Health Review Committee

Health of our Children and Young People

Report 27 January 2004

Appendix C

Health of School Age Children

Recommendation report for Health of School Age Children

1. Scope

1.1. The review of the health of school age children commenced in October 2003. The working group was comprised of:-

_ Councillor Mrs McNair Scott (Chairman)

_ Councillor Chapman

_ Councillor Mrs Peskett

_ Councillor Mrs Randall

_ Councillor Mrs West

_ Mary Hogg, Early Education and Childcare Unit

_ Mohammed Mossadaq, Social Services

_ Terry Rath, Education Department

_ Penny Velander, Policy Unit (Review Team Leader)

1.2. From the start this review had the potential to become too diverse by focusing on many aspects of children's health. It was recognised that careful scoping would be needed to make the review a manageable task. A mapping exercise was carried out to identify potential projects, statutory and non-statutory agencies that could be included.

1.3. Once the map was complete, it was decided to exclude anything to do with therapeutic support, mental health or the Children Matter Green Paper. This was because the Health Review Committee had already identified mental health and therapeutic support as topics for future reviews. In addition Best Value reviews were underway on Children Services and Education Other Than At School, which were taking the Green Paper into consideration. It was also decided that drugs, smoking, sexual relationships would be left out due to the high number of agencies already working with young people on these issues.

1.4. During the scoping exercise dental care was considered for inclusion. However it was felt that this needed to be part of a wider review on access to NHS Dentists

1.5. This left diet and physical activity as potential for the scope and at first glance they appeared to be issues that there was little local information on and yet many concerns were being voiced at a national level.

1.6. This raised the initial questions for the review - how healthy are school age children in Hampshire? and, how can we improve health levels?

1.7. Many of the review stakeholders had been identified through the mapping exercise. Lack of knowledge of Health Service structures showed that health officials would need to be contacted to establish key people and agencies across Hampshire. In addition national agencies would need to be identified as sources of information.

2. Methodology

2.1. From the beginning it was recognised there was no systematic information kept on children's weight, height etc. The only information kept related to national targets such as dental care, teenage pregnancy and immunisations. The lack of grass roots information indicated that there would need to be a `top down' approach to the review. Therefore the working group was dependent on research of national data and personal interviews at local level as the two main methods for gathering information.

2.2. Electronic searches were carried out on national health and sport agencies to ascertain their involvement and interest in children's eating and activity habits. Many of these organisations had carried out or commissioned research to support their campaigns, where practical copies of research were obtained. The statutory framework for both present and future services needed to be identified.

2.3. Personal interviews were arranged with relevant departments within the County Council and selected personnel within Health

2.4. A questionnaire was sent to each Primary Care Trust (PCT) to collect details of support and involvement through their Local Development Plan (LDP).
The Borough/District councils were approached to ascertain their level of involvement in local health initiatives

2.5. Two briefing papers and a variety of statistical information was prepared to inform the review work group.

2.6. The review working group met twice to consider and discuss all information and receive a presentation from the Hampshire Coordinator for the National Healthy Schools Scheme. All information was used to compile a global picture of health of school age children in Hampshire which informed the review recommendations

3. The size of the problem

3.1. Obesity contributes to a range of diseases including cardiovascular disease, diabetes and cancer. The National Audit Office estimates that over 30,000 deaths were attributed to obesity in 1998 and that obesity reduces life expectancy on average by 9 years. The prevalence of obesity is increasing. In 2001, 24 per cent of women and 21 per cent of men were obese, compared to 8 per cent of women and 6 per cent of men in 1980. In 2001, 47 per cent of men and 33 per cent of women were overweight but not obese. This is due mainly to less active lifestyles and changes in dietary habits

3.2. Obesity is also increasing in children. In 2001, 8.5 per cent of 6 year olds and 15 per cent of 15 year olds were obese. Between 1996 and 2001 the proportion of overweight or obese children increased from 24.6 per cent to 31.6 per cent (7 per cent). The proportion of obese children increased from 12.1 per cent to 15.6 per cent (3.5 per cent)

