NICE Coronary heart disease

Coronary Heart DiseaseGuidance for implementing the preventive aspects

of the National Service Framework

The Health Development Agency

The Health Development Agency (HDA) is a special health authority with a remitto improve the health of people in England and in particular, to reduce

inequalities in health. It achieves this by:

• Working with key statutory and non-statutory organisations at national,regional and local level

• Finding out what works and maintaining this evidence base

• Turning the evidence into action by building up the skills and capacity ofthose working to improve the public’s health

• Advising on the setting of standards for public health planning andpractice.

Contents

iiiINTRODUCTION

Methods used to develop the guidance 1Focusing on coronary risk factors 3

PREVENTION OF CHD THROUGHPROMOTING HEALTHIER LIFESTYLES 5

Chapter 1: REDUCING SMOKING PREVALENCE 7

1.1 Introduction 71.1.1 The National Service Framework

for coronary heart disease 71.1.2 Benefits of smoking cessation for CHD 81.1.3 Trends in smoking 8

1.2 Objectives of interventions to reduce smoking 91.3 Features of effective interventions 91.4 Components of a local strategy 10

1.4.1 Develop smoking cessation services 101.4.2 Reduce smoking in public places

including workplaces 121.4.3 Support national media campaigns 131.4.4 Use media advocacy 131.4.5 Monitor the voluntary advertising ban 141.4.6 Reduce sales of cigarettes to children

under 16 years old 141.4.7 Encourage the introduction of smoking

policies in schools 141.5 Reducing inequity 15

1.5.1 Black and minority ethnic groups 151.6 Tables of suggested activities to support

local actionIntervention, Evidence, Outcome, Who could be involved?,Skills and resources, Points to consider, Further information 17

1.7 References 21

Contents

Coronary heart disease: guidance for implementing the preventive aspects of the NSF

iv

Chapter 2: IMPROVING DIET AND NUTRITION 25

2.1 Introduction 252.2 Objectives of nutritional interventions 25

2.2.1 Professional knowledge and expertise 262.3 Features of effective interventions 272.4 Components of a local strategy 27

2.4.1 Schools 272.4.2 Local/community projects 282.4.3 Workplace 282.4.4. Healthcare 29

2.5 Reducing inequity 292.5.1 Black and minority ethnic groups 302.5.2 Children 30

2.6 Tables of suggested activities to support local actionIntervention, Evidence, Outcome, Who could be involved?, Skills and resources, Points to consider, Further information 31

2.7 References 40

Chapter 3: INCREASING PHYSICAL ACTIVITY 43

3.1 Introduction 433.2 Objectives of physical activity interventions 433.3 Features of effective interventions 443.4 Components of a local strategy 44

3.4.1 Healthcare interventions 443.4.2 Exercise referral schemes 443.4.3 Workplaces 443.4.4 Mass media 453.4.5 Schools 453.4.6 Older people 453.4.7. Physically active transport 46

3.5 Reducing inequity 463.6 Useful sources of information about community

based programmes 473.7 Tables of suggested activities to support local action

Intervention, Evidence, Outcome, Who could be involved?, Skills and resources, Points to consider, Further information 48

3.8 References 54

Contents

v

Chapter 4: REDUCING OVERWEIGHT AND OBESITY 57

4.1 Introduction 574.2 Objectives of weight management 58

4.2.1 Definitions of ‘lifestyle’ weight managementinterventions 58

4.3 Features of effective interventions 594.3.1 Skills 60

4.4 Reducing inequity 604.5 Further information 614.6 Tables of suggested activities to support

local actionIntervention, Evidence, Outcome, Who could be involved?, Skills and resources,Points to consider, Further information 63

4.7 References 68

STRATEGY DEVELOPMENT 71

Chapter 5: DEVELOPING A LOCAL STRATEGY 73

5.1 Establishing a local CHD implementation team 735.1.1 Milestones and goals 73

5.2 Developing local delivery plans 735.3 Building effective partnerships 74

5.3.1 New freedoms to promote and supportjoint working 74

5.3.2 Making the partnership effective 755.4 Involving local communities 75

5.4.1 Consulting local communities 765.4.2 Developing capacity 775.4.3 Engaging ‘excluded’ groups 77

5.5 Health needs assessment 775.6 Community profiling 775.7 Equity profiling 78

5.7.1 Audit of current provision 785.7.2 Personal and professional development audit 78

5.8 Monitoring progress 795.8.1 Developing local targets 805.8.2 Monitoring frameworks 82

5.9 Illustrative monitoring frameworks5.10 Further sources of information 875.11 References 90

Appendix 91Contributors 91

Glossary 93

Coronary heart disease is the biggest killer of men and women in this country. More than 111,000 people die fromthis condition, and about 300,000 have heart attacks every year. The national service framework for coronary heartdisease (NSF CHD), which the government published in March 2000, is our blueprint for tackling this chronic disease.This document is a key component of that blueprint.

The framework and The NHS plan describe a range of strategies to diagnose, treat and care for people who sufferfrom heart disease, and also how to prevent it occurring in the first place. The health service must give people whowant to make changes to their lifestyles, the support and advice that they need. Effective interventions at an earlystage will not only reduce the immediate risks, but also slow down the progression of the disease, identify the earlysymptoms and limit the incidence of death and long term incapacity.

This document explains how this is possible at local level. It provides evidence-based examples of effective interventionsfor dealing with all the primary risk factors for heart disease – smoking, poor nutrition, physical inactivity, overweightand obesity. It is, in effect, an early warning system for tackling heart disease.

I am confident that the document will help to transform prevention services throughout the NHS.

Alan MilburnSecretary of State for Health

Foreword by the Secretary of State for Health

i

The prevention of coronary heart disease (CHD) is agovernment priority. The white paper Saving lives: ourhealthier nation [Department of Health (DH) 1999] set atarget of reducing the death rate from heart disease,stroke and related conditions by 40% in those agedunder 75 years by the year 2010. CHD is common,frequently fatal and largely preventable. The burden ofheart disease is higher, and has fallen less in the UK than many other countries. It is the leading cause of death,killing over 110,000 people in England in 1998, including more than 41,000 under the age of 75 years (DH 2000a).

The recently published NHS plan reinforces CHD as a clinical priority and focuses on preventive aspects of the disease. The Plan emphasises theimportance of the NHS role of working in partnership with others to address health inequalities (DH 2000b). The plan highlights theimportance of the NSF CHD which, for the first time, sets out national quality standards for preventive and clinical services.

The HDA, at the request of the DH, has developed thisguidance. It is intended to assist local implementationteams [health authorities (HAs), primary care groups(PCGs) and primary care trusts (PCTs), local authorities(LAs) and other local stakeholders] in developing theirapproaches to addressing the preventive aspects of theNSF CHD. It therefore relates to Standards 1, 2, 3, 4 and 12 (see Box on the next page). The guidance should be read in conjunction with the NSF CHD main report (DH 2000c), Chapter 1 of the NSF (DH2000a) and relevant sections of Chapter 2 (DH 2000d) and Chapter 12 (DH 2000e). The HDA’sHealth update: coronary heart disease and strokeprovides useful information on trends and risk factors (HDA 2000).

The guidance covers strategy development andinterventions to promote CHD-related healthier lifestyles (smoking, nutrition, physical activity and weight management). In the strategy section, approaches that should underpin all health improvement work are covered briefly and furtherinformation is signposted where available. In the sections on risk factors, key objectives are presented that will contribute to CHD prevention together with an overview of effective approaches that will promotehealthier lifestyles. In addition to CHD, the risk factorsand the strategies listed in this resource will also have a significant impact on other initiatives in publichealth, such as The cancer plan, the forthcoming NSF for older people and the NSF on diabetes. A range of interventions to be developed locally issuggested, involving a range of players in a variety of settings, which could link with other local initiatives.

This work is evolving and represents the first stage ofsupport for those working on preventive aspects of the NSF CHD at a local level (see box on next page). The HDA welcomes comment on this document and suggestions on how to improve the guidance. Please contact Karen Ford ([email protected])or Hilary Whent ([email protected]) at the HDA.

Methods used to develop the guidance

A range of research and expert opinion has been drawnupon in preparing this report. Systematic reviews andliterature reviews have been scanned, and literaturesearches and consultation with expert informants havebeen carried out. Some 65 critical readers were sent afirst draft of this document and amendments were madein the light of their comments.

Introduction

Introduction

1

The HDA takes a broad approach to evidence, valuing arange of research methods, which contribute to themultidisciplinary nature of health improvement work.Implications from the research evidence have been drawnout and recommendations for local action are made.Gaps in the evidence base have been highlighted.

A broad front approach: upstream anddownstream

The government recognises the socio-economicinfluences on population health. In its strategy to improve

public health, it identifies the complex interaction of causes of poor health, and recommends action right across government to reduce social inequalities in health (DH 1999). Thegovernment’s strategy is informed by the evidence from the Independent Inquiry into Inequalities in Health, chaired by Sir Donald Acheson (Acheson 1998). This recommended that a broad front approach be taken to tackle the underlying, root causes of inequalities in health. The inquiry reported that policies to improve health are needed both ‘upstream’ and ‘downstream’.


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Preventive aspects of the National Service Framework

Reducing heart disease in the population

Standard 1

The NHS and partner agencies should develop, implement and monitor policies that reduce the prevalence ofcoronary risk factors in the population, and reduce inequalities in risks of developing heart disease.

Standard 2 The NHS and partner agencies should contribute to a reduction in the prevalence of smoking in the general population.

Milestones: pages 20–21 of NSF CHD (DH 2000c)

Prevention of coronary heart disease in high risk patients in primary care

Standard 3GPs and primary care teams should identify all people with established cardiovascular disease and offer themcomprehensive advice and appropriate treatment to reduce their risks.

Standard 4GPs and primary care teams should identify all people at significant risk of cardiovascular disease but who have notyet developed symptoms and offer them appropriate advice and treatment to reduce their risks.


Cardiac rehabilitation

Standard 12NHS trusts should put in place agreed protocols/systems of care so that, prior to leaving hospital, people admitted tohospital suffering from coronary heart disease have been invited to participate in a multidisciplinary programme ofsecondary prevention and cardiac rehabilitation. The aim of the programme will be to reduce their risk ofsubsequent cardiac problems and to promote their return to a full and normal life.


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‘For instance, a policy which reduces inequalities inincome and improves the income of the less well off, and one which provides pre-school education for all four year olds are examples of “upstream” policies which are likely to have a wide range ofconsequences, including benefits to health. Policiessuch as providing nicotine replacement therapy onprescription, or making better facilities for takingphysical exercise, are “downstream” interventionswhich have a narrower range of benefits’ (Acheson1998).

This guidance document fully endorses this approach to improving health.

Where evidence is available on the impact of upstream policies, it is reported. However, for the most part, there is greater evidence of the impact ofdownstream policies. There are more reported studies of interventions aimed at individuals (lifestyle and health related behaviours) than there are of policies that seek to influence the broader determinants of CHD.

This preponderance of research aimed at assessing the effectiveness of downstream policies should not beseen as evidence that downstream policies are moreeffective than upstream policies. It simply reflects the fact that downstream policies tend to be more amenableto research efforts that seek to assess the effectiveness of interventions.

Focusing on coronary risk factors

‘... by April 2001 all NHS bodies, working closely with local authorities will have agreed and becontributing to the delivery of local programmes of effective policies on:a) reducing smoking b) promoting healthy eatingc) increasing physical activityd) reducing overweight and obesity’(DH 2000c, page 57; DH 2000a, page 18)

The NSF CHD focuses on three main lifestyle behaviours that are associated with risk of CHD: smoking, physical activity and diet. It also focuses on obesity, which is associated with both these last two factors, and is also independently associated with some

increase in CHD risk. In addition, there is now strongevidence that a moderate intake of alcohol reduces the risk of CHD, but an excessive alcohol intake increases the risk.

Quantifying the impact of risk factors on CHD

It is hard to give figures for the proportion of CHD thatcould be prevented if lack of physical activity, poor diet(high fat, low fruit and vegetables) and smoking weresuccessfully eliminated. This is because many people withheart disease have multiple risk factors, and it is hard todisentangle the separate effects. The American PublicHealth Association did make an attempt at such anestimate (Smith and Pratt 1993) and the results areshown in the box below. A similar modelling exercise inthe UK would be expected to produce slightly differentfindings because more of the UK population are smokers,while fewer are obese. However, the information is usefulin giving some indication of the relative importance ofthese risk factors in terms of the potential for making animpact on CHD rates.

In the following sections, information is presented abouteffective interventions, which aim to bring about changein these risk factors. Implications are drawn from theevidence and suggestions are made for local action at anumber of levels, involving a range of players and linkingto other local initiatives. Further information sources arealso signposted.

The gaps have been identified in the evidence base. There is an urgent need for more and better designedevaluations of interventions aiming to improve health andwell being and the dissemination of results. Evaluation is

Introduction

Proportion of CHD attributable to variousmodifiable risk factors in the USA

Risk factor Best estimate Range% %

Cholesterol >200 mg/dl 43 39–47Physical inactivity 35 23–46Cigarette smoking 22 17–25Obesity 17 7–32

Source: Smith and Pratt (1993)

a planned set of activities, which helps people to see how work is progressing and whether or not it iseffective. It should be seen as an integral part of projectsand programmes. Evaluation requires relevant skills and it is worth considering making links with local researchers(within the NHS, LAs and academic institutions). There are many approaches to evaluation and sources of supportare listed on p89.

References

Acheson, D., 1998. Independent inquiry into inequalities in health.

London: The Stationery Office.

DH, 1999. Saving lives: our healthier nation. London: The Stationery Office.

DH, 2000a. National service framework for coronary heart disease:

Chapter 1. Reducing heart disease in the population. London: DH.

DH, 2000b. The NHS plan. A plan for investment. A plan for reform.


DH, 2000c. National service framework for coronary heart disease: main

report. London: DH.

DH, 2000d. National service framework for coronary heart disease,

Chapter 2. Preventing coronary heart disease in high risk patients.

London: DH.

DH, 2000e. National service framework for coronary heart disease:

Chapter 12. Cardiac rehabilitation. London: DH.

HDA, 2000. Health update: coronary heart disease and stroke.

London: HDA.

Smith, C. and Pratt, M., 1993. Cardiovascular disease. In: R. Brownson,

P. Remington and J. Davis, eds. Chronic disease epidemiology and

control. Washington: American Public Health Association.


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1.1 Introduction

Smoking is the cause of one out of every seven deathsfrom heart disease (nearly one in four deaths among menand one in 10 among women). Nine in 10 deaths fromlung cancer among men and nearly three in four amongwomen are estimated to have been caused by smoking –84% of all lung cancer deaths. Among those aged under65 years, two in five deaths from stroke were caused bysmoking. Smoking is also linked to many other seriousconditions, including asthma and other respiratory illnesses, cataracts, peripheral vascular disease,periodontal disease and brittle bone disease (Callum1998). Treating the illnesses and diseases caused bysmoking is estimated to cost the NHS up to £1.7 billionevery year (Raw et al. 1998).

Passive smoking – breathing in other people’s tobaccosmoke – is also a major cause of mortality and morbidity.It contributes to death from heart disease and a range ofother health problems (Royal College of Physicians 1992).

In December 1998, the Government’s first-ever whitepaper on tobacco, Smoking kills, set three targets, foradults smoking, smoking during pregnancy and childrensmoking (DH 1998a).

• To reduce adult smoking in all social classes so that the overall rate falls from 28% to 24% or less by2010, with a fall to 26% by the year 2005. In terms oftoday’s population, this would mean 1.5 million fewersmokers in England.

• To reduce the percentage of women who smokeduring pregnancy from 23% to 15% by the year 2010,with a fall to 18% by the year 2005. This will meanapproximately 55,000 fewer women in England whosmoke during pregnancy.

• To reduce smoking among children from 13% to 9% or less by the year 2010, with a fall to 11% by the year 2005. This will mean approximately110,000 fewer children smoking in England by the year 2010.

The cancer plan published in September 2000 introduces new national and local targets to address inequalities in smoking rates between socio-economic groups. At a national level the target is:

• To reduce smoking rates among manual groups from32% in 1998 to 26% by 2010 (DH 2000a).

1.1.1 The National Service Frameworkfor coronary heart disease

The NSF CHD (DH 2000b) states that ‘by October 2000 HAs, LAs, PCGs/PCTs and NHS trusts will have set up, or have firm plans in place [for a range of NHSsmoking cessation services which will enable national and regional targets for the numbers of smokers quitting to be met]. By April 2001, HAs, LAs, PCGs/PCTsand NHS trusts will have agreed and be contributing tothe delivery of the local programme of effective policieson reducing smoking; as an employer, have implementeda policy on smoking and be able to refer clients/serviceusers to specialist smoking cessation services, includingclinics …’

The immediate priorities for implementing the smokingcessation area of the NSF CHD are:

• By April 2001, health authorities will introducespecialist smoking cessation clinics, helping 150,000people

Chapter 1Reducing smoking prevalence

Reducing smoking prevalence

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• Delivering the early milestones set out in Chapter 1 ofNSF CHD: Reducing heart disease in the population(DH 2000b).

The requirements of smoking cessation are detailed in Appendix A, Chapter 1 of NSF CHD: Reducingheart disease in the population (DH 2000b).

1.1.2 Benefits of smoking cessation for CHD

The costs and benefits of smoking cessation are wellestablished (Raw et al. 1998).

• Reductions in smoking prevalence are guaranteed to bring population health gains (Raw et al. 1998; US Department of Health and Human Services 1990).

• Smoking cessation reduces the risk of dying fromsmoking related diseases.

Smokers have about twice the risk of dying fromCHD compared with lifetime non-smokers. Thisexcess risk is reduced by about half among ex-smokers after only one year of abstinence anddeclines gradually thereafter. After 15 years ofabstinence, the risk of CHD is similar to that ofpeople who have never smoked (Tang et al. 1992).

Smoking cessation is particularly important in thesecondary prevention of CHD. In smokers with existing CHD, the risk of premature CHD mortalitycan be reduced by 50% or more on giving up (USDepartment of Health and Human Services 1990).

• Reductions in smoking prevalence will produce sizeablereductions in common hospitalised events and costs(Naidoo et al. 1999).

• The cost savings that can be made through moderatesuccess in smoking cessation programmes aresignificant and cumulative (Naidoo et al. 1999).

