total 18Source: ECORYS own compilation, 2008

Types of interventionsTable 3.2 below provides an overview of the typologies and the number of interventionsthat fitted with these typologies.

Almost all the interventions (13 out of 18) include a multi-component approach,addressing a range of factors influencing childhood overweight and obesity. (In thesecases the intervention has been categorised under more than one typology.) Fiveinterventions have a one-component approach of which two focus on subsidising leisureactivities.

Table 5.4 Number of interventions that fit with identified typologies

Typology Number of interventions

in Kennemerland

Physical Activity programme 12

Healthy eating 7

Workshops 6

Postal communication 6

Changes to/incorporation into curriculum and use of homework 5

Subsidised leisure activity 4

Reduce sedentary activity 4

Behavioural change therapy 3

Counselling 3

Signposting 2

Interactive communication methods for advice and support 2Source: ECORYS own compilation, 2008

It was noticeable that the majority of the interventions (12 out of 18) focus on physicalactivity. Interventions that included a healthy eating component were much less common(7 out of 18). Notably, five of those 7 interventions including a “healthy eating”component were combined with a “physical activity programme” component and it wasrare to have a health eating component on its own.

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The physical activity component tends to include physical activity programmes offeredafter school time but on school premises (e.g. the Fit, Food, & Fun or Real Fit courses);physical activities offered by sport associations (e.g. like the youth sport membershipcard (jeugdsportpas); or other physical activity providers (e.g. like fit4fun in a leisurecentre).

Five out of the six interventions which include a “workshop” element include workshopsaimed at parents (e.g. parent meetings). Two examples are: the course Fit, Food & Funwhich include two parent evenings: and the food advice meetings for ethnic minoritywomen with children.

Three interventions explicitly109 include a “behavioural change therapy” element with, orwithout, a clear reference to counselling. These interventions were explicitly targeted atchildren who were either already overweight and/or obese or who failed a physicalendurance test (e.g. the All Pupils Active initiative).

Case study 1 The All Pupils Active initiative

The initiative All Pupils Active is a good example of intervention including a behavioural change therapy element

as it includes “motivational conversations’110 between the participating children and a counsellor (e.g. a specially

trained teacher). The conversations aim to intrinsically motivate the participating children to undertake more

physical activities and to become more responsible for their own behaviour.

The participating children (and their parents) are subsequently signposted to diverse sports activities in their

neighbourhood or, if applicable, to another intervention like the course Real Fit. In parallel, the participating

schools organise additional sport activities (next to their regular PE programme) including, for example, sports

days, or they link the initiative All pupils Active to another intervention like Sporthackers or the national initiative

Healthy School Canteen (gezonde schoolkantine).Source: Interview Sportservice Noord-Holland, October 2008; NISB: Alle leerlingen actief. NISB, 2008.

http://kic.nisb.nl/extern.htm?http://kic.nisb.nl/home/main-nieuws.php?flag=2&page_number=0&site=8&ID=4797

Four interventions could be described as “subsidised leisure activities”. They eitheroffered an individual subsidy to applicants to become a member of a sport association(e.g. like the special support assistance) or they were aimed at subsidising organisationsto organise leisure (e.g. sport) activities (e.g. like the youth sport subsidy or the buildingof Cruyff courts).

Only one intervention (the social card overweight for professionals) exclusively aimed toprovide “postal communication” (i.e. a document) regarding all organisations/services inthe case study area that focus on childhood obesity and overweight. It was targeted atprofessionals who work with young people and their parents to prevent overweight issues.The document offers this information on interventions in the region to stimulate propersignposting and more adequate information provision. Five other interventions, like thecourse Fit, Food & Fun and the course Real Fit also use postal communication (e.g.newsletters, brochures), but only as an “add-on” to publicize information about thecourses for parents and children: dates, prices, location, etc.

Target groupsTable 5.5 below offers an overview of the target groups and the number of interventionstargeting these specific groups.

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Table 5.5 Identified target groups

Target groups Number of interventions

All children All children (no age defined) 3

Primary school-going children (4-12 years old) 1




School going children

Secondary school-going children (13-18 years

old, vocational education)

1

Primary school children with overweight

problems (8-12 years old)

2

Secondary school children with overweight

problems (13-18 years old)

1

Children with overweight

problems

Primary and secondary school children with a

lack of physical activity (9-16 years old,

vocational education)

1

Parents of children (4-12 years old) 1

Ethnic minority women with children 1

Families with low income 1

Sport associations and their young members 2

Indirectly targeting children

Professionals 1

Total 18Source: ECORYS own compilation, 2008

Three interventions were aimed at all children. Typical interventions that targeted allchildren were subsidised leisure activities like the Cruyff courts, special assistancesupport, and the Whoznext initiative.

Six interventions were aimed exclusively at children (and/or parents) of primary schoolage with or without overweight and obesity problems compared with only twointerventions aimed at children (and/or parents) of secondary school age with or withoutoverweight and obesity problems. Two of the three interventions aimed at secondaryschool age children particularly target children who follow vocational education. It isarguable that often particularly this target group was less physically active in comparisonto other school-going children111.

Four interventions were specifically set up for children who have overweight problems(they were weighed) or clearly lack physical activity (on the basis of a physical endurancetest).

Six interventions targeted children indirectly. Three of these interventions were targetedat the family; to influence the parents to improve the eating habits and/or physical activityhabits of their children. Two other interventions were targeted at sport associations toincrease the number of young members and/or to adjust their sport supply to the needs ofyoung members (e.g. for example the Pilot Know Your Talent).

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Evaluation resultsOnly five interventions (out of the 18) had evaluation material readily available112. Forsix interventions anecdotal information was available regarding outcomes and possibleimpact, but no evaluation was carried out. For seven interventions no information couldbe identified at all. For two of these, this can be explained by the fact that they have onlybeen recently set up.

On the basis of available information, more than 6,601 children were directly targeted bythe identified interventions and 47 ethnic minority women with children. A considerablenumber of schools (particularly primary schools) were involved in the identifiedinterventions.

The available evaluation results indicate that some interventions seem to lead to positiveoutcomes.

Evaluation results of the course Fit, Food & Fun

The course Fit, Food, & Fun is a multidisciplinary course for children aged 8-12 with overweight and/or obesity

problems. They participate voluntarily after registrations to the course by their parents. After school time at a

school venue they are weekly (for 10 weeks) involved in a PA programme (1 hour a week, given by a

physiotherapist), food lessons and homework (given by a dietician). The parents are invited to attend 2 parent

information meetings (evening) to gain useful information regarding healthy eating, physical activity and the up

bring of children in general.

The following results have been noted in the region of middle and south Kennemerland:

Heemstede (2007) results: weight difference with age group reduced after the course (6 weeks after the

last lesson). Stomach profile was also reduced. Children and parents reacted enthusiastic.

Heemskerk (2007) results: weight difference with age group increased after the course. The stomach

profile reduced somewhat. The parents participated well but the children were not always very involved:

they did not increase their knowledge on the topic of healthy eating although they did their homework.

Parents think that many of the children were simply not ready yet to follow this course and this resulted in

low participation. They also indicated that the children know what healthy is but just don't carry this out in

practice.

Heemstede (2005) results: weight decrease and stomach profile decrease after the course.. Average

length increase in 10 weeks of 1.5 cm is not normal: probably due to the fact that the position of the

children increased. The parents mentioned that their children play more outside and were more asked by

other children to play outside. The children also eat healthier and eat fewer sweets (less asking for

sweets).

As can be see from the results, the courses Fit, Food & Fun have been successful in the municipalities

Heemstede in 2005 and 2007, but less successful in Heemskerk in 2007.

Source: Zorgbalans: Resultaten FFF Heemstede ; Zorgbalans: Resultaten FFF Heemskerk;Zorgbalans: Metingen AVB 2007: voedingsvoorlichting, FFF. 2007;. Heming H, Jansen R:Evaluatie fit, food & fun, pilot voorjaar/zomer 2005, Nieuw Groenendaal sport & revalidatie,2005.

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Evaluation results of the initiative Group 6 on the move

In relation to this intervention, participating children (aged 9-10) decide what they want to learn in relation to

food and physical movement. Their wishes are shaped through the inputs of teachers and parents. Sport

activities are organised and in the curriculum attention is put on healthy living. Facilities in the neighbourhood

are used to encourage children to be more active (e.g. sport clubs, play grounds, etc.).

Preliminary evaluation results of the school year 2005-2006 indicate an increased intake of fruit among the

children, increased intake of light carbonated drinks, less candy eating, and an increase of outside physical

activity (can be seasonal).

Almost all of the participating schools have also registered in parallel- to receive the taste lesson chest

(smaakleskist) provided by the Ministry of Agriculture. This chest contains a lot of fun materials for children to

experiment with food. The intervention is also sometimes combined with other interventions for example the

Jeugdsportpas and the National School Breakfast initiative (Nationaal Schoolontbijt). The evaluation indicated

that the participants especially liked the introduction to new forms of physical activity. Parents liked to participate

in the children's activities and several schools have, as a result, adjusted their snack policy (pauzehapjes). The

evaluation shows that several schools wanted to keep certain elements of the intervention in the upcoming

years: the marathon around the school, the taste lessons (smaaklessen), the assignments in physical activity

diary ‘Hupla’ and the cooking activities.

This intervention has been included as good practice in the Leeflijn of the manual prevention of overweight in

local health policy developed by the Ministry of Health.Source: Interview GGD Kennemerland, October 2008

Delivery partnersA partnership and cross-agency approach was an important feature throughout the 18identified interventions: 15 out of the 18 interventions were carried out by differentpartnership. The funding organisations were mostly not included in the delivery of theinterventions because funding was usually offered in the shape of a subsidy.

The table below offers an overview of the key delivery partners involved in the 18identified interventions. The Sportservice Noord-Holland was involved in 12 out of 18interventions and primary schools rank second with involvement in 9 interventions.Table 5.6 Key delivery partners

Source: ECORYS own compilation, 2008

Delivery partner Number of interventions

Sportservice Noord-Holland 12

Primary schools (including staff) 9

GGD Kennemerland 8

Sport association or leisure centre 6

Zorgbalans 6

Secondary schools (including staff) 5

Neighbourhood organisations and other

local organisations

4

Municipalities 3

Cruyff foundation 1

Parents 1

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5.3.2 Success factors

Partnership approachesPartnership approaches involving the appropriate stakeholders were a key success factor.One of the most important stakeholders in relation to childhood obesity in Kennemerlandwas the regional project group “Overweight Kennemerland”. This project group was apartnership of the Sportservice Noord-Holland (regional organisation responsible forsport activities); the GGD Kennemerland (regional public health service for children aged4-18); JGZ Kennemerland (regional juvenile health care provider for children aged 0-4);Zorgbalans and ViVa! Zorggroep (regional health care providers)113.

The aim of this group was to increase the cooperation and linkages between the variousactivities of participating organisations and to exchange expertise. In 2005, the projectgroup Overweight Kennemerland set up a regional plan “Signalling, approach andprevention of overweight of children aged 0-19 in the region Middle and South-Kennemerland”114. The plan includes a combination of interventions that have previouslybeen developed either by one or several of the partners or by for example, the KnowledgeCentre Overweight or the Food Centre Netherlands.

The interventions were organised in such a way that they were coordinated by one partner(Real Fit was for example coordinated by the Sportservice Noord-Holland and the courseFit, Food & Fun was coordinated by Zorgbalans) while the various sub-activities of theintervention were carried out by the partner with the most relevant expertise (for exampleZorgbalans always takes care of any healthy eating element) and also financed (ifpossible) by the most relevant partner.

Case study 2 Food advice meetings for ethnic minority women

An example of successful cooperation within the regional project group overweight Kennemerland is the

collaboration between the two organisations Zorgbalans and Sportservice Noord-Holland providing food advice

meetings for ethnic minority women to feed their children more healthily.

These meetings are organised by Zorgbalans and originally included only advice on “healthy eating” for the

parents. Due to the cooperation with the sport service in relation to other interventions, this advice has been

broadened and now also includes a “physical activity” element for the parents to take into account.Source: Interview Sportservice Noord-Holland, October 2008; Interview Zorgbalans, October 2008

The interviews highlighted the importance of an institutional partnership such as theproject group Overweight Kennemerland. However, interviewees commented that itssuccess was completely dependent on the contributions of the individuals - not of theorganisations - in the partnership.

Embedding interventions in into regional and local policyWhen interventions were embedded into regional and local policy and subsequently intomulti-annual regional and local programmes they can engage important regional and localstakeholders and lever in the necessary funding. Eight interventions receive essential co-funding from the province of Noord-Holland because they relate to provincial prioritiesset in social domain115.

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Fourteen interventions were implemented using (co-)funding of the relevantmunicipalities without which they would not be able to take place. For example, in themunicipalities of Heemskerk and Zandvoort a considerable number of interventions were(co-) financed by the respective municipalities because they fit with local campaigns (forinstance the Vet Gezond! intervention for which annual resources were allocated).

The limited number of interventions carried out in the municipality of Beverwijk (6 out of18) was due to the small amount of municipality (co-)funding116 (and therefore alsolimited co-funding of the province). The lack of municipal funding was related to the factthat childhood obesity has received - so far - little or no political attention in the localcouncil of Beverwijk.

However, it seems that the municipality of Beverwijk was slowly trying to overcome thelack of political attention as it was tendering to build a Cruyff court. This was a playingfield to offer young people the facilities to undertake outside sport activities (such assoccer). The Cruyff foundation acts as a co-financing organisation and was particularlyinterested in offering sport facilities to young people with an ethnic minority background:these being the group of children who run the highest risk of overweight or obese in themunicipality of Beverwijk (and the region Kennemerland).

Wider impact possible through involvement of schoolsNine out of the 18 interventions were carried out in primary and secondary schools eitherduring school hours (e.g. incorporation in the school curriculum) or after school (withschool premises made available).

The after-school interventions typically fall in the Dutch concept of “Brede School”which stands for cooperation between all stakeholders involved in the upbringing ofchildren and young people like schools, childcare, sport associations, libraries, etc. Untilnow, schools predominantly took a central role in this cooperation.

Course Real Fit

The course Real Fit is a good example of an after school interventions which falls in the “Brede School” concept

as it includes cooperation between multiple partners in which the schools play a central role.

The participating school arrange the venue after school time and publicise the course among its pupils; the local

sport service (Sportservice Noord-Holland) subsequently arranges the sport element and a healthcare

organisation (Zorgbalans) arranges the healthy eating element.Source: Interview Zorgbalans, October 2008

Course Beter (Zw)Eten

The intervention Beter (Zw)Eten is a good example of an intervention incorporated in the school curriculum. It is

carried out in primary schools in the region of Kennemerland (Beverwijk, Heemskerk, Zandvoort) for 8-9 year

olds and includes a multi-component approach of 4 weeks offering “healthy eating” classes, physical activities,

consultation meetings, parent meetings, stimulation of healthy food in the school canteen and where needed

individual support for children who are likely to become/are overweight. The evaluation of the intervention shows

that many teachers are enthusiastic about the fact that they can include the discussed subjects in their regular

learning programme after the project period of 4 weeks (facilitated by a project map)117.Source: Interview GGD Kennemerland, October 2008

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Embedding the interventions in a school environment has multiple advantages. First, theinterventions were more easily accessible for children because they typically take placewithin their school which tends to be close to their home118 . Secondly, the interventionsgenerally target a large audience (all school-going children or children of a specific class)which increases the likely impact of the intervention. Third, when the intervention wasembedded in the school curriculum, there were few barriers (such as administrativepaperwork, negative stigma, participation fee) attached to registration and participationbecause all school-going children automatically participate.

Integration into a school-environment however also contains a potential weakness: sincethe cooperation of schools was essential but many organisers of the various interventionshave reported problems convincing local schools to cooperate. Currently, many schoolswere overwhelmed by new responsibilities (as part of the Brede School concept)alongside their essential task of providing education119 and - as a result - they were facedwith budgetary and personnel constraints.

Adjusting the offer of sport associations to the needs of young people leads to increasedmembership of young people

Young people (particularly between the age of 13 and 18 years) often give up theirmembership of a sport association because the offer does not appeal to them and becauseother activities (like employment) become more important for them120. As a result,several interventions in the region of Kennemerland/ Beverwijk (4 out of 18) aim toadjust the offer of sport associations to make membership more attractive for youngpeople. The results vary but overall seem to indicate that young people become - as aresult of the interventions - more aware and interested in the offer of sport associations.Two good examples of reasonably successful interventions were the jeugdsportpas ensporthackers.