3.3. Weight is defined according to body mass index (BMI). This is calculated by dividing weight in kilograms by the square of height. For adults four groups are defined according to their BMI

_ Underweight = BMI below 20

_ Desirable weight = BMI 20-25

_ Overweight = BMI 25-30

_ Obese = BMI over 30


For children there are no commonly agreed definitions of obesity or overweight. Children with overweight or obese parents are more likely to be in the top BMI quintile. It would be logical to presume from Annex C1a that the normal BMI for 2-15 year olds lies between 15-20. Therefore any BMI above 20 would indicate Obesity or overweight.

4. The Legislative Framework

4.1. The Department of Health has created a Children's Taskforce to focus on the care of children and young people. They have responsibility for ensuring that the NHS Plan is delivered for children and have specific responsibility for overseeing the development of the National Service Framework for Children (NSF). The NSF has been put out for consultation and, after inclusion of recommendations from the Green Paper, the final guidance will be published in 2004.

4.2. The Department for Media, Culture and Sport's strategy document `A Sporting Future for All' sets out the Governments vision for increasing sport in education. It proposes a five-part plan that focuses on school sports facilities; specialist sports colleges, out of school activities, sport's co-ordinators and elite sport. In December 2002 a new strategy, Gamelan, set out to combat the `couch potato' culture and increase mass participation in fitness activities. The summary of this report notes `Participation falls dramatically after leaving school and continues to drop with age. But the more active in sport and physical activity you are at a young age the more likely you are to continue to participate throughout your life'. Sport England is managing funds from central government to support local authorities in setting up Schools Sports Partnerships.

4.3. In 1997 the white paper `Excellence in Schools' stated that it was the Governments intention for all schools to become `healthy schools'. The National Healthy Schools Standards (NHSS) emerged in 1999 and provides a framework for schools to work through a `whole school approach' to achieve healthy school status. This scheme is jointly funded by the Department of Health and the Department for Education and Skills. In 2002 a national target was set for `All schools with 20%+ free school meal eligibility (approximately 7000 schools nationally, 86 in Hampshire) to achieve National Healthy School Standard level three status by 2006'.

4.4. Education Act (2002) sets out guidance for the provision of personal, social and health education within all key stages of the National Curriculum.

5. National research and findings

5.1. The Department of Health commissioned research for a series of annual surveys, which constitute The Health Survey for England. Since 1995 the surveys have included children aged 2-15, these results were published in a report The Health of Young People '95-97. The aim of the health survey is to monitor trends in the nation's health and identify the likelihood of specific risk factors. Evidence from the survey clearly shows how children's weight is increasing whilst physical activity levels are decreasing. Physical activity levels fell from about the age of 10 and the decline was greater for girls than boys (Annex C1b). In addition the report identified that `the eating habits of children 2-15 varied by social class in both sexes. The proportion consuming fruit and vegetables more than once every day tended to decrease from Social Classes I and II to Social Classes IV and V. On the other hand, the proportion consuming sweet foods and soft drinks was lower in Social Classes I and II than in Social Classes IV and V.

5.2. The Food Standard Agency has commissioned the University of Strathclyde to conduct a review of research on the effects of food promotion to children. Conclusions of the review show that:

_ There is a lot of food advertising to children

_ The advertised diet is less healthy than the recommended one

_ Children enjoy and engage with food promotion

_ Food promotion is having an effect, particularly on children's preferences, purchase behaviour and consumption

_ This effect is independent of other factors and operates at both a brand and a category level


The Food Standard Agency has presented a number of options for further action and is inviting people to comment and make further suggestions. This information can be found on their website www.foodstandards.gov.uk/healthiereating/promotion/options/