1.1.3 Trends in smoking

AdultsThe prevalence of smoking in the UK over the past 20years or so has fallen. In 1998, 27% of adults aged 16 years and over smoked cigarettes compared with 40%

in 1978. However, most of this decline occurred in the1970s and 1980s. In the 1990s, the decline in smokingprevalence among adults levelled off (DH 2000c).

The prevalence of smoking is higher among people inmanual than non-manual social classes (32% comparedwith 21% in 1998). The widening of this gap over thepast 20 years reflects a steeper decline in smokingprevalence among non-manual classes compared withmanual classes (DH 2000c).

The social class differentials in smoking are reflected inthe social gradients of deaths caused by smoking. Thepercentage of deaths from ischaemic heart diseasecaused by smoking ranges from 39% for men aged35–64 years in social classes I–II to 49% of those inclasses IV–V. For women aged 35–64 years the figuresrange between 35% for classes I–II to 46% for classes IV–V (Callum 1998).

Pregnant womenThe proportion of women who smoke during pregnancyhas fluctuated over the past eight years (Owen et al. 1998;Owen and Penn 1999). In 1999 nearly a third of women(30%) smoked during pregnancy compared with 27% in1992. Among young pregnant women (aged 16–24 years)from social groups C2DE (similar to manual and unemployedclasses), the percentage is even higher, with 51% smokingduring pregnancy in 1999 (Owen and Penn 1999).

TeenagersIn 1999, an estimated 9% of children aged 11–15 yearssmoked cigarettes (DH 2000c). This figure has variedconsiderably over time, showing a low of 8% in 1988and a high of 13% in 1996 (DH 2000b). As the majorityof smokers take up the habit in their teens, any increasesin the rates of young smokers will eventually feedthrough into adult smoking rates.

Black and minority ethnic groupsCigarette smoking among minority ethnic groups isgenerally less than among the UK population as a whole(28%1). However, a more detailed examination revealsimportant differences between and within groups. Thesmoking rate among Bangladeshi men is very high (49%).


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1Differences between the HEA (1999a) and DH (2000c) surveys in

timing and methodology most likely account for the 1% difference in

the estimates of the percentage of adults who smoke.

This same group of men also has high rates of chewingtobacco products. Smoking rates are even higher amongmiddle-aged and older Bangladeshi men (54% and 70%for men aged between 30–49 and 50–74 years,respectively). Smoking rates among African-Caribbeanmen and women resemble, and sometimes exceed, therates for the UK population as a whole. Smoking ratesamong African-Caribbean women are higher for youngerwomen [Health Education Authority (HEA) 1999a].

Poverty and smokingTraditional measures of social class tend to underplay theextent to which smoking has become concentrated in thepoorest sections of society. Recent studies have shownthat smoking levels have remained virtually unchangedamong those in the poorest groups, and among lonemothers smoking levels have risen (Marsh and McKay1994; Dorsett and Marsh 1998; Jarvis 1998). In a detailedstudy, lone parents living in rented accommodation andrelying on social security benefits were found to havesmoking levels in excess of 75% (Dorsett and Marsh 1998).

1.2 Objectives of interventions to reduce smoking

The importance of a comprehensive approach has longbeen recognised (WHO 1979). As well as approachesaimed at the individual, there has been a recognition ofthe need for policy and legislative measures and socialand environmental initiatives as essential components ofany strategy to reduce tobacco use (WHO 1998). Ideally,each component of such a comprehensive strategy wouldencompass the following objectives:

• Promote quitting (not cutting down) among adults andyoung people

• Reduce exposure to environmental tobacco smoke

• Create a social environment that is supportive of non-smoking and cessation.

In the context of reducing smoking among adults, asecondary objective could include strategies to preventthe uptake of smoking among young people. However, it is important to note that there is little evidence thatteenage strategies, especially in the absence of adultstrategies, have any impact on the uptake of smokingamong children (Reid 1996; Hill 1999).

Local strategies to reduce smoking prevalence shouldreflect the policies and population groups set out in thewhite paper on tobacco Smoking kills (DH 1998a), TheNHS plan (DH 2000d, Chapter 13), NSF CHD (DH 2000b)and The cancer plan (DH 2000a).

Local strategies should also include an alliance of NHS,local government, education and commercial interests, as well as voluntary agencies, to help reduce smokingand to provide information on smoking by using localmedia, creating local activities and promoting debate togenerate interest. Some areas of the country already have smoking alliances. These cover about 60% of thepopulation of England and are supported by the DH.

1.3 Features of effective interventions

A comprehensive approach – combining community wideapproaches with economic and regulatory measures –was identified by the US Surgeon General as the strategy most likely to have the greatest long-term,population impact (US Department of Health and Human Services 2000). Educational and clinicalapproaches were considered to be of greater importance in helping individuals resist or abandon the use of tobacco.

Community wide approaches typically involve a range of agencies including health services, voluntary agencies, the media (paid and unpaid), as well as government andlocal authorities (see 5.3, Building effective partnerships,p74). Together, they undertake a range of activities suchas direct smoking cessation, helplines, training andresources for health professionals, development ofpolicies to reduce smoking in public places, mediacampaigns and advocacy, reducing sales to minors andwork in schools. Overall, community interventions seek toinfluence both individual behaviour and the environmental,social and cultural conditions that affect tobacco use(Lantz et al. 2000).

The impact of a comprehensive approach is difficult toevaluate, especially given the potential for individualcomponents to work synergistically to produce combined effects (Chapman 1993; US Department ofHealth and Human Services 2000). For example, theeffectiveness of school based programmes appears to be enhanced when they are included in broad basedcommunity interventions (Lantz et al. 2000). Nevertheless,


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studies that have sought to measure the effects of acomprehensive approach have yielded encouragingresults (US Department of Health and Human Services2000; Lantz et al. 2000; Sowden and Arblaster, 2000a,b;Wakefield and Chaloupka 2000).

It is accepted that population-wide approaches should aimto reduce both adult and teenage smoking. But where shouldthe emphasis lie? Experts agree that teenage smoking ratesare unlikely to decline in the absence of a fall in adult rates.The view that smoking among adults should therefore betackled ahead of teenagers was discussed by Hill (1999)in a recent article. His argument is fivefold:

• First, reducing smoking among adults will lead to aquicker and bigger reduction of tobacco related harm, because there is a higher level of smokingrelated mortality and morbidity among adults thanteenagers

• Second, reducing smoking among adults will provideprotection to the unborn and recently born againstexposure to direct and indirect tobacco smoke

• Third, quitting by adults (especially by parents) reducesthe likelihood of children taking up smoking

• Fourth, while there are clear ethical reasons foreducating children about what is the largestpreventable cause of death, beyond this, the methodsof delivering interventions are fraught with practicalproblems and the evidence of effectiveness ofinterventions aimed at young people is poor

• Finally, the fact that the tobacco industry itselfsupports antismoking campaigns targeted at teenagersshould be taken as a warning signal: ‘Even PhillipMorris was confident that [antismoking] youthcampaigns could do them little damage’ (Hill 1999).

1.4 Components of a local strategy

1.4.1 Develop smoking cessation services

• The health improvement programme (HImP) shouldemphasise the importance of an integrated serviceincluding primary care advice, specialist smoking cessationclinics, one-to-one cessation advice [Health Service Circular(HSC) 1998, 1999; Action on Smoking and Health

(ASH) 2000a,b]. The requirements for smoking cessationare detailed in Appendix A, Chapter 1 of NSF CHD:Reducing heart disease in the population (DH 2000b).

• Build upon and develop these guidelines for localcessation services.

• Provide special services for pregnant women.

The NHS plan (DH 2000d) states that ’the specialistsmoking cessation services will focus on heavilydependent smokers needing intensive support, and onpregnant smokers as part of antenatal care. Primary caregroups will take the lead in commissioning – and whereappropriate providing – these services’. In support of thesmoking cessation treatments bupropion is now availableon prescription and The NHS plan recommends thatnicotine replacement therapy (NRT) should also be madeavailable on prescription. These services followedevidence based guidelines for smoking cessationpublished in December 1998 (Raw et al. 1998). Theseguidelines have been updated and will be available inDecember 2000. The Committee on Safety of Medicineswill consider whether NRT can be made available forgeneral sale. An evaluation of the first year of thedevelopment of the national cessation services hasrecently been published (Adams et al. 2000).

At a meeting of smoking cessation experts held in July2000, it was agreed that the smoking cessation servicesshould offer support to all people who request it. Thefocus on particular groups could be achieved throughrecruitment to the services – for example by engagingmidwives or promoting the services at antenatal classes(ASH 2000a,b; http://www.ash.org.uk/?cessation). Themeeting, with representation from the DH, identified amodel approach to smoking cessation services in primarycare, which also sought to provide clarification on the roleof intermediate cessation services. Discrepancies in theguidelines concerning intermediate services had causedconfusion in some health action zones (HAZs) (Adams etal. 2000). Both intermediate services and specialist clinicshave been subsumed in the model by the term ‘qualifyingspecialist services’ for which a minimum standard ofservice to the smoker has been set and for which thecentrally provided smoking cessation budget may be used.

The model of the service is set out in Figure 1 on facingpage. For full details and further guidance see: http://www.ash.org.uk/?cessation


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Model of the service to the smokerEach smoker contacting the NHS should be offered apackage of both pharmaceutical aids and behaviouralsupport that meets their particular needs and circumstances.Given restrictions on who can prescribe drugs, andlimitations on the extent to which those who mayprescribe are able to offer support, it will not always bepossible to provide a ‘one-stop shop’. The aim must be tomake access to drugs and support as straightforward aspossible. The elements of the support package include:

• Influences on smokers’ motivations to quit, includingadvice from primary care professionals, nationalcampaigns, No Smoking Day and manufacturers’advertising

• Brief opportunistic interventions by the GP and otherprimary care professionals

• Prescribing pharmacotherapies: NRT and bupropion(Zyban)

• Behavioural support. This will need to be tailored tomatch the circumstances of the smoker, but the rangeof options includes:

Referral to a ‘qualifying’ specialist service – thesewould qualify for funding from the smokingcessation budgets if they offered a certain minimum service standard

Discussion of other support options (eg telephone,self-help) that the smoker could consider, if he/shechose not to attend a qualifying specialist service.

Reducing smoking during pregnancyFor pregnant women, pregnancy specific materials aremore cost effective than less specific, cheaper, standardinformation because of their greater effectiveness (Buckand Godfrey 1994). The intensity of the intervention alsoaffects outcome. While there is some evidence of theeffectiveness of advice when literature is coupled withfollow up, more intensive interventions (eg a structured


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Figure 1. Configuration of smoking cessation support services.

cessation course based on self-help booklets) providestronger evidence (Raw et al. 1998). Public educationcampaigns may be effective in shifting pregnant women’sattitudes and behaviour (Campion et al. 1994). Thedifficulties of advising outright cessation in pregnancy hasled some health professionals to suggest cutting down asan alternative. However, there is little evidence to showthat cutting down is of any health benefit (Raw et al.1998). Thus quitting as opposed to cutting down needsto be emphasised.

Many women who do stop smoking in pregnancy goback to smoking after the birth of the baby. In oneAmerican study over half (56%) of women who stoppedduring pregnancy were smoking within one month of thebirth (Secker-Walker et al. 1995). Relapse preventioninterventions with pregnant women and women whohave recently given birth are needed.

• All those responsible for providing antenatal careshould ensure that relapse prevention is included as a component in the smoking cessation service.

The lower rate of cessation associated with mothers from lower socio-economic groups, led the ScientificAdvisory Group on Inequalities to conclude that‘interventions that target the individual behaviour alone may not be sufficient ... broader policies to combat inequality are also required’ (Acheson 1998).

Further information on smoking and pregnancy can beobtained in the following reports:

• Smoking and pregnancy: a survey of knowledge,attitudes and behaviour 1992–1999 (Owen and Penn1999)

• Smoking and pregnancy: guidance for purchasers andproviders (HEA 1994a)

• Helping pregnant smokers quit: training for healthprofessionals (HEA 1994b)

• Smoking and pregnancy: developing a communications strategy for cessation (Owen and Bolling 1996)

• Smoking and pregnancy: a growing problem (HEA1996a).

Mechanisms for delivering cessation services for youngpeople are outlined in the document Smoking cessationin young people: should we do more to help youngpeople quit? (HDA 2000a).

1.4.2 Reduce smoking in public places including workplaces

Restricting smoking is important not only for limiting thepublic’s exposure to toxins in sidestream smoke, but alsofor broader policy reasons. First, it puts smoking in abroader context than one of personal choice and personalrisk and legitimises it as a social problem; second, it maybe the source of litigation against employers or businesses;and third, the spread of smoking restrictions reduces theopportunities to smoke and thus reduces consumption(Borland et al. 1991; Brenner and Mielck 1992; Marcus etal. 1992; Wakefield et al. 1992; Jeffery et al. 1994;Glasgow et al. 1997; Brauer and Mannetje 1998).

The Health and Safety Executive (HSE) has beenexamining current practice on restricting smoking at workwith a view to issuing an Approved Code of Practice (ACoP).There are potential legal liabilities for employers who donot address passive smoking in the workplace. Employeeshave recourse to civil law, contract and employment lawand the general provisions of the Health and Safety atWork Act (1974). The ACoP will clarify the legal positionfor both employers and employees, and enable LAenvironmental health officers (EHOs) to intervene.

Local plans should include objectives to:

• Ensure that all local hospitals have smoking policies(DH 1998a; HEA 1999b), and that these are fullyimplemented

• Implement policies to restrict smoking in public places[Scientific Committee on Tobacco and Health (SCOTH)1998]

• Encourage restaurants, bars and other leisure facilitiesto provide smoke free areas.

Many employers now find an advantage in smokingrestrictions through savings on sickness absences,increased productivity, lower insurance and cleaningcosts. The checklist in Box 1.1 will help managers ofworkplaces to develop an effective strategy on smoking.


12

Further informationFor examples of case studies of effective practice withinthe NHS see Tobacco control policies within the NHS:case studies of effective practice (HDA 2000b). For furtherinformation on developing, reviewing and amendingtobacco control policies, see Been there, done that: revisitingtobacco control policies in the NHS (HEA 1999b). Samplepolicies and consultation questionnaires can be found inSmoking policy for the workplace: an update (HEA 1999c)and Towards tobacco-free environments: guidelines forlocal authorities (HEA 1999d). Also see the ASH website:http://www.ash.org.uk

1.4.3 Support national media campaigns

Mass media campaigns can influence smoking behaviour(DH 1998a; Lantz et al. 2000; Sowden and Arblaster2000a,b) and may be especially appropriate for reachingthose who are less educated (Mackaskill et al. 1992) andthose in poor communities (Jenkins et al. 1997). Messagecontent and the intensity and duration over which themessages are delivered appear to be important factors indetermining the impact of mass media campaigns (Greyet al. 2000; Lantz et al. 2000).

Media campaigns should focus predominantly on adults,since the majority of cigarettes (>95%) are consumed byadults and adult smokers are a major factor influencingthe uptake of smoking by minors.

Local media may be used to raise the profile of nationalcampaigns (No Smoking Day). For ideas in planning localmedia campaigns see: http://www.no-smoking-day.org.uk/campaign.htmTel: 020 7916 8070.

• Local plans should include links to the network of localsmoking control alliances in England.

1.4.4 Use media advocacy

There is some evidence that the use of media advocacy(see Box 1.2) may affect tobacco consumption (Buck andGodfrey 1994), but its major role is in social marketing.This involves shaping the media agenda, prompting policychanges and influencing the social norms aroundsmoking (Reid et al. 1992). Media advocacy techniques


Box 1.1 Management checklist for a smoking policy

• Review current situation.• Assess need, capacity to change.• Make sure you consult with everyone.• Seek feedback, not permission.• Decide on the policy details.• Decide on a total or partial ban.• Decide what restrictions to impose if a total ban

is not possible.• Communicate final decisions clearly to all staff.• Label smoking and smoke-free areas.• Monitor and review the policy.

Source: HEA (1999c)

Box 1.2 Checklist for setting up local media advocacy work

First think about the following points:• What you hope to achieve• Who your campaign is aimed at• How much you think it will cost• How it will be supported by local activity and

action• How you plan to evaluate it (have you achieved

what you hoped?).

Create a media plan:• What stories or angles will attract the media?• What information is needed for a newsworthy

press release?• Draw up a media list – names and contact

numbers of relevant journalists• Find out the deadlines for media you are

targeting• Find out how media contacts want you to

communicate with them (press release, directcontact)

• Decide who will act as spokespersons• Coordinate media schedules with partners who

may also be using the media• If the campaign is a long one, create a media

calendar to ensure a constant supply of newsitems.

13

may be especially effective with poor communities(Jernigan and Wright 1993) since low income groups,including smokers, are high consumers of TV.

For further guidance on media advocacy and factors thatinfluence its effectiveness, see An investigation into thepotential of media advocacy as a health promotionstrategy (HDA in press).

1.4.5 Monitor the voluntary advertising ban

Indirect marketing of cigarette brands is the growing andpreferred marketing strategy of the tobacco industry,perhaps in response to threats of advertising restrictions.Until legislation is introduced, the existing ‘voluntaryagreements’ on tobacco promotion should continue to be monitored locally, not so much because theserestrictions have been found to be effective in preventinguptake of smoking, but because infringement of the rules offers opportunities for media advocacy. Thoseprovisions include, for example, banning advertising onbillboards near schools and promotions in magazines foryoung people.

People working locally should be vigilant in monitoring anynew marketing strategies, for example, using events atdiscos, student functions and the Internet to promote brands.

1.4.6 Reduce sales of cigarettes to children under 16 years old

Combining regular test purchasing with a high profilemedia approach has been found to be successful inreducing the incidents of reported sales of cigarettes topeople under 16 years of age. Overall, the evidence ofeffectiveness of sales restrictions suggests that vigorouslocal enforcement of the law forbidding sale of tobaccoto under-16s can reduce sales (Stead and Lancaster2000). This strategy has also been shown to have a small delaying effect on the uptake of smoking amongchildren. There is little evidence, however, to suggest thatit has any effect on the uptake of smoking amongchildren. Considerable resources are required, both interms of trading standards officers’ and court time.

The existing law is not being applied effectively (DH1998a). The Local Government Association and LocalAuthorities Co-ordinating Body on Food and Trading are

developing a new enforcement protocol to address this.Features of the protocol are listed in Box 1.3.