Jeugdsportpas

The jeugdsportpas offers children in primary school (aged 4-12) the chance to become acquainted with different

sports without immediately becoming a member of a sport association. In four lessons of 1 hour each – after

school in a sport association or elsewhere- they learn the basics of a sport which interests them. The parents

contribute €5 for 1 sport and the involved municipalities contribute the rest of the budget. The Sportservice

Noord-Holland coordinates the intervention. Evaluation in the municipality of Heemskerk121 shows that in 1 year

800 children have participated - which is a considerable number in comparison to other intervention - and it is

estimated that approximately 10% of the participating children decide to become a member of a sports

association.Source: Interview gemeente Heemskerk, October 2008; Interview Sportservice Noord-Holland, October 2008

Sporthackers

An evaluation of the intervention Sporthackers- which aims to adjust the sport offer of vocational secondary

schools (VMBO) and sport associations and includes the organisation of sport clinics during holidays and in

schools- shows that after participation, the membership of a sports association increased by 12% (only

measures in Zaanstad) en the number of young people involved in any sport increased on average with 3.3%.

Four VMBO schools participated in the interventions in combination with 31 sport associations. In total, 497

young people participated in sport clinics during the holidays and 3,269 young people participated in sports

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clinics in schools. In total 42 sport associations received support to adjust their sport offer to the needs and

interests of young people129.Source: Interview Sportservice Noord-Holland, October 2008

A weakness with interventions aiming to adjust the offer of sport associations to theneeds and interests of young people was that they generally only interest young peoplewho were already involved in sport activities. The hard-to-reach group of young peoplenot undertaking physical activity has a more limited engagement with such interventions.Another problem was the difficulty getting sport associations interested due to a lack ofavailable staff to offer the sport clinics to the young people122. The introduction ofcombined functions for professional sport teachers can, however, solve this issue (seeSection 5.3.3 for more information).

5.3.3 Barriers to success

Reliability on temporary fundingA weakness of almost all examined interventions (17 out of 18) was their dependence ontime-restricted local (municipal funding), regional (provincial funding), and/or national(e.g. Ministry of Health) subsidies.

The sustainability of the interventions was highly dependent on national, regional and/orlocal political attention for childhood obesity. If political attention reduces, subsidies canbe partially or completely cut leading to the cancellation of interventions. In addition, theduration of the subsidies was often fixed (ranging between approximately 1 to 3 years).This implies that those organisations that were implementing the interventions need to(re-)apply for subsidies to guarantee continuation of the interventions.

Fit, Food & Fun

The Fit, Food and Fun course depends heavily on available subsidies and is financed through multiple

channels: (1) provincial and local co-financing agreements through the municipal campaign Vet Gezond! (See

before); (2) other co-financing from the province and the municipalities through the regional plan of the project

group Overweight Kennemerland (such as the BOS-impuls); and (3) ZonMw funding 123,124. A subsidy is

requested by different partners involved in the intervention: ZonMw funding is for example requested by

Zorgbalans, while the Sportservice Noord-Holland is responsible for acquiring provincial and municipal co-

funding.Source: Interview Zorgbalans, October 2008

Lack of monitoring and long-term evaluation of interventionsAs mentioned before, a weakness of almost all of the examined interventions was the lackof evaluation. From the 18 interventions examined in our research, only five have readilyavailable evaluation results.125

However, none of the examined interventions provided evidence of long-term results andimpacts. This was due to several factors. First, the effectiveness of preventive measureswas extremely difficult to measure. The evaluation of the intervention “beter (zw)eten”124

for example shows some promising results: it has led to an increasing number of childreneating breakfast, undertaking more physical activities and watching less television andsitting behind the computer; also, the knowledge of the children regarding healthy eatinghas increased. However, it is unknown whether these effects will continue to exist on a

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long-term basis and whether these effects will change behaviour and reducing overweightand obesity in the future. Second, evaluations were frequently not carried out or notcompleted due to a lack of funding and/or evaluation capacity. Third, attention tended tofocus on process-evaluation (beneficiary satisfaction etc.) instead of measuring (long-term) effects.

As a result of a lack of monitoring and (long-term) evaluation, our interviews highlightedthat the offer of interventions was not always timely and adequately adjusted for theneeds of the target groups. It is, for example, suggested by multiple interviewees, that theproject group overweight does not always take sufficient time to invest in researching theneeds for interventions; the content of their interventions; and to learn from their previousinterventions. In addition, they sometimes seem to hold on to their specific methods ofworking instead of being open to new methods.

The cause of the above was partially rooted in the fact that funders (like municipalities)do not always value building the evidence base nor formulate their research question andrequirements in the most helpful way. For example more of a focus on a demand study,measurable targets, monitoring and (long-term) evaluations would help build a picture ofwhat works, where and when. The lack of a sufficient evidence base makes it - so far -difficult to define acceptable and realistic targets.

Lack of impact due to short duration of interventionsMany of the examined interventions were of limited duration. The intervention 'Beter(Zw)Eten' for example lasts 4 weeks, the intervention course 'Fit, Food & Fun' lasts 10weeks; and the course 'Real Fit' lasts 12 weeks. As a result, these interventions will mostlikely obtain short-term effects such as raising awareness; more physical activity; etc. Ithas been proven that these effects slowly subside over time leading to no long-termeffect126.

Lack of participants caused by socio-cultural environment and other factorsThe interventions aimed at children who were overweight and/or obese generally seem tolack participants. The research suggested a variety of possible causes. First, parents whowere responsible for subscribing their children to such a course often do not recognizethat their children were overweight and/or obese. Second when the parents acknowledgetheir child has a problem, they often experience the administrative paperwork, theindividual participant fee127 or the negative connotation (stigma) surrounding obesity asbarriers. Third, families who have the highest risk of becoming obese or overweight werethose with a relative low income and/or with an ethnic minority background (particularlythose with a Turkish, Moroccan or Surinam/Antillean background) who may need aspecific approach to engage them. This group tends to be more difficult to reach throughinformation and advice meetings, information leaflets, folders and other publicitymaterial. Fourth, it was mentioned that organisations responsible for referring overweightand/or obese children (such as the GGD) often do not refer to courses such as 'Fit, Food& Fun' and 'Real Fit' because they were either unaware of the existence of these coursesor they were not persuasive enough to convince the parents to register their child.

Large-scale interventions which were integrated in the school curriculum can potentiallygenerate much greater impact128.

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Lack of “sport” specialists in schools and sport associationsTo stimulate children to undertake physical activity our interviewees identified theimportance of schools having access to a 'sport' specialist (professionele gym leraar ofvakleerkracht). Dutch schools were required to employ a sport specialist, but the Dutchgovernment since removed this requirement. This had led to a reduction in the quality ofthe sport offer of schools (non-specialists would take over the task) and also led toreduced communication with other sport suppliers due to a lack of knowledge, interest-raising and a lack of referral.

Since 2004 however, the Dutch government has been stimulating the employment ofsport specialists and since 2008, municipalities can apply for funding for a combinationmeasure “impuls brede school”129. This measure enables schools to employ a sportspecialist (target of 2,500 to be hired) with a remit of combining their school basedresponsibilities with other sport activities in a sport association or elsewhere.

The municipality of Heemskerk in the region Kennemerland was applying for funds andhopes that the employment of a sport specialist will increase the quality of the sport offerin their schools and stimulate linkages, communication and proper referral between thevarious sport suppliers within the municipality.

Lack of knowledge regarding the costsNone of the identified 18 interventions could provide a clear cost overview. Only ahandful of interventions could provide even partial information. As a result, it was as yetimpossible for stakeholders to gain useful insights into the costs and cost effectiveness ofavailable interventions. This impedes good decision making regarding what interventionsto implement in future.

Table 5.7 below provides the information regarding costs that was available. The amountallocated to interventions ranged between €224.246 for an intervention targeting manyschool children simultaneously (all pupils active interventions) and €27.890 for anintervention targeted a small number of participating children (intervention project beter(zw)eten).

Table 5.7 Cost information

Intervention Ministry

of

Health

Participating

organisation

Parents ZonMW

funding

Municipality

funding

Provincial

funding

Course fit,

food, & fun

-- -- Between

€40-€56

annually

Not available Not available Not available

Kidsclub -- -- €128

annually

-- Not available Not available

Food advice

for ethnic

women

-- €25 per

meeting

-- Not available -- --

All pupils

active

-- -- -- -- Not available €224.246

(2007)

66

Jeugdsportpas -- -- €5 per sport -- Not available --

Course real fit -- -- €100

(refund of

€50 if

participation

is sufficient

-- Not available Not available

Sporthackers -- -- -- -- €83.200130

(2007)

€73.523 (2007)

Pilot know

your talent

€267.250 Not available -- -- 42.7 % of the total budget

(€625.500)

Project Beter

(Zw)eten

-- -- -- -- €27.890 (10 schools in 1

municipality)

Group 6 on

the move

-- -- -- -- €52.136 (7 schools: 10 groups)

Parent

meetings

-- €50 for

material

costs

-- Not available -- --

Source: ECORYS own compilation, 2008

5.3.4 Conclusions

In the Netherlands, national support for regional and local interventions was extensive.This translates in the region of Kennemerland into a vast number of interventions -carried out through national, regional and local funding - of which some have alreadyshown encouraging results while for others the results were not yet clear.

The setting of the different interventions varied. A slight majority was embedded in acommunity setting, but the school setting was also highly relevant. Almost all theinterventions include a multi-component approach, addressing a range of factors thatinfluences childhood overweight and obesity. It was noticeable that the majority of theinterventions focus on physical activity. Interventions that include a healthy eatingcomponent were much less common. Most interventions either target children (and/orparents) of primary school age with or without overweight and obesity problems or theytarget children indirectly by targeting the family or sport associations.

Clearly some municipalities within the region of middle and south Kennemerland wererunning more interventions than in Beverwijk. For example, the municipalities ofHeemskerk and Zandvoort fund many different interventions due to their multi-annualcampaigns Vet Gezond! while the municipality of Beverwijk was as yet struggling withgaining political support to get the subject of childhood obesity on the political agenda.As a result, only a minimum of 6 out of the 18 identified interventions in the region ofmiddle and south Kennemerland have yet been carried out in Beverwijk.

Partnership approaches were a key success factor for implementing preventativeinterventions. One of the most important stakeholders in relation to childhood obesity inKennemerland was the regional project group “Overweight Kennemerland” which was apartnership of the Sportservice Noord-Holland (regional organisation responsible for

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sport activities); the GGD Kennemerland (regional public health service for children aged4-18); JGZ Kennemerland (regional juvenile health care provider for children aged 0-4);Zorgbalans and ViVa! Zorggroep (regional health care providers). Another successfulpartnership relates to the Dutch concept of “Brede School” which stands for cooperationbetween all stakeholders involved in the upbringing of children and young people likeschools, childcare, sport associations, libraries, etc.

A clear weakness of almost all examined interventions was their dependence on time-restricted local (municipal funding), regional (provincial funding), and/or national (e.g.Ministry of Health) subsidies. This makes the sustainability of the interventions highlydependent on national, regional and/or local political attention for childhood obesity.Another weakness was the lack of (long-term) evaluation and monitoring. In addition,none of the identified interventions could provide a clear overview of the total costsinvolved. As a result, it was as yet impossible for stakeholders to gain useful insights intothe costs and cost-effectiveness of available interventions. This impedes good decisionmaking regarding what interventions to implement in the future.

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6 Discussion, Conclusions andRecommendations

6.1 Introduction

This chapter provides comparisons regarding findings from the English and Dutch casestudies. Specific attention was paid to the policy and strategic context for both case studyareas, demographic comparisons, and comparisons regarding the identified interventionsin each country. Below, conclusions and some recommendations for research and policyand practice were presented.

6.2 The policy and strategic context for prevention of childhood obesity

Both the Netherlands and the UK have in place a range of policy initiatives that addressoverweight and obesity among school-age children. At the national level both countriesseek to reduce the prevalence of overweight and obesity particularly among youngpeople, and have in response to this set goals and targets. This highlights the high prioritygiven to this matter by both countries, with obesity being recognised as an importanthealth issue. Both countries target areas with the greatest problems – in the Netherlandsby targeting lower socio-economic groups and in the UK through action to address healthinequalities. Via national policy outlining action to address obesity, (Healthy Weight,Healthy Lives and Choosing a Healthy Life) both countries have recognised that efforts toinfluence the food industry and the advertising and marketing sectors should be included.

There were similarities between the policy and strategic approaches of both countries.The emphasis on partnership was outlined in the PON and Covenant in the Netherlandsand in England via the NICE guidelines. Also the Dutch ‘leeflijn’ directly compares tothe National Service Framework for Children, Young People and Maternity Services inthe UK.

At the local level, community public health takes a lead role in both countries, via thelocal health care organisations; the PCT in England and via the equivalent organisation inthe Netherlands, the GGD. One notable difference was that the UK does not have adatabase providing information on all the available preventive measures to addressobesity. In addition, evidence from the case studies suggests that General Practitioners(doctors) and hospitals play a more prominent role in the delivery of Dutch interventions.

The presence of the Gezonde Schools in the Netherlands and the Healthy Schoolsprogramme in the UK demonstrates a shared vision and approach, as well as a recognition

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of the importance of the school as a setting for addressing health behaviour amongchildren. The value of the school in providing an accessible cross-section of the totalpopulation of children and young people was recognised in both countries andinterventions were generally implemented through the framework of these programmes.These also ensure that school-based interventions were consistent across each country,were embedded in shared philosophies and policies, and in addition these establishednational programmes can provide a channel for resourcing activity and directinggovernment funding.

6.3 Crewe and Nantwich and Beverwijk and Kennemerland – how dothey compare?

In terms of prevalence figures of obesity among children, the rate for Crewe andNantwich (8.3% of 4-5 years old) was lower than the England average of 9.9% (4-5 yearolds)131. The prevalence of childhood obesity in Beverwijk (4.8% of 4-15 years old102 )was higher compared to the Dutch average (3.1% of those aged 4-15 years104). Overall,the prevalence of childhood obesity was in the UK was high when compared to theNetherlands.

With regard to physical activity patterns, a higher share of the children in Crewe andNantwich (5-16 years) were active in physical exercise and school sports (at least 2 hoursa week) compared to England as a whole. However, this share was still slightly less thanin Beverwijk (4-15 years old were physically active during 2 to 3 hours weekly – i.e.,92% compared to 90.5% in Crewe and Nantwich). In Beverwijk, 91% of the childrencycle or walk to school. In England, traditionally much more reliance was put on takingchildren to school by car although actions to encourage cycling and walking to school arenow being promoted.

6.4 Preventive public policy: comparative analysis of interventionsidentified in England and the Netherlands

6.4.1 The balance between physical activity and healthy eating

The majority of the interventions identified in the Dutch case study were primarilyfocussed on physical activity with healthy eating featuring to a lesser extent overall,although a proportion of the Dutch interventions addressed both of these typologies. Thisalso reflects the balance towards physical activity evident in the country's national policy.This finding implies that the approach to preventing obesity in the Netherlands was seenprimarily to be about increasing levels of physical activity. In the context of theinfrastructure of Dutch towns and cities (including cycleways and facilities for cycling)and the culture of cycling and walking that was in place this seems to be a an appropriateapproach.

The majority of the interventions identified in Crewe and Nantwich were clearly focussedon healthy eating and on the improvement of children's diets. However, two of these alsoincluded a physical activity element alongside promotion of healthy eating. This may bedue to the fact that interventions which were generally led by health authorities tend tofocus more initially on changing eating behaviours; an area in which it was possible to

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legislate (e.g. in relation to the nutritional content of school meals) and to implementinterventions with relative ease. In terms of physical activity there needs to be suitablefacilities available and wider issues such as safety require consideration (e.g. inpromoting walking and cycling to school). In the UK the infrastructure to encouragecycling and walking was not in place to the extent that it was in the Netherlands.

The Dutch case study was highly focused on physical activity, healthy eating andbehavioural change strategies were available but to a lesser extent. The number ofinterventions in the region, and the diversity of the interventions show a scattered patternof interventions. Also, interventions in Beverwijk (and Kennemerland) were not wellconnected to national interventions focused on tackling childhood obesity.