5.3. The Health Development Agency has been reviewing the management of children who are obese or overweight and have concluded that parents are the key. Family based programmes that involve the parents and children together are proven to be effective in preventing and treating obesity and maintaining weight loss. Evidence shows that parents can successfully treat their child's obesity by actively changing the whole family's approach to diet and physical activity and by avoiding couch potato lifestyles. In addition schools are found to have an important role, particularly for girls, through a `whole school approach' such as that advocated through the Healthy Schools Scheme. www.hda.org.uk

5.4. The Medical Research Council Resource Centre for Human Nutrition has been working closely with the Association for the Study of Obesity and the London School of Hygiene and Tropical Medicine. They have called for `urgent and concerted action, embracing both diet and physical activity, across all sectors of society to tackle the swelling tide of obesity that threatens UK children' They have produced a dossier `A Leaner Fitter Future' which includes statements from twenty-eight organisations including health professionals, school, industry, sport and consumer groups. www.mrc.ac.uk

5.5. The Soil Association recently released the `Food For Life' report promoting the case for decent school meals. They claim that the daily amount spent on each child's school lunch can be as low as 31p, compared with around 60p spent on prisoner's lunch. Acknowledging that poor diet leads to a myriad of health problems in later life they recommend that Government guidelines should be widely available on the types of food that should be served in schools. Targets to reduce the amount of unhealthy food eaten should accompany this. The Soil Association report cites a range of good practice in schools, an initiative between Sopley Primary School and HC3S (Hampshire Catering) is presented as an excellent example. A recent survey also states that 80% of parents would like vending machines removed from schools or if staying only provide healthy products. www.soilassociation.org.uk

5.6. National School Fruit scheme. In 1991, the World Health Organisation recommended that people should eat at least five portions of fruit and vegetables every day, primarily to reduce the risk of cancer. The Committee on Medical Aspects of Food and Nutrition Policy (COMA) endorsed this recommendation in 1998 and added to the NHS plan. Results of the government's National Diet and Nutrition Survey showed that `among four to 18 year olds, one in five eat no fruit at all in a week'. Comparisons with other countries show that fruit and vegetable consumption among children in the UK is substantially less. Research has also shown that `the strongest determinants of fruit and vegetable consumption in adults were whether they had been in the habit of eating many fruit and vegetables in childhood'.

5.7. The Welsh Assembly voted on 11 November 2003 to accept plans to provide primary school children with free school breakfast. The Assembly was acting on research from Reading University that found that 9 to 16 year olds performed better at mental tasks after a conventional breakfast that contains `complex carbohydrates'. The Assembly plans to pilot the scheme in schools in socially deprived areas in 2004. By September 2006, all primary schools will have the chance to participate and are encouraged to use local sources of food where possible. Of Wales' 1,700 primary schools, 34 currently offer breakfast. www.wales.gov.uk

5.8. The King's Fund, in June 2002, published the results of research into `What young people think makes schools healthy'. A questionnaire, devised by a group of young people aged 12-18, asked students to vote for their top three out of fourteen issues. The questionnaire was sent to all 650 secondary schools in London, 392 were returned from students in 41 secondary schools. The responses, ranked by importance, showed school food to be the top concern (98%) and PE lessons and fitness to be the third (82%). Additional comments highlighted that:

_ 45% of respondents did not have breakfast, some respondents did not eat all day

_ Concerns over price and monotony of school meals, and the need for more culturally appropriate food

_ Two thirds of respondents did two hours or less physical education a week (British Heart Foundation recommends an hour a day)

_ Having a choice of activities made PE more enjoyable


Findings from this research were fed into the `Improving London Young Peoples Programme' www.kingsfund.org.uk

6. Hampshire projects

6.1. In Hampshire research and interviews showed that a lot of effort is going into improving children's diet and activity levels, however there is little, if any, overall coordination of work, projects or funding. Pockets of good practice exist in comparative isolation; these need be shared with other agencies in the same community for information and with other communities to spread good practice.