Proof-of-age card schemes have been developed, but thegovernment recommends that a single system be agreed. Thevending machine trade association, the National Associationof Cigarette Machine Operators, has produced a new,stricter code for its members to clarify siting arrangementsand monitoring for vending machines (DH 1998a).

1.4.7 Encourage the introduction of smoking policies in schools

A formal, well publicised school policy on smokingreinforces non-smoking as the norm in society, supportshealth messages in the curriculum and may have positive effects on smoking levels among pupils, staff and all adult users of the premises (see Box 1.4).Additional potential benefits include reducedabsenteeism, reduced costs and elimination of theharmful effects of passive smoking.

• Provide support to schools to introduce no smokingpolicies.

The National Curriculum Science Order recommends thatteaching the harmful effects of tobacco, alcohol andother drugs should begin at Key Stage 2 (age 7–11years). The Office of Fair Standards and Training inEducation (OFSTED) 1999 report Drug education inschools and the Department for Education andEmployment (DfEE 1998) report Protecting young people:good practice in drug education in schools and the youth


Box 1.3 Enforcement protocol

• Local authorities should publish a clear statementon underage tobacco sales.

• Ensure that all shops and vending machinesdisplay notices stating the law.

• Use test purchases to assess local compliance byretailers. Gather information about premiseslikely to be breaching the law.

• Use media advocacy to raise the profile locally.• Educate to increase compliance.• Detail enforcement action taken, prosecutions

and fines, to act as a deterrent.

14

service recommend teaching young people from the ageof five years upwards about the risks and consequencesof tobacco, alcohol and drug use, together with teachingthe life skills needed to resist the pressure to misuse thesesubstances. Teaching should clearly cover issues relevantto the child’s age and experience. This frequently entailstackling smoking and alcohol-related issues first, as theseare the substances that young people will generally beexposed to first.

1.5 Reducing inequity

With little or no decline in the lowest income groups,smoking has become concentrated in Britain’s pooresthouseholds. For example, among lone parents on benefitsand living in council housing, more than three-quarterssmoke (Dorsett and Marsh 1998). Moreover, recentresearch suggests that nicotine dependence is higher inpeople experiencing disadvantage (Jarvis and Wardle1999). In keeping with these findings, the Independent

Inquiry into Inequalities in Health recommended a short-term strategy to reduce nicotine dependence, which islikely to be stronger in disadvantaged smokers, throughthe provision of free NRT. A complementary, longer-termstrategy aims at removing the cultural and environmentalbarriers that disadvantaged people face. Communitybased interventions, brief advice from a GP andspecialised smoking clinics are also recommended aseffective settings in which to provide NRT (Acheson 1998).

Attempts to set up community based projects to promotesmoking cessation have met with mixed success. In areport of initiatives set up in low income communities inScotland, the authors concluded that:

‘small grant funding for time limited projects canpromote work on smoking amongst women livingor working in low income communities. Althoughreducing smoking was a long term goal for themajority of the initiatives most did not perceivethemselves as a cessation group. As a result they did not measure success by the numbers quitting.Changes in individual smoking behaviours werenoted and these ranged from extending the period of smoke free time, to restricting smoking to a specific room or location and trying nicotinereplacement therapy’ (ASH Scotland and HEBS 1999).

Examples of other community based projects fundedthrough small grants schemes can be found inEmpowering smokers to quit: success principles forcommunity stop-smoking projects (HEA 1996b).

The use of mass media, especially TV, may be particularly appropriate for reaching less educated and/ordisadvantaged smokers. This reflects the tendency for theless educated to receive information from TV more oftenthan those who are more educated (Buck and Godfrey1994). Indeed, research has shown that mass mediaantismoking campaigns can have a significant impact onlow income and low educational groups (Macaskill et al.1992; Jenkins et al. 1997).

1.5.1 Black and minority ethnic groups

Little has been published on the impact of smokingcessation interventions in reducing tobacco use amongblack and minority ethnic groups in England. However,studies from the USA suggest that they can be effective


15

Box 1.4 Checklist for a school’s smoking policy

• Put the development of a smoking policy on theagenda.

• Review the current situation.• Identify staff with sufficient skill and seniority to

take responsibility for developing a new policy ifnecessary.

• Form a working party involving key people fromthe school and community, if appropriate.

• Establish a rationale for the policy.• Identify educational, health and economic

reasons for introducing a policy or improvingexisting conditions.

• Draft the policy.• Evaluate the draft policy by consulting with all

relevant parties, identify potential constraints andproblems.

• Inform everyone about the policy before it isimplemented.

• Allow sufficient time for implementation of thenew policy – three to six months is considered areasonable time between initiating andimplementing the policy.

• Monitor the operation of the new policy.

(Botvin et al. 1992; Elder et al. 1993; Lillington et al.1995; Elder et al. 1996). In the absence of UK studies,patterns of tobacco use (HEA 1999a) and research intothe role of tobacco within and between black andminority ethnic groups (Maltby et al. 2000) can providesome pointers for the way forward. Examples of these arehighlighted below (HEA 1999a; Maltby et al. 2000).

• The high rates of tobacco chewing, especially among Bangladeshis, suggests that this practice should be included in interventions aimed at reducingtobacco use.

• Sensitivity to gender issues is vital.

• Literature should be multi-lingual and in a style that isculturally familiar (eg use of vignettes to highlighthealth risks associated with tobacco use).

• Information campaigns should be developed to redressmisperceptions about tobacco use (eg belief thattobacco use can relieve indigestion; belief that healthypractice in other areas such as diet and exercise willoffset the detrimental effects of smoking).

• Ethnic differences in attitudes and beliefs aboutcigarette smoking should be incorporated into smokingcessation interventions.

Thus, to be successful, a tobacco cessation campaignmust take account of the culture, tradition and religion of the particular target group. In so doing it

will need to involve community groups, religious groups,smoking cessation coordinators, local tobacco alliances,primary health care (PHC) teams, culturally relevant localand national media as well as key individuals withindifferent ethnic groups.

In response to ethnic health inequalities, the governmenthas announced that £1,000,000 will be made available to help reduce the high rates of smoking among certainethnic groups.

Further information on black and minorityethnic groupsDH, 1996. Directory of ethnic minority initiatives, G60/008 3934 1P 5K

May 96 (23). London: DH.

Gervais, M. and Jovchelovitch, S., 1998. The health beliefs of the

Chinese community in England: a qualitative research study.

London: HEA.

HEA, 1999. Black and minority ethnic groups and tobacco use in

England: a practical resource for health professionals. London: HEA.

HEA, 2000. Black and minority ethnic groups in England: the second

health and lifestyles survey. London: HEA.

McKeigue, P. and Sevak, L. 1994. Coronary heart disease in South

Asian communities. London: HEA.

Sproston, K., Pitson, L., Whitfield, G. and Walker E., 1999. Health

and Lifestyles of the Chinese population in England. London: HEA.


16


17

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18

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994;

Rei

d 19

96).

Can

enh

ance

nat

ural

qui

t ra

te a

ndm

ay r

educ

e re

laps

e (R

eid

1996

;M

cVey

and

Sta

plet

on in

pre

ss);

may

also

red

uce

upta

ke o

f sm

okin

g in

youn

g pe

ople

(Sow

den

and

Arb

last

er 2

000a

).

Briti

sh H

ospi

talit

yA

ssoc

iatio

n, T

heRe

stau

rant

Ass

ocia

tion,

Brit

ishIn

stitu

te o

fIn

nkee

ping

, Bre

wer

san

d Li

cens

edRe

taile

rs A

ssoc

iatio

n,A

ssoc

iatio

n of

Lice

nsed

Mul

tiple

Reta

ilers

, em

ploy

ers

and

empl

oyee

s, N

HS.

Nat

iona

l and

loca

lm

edia

, com

mun

ityse

ttin

gs a

ndac

tiviti

es, w

orkp

lace

san

d pu

blic

pla

ces.

Inte

rven

tion

Oth

er t

reat

men

ts

Evid

ence

Insu

ffic

ient

evi

denc

e of

eff

ectiv

enes

sfo

r hy

pnot

hera

py a

nd a

cupu

nctu

re,

etc.

(Abb

ot e

t al

. 200

0; W

hite

et

al.

2000

).

Wh

o c

ou

ld b

ein

volv

ed?

Priv

ate

sect

or, l

inks

with

oth

er s

mok

ing

cess

atio

n pr

ovid

ers.

In v

iew

of

lack

of

evid

ence

bas

e,co

nsid

er c

onta

ctin

gre

cogn

ised

prof

essio

nal

asso

ciat

ions

for

trai

ned

indi

vidu

als.

Skill

s an

d r

eso

urc

es

Cos

tly; r

equi

res

min

imal

leve

lof

exp

osur

e an

d de

velo

pmen

tof

new

mes

sage

s to

avo

idco

nsum

er b

urn-

out.

Poin

ts t

o c

on

sid

er

Smok

ers

shou

ld b

e gi

ven

info

rmat

ion

abou

t ot

her

trea

tmen

ts t

o en

able

the

m t

om

ake

an in

form

ed c

hoic

ew

ithou

t di

scou

ragi

ngat

tem

pts

to s

top.

Lev

el o

ftr

aini

ng li

kely

to

vary

fro

mno

ne t

o su

ffic

ient

to

just

ifym

embe

rshi

p of

a p

rofe

ssio

nal

body

(Raw

et

al. 1

998)

.

Cha

rter

agr

eed

betw

een

gove

rnm

ent

and

licen

sed

hosp

italit

y tr

ade.

The

HSE

ispr

oduc

ing

a ne

w A

CoP

on

smok

ing

in t

he w

orkp

lace

,w

hich

will

pro

vide

pra

ctic

alad

vice

on

how

to

com

ply

with

the

law

.

Hig

h re

ach;

wor

ks w

ell w

ithot

her

inte

rven

tions

suc

h as

tax

incr

ease

s; c

an s

uppo

rtlo

cal c

essa

tion

serv

ices

; foc

ussh

ould

be

on a

dults

.

Furt

her

info

rmat

ion

Briti

sh H

ypno

ther

apy

Ass

ocia

tion

(BH

A),

1W

ythb

urn

Plac

e, L

ondo

nW

1H 5

WL

Tel:

0207

723

4443

, em

ail:

fireb

ird@

agon

et.c

o.uk

Briti

sh S

ocie

ty o

fH

ypno

ther

apist

s (B

SH),

37O

rbai

n Ro

ad, L

ondo

n SW

67J

Z Te

l: 02

0 73

85 1

166

Ass

ocia

tion

of G

ener

alPr

actit

ione

rs o

f N

atur

alM

edic

ine

(AG

PNM

), 38

Nig

elH

ouse

, Por

tpoo

l Lan

e,Lo

ndon

EC

1N 7

UR

Te

l: 02

0 74

05 2

781.

Inst

itute

of

Com

plem

enta

ryM

edic

ine

(ICM

), PO

Box

194

,Lo

ndon

SE1

6 1Q

Z Te

l: 02

0 72

37 5

165.

DH

(199

8a),

HEA

(199

9c,d

).Th

e N

atio

nal H

SE (N

HSE

) is

deve

lopi

ng a

too

lkit

to h

elp

with

the

impl

emen

tatio

n of

its p

olic

ies.

DH

sm

okin

g po

licy

team

,D

H c

omm

unic

atio

ns t

eam

,re

view

of

use

of m

ass

med

iaca

mpa

igns

in E

ngla

ndav

aila

ble

from

HD

A (G

rey

etal

. 200

0). C

ochr

ane

Libr

ary

web

site

htt

p://w

ww

.upd

ate-

soft

war

e.co

m/c

libho

me/

clib

Ou

tco

me


20

One

yea

r ne

t qu

it ra

tes

estim

ated

0.3

–0.5

% (R

eid

etal

., 19

92; B

uck

and

God

frey

1994

); in

fluen

ce o

n pu

blic

opin

ion;

pro

vide

s ba

sis f

orot

her

initi

ativ

es; m

ayco

ntrib

ute

to im

pact

of

mas

sm

edia

cam

paig

n;

exte

nds

deba

te a

bout

smok

ing.

Impa

ct o

f m

onito

ring

loca

lin

frin

gem

ent

of v

olun

tary

agre

emen

t no

t kn

own,

but

does

off

er o

ppor

tuni

ties

for

med

ia a

dvoc

acy.

Loca

l act

ivity

can

red

uce

sale

s; u

sefu

l for

med

iaad

voca

cy; m

ay h

ave

a sm

all

dela

ying

eff

ect

on c

hild

ren’

sup

take

.

Impl

emen

tatio

n va

ries

so t

hat

outc

ome

is un

clea

r; re

info

rces

non-

smok

ing

as t

he n

orm

;ot

her

pote

ntia

l ben

efits

incl

ude

redu

ced

abse

ntee

ism,

redu

ced

cost

s an

d el

imin

atio

nof

pas

sive

smok

ing.

Adv

erti

sing

ban

Redu

ce il

lega

l sal

es

Smok

ing

polic

ies

insc

hool

s

Poss

ible

eff

ect

on a

dult

cons

umpt

ion

and

teen

age

prev

alen

ce (R

eid

et a

l. 19

92;

Sow

den

and

Arb

last

er, 2

000a

).

Loca

l act

ivity

can

red

uce

sale

s. T

his

may

hav

e a

smal

l del

ayin

g ef

fect

on

child

ren’

s up

take

of

smok

ing.

Impa

ct o

n up

take

of

smok

ing

unce

rtai

n.

Gov

ernm

ent,

heal

thpr

omot

ion

spec

ialis

ts,

toba

cco

advo

cate

san

d ot

hers

can

mon

itor

exist

ing

volu

ntar

yag

reem

ents

.

Mag

istra

tes,

ret

aile

rs,

loca

l tra

ding

stan

dard

s of

ficer

s,sc

hool

s, p

aren

ts,

loca

l gov

ernm

ent

asso

ciat

ion,

LA

s,N

atio

nal A

ssoc

iatio

nof

Cig

aret

te M

achi

neO

pera

tors

.

Scho

ol t

each

ers,

gove

rnor

s, h

eads

,pa

rent

s, p

upils

, loc

alco

mm

unity

(for

polic

ies

that

invo

lve

non-

smok

ing

insc

hool

pre

mise

s fo

rco

mm

unity

act

iviti

es).

Inte

rven

tion

Med

ia a

dvoc

acy

and

No

Smok

ing

Day

Evid

ence

Effe

ctiv

enes

s lo

wer

tha

n m

ore

inte

nsiv

e in

terv

entio

ns b

ut h

ighl

yco

st-e

ffec

tive

beca

use

the

reac

h is

muc

h gr

eate

r (R

eid

et a

l., 1

992;

Buck

and

God

frey

199

4).

Wh

o c

ou

ld b

ein

volv

ed?

NH

S, lo

cal

gove

rnm

ent,

com

mer

cial

inte

rest

s,vo

lunt

ary

agen

cies

.

Skill

s an

d r

eso

urc

es

Che

aper

tha

n pa

idad

vert

ising

but

sub

stan

tial

reso

urce

s re

quire

d fo

rge

nera

ting

stor

ies;

good

con

tact

s w

ith lo

cal

med

ia a

nd t

he le

isure

and

hosp

italit

y tr

ade.

Tra

inin

g in

med

ia a

dvoc

acy

need

ed.

Requ

ires

subs

tant

ial

reso

urce

s.

Poin

ts t

o c

on

sid

er

Relie

s on

goo

d lin

ks w

ithot

her

agen

cies

(eg

volu

ntar

yse

ctor

, loc

al g

over

nmen

t,ho

spita

lity

trad

e) t

o cr

eate

loca

l act

iviti

es.

Loca

l act

ivity

cou

ld in

clud

em

onito

ring

infr

inge

men

ts t

ovo

lunt

ary

agre

emen

ts (e

gad

vert

ising

on

billb

oard

s ne

arsc

hool

s, p

rom

otio

ns in

mag

azin

es a

imed

at

youn

gpe

ople

).

Exist

ing

law

sta

tes

that

it is

illeg

al t

o se

ll to

bacc

opr

oduc

ts t

o un

der

16s,

but

enfo

rcem

ent

is pr

oble

mat

ic.

Poss

ibly

add

s to

per

cept

ion

that

sm

okin

g is

a fo

rbid

den

frui

t (K

ay S

cott

Ass

ocia

tes

2000

).

Supp

orts

hea

lth m

essa

ges

inth

e na

tiona

l cur

ricul

um.

Furt

her

info

rmat

ion

http

://w

ww

.no-

smok

ing-

day.

org.

uk/c

ampa

ign.

htm

Ex

ampl

e of

goo

d pr

actic

e:Ro

y C

astle

Goo

d A

ir A

war

ds

DH

(199

2). I

ssue

d w

ith D

Hci

rcul

ar E

L (9

2) 7

1.

Nat

iona

l Ass

ocia

tion

ofC

igar

ette

Mac

hine

Ope

rato

rsha

s pr

oduc

ed a

cod

e fo

rm

embe

rs. L

ocal

Gov

ernm

ent

Ass

ocia

tion

(LG

A) a

nd L

ocal

Aut

horit

ies

Coo

rdin

atin

gBo

dy o

n Fo

od a

nd T

radi

ngha

ve p

rodu

ced

an L

Aen

forc

emen

t pr

otoc

ol.

HEA

(199

3, 1

999e

).

Ou

tco

me

1.7 References

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Sowden, A. and Arblaster, L., 2000b. Community interventions for

preventing smoking in young people, Cochrane Review. In: Cochrane


Stead, L. and Lancaster, T., 2000. A systematic review of interventions

for preventing tobacco sales to minors. Tobacco Control, 9, 169–176.

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rapidly does the excess risk of ischaemic heart disease disappear?

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benefits of smoking cessation, a report of the Surgeon General, DHHS

Publication No. CDC 90-8416. Rockville, MD: National Centers for

Disease Control and Prevention, Office on Smoking and Health.

US Department of Health and Human Services, 2000. Reducing tobacco

use, a report of the Surgeon General, DHHS Publication No. CDC20402,

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Control and Prevention, Office on Smoking and Health.

Wakefield, M. and Chaloupka, F., 2000. Effectiveness of comprehensive

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23

Box 2.1 Identification of barriers to healthy eating and interventions to address them: an example

Chapter 2Improving diet and nutrition

Improving diet and nutrition

252.1 Introduction

Diet plays a fundamental role in the development ofCHD. The type and amount of fat and its relationship toblood cholesterol levels have been recognised for sometime as being particularly influential. Salt intake has beenimplicated in relation to blood pressure and, more recently,an increased intake of fruit and vegetables has beenidentified as an important factor in reducing the rates of both heart disease and some cancers (DH 1994,1998). The promotion of healthy eating is important inreducing the risk not only of CHD but also of otherchronic conditions, such as obesity and diet related cancers.