6.4.2 Setting of the interventions

In the UK case study, preventive interventions to tackle childhood obesity were pre-dominantly embedded in a school setting (6 out of 11 interventions) while in theNetherlands, there was stronger emphasis on a community setting was evident (9 out of18 interventions). No preventive interventions to tackle childhood obesity were embeddedin a healthcare setting in either one of the case studies. This latter finding can be partiallyexplained by the exclusion criteria of our study. For example, regular controls of childrenby school GPs organised by the Public Health Services in both the UK and theNetherlands (organised by GGD Kennemerland in the Dutch case study area andorganised by Central and East Cheshire Primary Care Trust (CECPCT) in the UK casestudy) were excluded.

In the Netherlands, when schools were involved, school involvement was alwaysvoluntary, which explains the different levels of involvement. It can for example consistof minimal involvement, e.g. schools make their school facilities available (e.g.classrooms) or more involvement, e.g. allocating time of teachers to be involved ininterventions to tackle childhood obesity. In principle, the Dutch case study suggests thatindividual schools do not allocate direct funding (instead of staff time) to an intervention.In the UK case study however, interventions were sometimes funded by individualschools. This funding was either sourced through schools' own budgets (via the LocalEducation Authority, Cheshire County Council allocations) or via grant funding appliedfor by the schools themselves.

6.4.3 Targeting of the interventions

In both the UK and the Dutch case study areas, the interventions were mainly (in the UKall) targeted at school-age children at primary and secondary education levels. However,in the UK case study all school-age children were targeted while in the Dutch case studythe attention was more focussed on specific age groups of school-age children,particularly the 4-13 age group (i.e., primary education level – applicable to 6 out of 18interventions). In addition, in the Dutch case study area, several interventions (4 out of 18interventions) specifically targeted school-age children with overweight problems. Thevoluntarily participating children were weighed and measured before they were includedin the intervention or - in one specific case (the All Pupils Active intervention) - the

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children were asked to participate in a physical endurance test to identify whether they fitin the target group.

In the UK case study area, school staff and parents were targeted in addition to theschool-age children. In several of the Dutch interventions (5 out of 18 interventions), alsoother groups were targeted in addition to school staff and parents. This includes forexample ethnic minority women with children, professionals, families with a low incomeand sport associations and their young members. These interventions were all targeted atpreventing childhood obesity and thus focus – more indirectly- on combating childhoodobesity.

In the Netherlands it was therefore clear that much more attention was placed on specifictargeting while in the UK general targeting was the standard. In the UK it was generallyaccepted that primary level interventions should be targeted at general population groupse.g. the whole school community. Interventions that target overweight/obese childrenwere less common (one example was the MEND intervention in Crewe and Nantwich, asecondary level intervention) this may be due to a desire to avoid labelling among youngpeople and to avoid the stigma attached to being obese.

6.4.4 Factors that influence the implementation of the interventions

Link to national policy and strategiesIn the UK, the national policy context was highly influential in shaping and providing thefocus of local interventions. Overall, the interviewees in the UK indicated a very stronglinkage of their local interventions to national programmes. Five out of 11 interventionsin Crewe and Nantwich were directly related to national programmes (for exampleHealthy Start and the Food in School initiative). Two out of the 11 interventions in Creweand Nantwich were directly related to regional policy (for example Snack Right,Bike2School).

In the Netherlands, the link with national strategies clearly exists but it was less obvious.It was evident that guidelines were followed, policy advice was used in shapinginterventions (e.g. partnership) and best practice examples of effective interventions weretranslated to particular local contexts. Also, national funds were available to implementinterventions at the local level.132

The Dutch interviewees explained the local and regional policy context instead ofproviding a direct linkage to national policy. An explanation for this can be that Dutchgovernance was generally decentralised. Dutch municipalities were given muchindependence and decision power to set up their own political programme and actionpoints. This can result in large differences between municipalities with regard to theirattention for childhood obesity. For example, the municipality of Beverwijk has - untilnow - hardly given any attention to the topic of childhood obesity, which resulted in theimplementation of few preventative interventions. On the contrary, the municipality ofHeemskerk (located in the same region of Kennemerland) has set up a multi-annual localcampaign (Vet Gezond!) to specifically tackle the issue of childhood obesity. This hasresulted in a large number of interventions being carried out in this municipality.

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Due to the decentralised structure in the Netherlands, regional policy seems much moreinfluential in shaping and implementing interventions to tackle childhood obesity in theNetherlands: 8 out of 18 interventions in the case study were carried out with co-fundingfrom the province of Noord-Holland133

Dependence on public resourcesBoth in the UK and the Netherlands, a considerable weakness of the identifiedinterventions was their dependence on temporary public funding (local, regional and/ornational) with a duration between 1 to 3 years. The social domain co-funding subsidiesoffered by the province of Noord-Holland for example have a maximum duration of 3years134. In the UK case study, for example a considerable number of interventions werefunded through either Cheshire County Council (CCC) and/or the Central and EastCheshire PCT (CECPCT). In the Dutch case study, a considerable number ofinterventions were funded through co-funding arrangements between the Province ofNorth-Holland and relevant municipalities in the region of middle and southKennemerland.

As a result, the sustainability of the interventions was highly dependent on the continuedpolitical attention for childhood obesity. If political attention fades away, subsidies can bepartially or completely cut, leading to the necessary cancellation of interventions.Interviewees in the UK and the Netherlands emphasised that they intend their relevantinterventions to last for a longer period in time, but none could specify for how longbecause they were dependent on securing further funding in the future.

Involvement of partnersPartnership was central to the approaches of interventions identified in both countries.The approach at the local and regional level to joint working (for example the joint needsassessment process and the Local Strategic Partnership) in England has shaped thepartnership approach characteristic of interventions. All eleven of the Englishinterventions included two or more partners, however such partnerships usually had alead delivery partner, seen in some instances to dominate at the expense of other partners.The practice of partnership working was regarded by some to still be developing and thusnot as effective as might initially be assumed.

In the Netherlands the partnership organisation 'Overweight Kennemerland' was a keystakeholder that operates to build and strengthen the partnership approach. Here, as inEngland successful partnership was dependent upon the commitment of individuals andthe sense of involvement that each partners has in the intervention. A key barrieridentified in the Dutch case study was the constraints upon schools already burdened withdelivery of a full educational curriculum to take on additional responsibilities. While thiswas not an outcome identified in the case study it was nonetheless likely that this was tosome extent also an issue for English schools, which have to balance a wide range ofdemands on their time and resources. Although the award system associated with theHealthy Schools programme in England supports achievement of high standards and wasreflected in how schools perform in the inspection process. For this reason it isadvantageous for schools to achieve NHSS and to demonstrate this on their promotionaland literature.

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6.4.5 Brede school/extended schools

The Extended Schools concept introduced in England in 2004 has supported theintroduction of initiatives to promote healthy eating and increase levels of physicalactivity among school-aged children at either side of the school day. Both of the casestudies identified a large number of interventions based in the school setting and theDutch 'Brede School' in particular compares very favourably with the Extended Schoolconcept, involving physical activity and healthy eating interventions out of school timeand between different schools. The involvement of external organisations and the widercommunity was also a key feature of this approach in both countries.

6.4.6 Finance for interventions

Statutory organisations and authorities were the main sources of funding for interventionsin both case study areas and funds were closely tied in with local policy and strategicgoals. A common problem for both case study areas was the time limited nature ofavailable funding, with the continuity of interventions depending upon further fundingcoming forwards. This posed significant problems for planning in the medium to longterm. The need to secure external funding was an on-going issue for interventions, inEngland attempts to 'mainstream' interventions that aim to prevent obesity was regardedas one solution. Furthermore, five of the interventions included in the English case studywere part of national initiatives and as such were more likely to be subject to evaluationand have longer term funding allocated.

6.4.7 Evaluation and cost effectiveness

The dearth of local evaluation and monitoring was a key finding in both of the case studyareas, with only a minority of all the interventions being subject to evaluation study.Where evaluation has been completed this was often only in relation to impact and shortterm outcomes (e.g. participant feedback on the intervention or self-reported behaviourchange) rather than the measurement of longer term reductions in overweight/obesity.

The review of the evidence base relating to childhood obesity conducted by NICE135

noted that many of the obesity interventions tended to be of short duration with little orno follow-up, and that in general the monitoring of interventions was very low. It alsonoted a need for longer term follow-up of outcomes with a greater emphasis on rigour(e.g. via randomised controlled trials), and a need to build up a UK evidence base relatingto the effectiveness of multi-component interventions.

The lack of evidence for effectiveness has hampered opportunities for evidence-basedpractice. Generally there was little funding in case study areas specifically ear marked forevaluation studies to enable rigorous research to be undertaken. Information regardingcost effectiveness was absent from both case studies suggesting a significant gap ininformation about the extent to which investment in interventions was worthwhile.Therefore, as a consequence, there was a lack of clarity regarding the real costs andeconomic benefits associated with efforts to reduce obesity.

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While policy documentation frequently highlights the need for the evaluation of newinterventions and initiatives, the importance attached to this research activity was usuallyquite low and this was often reflected in the minimal levels of government fundingattached to evaluation activities. However, the recent Healthy Towns initiative providesan example of good practice, by placing a strong emphasis on evaluation from the outsetand a significant research budget to support this activity.

6.5 Conclusions

Key conclusions emerging from the case studies and cross national comparison have beenlisted below:

The case study results indicate that shared learning between both countries hasalready taken place and that this has influenced policy-making and the approachesadopted in the school and community settings.

Evidence from both countries indicates the value of 'whole school' approaches thatwere part of national programmes e.g. the Healthy School in England and theGezonde Schools in the Netherlands. These programmes offer an opportunity forlonger term intervention and were more likely to secure funding to continue and besustainable.

Prevention of childhood obesity works best at the local level – provision oforganisations in the borough (close to the parents and children)136

Policy (in UK at national level and in Netherlands at the local level) is highlyinfluential in shaping and providing the focus of local interventions

Preventive interventions should include three components to achieve success: healthyeating, physical activity and behavioural change

Funding for preventive interventions is very scattered and this hampers success Provision of preventive strategies is scattered and sometimes very targeted. This may

be one of the reasons that very little local evaluation has been done.

The cultural differences with regards to physical activity have been highlighted.Dutch infrastructure supports cycling and walking and may contribute towards thelower levels of obesity in the Netherlands

Comparing the two countries has highlighted that where there were culturaldifferences, responses to prevention may differ. In the UK the social stigma attachedto obesity and a recognition of the psychological impact of being labelled as 'obese'have led to a general approach that targets the whole population of school-agedchildren. However, in the Netherlands there is generally a more targeted approachfocussed on those regarded as overweight or unfit.

National interventions can confer significant benefits as they were more likely toattract funding in the longer term and to be subject to evaluation.

Where efforts to improve the health of children (and address obesity) were stronglyincorporated into the school curriculum and strengthened by other actions in theschool including contributing to its ethos, barriers around implementing interventionmay be overcome.

Environmental influences on obesity were being given a higher priority and nowfeature in policy at all levels and in intervention approaches. However, there is still

75

scope for environmental factors to have a greater emphasis in approaches tointervention.

6.5.1 To what extent do the findings suggest that European policy is beingimplemented in both countries and resulting in shared approaches?

As stated in Chapter 1 of this report, there is an increasing volume of evidence to indicatethat obesity is a significant public health problem that requires immediate and appropriatepolicy responses at the European, national, regional and local levels.

Both the UK and the Dutch case study show considerable efforts have been done on thenational, regional and local level to include the issue of childhood obesity on the politicalagenda. Both in the UK and the Netherlands, frameworks have been developed at anational level to provide guidance on the level and types of interventions (includingexamples of best practices) that could be offered at the national, regional and local level(i.e., National Service Framework for Children, Young People and Maternity Services inthe UK and the manual Prevention of overweight in local health policy (including theLEEFLIJN in the Netherlands).

In these frameworks and other policy documents and strategies considerable emphasis isput on the EU agreement to tackle obesity via a multi-policy or multi-strategy approach,i.e., the integration of policies across several arenas: from food to sport, education andtransport. The case studies make clear that the majority of the interventions that werefound in the case study areas consist of multiple components, e.g. emphasis was put onhealthy eating and physical activity and behavioural change.

Besides the multi-component approach, the Dutch and UK case studies were also similarwith respect to the importance of partnership. At a national level, the NICE guidelines inthe UK emphasise partnership. In the Netherlands the Covenant Overweight (CovenantOvergewicht) and Partnership Overweight Netherlands (PON, Partnerschap overgewichtNederland) were clear examples of a (public-private) partnership approach. At the locallevel, the Sustainable Community Strategy for Crewe and Nantwich 2000-2016,including the Local Strategic Partnership (LSP) of local and health authorities was a goodexample of using partnership to combat childhood obesity. In the Dutch case study, theregional project group “Overweight Kennemerland” was active as a regional partnershiptackling the issue of childhood obesity.

Still lacking in both the UK and the Netherlands was the lack of evidence of “effective”interventions. Because of the urgency of tackling obesity it is important to continueimplementing serious initiatives, while ensuring that they a culture of independentevaluation is developed.

Partially as a result of the availability of several, sometimes very targeted interventions atnational and local level and the scattered nature of time-limited funding (national,regional and local), long-term evaluation of interventions - particularly implemented at alocal level - were also lacking. For both the UK and the Dutch case study, local (long-term) evaluation results were missing due to either a lack of capacity in terms of

76

evaluation skills and resources. The answer here may be to encourage a culture of usingexternal independent evaluators to assess the impact of interventions.

As a result, much of the results of interventions implemented locally in both theNetherlands and the UK remain - as yet - anecdotal in nature. In this sense, it is difficultto share best practices as recommended by the European Commission. However, thiscase-study analysis provides valuable information about the barriers and factors forsuccessful implementation of preventative interventions to tackling childhood obesity.

6.5.2 Recommendations for research

Effective preventative policies need to be based on sound (scientific) evidence. Theevidence base of the cost-effectiveness of preventative interventions is limited and not yetfully explored. Little review-level evidence is available regarding the impact of social andenvironmental interventions for children and young people. It is therefore recommendedthat funding organisations ear mark multi annual funding to cost-effectiveness studies inthe field of childhood obesity.

In addition, future research in the area of preventive interventions to tackle the issue ofchildhood obesity should predominantly focus on developing an appropriate and commonevaluation approach for evaluation, focusing specifically on cataloguing the long-termimpact. For this purpose, monitoring systems should be developed and put in place.

As cost-effectiveness studies of public health interventions were still in their infancy,future research should also focus on how the capacity to undertake independentevaluations with regard to childhood obesity could increase.

6.5.3 Recommendations for policy and practice

Obesity is a complex health problem. It has been acknowledged that a multi-faceted,environmental approach is needed for effective prevention. It is therefore recommendedto tackle obesity in partnership, involving all relevant stakeholders. Both in theNetherlands and in the UK effective partnerships were beginning to emerge in practice,and this should be further stimulated.

As prevention of childhood obesity works best at the local level, interventions should beprovided by organisations in the locality (close to the parents and children). The nationalpolicy context is highly influential in shaping and providing the focus of localinterventions. To support coherence across the interventions it is recommended to linklocal and regional initiatives to national initiatives.

Linking to national initiatives is also an important factor for sustainable funding that isneeded to evaluate the impacts of the intervention. The findings of the case studies showthat the sustainability of the interventions is highly dependent on the continued politicalattention for childhood obesity. If political attention fades away, subsidies can be partiallyor completely cut, leading to the necessary cancellation of interventions. Interventionsdelivered as part of wider regional and national programmes (e.g. Healthy Schools in theUK) had the advantage of being part of an established initiative, with allocated resourcessuch as regional co-ordinators and health information. This helped to provide them with a

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high profile and to attract support and commitment from partners e.g. schools andparents.

Sharing of information in the area of good practice in nutrition and physical activity, andobesity prevention should be further stimulated at a national level as it provides valuableinsight of barriers and facilitators of tackling childhood obesity. In addition, sharinginformation should be done on a European level as it will reduce overlap and duplicationof efforts in addressing the issue of childhood obesity.

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

Table 1.0: Obesity among school age children in Crewe and Nantwich: Case Study Interventions

Interventionname

Typology Partners Funding& Costs

Duration TargetGroup

Setting Evaluation ormonitoring

Policycontext

Intervention Description

1 The FridayBoy Club

Physicalactivityprogramme

HealthyEating.

Change toprovision oftuck inschool.