6.2. The Hampshire Healthy Schools Scheme is designed to assist schools in planning and delivering an effective programme of health education that will develop a whole school community. The scheme covers seven health related focus areas, each school will select two areas initially but can progress to others when ready

_ Drug education

_ Environmental factors for health

_ Emotional health and well being

_ Healthy eating

_ Physical activity

_ Safety (including safe transport to school)

_ Sexual health and relationships education


Participating schools receive £300 towards supply costs, resources, training and some PSHE advisor time. In Hampshire approximately 315 schools are participating with 80 having achieved validation (Annex C2). Hampshire is working towards achieving the free school meal (FSM) target that was set nationally. There are approximately 86 schools with FSM eligibility of these 25 are already taking part in the healthy schools campaign. Annex C3 gives a breakdown of schools and their areas.

An acknowledged benefit in many schools focusing on healthy eating has been the `water is cool' scheme. This allows easy access to water at all times and confirms research that children who are not dehydrated have higher attention spans.

6.3. My School Lunch is a new initiative by HC3S (Hampshire Catering) to engage with more schools and pupils to raise awareness of, and change patterns to, healthier eating. This is done through healthy and varied menus for pupils to choose from and a focus on balance and education. In addition they have initiated:

_ A child friendly, interactive web site that provides information and resources for teachers and parents, and educational games for children.


_ A school reward scheme that awards points to schools for any extra school meals eaten. The points can be exchanged for outings, equipment resources etc.


HC3S also encourages schemes such as swipe cards that don't identify or discriminate against children claiming free school meals and therefore increase take-up. The most recent school to join this scheme is Whitchurch Primary School. HC3S provide the catering for all but nine primary schools however they only provide for nineteen secondary schools. They would like to engage with a higher number of schools across Hampshire and are encouraging schools to buy food from local providers.

6.4. Active Schools - focuses on a review of the PE programme and, like NHSS, aims to gain whole school improvements. In Hampshire approximately 300 schools are signed up for the Active Schools programme with 18 schools accredited. As a result of `Gameplan' sports partnerships are to be established around secondary schools with sports college status and will include all neighbouring schools to form local clusters, or webs. Funding from Sport England will pay for staff to work with local webs promoting and monitoring activities. All schools must be linked to a partnership web by 2006. To date there is five designated specialist Sports Schools in Hampshire: - Brighton Hill (Basingstoke), Hamble, Henry Court (Fareham), Perins (New Alresford), and Toynbee (Chandlers Ford). The aim, eventually, is to have eight

6.5. School Travel Plans (STP's) Funding is available from the Department of Education and Skills to schools that produce travel plans which will reduce school traffic in the local community and encourage young people to walk/cycle to school. At the moment 25% of all schools have STP's, this must increase to 60% by 2006. (Annex C4)

6.6. Out of School Care (OSC) - an increasing number of schools are providing before, after or holiday out of school clubs as part of the governments Childcare Strategy. Many clubs provide breakfast, snacks and tuck shops without an established policy on healthy eating. A promotion of `Healthy Play' could build on initiatives already in place in the school. The Early Education and Childcare Unit is responsible for support and training to such clubs and could play a lead role in joining up `in' and `out' of school initiatives.

6.7. Community Dieticians are funded by the PCT's and priorities for work are determined by the PCT local development plan (LDP). All support the NHSS by going into the classroom to lead health promotion sessions on healthy eating and diet. The Community Dieticians highlighted that inappropriately short lunch breaks (20 /30 minutes) in many secondary schools can act as a barrier to young people being able to access a healthy lunch. Many schools that have reduced the lunch break period have done so in an effort to reduce staffing costs.