Effective strategies to promote healthy eating are generallythose that work at several levels. It is important to identifythe barriers to dietary change in the local population andthen select interventions to address them (see Box 2.1).

2.2 Objectives of nutritional interventions

Diet is one of the key modifiable risk factors in theprevention of CHD. The government’s Committee on the Medical Aspects of Food and Nutrition Policy(COMA; DH 1994) recommended a reduction in fat(particularly saturated fat), a reduction in salt and anincrease in complex carbohydrates. In addition, fruit and vegetable consumption should be increased by atleast 50% (to at least five portions per day). Therecommendations are summarised in nutrition briefing papers produced by the HEA (1992, 1996). Also, it has been estimated that around one-third of all cancers might be influenced by diet. In 1998,COMA reviewed the evidence on diet and cancer in theUK (DH 1998). The working group recommendationswere consistent with other dietary recommendationsmade for the prevention of obesity, diabetes andcardiovascular disease.

Barrier

• Belief that the family is already eating enough fruitand vegetables

• Dislike of taste of vegetables and lack of confidencein cooking and preparing them; fear of waste andof rejection by the family

• Difficulty in finding affordable, good quality fruitand vegetables locally

Intervention

• Information about five portions a day and portionsizes

• Set up cooking skills clubs and tasting sessions, ordevelop cooking sessions as part of the activities ofexisting groups (eg women’s groups, youth groups)

• Set up community owned retailing and food cooperatives to introduce affordable supplies

26

In promoting a healthy balanced diet to reduce the risk ofcardiovascular disease and diet related cancers in thepopulation, interventions should focus on the following:

• Reducing the amount of fat, and in particular, theamount of saturated fatIt has been estimated that a 10% reduction insaturated fat intake within the UK population wouldbe associated with a reduction in CHD mortality ofbetween 20% and 30% (Marmot 1994). Therefore, tohelp achieve a healthy diet, people should beencouraged to use reduced fat spreads and dairyproducts in place of full fat versions, to replace oils andfats high in saturates with those high inmonounsaturates, to reduce the amount of fat used incooking, to trim fat from meat and to reduce theamount of products such as biscuits, pastries, cakes,and crisps in the diet.

• Increasing the amount of fruit and vegetableseaten to at least five portions each dayApart from being rich sources of carbohydrate, dietaryfibre, antioxidants and other bioactive factors, fruit andvegetables are also rich sources of potassium, which isassociated with lower blood pressure and a lower riskof stroke (Joshipura et al. 1999). For many people, thiswill mean almost doubling their intake. It will meanhaving fruit and vegetables at most meals, and assnacks between meals. Access to affordable, goodquality supplies of fruit and vegetables must beensured and skills and confidence to prepare and cookfruit and vegetables should be developed [NationalHeart Forum (NHF) 1997].

• Increasing the intake of fibre rich, starchy foods,such as bread, potatoes, pasta and rice, by half asmuch againMake these foods the main part of most meals, andreplace fattier snacks.

• Reducing the average salt intake by around athirdThere is now a consensus that dietary sodium is afactor in the development of high blood pressure (DH 1994). People should be encouraged to graduallyreduce the salt they add to food, both in cooking andat the table. Also, people should be more aware oflow-salt alternatives to processed foods if available andshould recognise the salt content of processed foodsby reading food labels.

• Increasing the amount of fish eaten to at leasttwo portions each week, one of which should bean oily fish Encourage people to eat fish more often: this maymean working with communities to develop theircooking skills and confidence to cook fish.

A useful tool to support health promoters in promoting abalanced diet is The balance of good health [HEA, DH andMinistry of Agriculture, Fisheries and Foods (MAFF) 1994].It shows what proportion of the diet should come fromthe different food groups and could provide a consistentand easily understood message about a balanced diet1.

The balance of good health has also been modified foruse with black and minority ethnic groups. The BritishDietetic Association and Sainsburys have developed anAfrican-Caribbean version and the British NutritionFoundation has produced a model suitable for use withthe Chinese community. Dietitians at WandsworthCommunity Health Trust, with support from SpillersMilling, formed a healthy alliance and produced a versionsuitable for use with South Asian groups.

2.2.1 Professional knowledge and expertise

Identifying the barriers and developing an integratedprogramme of complementary activities will require theinput of staff with a range of skills. While most areashave access to a community dietitian, it is quite commonfor clinical duties to interfere with the dietitian’s ability tospend time in the community. In planning the resourcesneeded to implement the strategy, it may be worthconsidering ring fencing a block of dietitian time todevote to community work. Public health nutritionists canprovide the expertise to develop and implement a publichealth nutrition strategy and to work on other nutritionissues at a population level. In recent years, the NutritionSociety has introduced a registration system for publichealth nutritionists (RPH Nutr). In addition, the NutritionSociety has recently developed an associate registration


1The balance of good health does not apply to children under two years

of age, who need a diet that is higher in fat and lower in fibre rich,

starchy foods, to children aged between two and five years (a gradual

transition towards a diet consistent with The balance of good health is

needed here) or to people with special dietary requirements or those

under medical supervision.

• Clear goals were set, based on theories of behaviouralchange, rather than relying on the provision ofinformation alone

• There was personal contact with individuals or smallgroups sustained over time

• Participants received personalised feedback on anychanges in their behaviour and risk factors

• Changes in the local environment were promoted, forexample in shops and catering outlets to help peoplechoose a healthy diet.

Providing information alone is not a solution. Improvingpeople’s knowledge about diet does not necessarily lead to behaviour change. Improvements in knowledge should be accompanied by the development of skills and provide the opportunity to put the knowledge intopractice. For example, there is little point in encouraging people to eat more fish, in particular oilyfish, if access to these foods is not available, and ifpeople lack the skills and confidence to prepare and cook fish. Integrated programmes of activity could bemore effective if they first identify the barriers to dietary change, and then provide the information, skillsand opportunities to put the suggestion into practice(NHF 1999).


2.4.1 Schools

A meta-analysis of 12 intervention studies to promoteheart-healthy eating behaviour in schools concluded thatthey can have a significant effect (McArthur 1998).

Two reviews have identified the following features of aneffective school intervention (Contento 1995; Roe et al.1997):

• Nutrition education interventions are more likely to beeffective when they employ educational strategies thatare directly relevant to a particular behaviour (eg dietor physical activity) and are derived from appropriatetheory and research

• Interventions need adequate time and intensity to be effective


27

scheme for newly qualified public health nutritionprofessionals who have not yet accumulated the three years’ experience required for full registration as a public health nutritionist. The Register of Public Health Nutritionists can be found onhttp://www.nutsoc.org.uk/RPHNutr.html or contact JackieLandman at the Nutrition Society (020 7602 0228) forfurther information on the associate scheme.

Local people are an important addition to this skill base.Research suggests that the efficiency and effectiveness ofcommunity based interventions can be improved by usinglocal people to complement the work of healthprofessionals. McGlone et al. (1999) suggested that ‘iflocal food projects are to work, then they must genuinelyinvolve local people’. Services provided by local peopleare often considered more appropriate and moreaccessible for the health needs of the community. Suchservices foster self-reliance, community participation andcan help overcome barriers. They also allow access togroups that are typically hard to reach and can beparticularly beneficial for black and minority ethnicgroups. These benefits are two way, as local people havethe opportunity to develop their own skills. Exploratorywork with this peer education approach (Hodgson et al.1995; Kennedy et al. 1999) showed that it was possibleto achieve both significant increases in nutritionknowledge and potentially beneficial changes in thedietary practices of low income families. The bestapproach appears to be one in which guided ‘hands on’food preparation/cooking sessions allow the participantsto acquire knowledge and skills. However, it was notedthat this approach was resource intensive, particularly inprofessional staff time, and there is little evidence ofeffectiveness in terms of dietary change. This approachmay result in potential health, social and economicbenefits and therefore warrants further study.


A meta-analysis of randomised controlled trials shows that dietary interventions can be effective in reducingCHD risk factors (Brunner et al. 1997). A systematic reviewof the effectiveness of interventions to promote healthyeating found that characteristics of a successfulintervention had the following features (Roe et al. 1997):

• It focused on diet alone, or diet plus physical activityrather than tackled a range of risk factors

• Family involvement enhances the effectiveness of programmes for younger children

• Incorporation of a self-evaluation or self-assessmentand feedback is effective in interventions for older children

• Effective nutrition education includes consideration ofthe whole school environment and community

• Interventions in the larger community can enhanceschool nutrition education

• The most effective interventions focus on diet alone ordiet and physical activity.

2.4.2 Local/community projects

This section includes a range of interventions from small-scale local projects to well funded communityinterventions. Little rigorous evaluation of theeffectiveness of the small scale projects has been carried out.

Roe et al. (1997) concluded that intensive, smaller scaleprojects generally resulted in positive changes in diet andblood cholesterol, at least in the short term. However,many large community-wide studies failed to show asimilar effect because they were conducted in the 1980s,a time when awareness of CHD risk factors had increasedin the population. Therefore, in one study, the reductionin blood cholesterol observed in the interventioncommunities was also found in the comparisoncommunity. In addition, there was a diversity of otherinformational and educational interventions; therefore,the investigators were unable to attribute any change totheir specific intervention.

Effective community interventions appear to:

• Focus on diet or diet plus physical activity

• Use a theoretical model

• Use diverse multiple interventions at individual, group,community and environmental level

• Include small-group interventions (Contento 1995; Roeet al. 1997).

McGlone et al. (1999) identified the characteristics ofprojects that appear to have been ‘successful’ using arange of criteria:

• Flexibility needed by agencies to respond to the needsof particular communities

• Access to secure, and ongoing, funds

• Professionals work in partnership with a community

• Projects need to involve local people, and ensure equalrespect

• Evaluation should not be confined to narrow clinical andbehavioural measures. Include food purchasing patterns,structural changes and social outcomes, for example

• Strike a balance between partnerships and localownership

• Local and national networks should enable sharing ofexperiences

• Training for professionals and members of thecommunity to acquire skills for a new way of working

• Government policies that do not deter volunteers (egsocial welfare benefits)

• Provide incentives for local projects and smallbusinesses, such as tax relief

• Allow time for community projects to develop, on thebasis that there is no ‘quick fix’ and that local policyshould support realistic time frames for communityfood projects.

However, to date, there has been no systematicevaluation of the effectiveness of local projects.

2.4.3 Workplace

Three out of four good-quality interventions showedpositive effects of nutrition workplace interventions, withdecreases in blood cholesterol of between 2.5% and10% (Roe et al. 1997). An HEA review of theeffectiveness of health promotion interventions in theworkplace (Peersman et al. 1998) identified four studies


28

Another systematic review (Roe et al. 1997) includedinterventions in the primary healthcare setting. Four‘good quality’ studies were identified in the past 10 years. Modest and sustained effects on both blood cholesterol and dietary fat intake were achieved fordietary interventions only, or for multifactorialinterventions.

Characteristics of an effective healthcare interventioninclude:

• Small group or one to one counselling sessions

• Targeting higher risk groups, which is also more cost-effective (Van der Weidjen 1998; Wood et al. 1998)

• Family counselling and education for those at increasedrisk

• Tailoring to the personal characteristics of individuals

• Educational and behavioural frameworks which areclient centred

• Staff training and development (topic basedknowledge and counselling skills)

• Low intensity interventions, such as mailed, computergenerated, personalised, nutrition education materialfor well-motivated groups (Roe et al. 1997).


There are inequalities in diet between those on higher and lower incomes (Acheson 1998). The most striking difference is that people in lower socio-economic groups tend to eat less fruit andvegetables. The 1997 National Food Survey (MAFF 1998) found that consumption of fruit andvegetables by those in the upper socio-economic groups was a third higher than that of those in lowergroups. This social class difference has also been reported in children (Gregory et al. 2000). Studies have shown that people on a low income can describe a healthy diet as well as those on higher incomes (Lobstein 1997). Food poverty, affordability and access to a healthy and varied diet have beenidentified as possible barriers (Lobstein 1997; DH 1996).


29

on healthy eating with adequate methodologies. Threeshowed positive effects on fat, fruit and vegetable intake,intention to change the diet and self-efficacy.

Characteristics of an effective workplace interventioninclude:

• Visible and enthusiastic support and involvement frommanagement

• Involvement by employees at all levels in the planningand implementation phases

• A focus on definable and modifiable risk factors ratherthan multiple risk factor interventions

• Screening and/or individual counselling

• Changes to the composition of best selling foodsprovided in canteens and vending machines

• Tailoring to the characteristics and needs of theemployees

• Use of local resources in organisation andimplementation of the intervention

• Combine population based policy initiatives withintensive individual and group oriented interventions

• Built-in sustainability.

2.4.4 Healthcare

In a meta-analysis by Brunner et al. (1997), the studyparticipants were well motivated. Most studies wereconducted in either a healthcare or an institutionalsetting. Interventions included dietary advice to reduce fat or sodium and to increase fibre. The authorsestimated that, if changes in dietary behaviour weresustained, they could lead to a reduction in the incidenceof CHD by 14% and the incidence of stroke by 9%.

A meta-analysis by Yu-Poth (1999) reported a 10%reduction in plasma total cholesterol with a low intensityintervention, and a 13% reduction with the high intensityintervention. Tang et al. (1998) reported reductions in bloodcholesterol following individual dietary advice to modify fatintake: 8.5% at three months and 5.5% at 12 months.

raised by the recent National Diet and Nutrition Surveys,of children aged 11⁄2 to 41⁄2 years (Gregory et al. 1995)and 4 to 18 years (Gregory et al. 2000). Acheson (1998)concluded that ‘pre-school education or day care may beespecially effective in improving the achievement andhealth of the most disadvantaged children’. A recentreview by Tedstone et al. (1998) of the effectiveness ofinterventions to promote healthy eating in pre-schoolchildren aged 1–5 years found that pre-school and daycare centres were likely to be appropriate settings forinterventions, and that parental involvement mayenhance the effectiveness of interventions and should be facilitated. In more detail, the review reported that:

• Traditional, video or computer-based teaching methods were successful at increasing nutritionknowledge and the effectiveness was enhanced by theinclusion of parents

• Behavioural modification techniques using repeatedexposure to initially novel foods were successful inincreasing willingness to consume the foods only iftasting was facilitated as part of the exposure

• The use of reward to encourage consumption of foodswas not successful once the reward had been removed

• One to one diet counselling that was ‘needs focused’was successful at bringing about improvements in UKmothers.

Acknowledgement

Information in Table 2.6 concerning some of the local community interventions was drawn in part fromMaking Links – a toolkit for local food projects (Sustain2000).

30

The Acheson report (Acheson 1998) recommendedfurther development of policies that will ensure adequateretail provision of food to those who are disadvantaged.A report by Policy Action Team (PAT) 13 (1999)confirmed that accessing affordable, good quality fruitand vegetables within some local areas might be difficult.However, access should not be seen purely in terms ofphysical proximity, and other kinds of access need to beconsidered, for example, financial access, knowledge andinformation (HEA 1998a). In areas where a large proportionof the population is unemployed, on low income or inreceipt of benefits, interventions to improve people’saccess to a healthier diet are likely to be a key priority.

2.5.1 Black and minority ethnic groups

Improving the health of minority ethnic groups is also apriority in the government’s drive to reduce socialexclusion and inequalities in health. Further impetus wasprovided by Acheson (1998), who recommended that theneeds of black and minority ethnic groups be consideredspecifically. The HEA (2000) found that among black andminority ethnic groups, understanding of healthy eatingmessages varied widely across groups and knowledge offoods high in complex carbohydrates, fibre, fat andsaturated fat was often poor across all ethnic groups.There is, therefore, a need to raise awareness of the linksbetween diet and CHD among these groups and topromote culturally relevant messages.

2.5.2 Children

Early childhood experiences strongly influence dietarypreference and good eating habits. While they may nothave an immediate effect on the rates of CHD, strategiesto promote healthy eating among children will benefit inthe longer term. They will help to address the concerns



31

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ritio

nist

s, h

ealth

prom

otio

n sp

ecia

lists

, in

mee

ting

the

stan

dard

.

Poin

ts t

o c

on

sid

er

Scho

ols

agre

e pr

iorit

ies

with

coor

dina

tors

of

loca

l hea

lthy

scho

ol p

rogr

amm

es. H

ealth

yea

ting

may

not

be

the

first

prio

rity.

This

is an

opp

ortu

nity

to

beco

me

invo

lved

in t

hest

rate

gic

plan

ning

to

mee

tth

e he

alth

y ea

ting

stan

dard

.

Lega

l req

uire

men

ts f

or s

choo

llu

nche

s w

ill in

crea

se t

hepr

iorit

y fo

r he

alth

y ea

ting.

All

LEA

s ha

ve n

ow s

igne

d up

to a

chie

ve t

he N

HSS

.

Furt

her

info

rmat

ion

Futu

re o

f fo

od in

sch

ools

repo

rt(1

998)

. Ava

ilabl

e fr

eeof

cha

rge

from

Pen

ny R

olfe

,C

hart

wel

ls, Ic

knie

ld H

ouse

,40

Wes

t St

reet

, Dun

stab

le,

Beds

LU

6 1T

A.

McM

ahon

, W. a

nd M

arsh

,T.

, 199

9. F

illin

g th

e ga

p.C

hild

Pov

erty

Act

ion

Gro

up.

Cos

t £5

.00,

http

://w

ww

.cpa

g.or

g.uk

or94

Whi

te L

ion

Stre

et,

Lond

on W

1 9P

F. T

el: 0

2078

37 7

979.

The

ir w

ebsit

eal

so c

onta

ins

brie

fing

pape

rson

sch

ool m

eals

and

heal

thy

eatin

g an

d sc

hool

mea

ls in

Scot

land

.

Nat

iona

l Hea

lthy

Scho

olSt

anda

rd g

uida

nce.

DfE

E (1

999)

. Ava

ilabl

e fr

eefr

om D

fEE

Publ

icat

ions

, PO

Box

5050

, Ann

esle

y,N

ottin

gham

NG

15 0

DJ.