WW(delivery)

CNBCschools

WW funded

No informationon interventioncosts

September2007 -

Vulnerableyoungpeople

School Monitoringagainstoutcome data.Well attended(up to 250each Friday).School staffsupportive andbenefits forpupils noted.

Meeting theHealthySchoolsagenda &CEPCT andCNBC policy

‘Friday Boy’ (former WWvolunteer) attends schoolson a Friday lunch-time.Pupils invited toparticipate in physicalactivity, healthy snacksrequired and to learnabout human biology.Also addresses mentalhealth (bullying).Strongest focus onphysical activity in theplayground.

2 Chill and Chat Peer WW WW funded September Vulnerable Community None. Reports Healthy Club that aims to promote

79

Youth Club(HealthyLiving Centre)

support (delivery)Schools andCECPCT

No informationon interventioncosts

2007 - youngpeople

of significantbenefits forindividuals.Club has20-25

members

SchoolsAgenda

general good health and inparticular to raise the self-esteem of young people.Opportunities for healtheducation and foraddressing obesity issuesin a supportiveenvironment. Referral isvia the school nurse andfocus is on the mostvulnerable. Emphasis onpeer support for goodhealth.

3 Healthy Lynx Physicalactivityprogramme

Lifestyleactivity

CNBC,HealthDevelopmentTeam(delivery)and schools

CNBC andcontributionfrom schoolsand grants

£25 per HealthLynx Session(1-2 hours)

2003- School-agedchildren

School Monitoringdata collectedand feedbackformscompleted bypupilsparticipating

HealthySchoolsagenda,SustainableCommunityStrategy,CNBCCorporateStrategy

Project to encouragephysical activity in schooltime, and out of school.Focus on pupils who don’tenjoy the school PEcurriculum and on informalnon competitive activities.

4 The NationalSchool FruitScheme, 5 ADay & The

Healthyeating.

Change to

CCC(delivery)andCECPCT

Funded by DHand £42 millionfrom theNational

2001 - Primaryschoolchildren

School Nationalevaluationevidence (pilotschools) – 44%

Local andregionalpolicy andEvery Child

The Food in Schoolsprogramme is a jointventure between the DHand DCSF – includes a

80

Food inSchoolsProgramme

provision oftuck inschool

Lottery of schoolsreportedincreased fruitconsumption,improvementsin knowledgelevels andethos ofschool.Positiveresponse fromparents

Matters; Foodand HealthAction Plan

range of nutrition relatedactivities. The SchoolFruit and VegetableScheme is part of the 5 ADay initiative - children inprimary schools (LEAmaintained) 4-6 years areentitled to a free piece offruit or vegetable eachday. Operates acrossEngland.

5 Bike2School/Safe Routesto School

Lifestyleactivity.

Reducesedentaryactivity.

CheshireHealthySchools Co-ordinator(delivery)and Schools

The TravelPlans arefunded viaeither local ornational govtgrant funding

2002- School-agedchildren andparents

School andCommunity

No informationavailableregardingevaluation.New SchoolTravel Planshave beendeveloped for30 schools inCrewe andNantwich.

CNBC’sSportsStrategy andNW Plan forSports andPhysicalActivity

Nationalrecommendations for thedevelopment of TravelPlans that encouragewalking and cycling toschool are implementedby local authorities.Bike2School is a CNBCled project (with Sustrans)linked to Routes2Action atermly publication that isfree. Individual schoolsdevelop travel policies andfunding is available tosupport this. There is alocal Cycling Champion to

81

encourage and supportschool-children.

6 ExtendedSchools – outof schoolsports andphysicalactivities, andbreakfastclubs.

Healthyeating.Physicalactivityprogramme

ExtendedSchoolsOfficer(CCC) -delivery,CECPCT &parents

DCSF fundedprogramme

Programmecommencedat 2003/04and at 2004-05 C&N had1 full serviceextendedschool.

School-agedchildren andparents

School Someevidenceregardingimpact atnational level.Benefits foryoung peopleinclude:increasedmotivation andself-esteem.Alsobehaviouralimprovementsand new skillsor interests.

Every ChildMatters andthe HealthySchoolsAgenda.Govt. has settargets for allschools toextend from8am – 6 pmby 2010

Extended Schools areexpected to offer qualitychildcare, a menu ofactivity (including physicalactivity) and parentingsupport. Meals providedunder Extended Schoolsare required to meetnutritional guidelines. As aresult of ES some childrenmay have the majority oftheir nutrition at school.

7 The CheshireHealthySchoolsProgramme

Changesto/incorporation into thecurriculum

Healthyeating.

Physicalactivity

CCC, CNBC,CECPCT(delivery)

Funded byCCC andCECPCT

Establishedin England in1999

School-agedchildren,staff andparents.

Schools Behaviourchange(national) ismonitored viathe HRBSSurvey.Cheshireresults indicatean increase inphysical

CCC HealthScrutiny Sub-Committee,HealthyWeight,HealthyLives, EveryChild Matters& NWFramework.

Takes a 'whole school'approach to health andaddesses issues acrossthe school – staff, parents,curriculum and pupils.Multi-agency approach inCheshire which utilises the'Lightening the Load…'toolkit. 49 C&N schoolsparticipate and 40 have

82

programme.

Changes toprovision oftuck inschool.

Reducesedentaryactivity.

activity andreports oflowerconsumption ofsweets andcrisps. CaseStudies fromCheshire alsocompleted.

achieved full status. Theseschools have projects andeducation initiatives inrelation to both healthyeating in encouragingparticipation in physicalactivity.

8 Play OutreachProgramme

Physicalactivityprogramme

Lifestyleactivity

Signposting

Reducesedentaryactivity

CNBC(delivery),parents andyoungpeople

Funded byCNBC


Community No formalevaluation butfeedback formsare given tochildren andparents - theseinform servicedevelopment

CNBC Sports& PhysicalActivityStrategy, NWPlan for Sportand PhysicalActivity,CCC's HealthScrutiny sub-committee

Child-centred programmeto promote play in publicspaces with a focus on themost vulnerablecommunities. Alsoinvolves parents andsignposts to otherservices. Offers widerange of play activities.

9 GovernmentNutritionalStandards forschoollunches and

Healthyeating.

Change toschool

DCSF andCCC(delivery)

CCC fundingstructures


Schools No information.

In Crewe 7primaryschools

HealthySchools andPublic SectorFoodprocurement

New governmentstandards initiallyimplemented in primaryschools in 2008(secondary schools by

83

other schoolfood

mealcontent

Change toprovision oftuck inschool.

involved in newlunch-timemenusprovided byCountyBusinessServices (thetrading arm ofCCC).

Initiative 2009). These aremandatory and cover alleating in school – lunchesand snacking. Specificguidelines on nutritionalcontent have to be met:levels and amounts offats, sugars, fruit andvegetables etc. InCheshire new initiativesinclude: salad bars, localsourcing, informationabout healthy packedlunches and access tofresh water.

10

Snack Right Healthyeating.

Postalcommunic-ation.

Workshops

CECPCT,Children'sCentres,parents/carers andAldi(supermarket)

DH(Communitiesfor HealthFund). Totalfunding£213,000approx.

May 2007 - Parentsunder 19years

Community Planned(evaluation byJohn MooresUniversity).Baseline datahas beencollected.OperatesacrossCheshire andMerseysideand focuses onthe most

Runsalongside thenationalHealthy Startscheme.

Uses a Social Marketingapproach (to countermainstream foodadvertising). Targetseconomically inactiveparents and their children(including under 19s andteenage parents inCrewe). The projectpromotes breast feedingand healthy snacks inunder 4s and theirparents. There have been

84

deprivedareas.

15 Snack Right events atchildren's centres (2 ofwhich were in Crewe andNantwich) and a leafletingcampaign targeted113,000 households.

11

Healthy Start Healthyeating.

Use ofincentives/rewards

CECPCTand localshops

DH funded Launched in2004 acrossthe UK(replaces theWelfareFoodScheme)

Parentsunder 19years

Community Other UKevaluations butnot in Cheshire

NationalServiceFrameworks,Sure Startprogramme.

Aims to tackle healthinequalities (high infantmortality rate amongst thepoorest) and providesfood vouchers to youngmothers (particularly thoseunder 18 years).Pregnant women andyoung mothers are eligible(income less than£15,575) for vouchers (£3each) that can beexchanged at shops forfruit, vegetables, milk orvitamins. Referral is viaante-natal clinics andHealth Visitors.

Key:WW – Wishing Well Healthy Living CentreCNBC – Crewe and Nantwich Borough CouncilCECPCT – Central and East Cheshire Primary Care TrustCCC – Cheshire County Council

85

Table 1.2: Crewe and Nantwich projects and activities that impact on the health of school-age children

Local project and activities that are promoting/ impacting on thehealth of school-age children

Other service, initiatives and projects that impact on the health ofthe whole community (including school-age children)

School travel plans Crewe and Nantwich at Play School environment and physical layout (play space, sport

facilities, stairs, dining hall layout) School crossing patrols The school curriculum (e.g. biology, PHSCE, PE) MEND Statutory health services (dietician, health visitors, GPs, school

nurses etc) National Child Measurement Programme

Step-by-Step walking programme Local urban planning and regeneration strategies (addressing

the 'obesogenic'137 environment) Local transport policies and existing transport infrastructure (e.g.

traffic management in favour of the pedestrian) Leisure and sports facilities (availability, variety, cost and

accessibility) Green infrastructure (parks, open spaces, and access to the

countryside) The availability of supermarkets, markets (e.g. farmers markets)

and fresh fruit and vegetables. Affordability is also a factor Provision of and accessibility of play grounds and play facilities. Everybody Health and Fitness (CNBC's fitness brand) Food advertising and food processing and manufacture (the UK

government is currently working with the food industry on salt,fat, sugar and portion sizes)

Crewe and Nantwich Community Sport and Physical ActivityNetwork (CNSPAN)

The Wishing Well Healthy Living Centre. Weigh2Go interventionEagle Bridge Centre – health and wellbeing centre

86

8 Annex 2: Overview of interventions in the Dutch case study

Table 1.0: Interventions to prevent childhood obesity in middle and south Kennemerland- those marked with an * taking place in BeverwijkNr. Intervention

name

Typology Setting Funding Duration and

timescale

Partners Target group Description Evaluation results

1 Course Fit, Food

& Fun

Workshops (inc parent

meetings)/Reduce

sedentary

activity/Healthy eating/

PA programme/

Behavioural change

therapy/Postal

communications

(brochures)

School Parent

contribution

(between €40 -

€56 annually

depending on

membership of

service

passport)

ZonMW

subsidy to fund

manpower of

Zorgbalans

Municipal and

provincial co-

Duration: The

intervention

has a duration

of 10 weeks

Set up: The

intervention

has been set

up in 2005

and is

currently still

running.

Coordination:

Zorgbalans

Delivery:

project group

overweight

Kennemerland:

sportservice

Noord-Holland

carries out the

PA programme

while Zorbalans

carries out the

healthy eating

component.

Children aged

8-12 with

overweight

and/or obesity

problems

In 2008/09 9

children

participated in

Haarlem (6

parents); 5

children in

Heemskerk (4

parents); 8

children in

Zandvoort (10

Multidisciplinary

course after school

time at a school

venue: PA

programme (1 hour a

week, given by a

physiotherapist),

food lessons and

homework (given by

a dietician), 2 parent

information meetings

(evening) regarding

healthy eating,

physical activity and

the up bring of

children in general

Three evaluations (2 in

Heemskerk and 1 in

Heemstede) have been

carried out. Different

results: in 1 course

weight difference with

age group reduced after

the course and 1

course weight

difference with age

group increased after

the course; in 3 courses

stomach profile

reduction after course;

1 course children and

parents enthusiastic

87

funding (BOS

impulse)

Also

involvement of

primary schools.

parents); 10

children in

Heemstede (9

parents)

about the course; 1

course children did not

participate very well

(not ready for it

according to the

parents); 1 course

noticeable that the

children play more

outside and are also

asked by other children

more often to play

outside; 1 course more

healthier eating after

the course (less asking

for candy)

2 Kidsclub PA programme, postal

communication

(brochures)

Community Parent

contribution

(€128 annually)

Municipal and

provincial co-

funding

Duration:

Annually

Set up: The

intervention

has been set

up in 2008

and is still

running.

Coordination

and delivery:

Sportservice

Noord-Holland

Also delivery

organised by

participating

leisure centres

and/or sport

associations

Children aged

8-12 with

overweight

and/or obesity

problems

The

participating

children

already

participated in

the Fit, Food

& Fun course

It is a sport and

game hour for

children, carried out

in a leisure centre or

sport association.

They get acquainted

with different sports

and through this they

learn necessary

sport skills which will

increase and

facilitate their

physical activity in

No evaluation results

yet, this intervention is

newly introduced.

Intermediary results so

far in Heemskerk

(anecdotic):

participation is low (due

to the high parent

contribution) and the

switch from

physiotherapy in a

school facility (during

88

the future. the course fit, food, &

fun) to sports in a

leisure centre/sport

association is too large.

3 Food advice for

ethnic women

Workshops (inc parent

meetings)/Healthy

eating/ Signposting

Community Contribution of

the participating

ethnic women

organisations

(€25 per

meeting)

ZonMW

subsidy to fund

manpower of

Zorgbalans

Duration:

One-off

meetings

Set up: The

intervention

has been set

up in 2006

and is still

running.

Coordination:

Zorgbalans

Delivery in

cooperation with

project group

overweight

Kennemerland

Ethnic

minority

women with

children

So far 47

participants in

Heemskerk

and Velsen

Existing ethnic

minority women

groups who already

regularly come

together, convene at

a suitable place (can

be a community

centre, a mosque,

elsewhere) to

receive advice and

information from a

dietician of

Zorgbalans in

relation to improve

the healthy eating

and physical activity

of their children.


available.


far in Heemskerk and

Velsen (anecdotic):

these meetings are

reasonably successful

and have enough

participants because

they are organised for

existing groups of

ethnic minority women.

So there is no need to

search for participants.

Of the 47 participants,

13 have been

signposted to

interesting sport

activities for their

children.

4 All pupils active

(alle leerlingen

actief)

Counselling/ Behavioural

change therapy/

Workshops (parent

School Municipal and

provincial co-

funding

Duration:

Unclear

Coordination:

Sportservice

Noord-Holland

School-going

(vocational

education)

This intervention

consists of a mix of

activities: children



newly introduced. The

89

meetings)/ Signposting/

Changes to /

incorporation into

curriculum and use of

homework/ healthy

eating/ PA programme

(provincial

contribution in

2007:

€224.246)

Set up: The

intervention

has been set

up in 2008

after 2 years

of piloting in 6

places

throughout the

Netherlands. It

is currently

still running.

Delivery:

Sportservice

Noord-Holland,

GGD

Kennemerland

and

participating

primary and

secondary

schools

(vocational)

children aged

9-16 who did

not pass a

physical

endurance

test (including

measurement

of fat

percentage)

are involved in

motivation

conversations to

spur a behaviour

change. The

parents also receive

counselling to take

away any existing

obstacles. The

children and parents

are signposted to

diverse sport

activities in the

neighbourhood or to

an intervention like

the course Real Fit.

The participating

schools organise

extra sport activities

(sport days) and

arrange support of a

dietician/psychologist

or otherwise in

relation to healthy

eating. The

intervention is

sometimes combined

with other

evaluation results of the

pilots show however

promising results.

90

interventions like

sporthackers or

healthy school

canteen (gezonde

schoolkantine)

5 Cruyff court Subsidised leisure

activity/ PA programme

Community Cruyff

foundation

Municipal

funding

Duration:

Ongoing

Set up: Set up

nationally in

2003 and in

2007 in the

region of

Kennemerland

(Heemskerk).

Currently still

running

Delivery: Cruyff

foundation,

municipality and

cooperating of

diverse partners

(neighbourhood,

sport

associations,

schools,

sometimes also

SMEs)

Young people

(particularly

with an ethnic

minority

background)

A playing field is set

up/built to offer

young people the

facilities to undertake

diverse sport

activities (like

football). Diverse

physical activities on

and around the

playing field are

coordinated in

cooperation with all

the involved

partners.


available.

6 Special support

(sociale bijstand)*

Subsidised leisure

activity

Community Municipal

funding

Duration:

Annually

Set up:

Unclear.

Currently still

running.