6.8. Directors of Public Health work closely with health promotion colleagues to support the NHSS at both a strategic and local level. A lifestyle survey had been carried out by East Hants and Fareham and Gosport PCT's that took a holistic look at young peoples lifestyles rather than just focussing on weight and height. In addition Mid Hants and Fareham and Gosport PCT's weigh all children entering school and the latter has also won an award for it's `water is cool' scheme

6.9. Borough and District councils were contacted to establish what support they gave for healthy eating and physical activity in their area. Responses from Basingstoke, East Hants, Eastleigh, Rushmoor and Test Valley show a high degree of involvement towards physical activity and school travel plans. Only East Hants and Test Valley reported active involvement with healthy schools scheme. Test Valley is also a member of the Food Forum.

6.10. Hampshire Strategic Partnership has released its Community Strategy for consultation. Within it, Theme 2 - Health and Well-being (Annex C5) acknowledges that `more young people are leading sedentary lifestyles that cause ill health and obesity'. Despite this acknowledgement none of the four outcomes specifically target improvements for school age children.

7. Questionnaires to PCT's and responses

7.1. The Health Development Agency (HDA) issued clear guidance to PCT's showing how the NHSS contributed to national priorities and needed to be embedded into their LDP's. The HDA also advise that the 20% free school meal target should be reflected in local strategic plans. In order to ascertain how this was happening in Hampshire each PCT was sent a questionnaire in October requesting information on how they supported the NHSS through their LDP (Annex C6). Responses were received from Blackwater Valley and Hart, East Hants, Fareham and Gosport, Mid Hants and North Hants. Responses are still awaited from Eastleigh and Test Valley South and New Forest PCT's. No clear pattern emerged of a uniform approach by PCT's to supporting the NHSS although it was evident that there was an enormous amount of support for the scheme. A table of responses is attached as Annex C7.

7.2. Only Fareham and Gosport PCT includes plans for supporting NHSS through their LDP. Two PCT's included support through their service level agreement with the Health Authority. No PCT included the free school meal target in the LDP but three stated it was an integral part of their work.

7.3. All respondents provide funding to the NHSS through direct grant and allocated staff time.

7.4. All five PCT's have designated members of staff supporting the NHSS, although not all have Dieticians and School Nurses involved.

7.5. Only Mid Hants did not work in partnership with other agencies in their area to promote NHSS but all were engaged in working with parents at some level.

7.6. Two PCT's suggested that the Sports Partnership Co-ordinators may be able to collect information on levels of physical activity

7.7. Three PCT's raised concerns over obesity and fitness levels of school age children. East Hants PCT also mentioned the inequity of funding within the NHSS.

8. Conclusions

8.1. National research and statistics show a significant growth in the levels of obesity and overweight in children that is accompanied by a decrease in physical activity levels especially in young people. The combined result of these trends will be a growth in health problems in adult life and a huge burden on health services.

8.2. There are indications that children and young people would like to be able to eat healthier but it is not made the easy option. Awareness and sensitivity should be maintained for the potential for children and young people to acquire eating disorders

8.3. The working group recognise that there is a vast number of professionals, carers and volunteers across the county who are working to support and improve lifestyles for children and young people. Many areas of work could benefit from a more co-ordinated and joined up approach provided by a commonly owned vision.

8.4. In discussion, the Medical Research Council suggested that Hampshire statistics on overweight and obesity would reflect national trends. Although this may well be true we need to have an accurate understanding of trends at a local level. This can only be achieved by professionals pooling information to build up accurate local maps which can then be used as the basis for locality planning and development

8.5. The National Healthy Schools Scheme (NHSS) is recognised as a key component of the review. The scheme provides a potential door for many issues connected with diet and activity to be addressed and for children to benefit from the whole school involvement in its themes.

8.6. In answer to the initial questions posed for this review. Sadly, we do not know how healthy school age children in Hampshire are. However with the right strategic leadership we have a dedicated and enthusiastic workforce who can help establish this information.

9. Recommendations

Please see over for Recommendations and Action Plan

Review Recommendations and Action Plan

Health of School Age Children