The

‘You

r he

alth

y sc

hool

’se

ctio

n of

http

://w

ww

.wire

dfor

heal

th.

gov.

uk

Food

– a

fac

t of

life

: ran

geof

tea

chin

g re

sour

cem

ater

ial f

or p

rimar

y an

dse

cond

ary

scho

ols

(Brit

ishN

utrit

ion

Foun

datio

n).

Con

tact

020

740

4 65

04 o

rht

tp://

ww

w.n

utrit

ion.

org.

uk

Nat

iona

l hea

lthy

scho

ol s

tand

ard

(NH

SS)

Crit

eria

for

hea

lthy

eatin

g, t

o in

form

impl

emen

tatio

n of

who

le s

choo

lap

proa

ch.


33

Ou

tco

me

Off

er b

road

er b

enef

its

(eg

pre-

and

aft

er-s

choo

lca

re).

Opp

ortu

nity

to

enco

urag

e th

ein

take

of

frui

t on

cer

eal,

asju

ice

or a

fter

sch

ool a

ssn

acks

. May

also

hel

p to

addr

ess

low

inta

kes

of ir

onan

d ot

her

mic

ronu

trie

nts

(Gre

gory

et

al. 2

000)

.

HEA

You

ng P

eopl

e an

dH

ealth

Sur

vey

(199

9) r

evea

led

that

alm

ost

one

in f

ive

(18%

)yo

ung

peop

le a

ged

11–1

6ye

ars

neve

r (o

r ha

rdly

eve

r)ha

d br

eakf

ast

befo

re s

choo

l(m

ales

13%

, fem

ales

23%

).

Inte

rven

tion

Evid

ence

34 b

reak

fast

clu

bs; b

reak

fast

clu

bev

alua

tions

cur

rent

ly u

nder

way

.

Wh

o c

ou

ld b

ein

volv

ed?

LEA

Dire

ct S

ervi

ceO

rgan

isatio

ns; s

choo

lca

tere

rs; h

ead

teac

hers

, sch

ool

gove

rnor

s an

d PT

As;

regi

onal

and

loca

lco

ordi

nato

rs o

f th

ehe

alth

y sc

hool

spr

ogra

mm

es; s

choo

lsnu

triti

on a

ctio

ngr

oups

(SN

AG

s);

Kello

gg’s

http

://w

ww

.bre

akfa

st-c

lubs

.co.

uk/

Loca

l hea

lthy

scho

ols

prog

ram

me.

Skill

s an

d r

eso

urc

es

Paid

sta

ff t

o pr

epar

e fo

odan

d su

perv

ise c

hild

ren;

venu

e, f

acili

ties

and

equi

pmen

t fo

r th

e sa

fe a

ndhy

gien

ic p

repa

ratio

n an

dst

orag

e of

foo

d; a

ctiv

ities

/re

sour

ces

to o

ccup

y th

ech

ildre

n; r

esea

rch

supp

ort

toev

alua

te s

ucce

ss o

fpr

ogra

mm

e.

Poin

ts t

o c

on

sid

er

Cou

ld f

orm

par

t of

a w

hole

scho

ol a

ppro

ach

to im

prov

ing

diet

.

Brea

kfas

ts a

nd s

nack

s of

fere

dne

ed t

o re

flect

The

bala

nce

of g

ood

heal

th(H

EA, D

H a

ndM

AFF

199

4) (e

g w

hole

grai

nce

real

s w

ith s

emisk

imm

edm

ilk a

nd f

ruit)

.

Free

EU

inte

rven

tion

stoc

ks o

ffr

uit

coul

d be

use

ful.

Frui

t is

avai

labl

e to

sch

ools

but

this

mus

t be

in a

dditi

on t

o no

rmal

supp

lies

and

not

used

as

part

of s

choo

l can

teen

mea

ls.

Cur

rent

ly, g

over

nmen

t is

fund

ing

brea

kfas

t cl

ubs

inar

eas

of d

epriv

atio

n,in

clud

ing

HA

Zs, e

duca

tion

actio

n zo

nes

(EA

Zs) a

nd S

ure

Star

t ar

eas,

to

help

tac

kle

heal

th in

equa

litie

s.

Furt

her

info

rmat

ion

Brea

kfas

t C

lubs

. A h

owto

…gu

ide.

Kel

logg

’s N

ewPo

licy

Inst

itute

and

Kello

gg’s

. Ava

ilabl

e fr

omht

tp://

ww

w.b

reak

fast

-cl

ub.c

o.uk

Stre

et, C

. and

Ken

way

, P.,

1998

. Fit

for

scho

ol –

how

brea

kfas

t cl

ubs

mee

t he

alth

educ

atio

n an

d ch

ildca

rene

eds.

New

Pol

icy

Inst

itute

.C

ost

£12.

50.

Don

ovan

, N. a

nd S

tree

t, C

.,19

99. F

ood

for

thou

ght

–br

eakf

ast

club

s an

d th

eir

chal

leng

es.N

ew P

olic

yIn

stitu

te. C

ost

£7.5

0.

Repo

rts

avai

labl

e fr

om:

New

Pol

icy

Inst

itute

, 109

Coo

perg

ate

Hou

se, 1

6Br

une

Stre

et, L

ondo

n E1

7N

J(te

l: 02

0 77

21 8

421)

.

Scot

tish

Com

mun

ity D

iet

Proj

ect,

c/o

Scot

tish

Con

sum

er C

ounc

il, R

oyal

Exch

ange

Hou

se, 1

00 Q

ueen

Stre

et, G

lasg

ow G

1 3D

N(te

l 014

1 22

6 52

61).

Emai

lsc

dp@

scot

cons

umer

.org

.uk

Web

site:

http

://w

ww

.die

tpro

ject

.co.

uk

Info

rmat

ion

on E

Uin

terv

entio

n st

ocks

of

frui

tfr

om t

he In

terv

entio

nBo

ard’

s fr

uit

and

vege

tabl

ew

ithdr

awal

sec

tion

(tel:

0118

953

169

4). A

nin

form

atio

n sh

eet f

or s

choo

lsis

avai

labl

e (fo

rm H

OR

18).

Scho

ol f

ood

polic

y gu

ide

prod

uced

by

SNA

G.

Con

tact

Joe

Har

vey,

Hea

lthEd

ucat

ion

Trus

t (te

l/fax

:01

789

7739

15).

Brea

kfas

t an

d af

ter

scho

ol c

lubs

Gov

ernm

ent

has

rece

ntly

fun

ded

230

scho

ol b

reak

fast

club

s as

par

t of

its

driv

e to

tac

kle

ineq

ualit

ies

in h

ealth

.


34

Clu

bs c

an s

timul

ate

inte

rest

and

conf

iden

ce t

o de

velo

pco

okin

g sk

ills

out

of t

hesc

hool

set

ting;

Coo

king

for

Kids

rep

orts

opp

ortu

nitie

s to

rein

forc

e nu

triti

on a

nd f

ood

hygi

ene

less

on t

augh

t in

clas

s, a

hea

d st

art

in Y

ear

7fo

od t

echn

olog

y; g

ettin

g to

know

new

sch

ool/t

each

er in

adva

nce;

opp

ortu

nity

to

build

inte

rest

and

ent

husia

sm f

orco

okin

g sk

ills.

Part

of

a ‘w

hole

sch

ool’

appr

oach

to

heal

thy

eatin

g;re

info

rces

the

tau

ght

curr

icul

um o

n he

alth

y ea

ting

and

oral

hea

lth; c

ompl

emen

tsth

e ne

w n

utrit

iona

l sta

ndar

dsfo

r sc

hool

lunc

hes;

pro

vide

sid

eal o

ppor

tuni

ty t

o in

crea

sefr

uit

and

vege

tabl

e in

take

san

d pr

omot

e sn

acks

saf

e fo

rte

eth.

Hea

lthy

tuc

k sh

ops,

brea

k ti

mes

and

vend

ing

Food

and

drin

ksav

aila

ble

at b

reak

times

are

an

impo

rtan

t pa

rt o

f a

who

le s

choo

lap

proa

ch t

o he

alth

yea

ting

and

are

anid

eal o

ppor

tuni

ty t

oin

crea

se c

hild

ren’

sfr

uit

and

vege

tabl

ein

take

s.

Food

Sta

ndar

ds A

genc

y ha

s fu

nded

thre

e st

udie

s pr

omot

ing

frui

t an

dve

geta

bles

in s

choo

ls (A

nder

son

et a

l., U

nive

rsity

of

Dun

dee;

Bar

ker

et a

l., U

nive

rsity

of

Shef

field

; Moo

re e

t al

., U

nive

rsity

of

Brist

ol).

Loca

l gro

wer

s,m

arke

ts,

gree

ngro

cers

, foo

dco

oper

ativ

es a

ndsu

perm

arke

ts; L

EAs;

scho

ol c

ater

ers,

loca

lan

d re

gion

al N

HSS

prog

ram

me

coor

dina

tors

; hea

dte

ache

rs a

nd s

choo

lgo

vern

ors;

SN

AG

s;co

mm

unity

deve

lopm

ent

wor

kers

.

Ou

tco

me

Inte

rven

tion

Cook

ing

skill

scl

ubs

Coo

king

and

foo

dpr

epar

atio

n sk

ills

com

pulso

ry w

ithin

Nat

iona

l Cur

ricul

umFo

od T

echn

olog

y(K

ey S

tage

1 a

nd 2

,op

tiona

l at

Key

Stag

e3

and

4).

Nat

iona

l Ini

tiativ

es o

nco

okin

g sk

ills

incl

ude

Coo

king

for

Kid

s(D

fEE)

for

Yea

rs 6

and

7 an

d Fo

cus

onFo

od c

ooki

ng s

kills

bus,

Ret

ail S

ervi

ces

Ass

ocia

tion

(RSA

)an

d W

aitr

ose.

Evid

ence

Lang

et

al. 1

999

show

ed a

gen

eral

dear

th o

f co

okin

g sk

ills

in t

hepo

pula

tion

and

that

sch

ools

are

ake

y se

ttin

g fo

r le

arni

ng s

uch

skill

s.

Focu

s on

Foo

d is

bein

g ev

alua

ted

byth

e U

nive

rsity

of

Read

ing,

res

ults

due

2001

.

Cook

ing

for

Kids

repo

rted

a r

ange

of b

enef

its a

t en

d of

firs

t ye

ar,

soci

al a

s w

ell a

s ed

ucat

iona

l(W

aldo

n 19

99, u

npub

lishe

d re

port

).

Wh

o c

ou

ld b

ein

volv

ed?

DfE

E’s

Coo

king

for

Kids

; RSA

and

Wai

tros

e Fo

cus

onFo

od; L

EAs;

hea

dte

ache

rs, p

aren

ts a

ndsc

hool

gov

erno

rs,

scho

ol c

ater

ers,

teac

hers

of

food

tech

nolo

gy; l

ocal

chef

s re

stau

rate

urs

and

shop

s w

ho m

aybe

will

ing

tohe

lp/d

onat

ein

gred

ient

s.

Loca

l hea

lthy

scho

ols

prog

ram

me.

Skill

s an

d r

eso

urc

es

Acc

ess

to s

choo

l kitc

hens

or

com

mun

ity k

itche

nseq

uipp

ed f

or t

he s

afe

and

hygi

enic

pre

para

tion

and

stor

age

of f

ood;

tea

chin

gst

aff/s

choo

l mea

ls st

aff

will

ing

to p

artic

ipat

e ou

t of

hour

s; p

aren

ts o

r vo

lunt

eers

to a

ssist

with

sup

ervi

sion;

ingr

edie

nts

and

equi

pmen

t;fu

ndin

g so

urce

s (e

gEd

ucat

ion

Extr

a; T

heFo

unda

tion

for

Aft

er S

choo

lC

lubs

).

A d

edic

ated

per

son

tom

anag

e or

derin

g an

dpr

epar

atio

n of

frui

t/veg

etab

les;

fac

ilitie

s fo

rth

e sa

fe a

nd h

ygie

nic

stor

age,

was

hing

and

prep

arat

ion

of f

ruit

and

vege

tabl

es; f

or t

uck

shop

s/ve

ndin

g m

achi

nes,

som

eone

to

man

age

the

mon

ey; a

pric

ing

polic

yw

here

fru

it is

purc

hase

d;st

ock

rota

tion

and

tem

pera

ture

in v

endi

ngm

achi

nes.

Poin

ts t

o c

on

sid

er

Clu

bs t

ake

plac

e ou

t of

scho

ol h

ours

or

in h

olid

ays

and

for

mos

t ch

ildre

n th

is is

aon

e da

y ex

perie

nce.

Not

a r

epla

cem

ent

for

regu

lar

teac

hing

of

cook

ing

skill

s;ca

n be

a u

sefu

l par

t of

aw

hole

sch

ool a

ppro

ach;

for

som

e ch

ildre

n th

is m

ay b

eon

e of

ver

y fe

w o

ppor

tuni

ties

to c

ook.

New

Nat

iona

l Pla

n fo

r th

eN

HS

has

anno

unce

d a

Nat

iona

l Sch

ool F

ruit

Sche

me

whe

re e

very

chi

ld in

nur

sery

and

aged

fou

r to

six

yea

rs in

infa

nt s

choo

ls w

ill b

e en

title

dto

a f

ree

piec

e of

fru

it ev

ery

scho

ol d

ay (s

ee B

reak

fast

and

afte

r sc

hool

clu

bs).

Nat

iona

l Die

t an

d N

utrit

ion

Surv

ey o

f yo

ung

peop

le(G

rego

ry e

t al

.200

0) s

how

edlo

w in

take

s of

fru

it an

dve

geta

bles

and

hig

h in

take

sof

con

fect

ione

ry a

nd s

oft

drin

ks.

Frui

t an

d ve

geta

ble

inta

kes

are

low

est

in h

ouse

hold

s on

low

inco

me

and

rece

ivin

gbe

nefit

s.

Furt

her

info

rmat

ion

http

://w

ww

.wire

dfor

heal

th.

gov.

uk

Cook

ing

for

Kids

pro

ject

man

ual.

Ava

ilabl

e fr

ee f

rom

Joe

Mon

ks a

t th

eD

epar

tmen

t of

Hea

lth t

el02

0 79

72 2

000.

Focu

s on

Foo

ds c

ampa

ign:

http

://w

ww

.wai

tros

e.co

m/

focu

sonf

ood/

Tel:

0142

2 38

3191

.

Briti

sh D

iete

tic A

ssoc

iatio

nG

ive

Me

5 Pa

ckht

tp://

ww

w.b

da.u

k.co

m/

Tel:

0121

633

955

5.

Info

rmat

ion

on E

Uin

terv

entio

n st

ocks

of

frui

t(s

ee B

reak

fast

and

aft

ersc

hool

clu

bs).

Scho

ol f

ood

polic

y gu

ide

prod

uced

by

SNA

G.

Con

tact

Joe

Har

vey,

Hea

lthEd

ucat

ion

Trus

t(te

l/fax

: 017

89 7

7391

5).


35

Cook

and

eat

Sess

ions

Mai

nly

loca

lin

itiat

ives

, som

eba

sed

orig

inal

ly o

nth

e fo

rmer

Get

cook

ing!

prog

ram

me.

Can

hel

p pe

ople

acc

ess

affo

rdab

le m

eals;

may

red

uce

soci

al is

olat

ion;

empo

wer

men

t of

pro

ject

wor

kers

and

dev

elop

men

t of

thei

r sk

ills

base

; may

pro

vide

poin

t of

acc

ess

to o

ther

heal

th a

nd s

ocia

l ser

vice

s.

Com

mun

ity

cafe

s

Run

on a

loca

l and

‘not

for

pro

fit’ b

asis,

ofte

n pa

rt o

f a

wid

erco

mm

unity

cen

tre

offe

ring

othe

rse

rvic

es; a

im t

opr

ovid

e af

ford

able

(not

nec

essa

rily

heal

thy)

mea

ls in

aso

ciab

le a

tmos

pher

e,to

red

uce

soci

aliso

latio

n.

Not

wel

l doc

umen

ted;

an

eval

uatio

nof

a c

omm

unity

caf

é in

sou

thea

stEn

glan

d (K

adus

kar

et a

l.19

99)

coul

d no

t de

term

ine

whe

ther

the

cafe

was

suc

cess

ful i

n its

aim

of

prov

idin

g ch

eap,

goo

d qu

ality

foo

d.

Ou

tco

me

Sust

ain

(200

0) r

epor

ted

that

such

pro

ject

s co

uld

incr

ease

nutr

ition

al k

now

ledg

e an

dim

prov

e sk

ills

as lo

ng a

s th

eap

proa

ch w

as r

elev

ant

topa

rtic

ipan

ts’ c

ultu

ral a

ndso

cio-

econ

omic

circ

umst

ance

s.

Eval

uatio

ns a

lso r

epor

t w

ider

heal

th b

enef

its s

uch

asre

duci

ng s

ocia

l iso

latio

n, a

ndbu

ildin

g se

lf co

nfid

ence

.

May

pro

vide

a f

orum

inw

hich

to

disc

uss

othe

r he

alth

issue

s.

Inte

rven

tion

Evid

ence

Car

aher

et

al.(

1999

) sug

gest

ed t

hat

rede

signe

d co

okin

g an

d fo

odcl

asse

s ch

ange

d di

ets

of y

oung

peop

le a

nd t

heir

fam

ilies

.

A g

ener

al la

ck o

f co

okin

g sk

ills

inth

e po

pula

tion

was

fou

nd a

ndco

nfid

ence

to

cook

var

ied

with

age

and

gend

er (L

ang

et a

l.19

99).

Incr

ease

d se

lf co

nfid

ence

and

este

em f

ound

in G

et C

ooki

ng in

Wal

es(C

arah

er a

nd L

ang

1995

).

Saff

ron

Food

and

Hea

lth P

roje

ct(D

obso

n et

al.

2000

) sug

gest

s th

atth

e ai

m o

f co

mm

unity

foo

d pr

ojec

tsm

ust

be t

o ge

t pe

ople

inte

rest

edan

d im

prov

e co

nfid

ence

and

bas

icco

okin

g sk

ills.

Wh

o c

ou

ld b

ein

volv

ed?

Sess

ions

cou

ld b

e ru

nin

gro

ups

such

as

wom

en’s

gro

ups,

yout

h cl

ubs;

chu

rch,

tem

ples

or

relig

ious

sett

ings

; loc

alca

terin

g co

llege

s,an

d ho

me

econ

omic

ste

ache

rs; L

AC

A; l

ocal

reta

ilers

or

gard

enin

gan

d al

lotm

ent

sche

mes

for

pro

duce

and

ingr

edie

nts;

heal

th v

isito

rs.