Coordination

and delivery:

municipality

Families with

a low income

Families with a low

income can apply for

municipal funding for

their children (and

parents) to become a

member of a sport

association (€200

per family in

Heemskerk, Dutch


available.


far in

Heemskerk(anecdotic):

Participation so far has

been low. It seems that

not many people are

91

national average is

€100)

acquainted yet with this

support programme or

they fear the

bureaucracy.

7 School sport

programme

(school sport

programma)*

Changes to /

incorporation into


homework/ PA

programme

School Municipal

funding

Duration:

Unclear

Set up:

Unclear.

Currently still

running.

Delivery:

participating

primary

education

school

Children aged

9-11 in

primary school

education

(group 6 and

7)

In Heemskerk

13 primary

education

schools were

involved

leading to the

participation of

2500 children.

The school sport

programme consists

of 10 different

physical activities:

this can include a

sport day; skating

lessons, sport

tournaments and

otherwise.


available.


far in Heemskerk

(anecdotic): The

number of participating

schools and children

has been very high.

The impact of this is

unclear. What can be

said is that the school

tournaments mostly

only stimulate children

already physically

active, as a result the

impact to prevent

obesity is likely to be

low.

8 Jeugdsportpas

(JSP)

PA programme/ postal

communication

(brochures)

Community

and school

Parent

contribution (€5

per sport)

Duration:

Annually

Set up:

Coordination:

sportservice

Noord-Holland

Children aged

4-12 in

primary school

education

At the start of the

school year, children

receive a flyer with

information regarding

Evaluation results in

Heemskerk show that

the participating

children like to work

92

Municipal

funding

Unclear.

Currently still

running.

Delivery:

sportservice

Noord-Holland,

sport

associations,

and primary

schools

(groups 1-8)

In Heemskerk

15 primary

education

schools

participated

(of which 1 in

Beverwijk

located). In

total 800

children

participated.

the JSP. If their

parents register them

they can receive 4

lessons of 1 hour

each at a sport

association (or

elsewhere) after

school to get

acquainted with a

sport they find

interesting (8

different sport

activities are

offered). For each

period (3 a year)

children can

participate in 1 sport.

After the sport

lessons, the children

can decide to

become a member of

the relevant sport

association.

with new and unfamiliar

sport equipment and to

receive sport clinics of

professional sportsmen.

The impact according to

the evaluation has been

that many of the young

participants have

become a member of

participating sport

association

(approximately 10% of

the participants).

9 Course Real Fit Workshops (inc parent

meetings)/Reduce

sedentary

activity/Healthy eating/

PA programme/

School Parent

contribution

(€100 from

which they

receive back

Duration: 12

weeks

Set up:

Unclear.

Coordination:

Sportservice

Noord-Holland

Delivery: project

Young people

aged 13-18

with

overweight

and/or obesity

Multidisciplinary

course after school

time at school venue

including healthy

eating lessons,

Nationally an evaluation

has been carried out by

the House of Sport

(Limburg) in

cooperation with the

93

Behavioural change

therapy/Postal

communications

(brochures)

€50 in case of

sufficient

participation)

Municipal and

provincial co-

funding

Currently still

running.

group

overweight

Kennemerland

and secondary

schools

problems physical exercise (in

a fitness centre) and

parent information

evenings to offer

advice on healthy

eating (offered by a

dietician), raising

children and

sufficient physical

exercise.

University of Maastricht.

In the region of

Kennemerland no

evaluation has been

carried out yet.


far in (anecdotic):

Parents are not keen to

register their child for

this programme.

Probably because they

don't find their children

overweight and/or also

due to the stigma

attached to being

overweight. Another

mentioned reason is the

lack of signposting (and

persuasion to register)

to this intervention by

the public health

authorities (GGD).

10 Sporthackers PA programme/

Changes to /

incorporation into


homework/ Postal

Community

& Schools

Municipal and

provincial co-

funding (In

2006/07

Province

Duration:

Unclear

Set up:

Unclear.

Coordination:

Sportservice

Noord-Holland

Delivery:

Young people

aged 13-18 in

vocational

education

Sporthackers tries to

stimulate young

people to (continue)

to be physically

active. The basis of

According to a process

evaluation the number

of young people

involved in sports

increased on average

94

communication/

Interactive

communication methods

for advice and support

subsidy

entailed

€138.571 and

in 2007/08:

€73.523 and

€83.200 came

from other

contributors

Currently still

running.

Consortium of

Sportservice

Noord-Holland,

RTV Noord-

Holland (radio

and TV)

vocational

secondary

schools

4 schools

participated

and 31 sport

associations.

In total 497

young people

participated in

the sport

clinics during

the holidays

and 3269

participated in

school sport

clinics.

this intervention is

shaped by the

available sport

supply of the

participating schools;

the organisation of

sport clinics during

holidays; and the

sport supply of sport

associations. This

supply is adjusted to

the needs of young

people and marketed

better to young

people.

with 3,3% after they’ve

participated and

membership of youth

clubs increased with

12% (only measured in

Zaanstad). A weakness

of the project has been

the low participation

number of sport

associations and their

lack of capacity. In

addition, the idea to

reach young people

who are not physically

active did not succeed:

81% of the participants

were already involved

in sport activities before

the intervention.

Enthusiasm was high

among the participants

and participating

schools.

11 Pilot know your

talent (ken je

talent)

Workshops Community National

funding138 of

the Ministry of

Health,

€267.250

Duration:

Unclear

Set up: 2008.

Currently still

Coordination

and delivery:

Sportservice

Noord-Holland

Sport

associations

and their

young

members

Services are offered

to participating sport

association to get

young members

involved in volunteer



newly introduced.

It is recommended to

95

Contributing of

participating

sport clubs

Co-funding of

participating

municipalities139

and

sportservice.net

pay the

remaining

42.7%.

Total €625.500

running Also delivery

organised by

sport

associations

work for the sport

association: analysis

of the situation,

workshops and

training, tailored

support to implement

change, education

and training of young

members (using

existing and new

techniques)

organise an effect

measurement 1 year

after the intervention to

see whether the

number of young

volunteers has

increased and also to

check up whether their

is any need for post-

support. Unfortunately

Sportservice Noord-

Holland did not include

this element in their

project and leave it to

the responsibility of the

participating youth

clubs to organise this.

12 Whoznext PA programme,

subsidised leisure

activities, interactive

communication

Community Municipal

funding and

sometimes

small

contribution of

participating

sport

associations

Duration: 12-

18 months

Set up:

Unclear.

Currently still

running

Delivery:

Sportservice

Noord-Holland,

sport

assocations,

schools and

community

centres

Young people Whozenext is a

national campaign

which aims to offer

young people a

voice in sports. A

whoznext team

consists of 4 to 8

young people in

combination with a

team coach from the

participating sport


far (anecdotic):

Available evaluations

do not examine impact:

it is already great if the

teams still exist after 1

or 2 years

96

association, school

or community centre.

The team receives

€450 (besides other

support and training)

to organise at least 3

activities (can be a

party, excursion to a

sport association

during school PE,

skate tournament,

etc.). The whoznext

teams are connected

to each other on a

national level and

they can exchange

information.

13 Fit4family140 * PA programme Community Private

incentive of the

Fit4family

foundation

Delivery:

Annually

Set up:

Unclear

Delivery:

Fit4family

foundation

Young people

and their

parents

Parents and their

children can fitness

in the same fitness

club: for children lots

of fun materials are

available. For some

children with

overweight problems

a simple individually-

tailored programme

is made


available.

97

14 Project Beter

(Zw)eten*

Reduce sedentary

activity/ healthy eating/

PA programme/

Counselling/ Changes to

/ incorporation into


homework/ Reduction

sedentary activities

School Provincial141

and municipal

co-funding

For 10 schools

in 1

municipality

(2008/2009):

€27.890

Of which

€7.800 for

GGD, €5.215

for Zorgbalans,

€2.750 for local

sport provider

and€5.000 for

material costs.

Duration: 4

weeks

Set up: 2006.

Currently still

running

Coordination:

GGD

Kennemerland

Delivery: project

group

overweight

Kennemerland

and primary

schools

308 hours

provided by

JGZ 4-19

(GGD); 139

hours provided

by Zorgbalans;

and 50 hours

provided

sportservice N-

H

Primary

school

children aged

8-9 (group 5)

16 primary

education

schools

participated in

2007/2008 of

which 1 in

Beverwijk.

Ex ante

measurement of

length and weight;

courses on healthy

eating; physical

activities; information

meetings for parents;

individual

counselling; advice

school policy; post

measurement of

length and weight

This intervention has

been evaluated in

Haarlem during the pilot

phase in 2007 (10

schools in total) Yes. A

new evaluation

including all

participating primary

schools in middle and

south Kennemerland

(16 schools of which 1

in Beverwijk in

2007/2008) is expected

to be published in

November 2008.

Results from the

evaluation in Haarlem:

the intervention is

appreciated by its

participants. Increased

percentage of pupils

taking breakfast; no

changes regarding

consumption of fruit and

vegetables; knowledge

of nutrition has

increased; and

98

reduction in sedentary

activities.

Anecdotic information:

The above mentioned

positive evaluation

effects are likely to be

only temporary and will

likely reduce over time.

15 Groep 6 on the

move

Reduce sedentary

activity/ Healthy eating/

PA

programme/Incorporation

into curriculum and use

of homework

School Provincial142

and municipal

co-funding

For 7 schools

(10 groups):

€52.136

Of which

€25.068 to fund

activities of the

GGD and

€270.68 for

activities of the

Sportservice

Noord-Holland

Duration:

Unclear

Set up: in

2007.

Currently still

running

Coordination:

GGD

Kennemerland

Delivery: GGD

Kennemerland,

Sportservice

Noord-Holland,

primary schools

and parents

Per individual

group: input of

104 hours by

the GGD and

Sportservice

Noord-Holland.

For an

Primary

school

children aged

9-10 (group 6)

8 Primary

education

schools

participated

The children decide

what they want to

learn in relation to

food and physical

movement. Their

wishes are shaped

through the inputs of

teachers and

parents. Sportive

activities are

organised and in the

curriculum attention

is put on healthy

living. Facilities in the

neighbourhood are

used to stimulate

children to move

(sport clubs, play

grounds, etc.)

Evaluation in

preparation, to be

finalised end of 2008.

Preliminary evaluation

results of the school

year 2005-2006

indicate an increased

intake of fruit among

the children (in %),

increased intake of light

carbonated drinks, less

candy eating, increase

of outside physical

activity (can be

seasonal).

Anecdotic information:

Almost all of the

99

additional

group: 26 hours

extra

schools have also

registered for the

smaakleskist of the

Ministry of Agriculture.

It contains a lot of fun

materials to experiment

with food. The

intervention is also

combined with for

example the

Jeugdsportpas and

Nationaal Schoolontbijt.

The children especially

like the introduction to

new forms of physical

activity. Parents like to

participate in the

activities of the children.

Several schools have

adjusted their snack

policy (pauzehapjes).

Several schools want to

keep certain elements

of the project in the

upcoming years:

marathon around the

school, smaaklessen,

assignments in physical

100

activity diary Hupla and

cooking activities.

This intervention has

been included as good

practice in the Leeflijn

of the manual

prevention of

overweight in local

health policy developed

by the Ministry of

Health.

16 Parent meetings Workshops/ Healthy

eating/ Signposting

School Participating

primary

education

schools pay

€50 to fund

costs of

materials.

ZonMW

subsidy to fund

manpower of

Zorgbalans

Provincial

funding to fund

manpower

Duration:

One-off

meetings

Set up:

Unclear.

Currently still

running.

Coordination:

Zorgbalans

Delivery:

Zorgbalans,

GGD

Kennemerland

and

participating

primary

education

schools

Parents of

children aged

4-12

Participating primary

education schools

take the initiative to

organise this

intervention. The

parents receive

advice in relation to

healthy eating

(breakfast), physical

activity, the cause of

overweight and

treatment, support in

upbringing of the

children (behaviour

influencing, parent

role model, watching


available

101

provided by

GGD

Kennemerland

TV, computer

games).

17 Youth sport

subsidy

(jeugdsport

subsidie)*

Subsidised leisure

activity

Community Municipal

funding

Duration:

Annually

Set up:

Unclear.

Currently still

running

Coordination

and delivery:

municipalities

Youth sport

associations

The youth sport

subsidy offers

funding to sport

associations in

Beverwijk for young

members. The height

of the funding is

depending on the

annual number of

young members.


available.

18 Social card

overweight for

professionals

(sociale kaart)143*

Interactive

communication methods

for advice and support

(website)/ Postal

communication

Community Unknown,

possibly

municipal

funding

Duration: Not

applicable

Set up:

Published in

2006.

Currently still

available.

Coordination

and delivery: :

project group

overweight

Kennemerland

Professionals

who work with

young children

and their

parents to

prevent

overweight

The social card

offers an overview of

all organisations in

the region of middle

and south

Kennemerland which

are active to help

prevent and/or treat

overweight of

children. It offers

information regarding

preventive activities,

websites, sport

opportunities, etc.


available.

102

9 Annex 3: Selection of Case Study Areas

Overview

An equivalent area in each country (UK, NL) was selected using agreed criteriasuch as population size etc - for comparison in the case studies. The method for theUK takes into account population size, dispersion (rural-urban classification), Indexof Multiple Deprivation (IMD), ethnicity and health as contextual factors. Themethod for NL takes into account population size, social economic status (SES),dispersion and ethnicity.2 A staged process was adopted whereby population wasused first to provide a list of 'average' local authorities, then IMD (UK) or SES (NL)was cross referenced against these to narrow it down further, then ethnicity, andfinally dispersion were compared against this narrowed down selection to come upwith a final shortlist. In the UK the selected area was also cross referenced to thelevel of health status.

Given the timescale of the project, the remit for the selection of acase study area was also partly driven by practical considerations.The selected area would have to be:

► Methodologically representative of the UK and NL – this wasachieved through establishing an 'average' location through the use ofa series of indicators such as population, deprivation, and ethnicity.

► Of a size suitable for study – i.e. an area where there will be a range ofinterventions taking place. An area too small or too rural would limitthe scope of the study in terms of the range and volume ofinterventions selected and the likely scale of evaluation.

► Accessible– given economic constraints and the very hands onresearch approach envisaged, a secondary consideration was the timeand expense of case study visits3.

2 All the data (population, rural-urban classification, ethnicity) used for the selection process, is obtained via CBS and are allfrom 2007. The data used for the calculation of the SES is a lso obtained via CBS, but these numbers are from 2006.

3 This paragraph for internal use only

The devised method took into account two main indicators and usedanother three to provide a contextual background. The two keyindicators were:

1. Population Size (UK: Census 2001, NL: CBS 2007)

2. Index of Multiple Deprivation (UK: National Statistics 2004)

Social Economic Status (SES) (NL: CBS 2006)

With contextual indicators of:

3. Dispersion characteristics (urban and rural classificationinformation) (NL: CBS 2007)

4. Ethnicity (UK: Census 2001, NL: CBS 2007)

5. Health4 (UK only)

9.1.1 Population size (UK)

The population size of local authorities in England and Wales were consideredfrom information available from the 2001 census. Information from the censuswas downloaded from national statistics and cleaned to ensure that it was onlylocal authorities which were included (e.g., regions and counties were excludedotherwise people would be counted twice). An average population size was thencalculated from data from the column – '2001 population of all people', from thisdata5, the average size was identified to be 142,9786.

We considered using urban areas, as a measure to identify the most average 'town'(as previously suggested) but when the average town size was calculated, this was30,111. We also considered then removing the smallest urban areas to calculatean average of those over 50,000 but decided against this. However, whilstproviding a good sample of urban areas (following initial proposals to use a'town') we felt that it would be difficult when most other data is collected atadministrative level. We also had concerns about how this would stand upmethodologically and therefore, on reflection, decided that a local authorityapproach would be the most practicable.

All of those local authorities with close to average (143,000) populations wereidentified. This provided a shortlist of around 20, with 10 locations above and 10below the average.

Population size (NL)

The population size of local authorities in the Netherlands was considered frominformation available from Statistics Netherlands (CBS) for the year 2007. In thepopulation statistics compiled by Statistics Netherlands the inhabitants of a given

4 Note – health deprivation already forms part of the IMD composite score and this may need to be referenced accordingly.5 Table KS01 Usual resident population – ONS copyright 2003 saved as size of local authorities 2001 in demographics folder

unique number 149_D.

104

area are the people registered in the population register, whose address is locatedin that area. Information on population size was downloaded from StatisticsNetherlands. An average population size was then calculated, the average sizewas identified to be 36,925.

All of those local authorities with close to average (36,925) populations wereidentified. This provided a shortlist of around 10, with 5 locations above and 5below the average.

9.1.2 Index of Multiple Deprivation (UK)

Index of Multiple Deprivation (IMD) data which is available for 2004 was used toidentify areas which are deemed 'average' when a range of factors wereconsidered. The IMD provides a composite figure and rank for:

Income Employment Health Deprivation Disability Education and Skills Barriers to Housing and Services Crime Living Environment

The IMD therefore provides a useful indicator of overall deprivation, providing aninsight into the multiple factors at play in an area, particularly relevant whenstudying health.

It is therefore a useful measure of overall deprivation (NB although we understandthere may not be an equivalent measure in NL). The median IMD rank wascalculated to be 177.

Those local authorities close to this average were then highlighted. By calculatingthe difference between the local authority rank, and the median national rank, itwas possible to establish which local authorities were closest to the average, andwhich were above, or below average.

These ranks were then cross referenced against the population short list. Thoseauthorities with an average population size were then compared against each otherusing IMD ranks, and from this, a new short list was developed.

Socio-economic status (NL)

The closest Dutch equivalent to IMD used in the UK is the socio-economic status(SES), which is calculated by postal code area. Data, which is available for 2006from the Social and Cultural Planning Office (CPO) of the Netherlands, wasaggregated to local authority level and used to identify local authorities which aredeemed ‘average” when a range of factors were considered. The IMD provides acomposite figure and rank for:

Welfare Education

Income Type of buildings Housing price Family stage Number of babies

Unlike the IMD the SES provides no indication for the health status of an area.The average (national) SES rank was calculated to be 1873.

Those local authorities close to this average were then highlighted. A couple oflocal authorities were excluded from the final short list, because no SES data wasavailable.

By calculating the difference between the local authority rank, and the averagenational rank, it was possible to establish which local authorities were closest tothe average, and which were above, or below average.

These ranks were then cross referenced against the population short list. Thoseauthorities with an average population size were then compared against each otherusing SES ranks, and from this, a new short list was developed.

9.1.3 Urban – Rural Classification (UK)

DEFRA classification of local authority districts was then also used to ensure thatthe population of the selected local authority was not too dispersed. DEFRApopulation trends suggest that at the time of the census, 71.5% of England'spopulation lived in an 'urban area' and therefore we decided that if possible, wewanted to ensure that our selected local authority largely reflected this trend.

The DEFRA classifications are7:

very rural - 80% or more of their population live in either ruralsettlements or market towns, where a 'rural settlement' is any settlementof less than 10,000 people and a 'market town' is a settlement of between10,000 and 30,000 people which provides certain functions and servicesto its wider rural hinterland

mostly rural - if between 50% and 80% of their population live in ruralsettlements or market towns.

part rural - if not any of the above but either between 26% and 50% oftheir population live in rural settlements or market towns or more than37,000 of their population live in rural settlements or market towns. 5

major urban - not any of the above but either at least 50% or at least100,000 of their population live in an urban area with a total populationof 750,000 or more.

7 Defra Classification of Local Authority Districts and Unitary Authorities in England – A Technical Guide :http://www.defra.gov.uk/rural/ruralstats/rural-defn/LAClassifications_technicalguide.pdf

106

large urban - if not any of the above but either at least 50% or at least50,000 of their population live in an urban area with a total population of250,000 or more

other urban - if not any of the above.

We identified part rural, major urban, or other urban as possible areas, as theseclassifications would allow for a roughly average distribution of the population,with potentially a quarter living in rural areas.

These classifications were cross-referenced against other Local authorities whichhad been identified through the analysis of the first two indicators.

Urban – Rural Classification (NL)

Statistics Netherlands (CBS) uses the following classification for theconcentration of human activities, which is based on the average environmentdensity8:

very urban: average environment density of 2,500 or more addresses perkm2;

strong urban: average environment density of 1,500 to 2,500 addressesper km2;

moderate urban: average environment density of 1,000 to 1,500addresses per km2;

little urban: average environment density of 500 to 1,000 addresses perkm2;

not urban: average environment density of less than 500 addresses perkm2.

9.1.4 Ethnicity (UK)

As another contextual measure, ethnicity data was taken from the 2001 census by localauthority area, to ensure that the area selected could be said to be representative of thecountry as a whole. Using 2001 census information, we looked at the rank given to eachlocal authority based upon its proportion of white population.

As with the IMD rank, the difference from the 'middle' rank was calculated to give anidea of how far the local authority diverged from the median rank.

This data was then cross referenced against the short list of local authorities which helpedprovide information in addition to population and IMD. A couple of local authoritieswere excluded from the final short list, because their ethnicity rank differed so far fromthe median.

In NL ethnicity data was taken from the Statistic Netherlands for the year 2007. Ethnicityis defined by the origin of inhabitants which is determined by the country of birth and thatof their parents. Statistic Netherlands distinguishes inhabitants of Western and non-

8 http://www.cbs.nl/nl-NL/menu/methoden/begrippen/default.htm?ConceptID=658

Western origin. Data from both categories were added up to calculate the total ethnicpopulation percentage by local authority.

As with the SES rank, the difference from the average was calculated to give an idea ofhow far the local authority diverged from the average.

This data was then cross referenced against the short list of local authorities which helpedprovide information in addition to population size and SES.

Health (UK only)

9.1.5 Short listing process

From this point, a short list of potential local authorities was produced.

Possible 'average' case study areas in the UK based on series of variables were:

Local /UnitaryAuthorityname

Population

Differenceinpopulationfrom theaverageforEngland

Urban-Ruralclassification

Ethnicityrank (2001censuswith 1=highestproportionwhite)9

Differencebetweenethnicityrank andEnglandaverage(376/2 =188)

IMDrank

Differencein IMD fromthe medianfor England

Northampton

190,000 47,000 'otherurban'

309/376 121 135 42

Reading 143,096 -96 'largeurban'

330/376 142 153 24

Swindon 181,000 38,000 'otherurban'

259/376 71 171 6

Thurrock 143,000 0 'otherurban'

258/376 70 122 55

Telford 158,000 -15,000 'otherurban'

270/376 82 112 65

Solihull 199,000 -56,000 'majorurban'

273 /376 85 183 -6

Crewe andNantwich

111,000 32,000 'part rural' 178/376 -10 164 13

9 http://www.statistics.gov.uk/census2001/profiles/rank/ewwhite.asp

108

In terms of the composite IMD measure, Solihull and Swindon are the closest tothe average for England, followed by Crewe and Nantwich and then Reading.

The closest to average in terms of population size is Thurrock,followed by Reading, Crewe and Nantwich and Swindon.

The closest to average in ranking of white populations (2001) wereCrewe and Nantwich, Thurrock and Swindon

Therefore to provide a shortlist of three: Reading Crewe and Nantwich Thurrock

Bearing in mind that location for fieldwork and accessibility is an issue, we haveidentified Crewe, Northampton and Telford and the most accessible.

Possible 'average' case study areas in NL based on series of variables:

The closest to average in terms of population size is Beverwijk, followedby Veghel and Moerdijk.

The closest to Dutch average in terms of SES measure, Geldrop-Mierlo isthe closest, followed by Raalte and Veghel.

The closest to average ethnicity percentage (2007) is Beverwijk, followedHeemskerk and Veghel.

Local /UnitaryAuthorityname

Population (CBS2007)

Differenceinpopulationfrom theaveragefor theNetherlands

Urban-Ruralclassification (CBS2007)

Ethnicitypercentage by localauthority(CBS2007)

Differencebetweenethnicitypercentage in localauthorityand Dutchaverage(19.4)

SES(SCPO2006)

Differencein SESfrom theaverage fortheNetherlands (1873)

Rijssen-Holten

36,584 -342 ‘littleurban’

6.8 -12.6 1,601 -272

Goes 36,600 -325 ‘moderateurban’

13.0 -6.4 1,629 -244

Moerdijk 36,645 -280 ‘littleurban’

8.4 11.0 2,235 +362

Veghel 36,732 -193 ‘littleurban’

14.8 -4.6 1,669 -204

Beverwijk 36,835 -90 ‘largeurban’

19.8 0.4% 2,116 +243

Raalte 37,311 385 ‘littleurban’

6.0 -13.3 1,949 +75

Bronckhorst 37,788 863 ‘not urban’ 5.2 -14.2 1,582 -291

Geldrop-Mierlo

37,823 +897 ‘moderateurban’

14.0 -5.3% 1,877 +4

Heemskerk 38,006 1,080 ‘strongurban’

17.4 -2.0 1,414 -459

Dronten 38,182 1,257 ‘littleurban’

14.0 -5.4 2,127 254

110

Therefore to provide a shortlist of three: Beverwijk Veghel Geldrop-Mierlo

9.1.6 Crewe and Nantwich

Crewe and Nantwich was selected to be the case study area. It scored close to themean and median of each of the indicators which were looked at as part of theselection process. In particular, it scored close to average in terms of populationsize and IMD as well as the contextual characteristics, particularly being part ruraland with close to average health statistics.

Beverwijk

Beverwijk was selected to be the case study area. It scored close to the mean ofeach of the indicators which were looked at as part of the selection process. Inparticular, it scored close to the average in terms of population size, and ethnicity.

111

10 Annex 4: Identified typologies forinterventions to prevent childhood obesity

Table 2 Identified typologies for interventions to prevent childhood obesityTypology School Community HealthcareTopic or theme

1Reduce sedentary activity (watching TV andvideos) x x

2 Change to school meal content x3 Healthy eating x x

4Change to provision of tuck in school (i.e. morefruit) x

5 Physical activity programme x x x6 Lifestyle activity x x7 Subsidised leisure services x

Approaches8 Counselling x x x9 Postal communication (i.e. newsletters) x x10 Workshops x x

11Behaviour change therapy / behaviourmanagement therapy x x x

12 Traffic light system x13 Use of incentives / rewards x x

14Changes to / incorporation into curriculum anduse of homework x

15Interactive communication methods for adviceand support (e.g. telephone, website etc) x x

16 Peer support x x x17 Signposting x x x

Setting

The setting refers to the actual location for delivery (not who funded it or delivers theservice).

School setting = Embedded in a school environment

Community setting = A setting that is used by a wide range of people (including childrenand young people) for a range of community-based activities e.g. community centres,

112

children's centres, church halls, leisure centres (private and public), sport associations,and parks and green spaces.

Healthcare setting = Provisions provided in a health care centre by a health careprofessional (e.g. GP, obstetrics, paediatrics, internal medicine, physiotherapy, etc.)

Typology

Five interventions are defined according to the NICE-guidelines. See footnotes. Otherinterventions are defined according to other academic and in case not present, non-academic sources. See footnotes. Seven interventions have been defined on the basis ofour research into existing interventions tackling childhood obesity, both in the UK and inthe Netherlands.

1. Reduce sedentary activity = A clear and universal definition of a sedentary lifestyle iscurrently still lacking. Some authors have tried to determine the prevalence of sedentarylifestyles analysing the number of hours that individuals spend sitting down in a typicalday (behind a computer or television), or the number of hours expended walking or inother specific physical activities. Other researchershave investigated the energy expendedclimbing stairs, or how many times a week they participated in an activity that inducedsweating144. For this study, the reduction of sedentary activity is defined as a reduction insedentary behaviour (e.g. sitting behind the television, computer, using a car for shortjourneys or otherwise)

2. Change to school meal content = changes to the nutritional content of school meal toimprove their nutritional value and support healthier eating behaviours e.g. higher levelsof fruits and vegetables, reduced fats and sugars in meals145,146.

3. Healthy eating = interventions to promote and increase the levels of healthy eating inline with current government and/or other guidelines e.g. five fruits and vegetables a day.A healthy diet contains plenty of fruit and vegetables; is based on starchy foods such aswholegrain bread, pasta and rice; and is low in fat (especially saturated fat), salt andsugar142.

4. Change to provision of tuck in school (i.e. more fruit) = interventions that aim toincrease levels of healthy eating in line with government and/or guidelines with aparticular reference to snacks at school e.g. fruit and fruit juices sold in the tuck shop andhealthy snacks147 only available from the vending machine148.

5. Physical activity programme = the full range of human movement, from competitivesport and exercise to active hobbies, walking, cycling or activities of daily living(excluding physical activity as part of the regular school curriculum, e.g. PE). Physicalactivity varies by: volume or quantity (total quantity of physical activity over a specifiedperiod, usually expressed as kcal or METs149 per day or week). Frequency ofparticipation, typically expressed as number of sessions per day or week. Intensity,usually expressed as light, moderate or vigorous. Commonly used approximations are:light intensity = less than 4 METs, for example, strolling; moderate = 4 – 6 METs, for

113

example, brisk walking, vigorous = 7+ METs for example, running. Duration – timespend on a single bout of activity142.

6. Lifestyle Activity = Activities that are performed as part of everyday life, such asclimbing stairs, walking (for example, to work, school or shops) and cycling. They arenormally contrasted with ‘programmed’ activities such as attending a dance class orfitness training session142.

7. Subsidised leisure services = the funding of leisure services. This could range fromlocal funding for the establishment of a leisure centre to the supply of a subsidy to afamily to become a member of a sport association150.

8. Counselling = Different definitions of the term counselling exist. It generally means:the offering of individual advice or guidance, especially as solicited from aknowledgeable person (e.g. individual conversations - including advice - with childrenregarding their activities, life-style etc.)151,152.

9. Postal communication = individual information provision to children and/or parents inthe shape of a newsletter, flyer, brochure or otherwise. The provision is one-way from theinformation provider to the receiver153.

10. Workshops = Different definitions of the term workshop exist. It generally means: aneducational seminar or series of meetings emphasizing interaction and exchange ofinformation among a usually small number of participants (e.g. parent informationmeetings in the evening)154,155.

11. Behaviour change therapy / behaviour management therapy = Behavioural treatment(or behaviour therapy) draws on the principles of learning theory (stimulus–behaviourcontingencies or behaviour–reward contingencies). Consists of assessment (identifyingand specifying problem behaviours and the circumstances in which they are elicited),treatment (including setting specific, measurable and modest goals that are continuallyrevised) and monitoring. Behaviour change processes include stimulus control, gradedexposure, extinction and reward142.

12. Traffic light system = this is a calorie-based food-exchange system created by Epsteinand co-workers. Foods are divided into five groups (fruits and vegetables, grains,proteins, dairy and other foods), and the foods in each group are colour coded accordingto nutrient density: green for ‘go’, yellow for ‘eat with care’, and red for ‘stop’. Greenfoods are foods containing less than 20 calories per serving, yellow foods are the staple ofthe diet and provide most of the basic nutrition and red foods are those foods high in fatand simple carbohydrates. All sweets and sugared beverages are classified as red foods.Families are then instructed to count calories and cannot have more than four red foods aweek142.

13. Use of incentives / rewards = system of rewards to promote behaviour change e.g.vouchers for participating in physical activity interventions156

114

14. Changes to / incorporation into curriculum and use of homework = includesinterventions that lead to changes of the school curriculum and/or homework (e.g. aproject week around a certain theme, a healthy eating component in biology class or theadjustment of PE in school)157.

15. Interactive communication methods for advice and support = individual informationprovision to children and/or parents in the shape of a telephone conversation or website.The provision is not necessarily one-way from the information provider to the receiver158.

16. Peer support = peer support is a system of giving and receiving help founded on keyprinciples of respect, shared responsibility and mutual agreement on what is useful159. Itis derived from social cognitive theory. It is not based on psychiatric models anddiagnostic criteria.

17. Signposting = support in the shape of signposting (e.g. indicating, signing, guiding) toappropriate services (e.g. could be a certain activity, programme, health service, orotherwise)160.

115

11 Annex 5: Topic Guide for Interviews –Childhood Obesity

Introduction

Introduce researcher and thank interviewee for agreeing to take part.

Provide brief overview of background to study, if necessary (NB already covered inintroductory letters sent out in w/c 25 Aug): ECOTEC is a research and consultingcompany working mainly in social and economic policy research for public sectorclients. ECOTEC is part of an international company called ECORYS who are workingwith us on this research project. This project is being carried out as part of the ECORYSresearch programme..

The research focuses on the effectiveness of interventions aimed at preventingchildhood obesity in a selected area in the UK and Netherlands.