Skill

s an

d r

eso

urc

es

Venu

e, f

acili

ties

and

equi

pmen

t fo

r th

e sa

fe a

ndhy

gien

ic p

repa

ratio

n an

dst

orag

e of

foo

d; f

undi

ng;

ingr

edie

nts;

a p

roje

ct le

ader

with

pra

ctic

al f

ood

prep

arat

ion

skill

s, f

ood

hygi

ene

and

nutr

ition

alkn

owle

dge;

link

wor

kers

/pe

er e

duca

tors

, par

ticul

arly

for

wor

k w

ith m

inor

ity e

thni

cgr

oups

or

youn

g pe

ople

;bu

dget

man

agem

ent

skill

s.

Venu

e, f

acili

ties

and

equi

pmen

t fo

r th

e sa

fe a

ndhy

gien

ic p

repa

ratio

n of

food

s; a

pro

ject

lead

er w

ithfo

od p

repa

ratio

n an

d bo

okke

epin

g sk

ills;

tra

inin

g in

food

pre

para

tion

and

food

hygi

ene

for

volu

ntee

rs a

ndpa

id s

taff

.

Poin

ts t

o c

on

sid

er

Cou

ld b

e us

ed t

o en

cour

age

inta

kes

of f

ruit

and

vege

tabl

es b

y pr

ovid

ing

oppo

rtun

ity t

o ta

ste

new

varie

ties.

May

pro

vide

a w

ayin

to

wor

king

with

cer

tain

audi

ence

s (e

g So

uth

Asia

nw

omen

) as

a so

cial

lyac

cept

able

act

ivity

.

Caf

es r

elia

nt o

n ex

tern

alfu

ndin

g, a

nd s

o su

stai

nabi

lity

may

be

an is

sue;

invo

lvin

gth

e co

mm

unity

inde

velo

pmen

t se

ems

to le

adto

gre

ater

sus

tain

abili

ty;

shou

ld b

e ru

n as

a p

rope

rbu

sines

s, c

ompl

ying

with

envi

ronm

enta

l hea

lth (E

H)

and

trad

ing

stan

dard

s; lo

cal

circ

umst

ance

s im

port

ant:

part

icul

arly

goo

d fo

r pe

ople

who

are

hom

eles

s, la

ckco

okin

g fa

cilit

ies

or a

reel

derly

/sin

gle

on lo

w in

com

e.

Furt

her

info

rmat

ion

Food

and

low

inco

me

(FLI

)da

taba

se(h

ttp:

//ww

w.h

ea.o

rg.u

k),

our

heal

thie

r na

tion

inpr

actic

e (O

HN

iP),

HA

Znet

.

Sout

h A

sian

cook

ing

club

inLu

ton

HA

Z is

a Be

acon

Site

and

can

be v

isite

d at

: htt

p://

ww

w.n

hsbe

acon

s.or

g.uk

/

Saff

ron

Food

and

Hea

lthPr

ojec

t:ht

tp://

ww

w.c

rsp.

ac.u

k

Get

coo

king

and

get

shop

ping

pack

fro

m S

usta

in,

£14

(tel:

020

7837

122

8).

OK!

Let

’s c

ook,

Hea

lthy

Nor

folk

200

0, £

2 (te

l: 01

603

487

990)

.

No

dosh

goo

d no

shfr

omN

ight

safe

, Bla

ckbu

rn, £

1(te

l: 01

25 4

5876

87).

FLI d

atab

ase;

OH

NiP

;H

AZn

et.

Just

for

sta

rter

sfr

om t

heH

ealth

Edu

catio

n Bo

ard

for

Scot

land

(tel

: 013

1 53

655

00) ‘

star

ting

up’ a

dvic

ean

d re

cipe

s.

Com

mun

ity C

ater

ing

Initi

ativ

es c

onfe

renc

e re

port

and

‘how

to’

info

rmat

ion,

from

Com

mun

ity H

ealth

UK,

£7.5

0 +

£1.7

5 (p

&p)

(te

l: 01

225

462

680)

.

Hea

rtbe

at A

war

d ca

tere

rs’

guid

e (s

ee ‘C

ater

ing

awar

ds’).

LA, E

HO

and

trad

ing

stan

dard

s; fu

ndin

gco

uld

be a

vaila

ble

from

rege

nera

tion

rela

ted

initi

ativ

es

(eg

New

Dea

l for

Com

mun

ities

and

Sing

le R

egen

erat

ion

Budg

et);

links

with

loca

l sup

erm

arke

ts,

reta

ilers

, com

mun

ityow

ned

reta

iling

(foo

dco

oper

ativ

es) a

ndgr

owin

g sc

hem

es;

loca

l cat

erin

g co

llege

s,LA

CA

(inv

estig

ate

peer

educ

atio

n of

loca

lvo

lunt

eers

); jo

bce

ntre

s fo

r cat

erer

sse

ekin

g w

ork.


36

Com

mun

ity

grow

ing

sche

mes

May

var

y fr

om c

ityfa

rms

to a

llotm

ents

or s

chem

es s

et u

p on

was

tela

nd; c

anin

crea

se s

uppl

ies

ofaf

ford

able

veg

etab

les

and

frui

t lo

cally

; can

be li

nked

to

food

coop

erat

ives

;so

met

imes

set

up

with

an

envi

ronm

enta

l rat

her

than

hea

lth a

gend

a.

Brad

ford

‘Gar

deni

ng f

or H

ealth

’pr

ojec

t, ru

n w

ith B

angl

ades

hiw

omen

. Par

ticip

ants

rep

orte

dea

ting

mor

e fr

uit

and

vege

tabl

es,

bein

g m

ore

activ

e, lo

sing

wei

ght

and

feel

ing

mor

e co

nfid

ent

to g

oou

t al

one

(Hus

sain

and

Rob

inso

n20

00).

Ou

tco

me

Like

ly t

o be

bro

ader

tha

nin

crea

sing

the

avai

labi

lity

offr

uit

and

vege

tabl

es a

lone

(e

g pr

ovid

ing

a so

cial

mee

ting

plac

e in

the

loca

lco

mm

unity

); em

pow

erm

ent

of lo

cal c

omm

unity

and

ski

llsde

velo

pmen

t in

tho

seru

nnin

g it;

Bol

ton

Food

coop

erat

ive

deve

lope

d sp

in-

offs

, sup

plyi

ng f

ruit

tuck

shop

s in

sch

ools

and

deliv

ery

to t

he e

lder

ly. T

heTo

wer

Ham

lets

coo

pera

tive

has

subs

eque

ntly

dev

elop

ed a

loca

l far

mer

s’ m

arke

t.

Inte

rven

tion

Com

mun

ity

owne

dre

taili

ng (

food

coop

erat

ives

)

Loca

lly o

rgan

ised

initi

ativ

es t

hat

can

impr

ove

acce

ssib

ility

to f

oods

suc

h as

fru

itan

d ve

geta

bles

inar

eas

that

lack

loca

laf

ford

able

sup

plie

s.

In s

ome

area

s it

isdi

ffic

ult

to a

cces

saf

ford

able

goo

dqu

ality

fru

it an

dve

geta

bles

(PA

T 13

1999

).

Evid

ence

Eval

uatio

ns in

Bol

ton

and

in T

ower

Ham

lets

and

Ste

pney

(Pric

e an

dSe

phto

n 19

95; O

stas

iew

icz

1997

)sh

owed

incr

ease

d av

aila

bilit

y of

fru

itan

d ve

geta

bles

. It

allo

wed

peo

ple

totr

y ne

w f

oods

at

affo

rdab

le p

rices

;in

crea

sed

the

conf

iden

ce, s

elf

este

em a

nd d

evel

oped

new

ski

lls in

thos

e ru

nnin

g th

e co

oper

ativ

e.

Wh

o c

ou

ld b

ein

volv

ed?

LA E

HO

and

tra

ding

stan

dard

s; f

undi

ngco

uld

be a

vaila

ble

from

reg

ener

atio

n-re

late

d in

itiat

ives

(e

g N

ew D

eal f

orC

omm

uniti

es a

ndSi

ngle

Reg

ener

atio

nBu

dget

); s

uppl

iers

such

as

loca

lw

hole

sale

rs, f

arm

ers’

mar

kets

or

com

mun

ity a

llotm

ent

and

grow

ing

sche

mes

.

Incr

ease

buy

ing

pow

er b

y lin

king

with

oth

er lo

cal f

ood

coop

erat

ives

.

May

incr

ease

phy

sical

act

ivity

,re

duce

soc

ial i

sola

tion,

and

build

con

fiden

ce.

Part

icip

ants

in t

he B

radf

ord

Proj

ect

initi

ally

gre

w f

amili

arA

sian

vege

tabl

es b

ut t

hen

grew

and

sta

rted

to

eat

Briti

sh v

eget

able

var

ietie

sw

hich

are

che

aper

; also

deve

lope

d m

arke

tabl

ega

rden

ing

skill

s.

Skill

s an

d r

eso

urc

es

Venu

e, in

clud

ing

hygi

enic

stor

age

spac

e an

d t

rans

port

;eq

uipm

ent

such

as

till,

scal

es,

float

; sta

rt u

p co

sts

and

fuel

cost

s; s

taff

, inc

ludi

ng d

river

san

d a

book

keep

er.

Star

t up

cos

ts; l

and,

equi

pmen

t, st

orag

e, w

ater

supp

ly, s

eeds

; pro

ject

lead

ers

with

exp

erie

nce

in g

arde

ning

/ho

rtic

ultu

re w

ho w

ill n

eed

tobe

pai

d; a

boo

kkee

per;

ifw

orki

ng w

ith b

lack

and

min

ority

eth

nic

grou

ps m

ayne

ed a

link

wor

ker.

Poin

ts t

o c

on

sid

er

Food

coo

pera

tives

are

lega

len

titie

s an

d ha

ve t

o ru

n on

am

embe

rshi

p ba

sis. F

ees

for

mem

bers

hip

can

help

with

star

t up

cos

ts.

Com

mitm

ent

of t

he s

taff

ises

sent

ial t

o en

sure

sur

viva

l.Pa

ymen

t fo

r th

eir

time

may

help

.

Ther

e is

a ne

ed t

o co

mpl

yw

ith t

radi

ng s

tand

ards

and

EH r

egul

atio

ns, a

nd t

o su

pply

cultu

rally

app

ropr

iate

foo

ds.

Food

coo

pera

tives

are

not

view

ed a

s a

long

-ter

mso

lutio

n bu

t ca

n be

use

dal

ongs

ide

othe

r re

gene

ratio

nin

itiat

ives

to

impr

ove

acce

ss.

The

NH

S Pl

anst

ates

tha

t th

ego

vern

men

t w

ill w

ork

with

indu

stry

to

incr

ease

pro

visio

nof

fru

it an

d ve

geta

bles

and

whe

re n

eces

sary

to

esta

blish

loca

l foo

d co

oper

ativ

es.

Get

ting

acce

ss t

o la

nd a

ndse

ttin

g up

an

agre

emen

t fo

rits

use

ove

r a

suita

ble

perio

dof

tim

e; p

ossib

leco

ntam

inat

ion

of la

nd in

som

e ar

eas;

sha

ring

out

prod

uce

betw

een

part

icip

ants

and/

or

selli

ng it

on

to f

ood

coop

erat

ives

, far

mer

s’m

arke

ts, c

omm

unity

caf

es;

may

be

usef

ul in

are

as o

fre

gene

ratio

n w

here

acc

ess

toaf

ford

able

fru

it an

dve

geta

bles

are

poo

r.

May

hel

p m

eet

prio

ritie

s of

LA 2

1.

Furt

her

info

rmat

ion

Star

t yo

ur o

wn

food

co-

opvi

deo

Bolto

n co

-op,

£15

(tel

:01

204

3600

94/3

6009

5).

Food

for

tho

ught

repo

rt a

ndvi

deo.

Wol

verh

ampt

on F

ood

Co-

ops

Um

brel

la G

roup

Ltd

,£1

(tel

: 019

02 3

04 8

51).

The

co-o

p st

art

up p

ack

CW

S. A

vaila

ble

free

(tel

:01

61 8

27 5

349)

.

CW

S sm

all g

rant

sC

omm

unity

Div

iden

dSc

hem

e (te

l: 01

61 8

27 5

950)

.

FLI d

atab

ase,

OH

NiP

,H

AZn

et.

Sand

wel

l Bea

con

site

http

://w

ww

.nhs

beac

ons.

org.

uk/

FLI d

atab

ase.

Sust

ain

publ

icat

ions

:G

row

ing

food

in c

ities

(£10

); Ci

ty h

arve

st (£

30 f

ull r

epor

t,su

mm

ary

£5);

tel:

020

7837

122

8.

Fede

ratio

n of

City

Far

ms

and

Com

mun

ity G

arde

ns, S

tart

erpa

ck(te

l 011

7 92

3 18

00).

Loca

l Age

nda

21

(LA

21)

coo

rdin

ator

s;LA

leisu

re o

ren

viro

nmen

tal

serv

ices

; loc

alho

rtic

ultu

ral c

olle

ges.

Fund

ing

coul

d be

avai

labl

e fr

omre

gene

ratio

n re

late

din

itiat

ives

(eg

New

Dea

l for

Com

mun

ities

and

Sing

leRe

gene

ratio

n Bu

dget

).

Nat

iona

l Soc

iety

of

Allo

tmen

t and

Lei

sure

Gar

dene

rs L

td

(tel:

0153

6 26

6576

).


37

Com

mun

ity

shop

san

d si

mila

r sc

hem

es

Set

up in

res

pons

e to

clos

ure

of lo

cal s

hops

on h

ousin

g es

tate

s or

in r

ural

are

as; m

ay b

eru

n on

a ‘n

ot f

orpr

ofit’

bas

is, u

sual

lyby

vol

unte

ers.

Com

mun

ity s

hops

are

a r

ecen

tin

nova

tion,

whi

ch h

ave

not

yet

been

eva

luat

ed.

Ou

tco

me

Impr

oved

acc

ess

to a

ffor

dabl

efr

uit

and

vege

tabl

es; r

etai

lou

tlet

for

com

mun

itygr

owin

g sc

hem

es;

envi

ronm

enta

l ben

efits

inth

at p

rodu

ce is

not

tran

spor

ted

grea

t di

stan

ces;

incr

ease

d so

cial

cap

ital.

Inte

rven

tion

Farm

ers’

mar

kets

Mar

kets

tha

t al

low

farm

ers

and

grow

ers

to s

ell d

irect

ly t

oco

nsum

ers,

the

reby

redu

cing

the

pric

e.

They

are

oft

en s

et u

pas

env

ironm

enta

lin

itiat

ives

and

req

uire

prod

uce

to b

e gr

own

with

in a

cer

tain

radi

us o

f th

e m

arke

t.So

me

focu

s on

orga

nic

prod

uce.

Evid

ence

Farm

ers’

mar

kets

off

er g

ood

valu

efo

r m

oney

; pro

vide

an

oppo

rtun

ityto

buy

fre

sh, l

ocal

pro

duce

; giv

elo

cal p

eopl

e a

sens

e of

wel

l bei

ngan

d be

long

ing;

pro

vide

a s

ocia

lm

eetin

g pl

ace;

and

also

pla

y a

role

in r

evita

lisin

g th

e lo

cal r

ural

econ

omy

(Bur

et

al. 1

999;

Bul

lock

2000

).

Wh

o c

ou

ld b

ein

volv

ed?

LA a

nd t

radi

ngst

anda

rds;

any

loca

lgr

ower

s’as

soci

atio

ns;

LA 2

1 co

ordi

nato

r;N

atio

nal A

ssoc

iatio

nof

Far

mer

s’ M

arke

ts(te

l: 01

225

7879

14);

Soil

Ass

ocia

tion

loca

lfo

od li

nks

depa

rtm

ent

(tel:

0117

914

242

6).

Impr

oved

acc

ess

to f

oods

such

as

frui

t an

d ve

geta

bles

;us

eful

in r

ural

are

as w

here

publ

ic t

rans

port

is p

oor;

shop

staf

f ca

n de

velo

p m

arke

tabl

esk

ills

and

gain

wor

kex

perie

nce;

can

be

part

of

neig

hbou

rhoo

d re

new

alin

itiat

ives

.

Skill

s an

d r

eso

urc

es

Staf

f (p

aid

or v

olun

tary

) to

liaise

with

loca

l cou

ncil,

grow

ers

and

cons

umer

s;su

itabl

e ve

nue

in p

roxi

mity

to

area

of

need

; acc

ess

togr

ower

s w

illin

g to

par

ticip

ate

with

in t

he lo

calit

y.

Proj

ect

lead

ers

with

ret

ail

expe

rienc

e an

d/or

boo

kke

epin

g sk

ills;

driv

er a

ndtr

ansp

ort

to t

rave

l to

who

lesa

lers

; fun

ding

fro

mgr

ants

or

subs

idie

s; s

uita

ble

prem

ises

with

sto

rage

faci

litie

s an

d eq

uipm

ent

inth

e lo

calit

y, w

hich

com

plie

sw

ith E

H a

nd h

ealth

and

safe

ty r

egul

atio

ns.

Poin

ts t

o c

on

sid

er

Nee

ds h

elp

and

supp

ort

from

LA; n

eed

to e

ncou

rage

grow

ers

to p

artic

ipat

e; n

eeds

publ

icity

; an

acce

ssib

le v

enue

not

requ

iring

cos

tly p

ublic

tran

spor

t; en

sure

bon

a fid

egr

ower

s on

ly p

artic

ipat

e; m

ayim

prov

e ac

cess

to

reta

ilse

rvic

es a

nd in

crea

se s

uppl

yof

aff

orda

ble

frui

t an

dve

geta

bles

; may

aff

ect

trad

ein

loca

l sm

all s

hops

.

Mee

ts p

riorit

ies

of L

A 2

1.

‘Not

for

pro

fit’,

ther

efor

ede

pend

ent

on g

rant

s or

subs

idie

s; m

embe

rshi

p fe

esca

n he

lp s

tart

up

cost

s: m

ust

com

ply

with

tra

ding

stan

dard

s, E

H r

egul

atio

ns; i

nso

me

area

s m

ore

appr

opria

teto

tak

e pe

ople

to

shop

sra

ther

tha

n sh

ops

to p

eopl

e(P

AT

13 1

999)

; cou

ld h

elp

impr

ove

acce

ss t

o fr

uit

and

vege

tabl

es; m

ay c

ontr

ibut

e to

neig

hbou

rhoo

d re

new

alst

rate

gies

.