Crewe and Nantwich was selected as our study area in the UK, and our colleagues inthe Netherlands have also chosen an equivalent area to study. The project will look at anumber of specific interventions within each chosen area to establish their success, andto try to establish what works and what does not in order to inform public policy debate.

The purpose of talking to you today is to get more information about the interventionsunderway in Crewe and Nantwich and to find out how successful they have been atpreventing obesity in children. Our partners in the Netherlands will do the same. Ourresults will then be combined and a final paper will be written for academic publication.

The interview should last around 60 minutes, and with your agreement, we would like torecord the interview.

Before the interview, you should have already established:

► The nature of the policy context (but also explore thisfurther in interviews)

► The nature of the intervention(s): whether theintervention(s) aim(s) to reducesedentary activity (about physical activity interventions) oraim(s) to improvehealth (diet etc)

► How the intervention fits our typology.

116

Throughout the interview try to establish whether these typologiesprovide a good representation of reality.

Please refer to the intervention framework to familiarise yourself with thestructure of the analysis / information required to fill this in. The topicguide is designed around this framework, but is also intended to gather awider range of information.

This discussion will cover a number of key areas, including backgroundinformation about [the policy context / intervention], the delivery andimplementation, the impacts or outcomes and any lessons learnt.

The first few sections are background, but we would really like toconcentrate on finding out more about the outcomes and impacts of theintervention(s).

SECTION 1 – POLICY BACKGROUND IN YOUR AREA AND GENERALBACKGROUND INFORMATION ON THE INTERVENTIONS

In this first section, we would like to collect some background information aboutthe intervention(s). (Only ask the below questions 1-18 if additional background isrequired to that collected prior to interviews. i.e. you may not need to ask allquestions depending on the quality of data collected prior to interviews).

1 What is the policy context for the prevention of childhoodobesity in Crewe and Nantwich? Establish the key policiesand policy drivers. NB Only ask if data not already available ornot clear.

2 Who are the main organisations active in the policy area,and how are they working together? Probe on how theycollaborate, their roles, funding streams and ask for examplesof collaboration covering health, nutrition, diet, sports, cyclepaths, exercise, schools etc. NB Only ask if data not alreadyavailable or not clear.

3 What specific programmes, projects and interventionsare/were you involved in or are you aware of? Prompt withlist of things identified in desk review and list of things thatought to be happening but not sure if they are taking place. Askthem to list the interventions, then if list is very long focus on the3-5 most important. If necessary prompt through exploring thebasis on which funding was received.

4 In what capacity were/are you involved in theinterventions?

117

5 Why were these interventions established? Explore theneed which is being addressed by the intervention /rationale.

6 How do these interventions link to local/ national policy onchildhood obesity?

► Explore national, regional, local level policies► Does it work alongside, or does it fill a gap?

7 What are the timings of the intervention – how long has itbeen running, and what is the future timetable? Ask abouteach intervention identified.

8 Who are the target groups of the intervention? Ask abouteach intervention identified. Probe with:

► Behaviour – does the intervention target any specificattitudes or behaviours

► Environment – where are the target group living /attending school etc

► Populations – explore age range, sex, ethnicity,deprivation, levels of overweight or obese

► Clarify the level of targeting – size of group, and howselected (i.e. is it all children, or all overweight/obesechildren / all overweight etc)

9 Please could you explain what level the intervention isoperating at – e.g. at community level, school, county,regional / local level N.B. this to establish 'environment size'whether at Micro or Macro level – e.g. an area, a community, aneighbourhood, the whole local authority, the whole county /region

10 And where and when is the intervention delivered? (askabout each intervention identified) E.g. in a school (probewhere, classroom, hall), in a community centre, in a GPsurgery. Explore time of year, time of day – and why were thesetimings chosen.

11 How was/is the intervention(s) publicised or marketed totarget groups?

118

12 How many beneficiaries (i.e. children/youngpeople/parents/families) attend/take part? Explore regularityof attendance, how many attend on a regular basis etc

13 Could you explain how [the intervention] is funded andhow the funding works?

► Establish who the intervention is funded by► How much funding is received in total► Over what period has the funding been received / is the

intervention running► If a consortium funds the intervention – try to establish

how much is contributed by who, either get a % or figures

14 Are there any financial constraints upon delivery? Exploreissues around funding – how well funded the intervention is,and how costs compare with predicted costs, do attendeesneed to pay out-of-pocket expenses to attend?

15 Please could you explain a bit more about the managementstructure of [the intervention], who is responsible for :

► The management of the intervention► The delivery of services► The monitoring (if done) – explore this to establish who is

monitoring, how data is collected and who it is provided to► The evaluation (if any)

16 If partners are being worked with, who are they and whatare their roles? How well is this going? Explore howresponsibility is shared for delivery, monitoring, evaluating.

17 How does the intervention fit with other mainstreamservices? Explore links - Is this intervention filling in fordeficiencies/gaps in mainstream services?

► Are there any staff links, for example cross working, staffworking for multiple initiatives, agencies?

► Targets aims / objectives – is the intervention workingtowards the same targets?

119

► Measuring / monitoring links – does the intervention shareinformation, measurement, monitoring with other services?

► Evaluation links – is the intervention part of a biggerevaluation (e.g. part of a national programme, processevaluation?)

18 Are any innovative techniques or delivery methods used?

SECTION 2 – IMPACT AND OUTCOMES

We would like to know how effective the intervention(s) have been at preventingor controlling childhood obesity. For each question ask, if necessary about eachof the interventions identified.

19 What are target outcomes, or outcome measures used?

► Probe for concrete outcomes - for e.g. a 10% reduction inobese girls from different BMI groups (25-30, 30-35, >35).

► Alternatively, probe for information on the type and natureof data being collected to inform progress

► Explore any planned, or expected outcomes and anyunexpected outcomes

20 Has the intervention been evaluated?

a. If yes

► When was it undertaken? Dates and when in the course ofthe intervention? Is it something that will occur frequently?

► Why was it undertaken?► What method was used to measure, process, impact or

outcomes?► What were the key findings?► (How) has the evaluation been used?► Has any follow up work taken place?► Are the results published? If yes, collect copy

b. If no

► Is an evaluation planned? Why/why not? Formal orinformal?

► What will be measured / monitored?

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► Are you measuring anything to report back tofunders/partners?

SECTION 3 – OUTCOMES, BARRIERS AND FACILITATORS (If multipleinterventions, ask for specific details for each)

21 Overall, in your judgement, how successful has theintervention been to date at achieving its intendedoutcomes? If possible refer to any background material, or toearlier in the interview to probe using specifics.

22 In your view, what has worked well in terms ofimplementation, and why? What have been the facilitators?

23 What, if any difficulties/barriers have there been inimplementing the intervention(s)?

► Explore – support from colleagues/funders and partnerorganisations?

► Support from health / other experts – any linkages withother services?

► Probe – Barriers posed by parents/children?► Probe – social, cultural, economic barriers within

organisations and with target groups?► Any others?

24 How successfully have you been able to engage with theintervention's target group? If very, how has this beenachieved, and if not why?

► Prompt if necessary around interest in the intervention,attendance, drop out rate, barriers to certain groupsgetting involved, access, parental attitudes, children'sattitudes, timing, transport etc…

25 How much interest / support have you received fromcomplementary or mainstream services, or voluntarysector?

26 What, if any feedback have you received from beneficiaries/ attendees about the intervention? Probe: What have theyfound most/least beneficial?

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27 Have you, or your colleagues, noticed any changes in theindividuals attending the intervention? * Find out whatresearch based or statistical findings or evidence exists *

► Have there been changes in behaviour – explore, physicalactivity, food, diet / nutrition

► Clinical changes – weight gain or loss? Noticeable /measured health improvements?

► Quality of life

SECTION 4 – GOOD PRACTICE AND FINAL CONCLUSIONS

28 Are there any examples of 'good practice' within theintervention(s)? Explore both in terms of design, delivery andmonitoring / evaluating. NB Good practice – is when somethingis working well and can be used elsewhere.

29 Similarly, can you think of any examples of promising,effective or best practice in the case study area?

Promising practice – When practice is in the early stages ofdevelopment and has yet to be evaluated

Effective practice – When something is working well but canonly be achieved under similar conditions

Best practice – When something is working at the higheststandard and is working 'better' than good practice.

30 Finally, what would you say are the key factors whichimpact on the success of an intervention to prevent obesityand overweight in children?

SECTION 5 – CLOSING REMARKS

31 One of the ways in which we are analysing theinterventions in this research is through allocating'typologies'. We used these typologies to informjudgements on the spread of work taking place and inchoosing and selecting case studies.

Can we check with you, to see if you agree with the typology that we have givento [insert intervention name]

Take list of possible options to interviewee to check against.

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32 Can you think of anything else we should look at, oranyone else who you think that we should speak to, anyfinal comments? Record details.

Thank and close.

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12 Annex 6: References

1 Hall, N and Oortwijn, W: Preventative public policy and childhood obesity. Initial exploratory paper

submitted to ECORYS Research Programme, ECORYS Research and Consulting, 2007.2 Department of Health: Definitions of overweight and obesity, 2007

http://www.dh.gov.uk/en/Publichealth/Healthimprovement/Obesity/DH_41339483 Branca F, Nikogosian H, Lobstein T (eds):The Challenge of obesity in the WHO European Region and the

strategies for response. Copenhagen: WHO Regional Office for Europe, 2007.

http://www.euro.who.int/document/E90711.pdf4 The International Obesity Task Force (IOTF) http://www.iotf.org5 This may be based on an underestimate of prevalence as it is self-reported data6 IOTF: Childhood overweight in the European Union (EU27) and Switzerland. 2008

http://www.iotf.org/database/documents/ECO08ChildEU27Final.pdf7 Department of Health: Obesity general information, 2008.

http://www.dh.gov.uk/en/Publichealth/Healthimprovement/Obesity/DH_0780988 McPherson K, Marsh T, Brown M: Foresight- Tackling Obesities: future choices – modellingfuture trends in obesity and their impact on health (2nd edition). Government Office for Science,2007.9 McPherson K, Marsh T, Brown M: Foresight - Tackling Obesities: Future Choices – Modelling future

trends in obesity and their impact on health. Government Office for Science, 2007.10 ONS The Information Centre: Statistics on obesity, physical activity and diet: England, January 2008.

http://www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles-related-surveys/health-survey-for-

england11 Department of Health: Obesity general information, 2008.

http://www.dh.gov.uk/en/Publichealth/Healthimprovement/Obesity/DH_07809812 World Health Organisation: Health promotion: A discussion document on the concepts andprinciples. WHO Regional Office for Europe, Copenhagen, 1984.13 Kilpatrick D.G: Definition of public policy and the law. National Violence Against WomenPrevention Research Centre, 2000. www.musc.edu/vawprevention/policy/definition.shtml14 Kimm SYS, Glynn NW, Kriska A.M: Decline in physical activity in black girls and white girls during

adolescence. New England Journal of Medicine, 2002, 347 (10): 709-715.15 Stubbe J H, Boomsma D I, De Geus E J C: Sport participation during adolescence: a shift from

environmental to genetic factors. Medicine & Science in Sports & Exercise, 2005: 563-570.16 Oortwijn, Lankhuizen, Tsang, Cave, 2007.17 European Environment and Health Information System: Percentage of Physically ActiveChildren and Adolescents. Fact Sheet No. 24. 2007.http://www.euro.who.int/Document/EHI/ENHIS_Factsheet_2_4.pdf18 Dr Foster Research: Weighing up the burden of obesity, 200819 Department of Health, Department of Education and Schools, and Department if Culture Media and Sport:

Choosing Health, Obesity Bulletin. Issue1,Undated.20 Egger G: An Ecological Approach to the Obesity Pandemic: BMJ 1997; 315:447-480

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21 EPODE: EPODE: A standard for the prevention of childhood obesity and associated issues, 2006.22 Commission of the European Communities: Commission Staff Working Document. Impact Assessment

Report accompanying the White Paper from the Commission to the Council, the European Parliament, the

European Economic and Social Committee and the Committee of the Regions. A strategy for Europe onnutrition, overweight, and obesity related health issues. Brussels, European Commission, 2007.23 Woodman J, Lorenc T, Harden A, Oakley A: Social and environmental interventions to reduce childhood

obesity: a systematic map of reviews. EPPI-Centre report 1610. London: EPPI-Centre, 2008.24 EU Platform on Diet, Physical Activity and Health: ‘Diet, Physical Activity and Health – A European

Platform for Action’, March 15 2005.

http://ec.europa.eu/health/ph_determinants/life_style/nutrition/platform/docs/platform_charter.pdf25 WHO: The Challenge of obesity in the WHO European Region and the strategies for response.http://www.euro.who.int/document/E90711.pdf26 WHO Europe: The WHO ministerial conference on counteracting obesity, 2006.http://www.euro.who.int/obesity/conference200627 Branca F, Nikogosian H, Lobstein T (eds):The Challenge of obesity in the WHO European Region and the

strategies for response. Copenhagen: WHO Regional Office for Europe, 2007.http://www.euro.who.int/document/E90711.pdf28 WHO Europe: High level group on nutrition and physical activity, 2007

http://ec.europa.eu/health/ph_determinants/life_style/nutrition/nutrition_hlg_en.htm29 Oortwijn WJ, Lankhuizen M, Tsang F, Cave J: An analysis of the economic, social and environmental

impact of the rising prevalence of overweight and obesity in the European Union. Final report. TR-466-EC.

Santa Monica: RAND, 2007.30 Oortwijn WJ, Lankhuizen M, Tsang F, Cave J: An analysis of the economic, social and environmental

impact of the rising prevalence of overweight and obesity in the European Union. Final report. TR-466-EC.

Santa Monica: RAND, 2007.31 Woodman J, Lorenc T, Harden A, Oakley A :Social and environmental interventions to reduce childhood

obesity: a systematic map of reviews. EPPI-Centre report 1610. London: EPPI-Centre, 2008.32 Swinburn B, Egger G, Raza F: Dissecting obesogenic environments: the development and application of aframework for identifying and prioritizing environmental interventions for obesity. Preventive Medicine,

1999; 29: 563-570.33 Woodman J, Lorenc T, Harden A, Oakley A: Social and environmental interventions to reduce childhoodobesity: a systematic map of reviews. EPPI-Centre report 1610. London: EPPI-Centre, 2008.34 Commission of the European Communities: Commission Staff Working Document. Impact Assessment

Report accompanying the White Paper from the Commission to the Council, the European Parliament, theEuropean Economic and Social Committee and the Committee of the Regions. A strategy for Europe on

nutrition, overweight, and obesity related health issues. Brussels, European Commission, 2007.35 Woodman J, Lorenc T, Harden A, Oakley A: Social and environmental interventions to reduce childhoodobesity: a systematic map of reviews. EPPI-Centre report 1610. London: EPPI-Centre, 2008.36 Woodman J, Lorenc T, Harden A, Oakley A: Social and environmental interventions to reduce childhood

obesity: a systematic map of reviews. EPPI-Centre report 1610. London: EPPI-Centre, 2008.37 Voedingscentrum Nederland, Handleiding Preventie van overgewicht in lokaal gezondheisbeleid38 National Institute for Clinical Excellence: Obesity: Full guideline, section 1 - Introduction, methods and

recommendations, 2006.39 Foresight: Trends and Drivers of Obesity: A Literature Review for the Foresight project on obesity, 2007.

www.foresight.gov.uk40 Millstone et al 2006

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41 National Institute for Clinical Excellence: Obesity: Full guideline, section 1 - Introduction, methods andrecommendations, 2006.42 Swinburn B, Egger G, Raza F: Preventive Medicine 1999; 29 (6Pt1): 563-70.43 International Obesity Task Force: PHAPO working group – causal web, 2008.http://www.iotf.org/groups/phapo/causalweb.htm44 King L, Turnour C, Wise M: Analysing NSW state policy for child obesity prevention: strategic

policy versus practical action . Australia and New Zealand Health Policy 2007, 4:22; 10.1186/1743-8462-4-22.45 A method for cataloguing and storing data was devised to ensure a methodical approach to the storing of

relevant data and to assist in analysis Documents were uniquely coded and details about them stored in acommon reference directory. Further details on this system are available in the annex.46 NHS Centre for Reviews and Dissemination: Centre for reviews and dissemination (York University) –