Furt

her

info

rmat

ion

The

Nat

iona

l Ass

ocia

tion

ofFa

rmer

s’ M

arke

ts h

as a

list

of f

arm

ers’

mar

kets

(te

l: 01

225

7879

14)

http

://w

ww

.farm

ersm

arke

ts.

net

‘Eco

-logi

c’ p

ublic

atio

ns o

nfa

rmer

s’ m

arke

ts

(tel:

0122

5 48

4472

).

The

Soil

Ass

ocia

tion

prov

ides

trai

ning

on

sett

ing

up a

ndru

nnin

g a

farm

ers’

mar

ket:

(tel:

0117

914

242

6).

How

to

mak

e yo

urco

mm

unity

sho

p su

ccee

d.C

omm

unity

Ent

erpr

ise L

td(te

l: 01

31 4

75 2

345)

.

Villa

ge s

hops

and

pos

tof

fices

: a g

uide

to

depl

oym

ent

of v

illag

ein

vest

men

t to

res

cue,

sus

tain

and

revi

ve.V

IRSA

, £15

(tel

:01

305

259

383)

.

If th

e vi

llage

sho

p cl

oses

…a

hand

book

on

com

mun

itysh

ops.

Oxf

ord

Rura

lC

omm

unity

Cou

ncil,

£3.

50(te

l: 01

865

8834

88).

LA, E

H d

epar

tmen

tan

d tr

adin

gst

anda

rds;

Vill

age

Reta

il Se

rvic

esA

ssoc

iatio

n (V

IRSA

;te

l: 01

305

259

383)

;fu

ndin

g co

uld

beav

aila

ble

from

rege

nera

tion-

rela

ted

initi

ativ

es (e

g N

ewD

eal f

orC

omm

uniti

es a

ndSi

ngle

Reg

ener

atio

nBu

dget

).

Com

mun

ity O

wne

dRe

taili

ng: t

rain

ing

and

supp

ort

inse

ttin

g up

neig

hbou

rhoo

dsh

ops

(tel:

0143

5 88

3005

)ht

tp://

ww

w.c

omm

uni

t.ret

ailin

g.co

.uk


38

Supe

rmar

ket

tour

s

Usu

ally

led

by a

diet

itian

or

nutr

ition

ist w

ith s

mal

lgr

oups

of

cons

umer

s.M

ay f

ocus

on

inte

rpre

ting

food

labe

ls an

d he

alth

clai

ms

and

onse

lect

ing

food

s an

ddi

scus

sing

heal

thie

rpr

epar

atio

n m

etho

ds.

Som

etim

es u

sed

with

grou

ps w

ith a

part

icul

ar a

rea

ofin

tere

st (e

g di

abet

es).

Cate

ring

aw

ards

For

exam

ple,

Hea

rtbe

at A

war

d is

ana

tiona

lly r

ecog

nise

dbu

t lo

cally

run

aw

ard

mad

e to

cat

erer

sw

ho a

dopt

hea

lthie

rpr

actic

es, h

ave

good

stan

dard

s of

foo

dhy

gien

e an

d of

fer

nons

mok

ing

seat

ing.

Usu

ally

run

by

LAEH

Os

in p

artn

ersh

ipw

ith d

ietit

ians

and

heal

th p

rom

otio

nsp

ecia

lists

.

Incr

ease

in s

elf

repo

rted

‘hea

lthy’

purc

hase

s an

d be

havi

our

com

pare

dw

ith c

ontr

ols,

one

mon

th a

fter

tw

o-ho

ur t

our,

but

stud

y w

as o

fpo

or q

ualit

y (S

ilzer

et

al.1

994)

.

One

of

six s

chem

es e

valu

ated

by

HEA

in 1

998

show

ed s

igni

fican

tlygr

eate

r us

e of

hea

lthie

r ca

terin

gpr

actic

es in

aw

ard

hold

ing

prem

ises

(Pat

erso

n et

al.,

in p

repa

ratio

n).

A q

uart

er o

f H

eart

beat

Aw

ard

prem

ises

repo

rted

incr

ease

s in

sal

esof

som

e he

alth

ier

item

s bu

t sa

les

ofle

ss h

ealth

y ch

oice

s te

nded

to

rem

ain

the

sam

e (H

olds

wor

th e

t al

.19

99).

Gre

ater

pro

visio

n of

som

e he

alth

ier

food

s, h

ealth

ier

optio

ns a

nd g

reat

erco

mm

itmen

t to

hea

lthy

eatin

g(W

arm

et

al. 1

997)

.

Ou

tco

me

Acc

ess

to m

ains

trea

m s

hops

and

serv

ices

(PA

T 13

199

9).

Ove

rcom

e di

ffic

ultie

sex

perie

nced

by

peop

le in

carr

ying

hea

vy f

ruit

and

vege

tabl

es f

rom

sho

ps.

Inte

rven

tion

Tran

spor

t to

sho

pssc

hem

es

Can

be

run

on a

loca

lba

sis o

r by

link

ing

with

sup

erm

arke

tch

ains

or

loca

lre

taile

rs.

Evid

ence

Case

stu

dy

Hac

kney

Com

mun

ity t

rans

port

deve

lope

d to

incr

ease

acc

ess

tolo

cal a

ctiv

ities

for

disa

bled

and

elde

rly p

eopl

e. ‘P

lusb

uses

’ now

run

ever

y 30

min

utes

on

a fix

ed r

oute

whi

ch li

nks

up t

he lo

cal h

ospi

tal,

day

cent

res,

sch

ools,

sho

ps a

ndot

her

tran

spor

t in

terc

hang

es.

Wh

o c

ou

ld b

ein

volv

ed?

Loca

l sup

erm

arke

tsan

d lo

cal c

ham

ber

ofco

mm

erce

or

trad

e.

May

be

usef

ul a

s pa

rt o

f a

wid

er p

rogr

amm

e of

hea

lthy

eatin

g su

perm

arke

t in

itiat

ives

,bu

t m

ost

need

to

be

coor

dina

ted

natio

nally

rat

her

than

loca

lly.

Roe

et a

l. (1

997)

fou

nd f

our

good

qua

lity

supe

rmar

ket

stud

ies:

thr

ee p

oint

of

purc

hase

labe

lling

, one

vid

eofe

edba

ck w

hich

sho

wed

incr

ease

s in

sal

es o

fpr

omot

ed p

rodu

cts

whi

le t

hest

udy

was

run

ning

.

Bett

er r

elat

ions

hips

bet

wee

nca

tere

rs a

nd E

H d

epar

tmen

t;go

od p

ublic

rel

atio

ns (P

R) f

orca

tere

rs, a

com

mitm

ent

tocu

stom

er c

are

and

to f

ood

hygi

ene

trai

ning

; diff

icul

t to

dem

onst

rate

the

eff

ect

of t

hesc

hem

e on

the

ove

rall

diet

of

cons

umer

s.

Skill

s an

d r

eso

urc

es

Driv

ers,

veh

icle

s an

d fu

ndin

gto

sup

port

run

ning

cos

ts;

insu

ranc

e an

d co

mpl

ianc

ew

ith s

afet

y re

gula

tions

.

Die

titia

n/pu

blic

hea

lthnu

triti

onist

; goo

d re

latio

nshi

pw

ith lo

cal s

uper

mar

ket

and

abili

ty t

o id

entif

y an

d us

e PR

oppo

rtun

ities

.

EH, d

iete

tics

and

heal

thpr

omot

ion

expe

rtise

on

smok

ing

polic

ies;

par

tner

ship

wor

king

ski

lls; e

valu

atio

nsk

ills;

tim

e fo

r pr

oces

sing

annu

al r

enew

als

in a

dditi

onto

new

app

licat

ions

; fun

ding

to s

uppo

rt s

chem

e; P

Rsu

ppor

t.

Poin

ts t

o c

on

sid

er

Are

as t

hat

need

to

be li

nked

,fr

eque

ncy

of s

ervi

ces;

link

ing

with

loca

l ret

aile

rs b

ussc

hem

es.

Sche

mes

may

be

very

use

ful

in in

crea

sing

acce

ss t

oaf

ford

able

sup

plie

s of

fru

itan

d ve

geta

bles

.

Use

ful w

ith g

roup

s w

ith a

part

icul

ar f

ocus

(eg

diab

etic

s);

usef

ul t

o ba

se t

he t

our

onTh

eba

lanc

e of

goo

d he

alth

(HEA

, DH

and

MA

FF 1

994)

;op

port

unity

to

mak

e lin

ksw

ith lo

cal r

etai

lers

.

To m

axim

ise im

pact

may

be

best

con

cent

rate

d in

ven

ues

whe

re th

e sa

me

peop

le e

atev

ery

day

(eg

wor

kpla

ces,

priso

ns);

need

s to

hav

e bo

thdi

etet

ic a

nd E

HO

inpu

t,re

quire

s a

good

wor

king

rela

tions

hip

betw

een

the

two

depa

rtm

ents

; cou

ld h

elp

tosu

ppor

t HIm

Ps a

s re

quire

s jo

int

wor

king

bet

wee

n LA

and

HA

trus

ts. E

valu

atio

n is

vita

l, as

fund

ers

may

see

k ev

iden

ce o

fbe

nefit

s be

fore

com

mitt

ing

reso

urce

s to

con

tinue

the

sche

me.

Thi

s w

ill a

lso h

elp

tobu

ild e

vide

nce

base

nat

iona

lly.

Furt

her

info

rmat

ion

Com

mun

ity T

rans

port

Ass

ocia

tion

(tel:

0161

367

8780

).

Ferg

uslie

Par

k A

cces

s to

Shop

ping

pro

ject

rep

ort

(tel:

0141

887

965

0).

Reta

ilers

’ ow

n m

ater

ials

base

d on

The

bala

nce

ofgo

od h

ealth

(HEA

, DH

and

MA

FF 1

994)

cou

ld b

e us

edas

a r

esou

rce.

Hea

rtbe

at A

war

d St

arte

r pac

k;A

cat

erer

’s g

uide

to th

eH

eart

beat

Aw

ard

(pac

ks 5

);H

eart

beat

Aw

ard

flyer

s(p

acks

50).

Hea

rtbe

at a

war

d ce

rtifi

cate

san

d w

indo

w s

ticke

rs (p

acks

10 e

ach)

.

A g

uide

to e

valu

atin

g th

eH

eart

beat

Aw

ard.

(HEA

1998

).

The

Hea

rtbe

at A

war

d: M

akin

gth

e m

ost o

f the

med

ia(H

EA19

96).

All

HEA

pub

licat

ions

ava

ilabl

efr

om M

arst

on B

ook

Serv

ices

(tel:

0123

5 46

5565

).

Supe

rmar

kets

,nu

triti

onist

s ba

sed

inhe

ad o

ffic

e; lo

cal

pres

s; g

roup

s w

ithpa

rtic

ular

inte

rest

(e

g di

abet

ics,

mot

hers

of

youn

gch

ildre

n).

Cat

erer

s, c

ater

ing

trai

ners

, em

ploy

ers,

occu

patio

nal h

ealth

nurs

es; h

ealth

prom

otio

n sp

ecia

lists

with

an

inte

rest

inev

alua

tion.


39

Prom

otin

g he

alth

yea

ting

in p

re-

scho

ols,

suc

h as

fam

ily c

entr

es r

unby

soc

ial s

ervi

ces

orpr

ivat

e da

ynu

rser

ies

Pre-

scho

ol a

nd d

ay c

are

cent

res

wer

e lik

ely

to b

e ap

prop

riate

sett

ings

for

inte

rven

tions

(Ted

ston

eet

al.

1998

b).

Ou

tco

me

Aro

und

an e

ight

h of

ene

rgy,

fat,

and

satu

rate

d fa

t in

the

diet

is f

rom

the

foo

d ea

ten

away

fro

m h

ome.

Wor

kpla

ce c

ater

ers

may

prep

are

a sig

nific

ant

prop

ortio

n of

mea

ls fo

rre

gula

r cu

stom

ers

and

soha

ve a

n im

port

ant

influ

ence

on t

he o

vera

ll di

et.

Inte

rven

tion

Ado

ptio

n of

heal

thie

r ca

teri

ngpr

acti

ces

inw

orkp

lace

cat

erin

gan

d hi

ghlig

htin

g‘h

ealt

hier

‘ cho

ices

Evid

ence

Posit

ive

effe

ct o

n fo

od c

hoic

es f

orth

e du

ratio

n of

inte

rven

tions

mod

ifyin

g re

cipe

s or

hig

hlig

hted

heal

thie

r ch

oice

s in

var

iety

of

sett

ings

; no

good

qua

lity

stud

ies

ina

wor

kpla

ce s

ettin

g (R

oe e

t al

.19

97);

incr

ease

in s

ales

of

low

fat

mea

ls in

the

wor

kpla

ce w

hen

high

light

ed w

ith s

ymbo

ls on

men

usan

d po

ster

s (L

evin

199

6).

Mak

ing

smal

l cha

nges

to

best

selli

ng d

ishes

can

be

effe

ctiv

e in

prom

otin

g he

alth

ier

choi

ces,

and

pres

enta

tion

is im

port

ant.

Prom

otin

g m

enu

item

s is

succ

essf

ulw

here

par

alle

l cho

ices

are

on

offe

r(H

EA 1

998b

).

Wh

o c

ou

ld b

ein

volv

ed?

Cat

erer

s, s

ervi

cest

aff,

cate

ring

man

ager

s, c

hef

trai

ners

; wor

kpla

cem

anag

emen

t, hu

man

reso

urce

s,oc

cupa

tiona

l hea

lth;

cont

ract

cat

erer

sdi

etiti

ans/

in h

ouse

chef

tra

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Gregory, J.R., Collins, D.L., Davies, P.S.W., Hughes, J.M. and Clarke,

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Stationery Office..

Gregory, J., Lowe, S., Bates, C. J., Prentice, A., Jackson, L. V., Smithers,

G., Wenlock, R. and Farron, M., 2000. National diet and nutrition

survey: young people aged 4 to 18 years. Vol. 1, Report of the diet

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HEA, 1992. Scientific basis of nutrition education: a synopsis of

dietary reference values. London: HEA.

HEA, 1996. Nutritional aspects of cardiovascular disease. London: HEA.

HEA, 1998a. Deprived neighbourhoods and access to retail services:

a report on work undertaken by the Health Education Authority on

behalf of the Department of Health and the Social Exclusion Unit

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HEA, 1998b. The national catering initiative: promoting healthier

choices. London: HEA.

HEA, 1999. Young people and health: health behaviour in school-aged

children. A report of the 1997 findings. London: HEA.

HEA, 2000. Black and minority ethnic groups in England: the second

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HEA, DH and MAFF, 1994. The balance of good health.

London: HEA.

Hodgson, P., Wyles, D., Kennedy-Haynes, L. and Hunt, C., 1995. Friends

with food: the development of a nutrition education programme for

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Holdsworth, M., Haslam, C. and Raymond, N.T., 1999. An assessment

of compliance with nutrition criteria and food purchasing trends in

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Hussain, H. and Robinson, J., 2000. Gardening for health:

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Brunner, E., White, I., Thorogood, M., Bristow, A., Curle, D. and

Marmot, M., 1997. Can dietary interventions change diet and

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Ellison, R.C., Goldberg, R.J., Witschi, J.C., Capper, A.L., Puleo, E.M. and

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fault! Myths about food and low income. London: National Food

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Heart, 80 (suppl 2).


42

3.1 Introduction

There is international consensus that a physically active lifestyle is important for health and has greatpotential health gain (WHO/Federation of Sports Medicine 1995; US Department of Health and HumanServices 1996).

Physical activity has been shown to have the followingbenefits:

• Regular physical activity or cardiorespiratory fitnessdecreases the risk of cardiovascular disease mortality ingeneral and of CHD mortality in particular

• The level of decreased risk of CHD attributable toregular physical activity is similar to that of otherlifestyle factors, such as not smoking

• Regular physical activity prevents or delays thedevelopment of high blood pressure, and exercisereduces blood pressure in people with hypertension

• Physical activity is also important in controllingdiabetes, regulating weight and reducing the risks ofosteoporosis and colon cancer.

Since there is a high rate of inactivity in the population,the majority of the population could benefit fromincreasing their activity. The attributable risk frominactivity for CHD is considerable. It has been estimatedthat in the US, 35% of CHD deaths could be attributedto inactivity (Powell and Blair 1994). Physical activity is animportant element in controlling overweight and obesity(discussed in more detail in Chapter 4).

3.2 Objectives of physical activity interventions

The current guideline is to achieve 30 minutes of moderateintensity activity (such as brisk walking, heavy gardeningand heavy housework) on at least five days of the week(DH 1996). Walking and cycling are frequently cited asexamples of how to achieve this recommendation(WHO/Federation of Sports Medicine 1995; USDepartment of Health and Human Services 1996).

The overall prevalence of physical activity is low (see Box3.1). Data from the 1998 Health Survey for England (JointSurveys Unit 1999) showed that 37% of men and 25%of women met the current guidelines for activity (30minutes of activity per day on at least five days of the

Chapter 3Increasing physical activity

Increasing physical activity

Box 3.1 Proportion of men and women in England meeting physical activity guidelines by age, 1998

Age (years) 16–24 25–34 35–44 45–54 55–64 65–74 75+ All ages

Men 58 48 43 36 32 17 7 37Women 32 31 32 30 21 12 4 25

Source: Joint Surveys Unit (1999)

43

week). These levels drop with age. Participation is loweramong many black and minority ethnic groups.

An important step in the effective promotion of physical activity is developing strategies that encourage partnerships between a variety of professionals and community groups. Reviews of effective policy development emphasise the importance of a strong evidence base, ownership by arange of stakeholders, community involvement, needsanalysis and evaluation (HEA 1995; NHF 1995; Foster2000). For more data on the effectiveness of physicalactivity strategies, see Table 4.7 in Chapter 4: Reducingoverweight and obesity.


A review of randomised controlled trials of physicalactivity promotion found some evidence that physicalactivity can be increased and maintained for up to twoyears. Interventions that encourage walking and do notrequire attendance at a facility appear most likely to leadto sustainable increases in physical activity (Hillsdon et al.1999). Others have found that promoting lifestylephysical activity (eg walking) leads to similar changes inbehaviour and CHD risk factors as does promotingstructured, facility-based, interventions (Dunn et al. 1999).