CRD databases, 2008. http://www.crd.york.ac.uk/crdweb/47 British Medical Journal: British Medical Journal on-line, 2008. http://www.bmj.com/48 Healthy Schools: The Healthy Schools web-site, 2008. www.healthyschools.gov.uk49 British Medical Journal: BMJ online, 2008. http://www.bmj.com50 Gezond School: The Gezond Schools web-site, 2008. http://www.gezondeschool.nl51NTVG: Nederlands Tijdschrift voor Geneeskunde web-site, 2008. www.ntvg.nl52 RIVM: RIVM web-site, 2008. www.rivm.nl53 Gemeente Beverwijk: Gemeente Beverwijk web-site, 2008. www.beverwijk.nl54 In order to ensure the viability of the case study area as a unit for analysis.55 National Statistics: 2001, Census Results, 2008. http://www.statistics.gov.uk/census2001/census2001.asp56 Department for Communities and Local Government: Indices of Deprivation, 2007.

http://www.communities.gov.uk/documents/communities/xls/576504.xls57 DEFRA: Defra Classification of Local Authority District and Unitary Authorities in England – A TechnicalGuide, 2008. http://www.defra.gov.uk/rural/ruralstats/rural-defn/LAClassifications_technicalguide.pdf58 Statistics Netherlands: 2007, Census Results, 2008.

http://www.cbs.nl/en-GB/menu/themas/bevolking/nieuws/default.htm?Languageswitch=on59 Statistics Netherlands: 2006, Rural/Urban classification data, 2008.

http://www.cbs.nl/nl-NL/menu/methoden/begrippen/default.htm?ConceptID=65860 NICE and the National Collaborating Centre for Primary Care: Obesity: the prevention, identification,assessment and management of overweight and obesity in adults and children, 2006.61 Office for National Statistics: Results from the 2001 Census, 2008.

http://www.neighbourhood.statistics.gov.uk62 DEFRA: Defra Classification of Local Authority District and Unitary Authorities in England – A Technical

Guide, 2008. http://www.defra.gov.uk/rural/ruralstats/rural-defn/LAClassifications_technicalguide.pdf63 Department of Health and NHS: Crewe and Nantwich Health Profile 2007, 2008.www.communityhealthprofiles.info64 Association of Public Health Observatories (APHO), DH and NHS: Health Profile 2008 – Crewe and

Nantwich, 2008. http://www.apho.org.uk/resource/view.aspx?RID=50215&SEARCH=C*65 National Centre for Social Research: National Healthy Schools Programme Evaluation: asummary, 2007. http://www.healthyschools.gov.uk/Uploads/Resources/cb74f78a-0fd3-4935-a73b-0c041d81c615/NHSP%20Evaluation%20Summary.pd f66 The policy links and context were identified by interviewees and contacts but also fromdocumentation and web-based information on sources in relation to the interventions included inthe case study.

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67 Yorkshire and the Humber Public Health Observatory: social marketing a definition, 2008.http://www.yhpho.org.uk/social_marketing.aspx68 Department of Health: Letter from the Chief Medical Officer and the Chief Nursing Officerintroducing Change4Life, 2008. www.dh.gov.uk/en/publicationsandstatistics69 Department of Health: Department of Health news item, November, 2008.www.dh.gov.uk/en/news70The Improvement and Development Agency: The healthy Communities Programme, 2008.http://www.idea.gov.uk/idk/core/page.do?pageId=482046171 DH, DfES and DCMS: Choosing Health: Obesity Bulletin 2006, Issue 1.72 NICE: Obesity: guidance on the prevention, identification, assessment and management ofoverweight and obesity in adults and children, 2006.73 National Institute for Health and Clinical Excellence (NICE): Obesity: guidance on prevention,identification, assessment and management of overweight and obesity in adults and children.NICE Clinical Guideline 43, 2006.74 Voedingscentrum Nederland: The Netherlands in balance, Preventing Obesity Masterplan 2005-2010. Den Haag, Voedingscentrum Nederland, 2005.75 Ministerie van Volksgezondheid, Welzijn en Sport (VWS): Preventienota kiezen voor gezondleven. Den Haag, 2006. http://www.minvws.nl/kamerstukken/pg/2006/preventienota -kiezen-voor-gezond-leven.asp76 Every four years the Dutch government needs to set up national priorities with regard tocollective prevention as required by the law collective preventive public health (Wcpv, collectievepre RIVM: Wat doet het Centrum Gezond Leven?77 RIVM: Wat doet het Centrum Gezond Leven? RIVM, 2008.http://www.rivm.nl/gezondleven/centrum-gezond-leven/78 RIVM: De Gezonde Schoolmethode. RIVM, 2008.http://www.rivm.nl/gezondleven/werkwijze/werkplaats-gezondeschool/gezondeschoolmethode/79 IGZ: Organisatie, Missie. IGZ. http://www.igz.nl/organisatie/missie80 Beter voorkomen, Kwaliteitsprogramma preventie: Maatschappelijke verantwoording in eenbreder perspectief. http://www.betervoorkomen.nl/index.php/archive/26/81 In cooperation with the sport association NOC*NSF, the Dutch Institute for Sport and PhysicalActivity (NISB), the association of Dutch municipalities (VNG) and the Association of Sport andMunicipalities (VSG).82 NASB: Impuls NASB. NASB. http://www.nasb.nl/cat/1337/Impuls_NASB83 Convenant Overgewicht: Energie in balans 2007. Harder lopen. Den Haag, Koninklijke DeSwart, 200784 Identified neighborhoods by the Dutch government which will receive extra attention toovercome the social, physical and economic problems in the neighborhoods to ensure they becomea better place to live in the near future.85 Halberstadt J, Seidell J, HiraSing R, Renders C, van Bolhuis A: Partnerschap OvergewichtNederland: ketenzorg voor overgewicht en obesitas. Uitgangspunten en positionering ten opzichtevan andere ontwikkelingen in de publieke en curatieve zorg. Amsterdam, VU Medisch Centrum,2008.86 Bulk-Bunschoten AMW, Renders CM, van Leerdam FJM, HiraSing RA: Signaleringsprotocol

Overgewicht in de Jeugdgezondheidszorg. Amsterdam, VU Medisch Centrum, 2004.

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87 The BOFT principle takes up a central position: stimulation of breast feeding, stimulation ofbreakfast, stimulation of playing outside, reduction of soft drink intake and reduction of watchingtelevision and sitting behind the computer.88 Bulk-Bunschoten AMW, Renders C, van Leerdam FJM, HiraSing RA: Overbruggingsplan voorkinderen met overgewicht. Methode voor individuele primaire en secundaire preventie in dejeugdgezondheidszorg. Amterdam, VU Medisch Centrum, 2005.89 This prevention note was preceded by the prevention nota Living longer healthy (Langer gezondleven) in which overweight was already identified to be an important issue.90 NIGZ: Overgewicht. NIGZ. http://www.nigz.nl/index.cfm?act=dossiers.inzien&vardossier=5391 Bakker PP: Leren van de BOS-koplopers. Utrecht, Landelijk Ondersteuningsnetwerk BOS-impuls, 2007.92 In the Netherlands, GGD offices (gemeentelijke gezondheidsdienst) carry out public health carein assignment of municipalities. GGD offices are often organised on a regional level. There are 36regional GGDs in the Netherlands.93 GGD Nederland: TNO-onderzoek: Jeugd steeds sneller dikker. GGD’en pakken overgewichtjeugd aan. GGD Nederland.http://www.ggd.nl/ggdnl/uploaddb/downl_object.asp?atoom=34989&VolgNr=33394 Voedingscentrum Nederland: Handleiding preventie van overgewicht in de nota lokaalgezondheidsbeleid. Voedingscentrum Nederland, 2008.http://www.voedingscentrum.nl/NR/rdonlyres/09FF459C-2E2C-4A94-8840-A3A9AF873F9C/0/Handleidingpreventievanovergewichtinlokaalgezondheidsbeleidupdatemaart2008.pdf95 Voedingscentrum Nederland: De LEEFLIJN. Ingrediënten voor de aanpak van overgewicht.Voedingscentrum Nederland, 2008. http://www.voedingscentrum.nl/NR/rdonlyres/870F6BE0-9538-4FF4-93E4-61B9F86F0C2B/0/LEEFLIJN.pdf96 The last two organisations have recently merged and we will refer to Zorgbalans in the rest ofthis document.97 This region consists of 10 municipalities of which the city Haarlem is the largest: Bennebroek,Beverwijk, Bloemendaal, Haarlem, Haarlemmerlied & Spaamwoude, Heemskerk, Heemstede,Uitgeest, Velsen and Zandvoort98 CBS Statline: Population statistics per region and municipality. CBS.http://statline.cbs.nl/statweb/99 In the Netherlands, socio-economic status (SES) is measured on the basis of level of education,income and level of occupation. A high outcome indicates a high level of education, income orlevel of occupation.100 Nijbroek W, Cluitmans R: Overgewicht onder de jeugd in Kennemerland. Haarlem, GGDKennemerland, 2005101 11.502 children in group 2 and group 7 of primary education and class 2 of lower secondaryeducation. Special education is excluded from this research.102 Convenant overgewicht. Een balans tussen eten en bewegen. Den Haag, 2005.103 4-15 years old, no exact date provided.104 Elektronische Monitor en Voorlichting – Electronic Monitor and Counselling105 Robroek S, Cluitmans R: Gezondheid, welzijn en leefstijl van scholieren in Beverwijk. Resultaten van het

Emovo-onderzoek. Haarlem, GGD Kennemerland, 2007.106 Participants of the EMOVO project were 6.260 young people in class 2 and 4 of secondaryeducation.107 Ethnicity is determined on the basis of the birth country of the caring parent.

128

108 It is important to note here that this is partially logical due to the exclusion criteria of our study(the research excluded statutory services that address childhood obesity and that are not time-limited, population-based interventions aimed at prevention, e.g. one-to-one consultations betweengeneral practitioners, nurses or dieticians with individuals). For example, regular checks ofchildren by school GPs organised by the Public Health Services (GGD Kennemerland) inBeverwijk and the region of middle and south Kennemerland are as a result excluded.109 Several other interventions implicitly include a behavioural change therapy element throughtheir activities.110 Motivation conversations are organised according to the method of motivational interviewing.This is a special technique which requires special training. The counsellor does not try to convincethe student, but instead tries to empathize and show the difference between current behaviour andgoals and values of the student and support the student to believe they can change their behaviourthemselves.111 Sportservice Noord-Holland: Alle Leerlingen Actief. Sportservice Noord-Holland en VMBO-scholen starten met nieuw beweegproject Alle Leerlingen Actief!. Sportservice Noord-Holland,2007. http://www.sportservicenoordholland.nl/so_jeugd_alleleerlingen.htm112 Most funders set the requirement to include an evaluation component.113 The last two organisations have recently merged and we will refer to Zorgbalans in the rest ofthis document.114 Projectgroep Overgewicht: Signalering, aanpak en preventie van overgewicht bij kinderen van 0-19 jaar

in de regio Midden- en Zuid Kennemerland. GGD Kennemerland, 2005.115 Also referred to as social domain subsidies (sociaal domein subsidies)116 The municipality of Beverwijk did for example not tender to gain BOS-impuls subsidy whichcould have been used to undertake an intervention in relation to physical activity in themunicipality.117 Schraven M, Venemans A, Poort E: Evaluatierapport Beter (Zw)eten. Over gezonde voeding en

beweging. Haarlem, GGD Kennemerland, 2007.118 It is important to note that some after-school interventions are also open for school childrenfrom other schools.119 Which fits in the previously explained “brede school” concept.120 Sporthackers: Sporthackers. Sports service Noord-Holland.http://www.sporthackers.nl/news_svmbo.htm121 September 2008122 Sportservice Noord-Holland: Eindrapportageformulier projecten sociaal beleid, sporthackers. Sportservice

Noord-Holland.123 ZonMw is a Dutch organisation which aims to improve prevention, care and health bystimulating and funding research, development and implementation. Its main funders are theMinistry of Health and the Dutch organisation for academic research (NWO, NederlandseOrganisatie voor Wetenschappelijk Onderzoek).124 ZonMw:Missie.ZonMw, 2008. http://www.zonmw.nl/nl/organisatie/over-zonmw/missies/125 Some interventions have only recently been implemented and therefore lack evaluationmaterial.126 Interview Sportservice Noord-Holland, October 2008127 The fee of the Kidsclub intervention (€128 annually) for example has proven to be far too highto attract sufficient participants.128 Interview municipality of Heemskerk, October 2008

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129 Funded by the Ministry of Education and Health and co-funding organized by the participatingmunicipalities (after 1 year).130 Unclear whether this is all municipal funding131 APHO: Health Profile 2008. Crewe and Nantwich. APHO, 2008.http://www.apho.org.uk/resource/item.aspx?RID=52240132 For example, a part of the salary costs of a staff member of the Sportservice Noord-Holland(one of the most important partners in implementing interventions in the region of middle andsouth Kennemerland) is paid out of national funding directly related to the national programme“National Action Plan for Sport and Physical Movement”(Nationaal Actieplan Sport en Bewegen).133 Also referred to as social domain subsidies (sociaal domein subsidies)134 Provincie Noord-Holland: Subsidieverordering 100. Provinciaal blad, 2006. http://www.noord-holland.nl/zoeken/get_url.asp?page=/provstukken/OPENBAAR/AVV/AVV-PB2006-100.pdf135 National Institute for Health and Clinical Excellence: Obesity: guidance on prevention, identification,assessment and management of overweight and obesity in adults and children. NICE, Clinical Guideline 43,

2006. http://www.nice.org.uk/nicemedia/pdf/CG43FullGuideline1.doc136 Kliphuis L: Preventie in de eerste lijn moet de herkenbaarheid van een meubelboulevard krijgen. Pre Post2008; 10: 33: 10-11.137 Term referring to the environment's role in promoting obesity, the 'obesogenic' environmentpromotes high energy intake and low energy expenditure. As such obesity is a natural response tothe environment - the human body has good physiological defences against the depletion of itsenergy stores but poor defences against the accumulation of excess energy stores when food isabundant.138 Tijdelijke stimulerings regeling139 The municipalities can in turn apply for other national subsidies like BOS impuls subsidy andbreedtesport impuls subsidy to gain funding for this intervention140 Fit4family: Over fit4family. Fit4family, 2008.http://www.fit4family.nl/index.php?option=com_content&task=view&id=30&Itemid=46141 BOS impuls subsidy and social domain subsidies142 BOS impuls subsidy and social domain subsidies143 Projectgroep Overgewicht: Sociale kaart Overgewicht voor de regio Midden- en Zuid-Kennemerland.

Projectgroep Overgewicht, 2007.144 Varo J, Martinez-Gonzalez M, de Irala-Estevez J, Kearney J, Gibney M, Martinez J:Distribution and determinants of sedentary lifestyles in the European Union. International Journalof Epidemiology 2003; 32: 138-147. http://ije.oxfordjournals.org/cgi/content/full/32/1/138145 the Caroline Walker Trust (CWT) Guidelines for School Meals guidelines “provide figures forthe recommended nutrient content of an average school meal provided for children over a one-week period”. The values are based on the recommendations contained in the COMA reportDietary Reference Values for Food Energy and Nutrients for the United Kingdom.146 Nelson M, Bradbury J, Poulter J, Mcgee A, Msebele S, Jarvis, L: School meals in secondary schools in

England. Research report nr557. London, King’s College London National Centre for Social Research, 2004.http://www.food.gov.uk/multimedia/pdfs/secondaryschoolmeals.pdf147 No specific definition. Foods consumed between meals or instead of a main meal.148 Defined by ourselves.149 1 MET = a person’s metabolic rate (rate of energy expenditure) when at rest. MET values areassigned to activities to denote their intensity and are given in multiples of resting metabolic rate.For example, walking elicits an intensity of 3–6 METs, depending on how brisk the walk is, andmore strenuous activity such as running would have an intensity of 7–10 METs.

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150 Defined by ourselves151 The Free Dictionary by Farlex: definition counseling. The Free Dictionary by Farlex, 2008.http://www.thefreedictionary.com/counselling152 No academic definition available.153 Defined by ourselves154 Answers.com: definition workshop. Answers.com, 2008. http://www.answers.com/topic/workshop155 No academic definition available.156 Defined by ourselves157 Defined by ourselves158 Defined by ourselves159 Mead S, Hilton D, Curtis L: Peer support: a theoretical perspective. Psychiatric Rehabilitation Journal,

2001;25:134-141160 Defined by ourselves

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