Hillsdon et al. (1999) also reported that brisk walking hasthe greatest potential for meeting current physical activityrecommendations. Regular brisk walking can lead to themajority of health benefits associated with physicalactivity (Morris and Hardman 1997).

Interventions aimed at modifying the environment, suchas signs posted to increase stair climbing (Brownell et al.1980; Blamey et al. 1995), have proved effective alsoover the short term.


3.4.1 Healthcare interventions

Interventions in healthcare settings can increase physicalactivity for both primary and secondary prevention(Simons-Morton et al. 1998). Long-term effects are morelikely with continuing intervention and multipleintervention components such as supervised exercise,

provision of equipment and behavioural approaches(Simons-Morton et al. 1998).

Mixed results have been obtained on the effectiveness ofprimary care based interventions, but these have beenshown to be moderately effective. A recent study did notfind evidence of longer-term maintenance of increasedlevels of physical activity (Harland et al. 1999). A benefitof primary care based intervention is that it can reach awide range of the population (Harland et al. 1999).

3.4.2 Exercise referral schemes

These involve primary care staff (usually practice nurses orGPs) referring patients to leisure centres for advice andassistance in increasing physical activity. Although there isa lack of rigorous evaluation of these programmes, thereis some evidence of short-term increases in the level ofactivity. However, there is no evidence of a sustainedlong-term behaviour change. Data from case studies suggestan impact on a range of parameters in a variety of people.The effectiveness of the schemes may be improved when:

• Staff are trained in behaviour change strategies

• Quality supervision is achieved by adequatepractitioner–patient ratios

• Liaison between health and leisure service personnel isestablished and maintained

• Community based networks offer support beyond thereferral period, incorporating sustained, active living(Riddoch et al. 1998).

Some practitioners have expressed concerns about theamount of time and resources required to set up and runhigh quality referral schemes that address the needs ofonly a small section of the population. Targeting ofappropriate referrals will be an important task whereschemes are adopted.

3.4.3 Workplaces

Workplaces provide an organisational structure for coordination of health programmes. However, existingresearch, although not conclusive, shows that it can leadto increases in physical activity (Shephard 1990; Bovell


44

1992; Dishman et al. 1998). A booklet is available with ideas for introducing workplace physical activity,giving examples of three case studies (Elder 1996). Some interventions to promote active commuting usingwritten materials have shown increases in physical activity levels (Mutrie et al. 1999; see also section 3.4.7:Physically active transport).

3.4.4 Mass media

In mass media interventions, the number of contacts and tailored interventions was important for increasing effectiveness but there was little impact on long-term physical activity behaviour (Marcus et al.1998).

3.4.5 Schools

Physical activity programmes in schools have beenassociated with a number of positive changes. Mostinterventions are developed as a result of collaborationbetween schools and external advisory and supportservices, in the context of local healthy schoolsprogrammes (HEA 1998a). Reviews of activity promotion in schools (Shephard et al. 1980; Simons-Morton et al. 1988; Pieron et al. 1996; Harris1997; Sallis et al. 1990, 1993) have concluded that:

• Appropriately designed, delivered and supported physical activity curriculum can enhance current levels ofphysical activity and can improve physical skilldevelopment

• Young people benefit from access to suitable and accessible facilities and opportunities for physicalactivity

• Interventions are likely to be more effective when young people are involved in planningprogrammes.

A qualitative exploration of the views of young people(aged 11–15 years) shows clear gender differences, withyoung women less likely to engage in active pursuits. Aflexible and differentiated approach to physical activitypromotion may be required to meet the needs andpreferences of this group (Mulvihill et al. 2000).

Features of well-designed schemes [Department ofEnvironment, Transport and the Regions (DETR) 1999]include:

• Quality of teacher skills, knowledge and experienceenhanced through professional education and trainingprogrammes

• Differentiation in the design of interventions accordingto young people’s developmental and other needs

• A range of enjoyable, health enhancing physicalactivities

• A whole school approach to the promotion of physicalactivity, including

– a physical and health education curriculum– extracurricular activities– links with the local community– safe transport routes to schools

• The involvement and support of the local community

• Provision of appropriate activities to meet the religiousand cultural needs of people from minority ethnic groups

• A mechanism to demonstrate how a school willmeasure increases in the levels of participation inregular physical activity.

3.4.6 Older people

Physical activity promotion for older people (HEA 1995;Walters et al. 1999) should:

• Provide opportunities for affordable, accessible physical activity (particularly for those least likely totake part)

• Address psycho-social needs and combine fun andsocialising with physical activity

• Involve older people in the planning, implementationand evaluation of programmes

• Address the specific needs of different groups

• Address the political, social and economic barriers thatdiscourage older people from participating


45

• Ensure that the outdoor environment is safe andpleasant for taking exercise.

Addressing the environmental and planning aspects thatpromote or deter physical activity is important in meetingthe needs of older people. This includes factors that makeolder people feel unsafe, either from other people orhostile environments (Walters et al. 1999).

A WHO (1996) consensus statement is available on levelsof physical activity to improve health in older adults.

3.4.7 Physically active transport

Transport offers potential for health enhancing physicalactivity. Cycling and walking can be of suitable intensity,and trips such as commuting or travel to school areregular, frequent and often of a suitable length (71% ofjourneys are less than five miles, and 45% less than two)(DETR 1996). Mutrie et al. (1999) found significantincreases in walking to work when written interactivepromotional material was used, but no increases in cyclecommuting. Evidence suggests that promoting workplacebased cycling requires attention to environmental factors,both in the workplace (eg cycle parking and showers) andto the road environment (eg safety). Walking and cyclingto work have been shown to lead to improved healthoutcomes (Vuori and Oja 1999).


Deprived groups are twice as likely to be sedentary as themost affluent groups (Gordon et al. 1999). A higherproportion of men in lower social classes participate inmoderate or vigorous activity, but this is mainly due tooccupational physical activity. The trend does not apply towomen. However, a higher proportion of men and

women in non-manual occupations participate in sportsand leisure activities compared with those in manualoccupations.

The characteristics of good practice in work on physicalactivity and inequalities (HEA 1999a) include:

• Proactive outreach work

• A multidisciplinary approach

• Involving the targeted communities

• Developing new partnerships with professionals whohave good access to ‘hard to reach’ groups.

Barriers to participation in physical activity among blackand minority ethnic groups tend to be similar to many ofthose in other groups, including lack of time and concernsabout body shape. Additional barriers include racism,cultural inappropriateness (eg lack of single sex provision),the importance of family responsibilities and languageissues (HEA 1997a). More single sex exercise facilities mayencourage uptake among Asian women (HEA 2000).

Participation in physical activity tends to be low amongpeople with disabilities. A key issue is for people withdisabilities to participate in activities that they enjoy,perceive as supportive in maintaining activities of dailyliving and are activities which can be incorporated easilyinto routine life. Activities must be:

• Appropriate from a social, environmental andphysiological perspective

• Planned in close cooperation with the target group

• Involve specialist advice where appropriate (HEA 1997b).


46


47

3.6 Useful sources of information about community based programmes

The European Heart Network has produced a report Physical activity andcardiovascular disease prevention in the European Union. It summarises theevidence on the relationship between physical activity and cardiovascularhealth and provides recommendations to encourage a more activeenvironment.

http://www.ehnheart.org/pdf/activity.pdf

Europe on the move! is an information network of the Europeanprogramme for the Promotion of Health-Enhancing Physical Activity (HEPA).There are many links on their website to European local initiatives withcontact details. A guide for promoting walking in the community has beenproduced by the Finnish Rheumatism Association and links are available viathis site.

http://www.europe-on-the-move.nl/europe/start.html

Promotion of transport, walking and cycling in Europe: strategy directions isa web accessible document that includes useful and practical informationon promoting transport walking and cycling. It suggests strategies, definestargets, and provides advice on funding, advocacy and lobbying, monitoringand evaluation. It can be accessed at the Europe on the Move site.

http://www.europe-on-the-move.nl/europe/start.html

Looking to the future: making CHD an epidemic of the past (NHF 1999)reviews successes and failures of health policy in reducing high rates ofCHD.

Moving on: international perspectives on promoting physical activity is areport from a symposium in 1994 designed to support the Physical ActivityTask Force in its role of developing a national strategy for promotingphysical activity in England (Killoran et al. 1995).

A community approach to behavioural change in the promotion of physical activity,published by the Center for Disease Control and Prevention (CDC), is aimedat all those interested in a community-wide strategy (central and localgovernment, transport, health and community planners, exercise specialistsand health professionals, community groups, businesses, schools, colleges anduniversities).

http://www.cdc.gov/nccdphp/dnpa/pahand.htm

The CDC in the USA has a report entitled Physical activity and health whichcovers the promotion of physical activity in our daily lives.

http://www.cdc.gov/nccdphp/sgr/summary.htm

The CDC has also published a set of guidelines on the promotion of physicalactivity in children and adolescents, with guidance on the benefits andconsequences of physical activity.

http://www.cdc.gov/nccdphp/dash/physact.htm

For helpful advice on active school travel projects the School Travel AdvisoryGroup (STAG) report gives extensive recommendations for the developmentof active travel patterns in the school setting. These have been endorsed byDH, DETR and the DfEE.

www.local-transport.detr.gov.uk/schooltravel


48

Tabl

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ess

but

no e

vide

nce

ofsu

stai

nabi

lity

(Bul

l and

Jam

rozi

k19

98; M

arcu

s et

al.

1998

; Eak

in e

tal

. 200

0).

Iden

tific

atio

n of

leve

ls of

activ

ity, i

nter

vent

ions

bas

edon

pre

dict

ed r

isk.

Ass

essm

ent

prot

ocol

s,ta

ilore

d ad

vice

, res

pons

ive

tocl

ient

’s n

eeds

, kno

wle

dge

ofhe

alth

impa

ct o

f ph

ysic

alac

tivity

on

heal

th.

NSF

CH

D r

equi

rem

ent

to‘id

entif

y al

l peo

ple

atsig

nific

ant

risk

ofca

rdio

vasc

ular

dise

ase

…an

dof

fer

them

app

ropr

iate

adv

ice

and

trea

tmen

t to

red

uce

thei

rris

ks’ (

Stan

dard

4);

know

ledg

e of

loca

l fac

ilitie

sus

eful

; kno

wle

dge

ofm

essa

ges

abou

t ph

ysic

alac

tivity

may

be

low

am

ong

PHC

sta

ff; f

ocus

on

activ

eliv

ing

likel

y to

be

appr

opria

tefo

r m

any

peop

le.

Coa

ts e

t al

. (19

95).

Coun

selli

ng f

orbe

havi

our

chan

geFr

eque

nt p

rofe

ssio

nal c

onta

ct is

asso

ciat

ed w

ith a

dher

ence

(Hill

sdon

et a

l. 19

99).

Long

-ter

m e

ffec

ts a

rem

ore

likel

y w

ith c

ontin

uing

inte

rven

tions

and

beh

avio

ural

appr

oach

es (S

imon

s-M

orto

n et

al.

1998

).

Sust

aine

d be

havi

our

chan

gein

tar

get

grou

p, p

ossib

lere

duct

ion

in r

isk f

acto

rs

(eg

hype

rten

sion)

in t

arge

tgr

oup.

Mot

ivat

iona

l int

ervi

ewin

g,go

od k

now

ledg

e ab

out

phys

ical

act

ivity

and

loca

lfa

cilit

ies.

Ava

ilabi

lity

and

time

of P

HC

staf

f; m

ost

effe

ctiv

e in

tho

seac

tivel

y co

ntem

plat

ing

incr

easin

g le

vels

of p

hysic

alac

tivity

.

Har

land

et

al. (

1999

);H

illsd

on e

t al

. (19

99).

Phys

ical

act

ivit

yre

ferr

alSm

all b

ut p

ossib

ly m

eani

ngfu

lim

prov

emen

ts a

chie

ved

(Rid

doch

et

al. 1

998)

; no

evid

ence

of

long

-ter

mim

pact

.

Effe

ctiv

e pa

rtne

rshi

p be

twee

nhe

alth

and

leisu

re s

ervi

ces,

iden

tific

atio

n an

d re

ferr

al o

fap

prop

riate

pat

ient

s,su

stai

ned

beha

viou

r ch

ange

s.

Col

labo

ratio

n w

ith le

isure

serv

ices

tra

ined

sta

ff,

com

mun

ity n

etw

orks

to

supp

ort

post

-ref

erra

l; co

stly

,re

sour

ce in

tens

ive.

Effe

ctiv

enes

s im

prov

ed w

hen:

staf

f ar

e tr

aine

d in

beh

avio

urch

ange

str

ateg

ies,

and

qua

lity

supe

rvisi

on is

ach

ieve

d by

adeq

uate

pat

ient

/pra

ctiti

oner

ratio

s; o

ppor

tuni

ties

for

targ

etin

g gr

oups

with

clin

ical

cond

ition

s pu

ttin

g th

em a

tris

k.

Ridd

och

et a

l. (1

998)

.

Wh

o c

ou

ld b

ein

volv

ed?

PHC

sta

ff.

PHC

sta

ff,

phys

ioth

erap

ists,

leisu

re p

rofe

ssio

nals.

GP,

PH

C s

taff

, lei

sure

serv

ice

pers

onne

l,H

LC s

taff

.


49

Inte

rven

tion

Prom

otio

n of

act

ive

tran

spor

t

This

incl

udes

wal

king

to s

choo

l (e

g W

alki

ng b

uses

)an

d w

alki

ng/c

yclin

gto

wor

k.

Evid

ence

Wal

king

is a

key

inte

rven

tion

topr

omot

e ac

tive

lifes

tyle

s (M

orris

and

Har

dman

199

7). E

nviro

nmen

tal

chan

ges

are

impo

rtan

t to

fac

ilita

teits

upt

ake.

Are

as t

hat

prom

ote

the

need

s of

cyc

lists

and

ped

estr

ians

have

abo

ve a

vera

ge u

se o

f th

ese

mod

es (e

g Yo

rk t

rans

port

pol

icy:

Hou

se o

f C

omm

ons

1996

).

Ou

tco

me

Redu

ced

dang

er t

ope

dest

rians

/cyc

lists

by

enco

urag

ing

grea

ter

activ

etr

ansp

ort;

mod

al s

hift

tow

ards

the

se t

rans

port

choi

ces.

Skill

s an

d r

eso

urc

es

Cro

ss s

ectio

nal f

inan

cing

thro

ugh

HIm

Ps p

ossib

le; s

kills

– jo

int

wor

king

, tar

get

sett

ing

and

plan

ning

.

Poin

ts t

o c

on

sid

er

Prod

uctio

n of

a lo

cal

tran

spor

t pl

an (L

TP) i

s a

requ

irem

ent

for

LAs;

prom

otio

n of

cyc

ling

and

wal

king

is e

ncou

rage

d, a

s is

join

t w

orki

ng w

ith H

As,

HIm

Pco

ordi

nato

rs a

nd o

ther

s.

Sche

mes

add

ress

ing

dang

erfr

om v

ehic

les

(eg

20 m

phzo

nes)

hav

e sh

own

dram

atic

acci

dent

red

uctio

n ou

tcom

es(6

1% d

rop

in p

edes

tria

nca

sual

ties

and

a 67

% d

rop

inch

ild p

edes

tria

n an

d cy

clist

sca

sual

ties;

Web

ster

and

Mac

kie

1996

).

Furt

her

info

rmat

ion

HEA

(199

8c, 1

999b

,c);

DET

R (1

999,

200

0). F

ree

copi

es o

f th

e la

tter

(Sch

ool

trav

el s

trat

egie

s an

d pl

ans.

Abe

st p

ract

ice

guid

e fo

r lo

cal

auth

oriti

es) a

re a

vaila

ble,

tel

:08

70 1

2262

36 (q

uotin

g:99

ASC

S 02

40A

).

WH

O (1

998)

; web

site:

ww

w.w

ho.d

k/en

viro

nmen

t/pa

mph

lets

Wh

o c

ou

ld b

ein

volv

ed?

Tran

spor

t

LAs,

edu

catio

nse

rvic

es; b

usin

ess;

nong

over

nmen

tal

orga

nisa

tions

(NG

Os)

;lo

cal r

oad

safe

tyof

ficer

s; p

olic

e;

LA 2

1.


50

Inte

rven

tion

NH

SS, ‘

who

lesc

hool

’ app

roac

h

Scho

ol t

rave

l pla

ns[in

clud

ing

Safe

rRo

utes

to

Scho

ol(S

RTS)

]

Evid

ence

Posit

ive

outc

omes

hav

e be

enre

port

ed f

ollo

win

g im

plem

enta

tion

of p

hysic

al a

ctiv

ity p

rogr

amm

es in

scho

ols.

Cas

e st

udie

s ha

ve s

how

n in

crea

ses

in c

yclin

g, w

alki

ng a

nd b

us u

se

(eg

Wal

king

bus

es) (

DET

R 20

00a)

.

Ou

tco

me

Sugg

ests

all

pupi

ls ex

perie

nce

two

hour

s of

phy

sical

act

ivity

a w

eek;

enc

oura

ges

staf

f,pu

pils,

par

ents

/car

ers

and

othe

r ad

ults

to

beco

me

invo

lved

in p

rom

otin

gph

ysic

al a

ctiv

ity.

Skill

s an

d r

eso

urc

es

In-s

ervi

ce t

rain

ing

of t

each

ers.

May

invo

lve

phys

ical

cha

nges

to r

oad

layo

ut o

r sc

hool

envi

ronm

ent;

prov

ision

of

safe

cyc

le p

arks

.

Poin

ts t

o c

on

sid

er

Phys

ical

act

ivity

par

ticip

atio

nm

ay e

nhan

ce a

cade

mic

perf

orm

ance

and

enc

oura

gelif

elon

g ph

ysic

al a

ctiv

ity;

prov

ides

pos

itive

envi

ronm

enta

l im

pact

(eg

redu

ced

car

trav

el);

help

sfu

lfil N

atio

nal C

urric

ulum

requ

irem

ents

for

sci

ence

and

phys

ical

edu

catio

n as

wel

l as

cont

ribut

es t

o th

e na

tiona

lfr

amew

ork

for

pers

onal

,so

cial

and

hea

lth e

duca

tion

(PSH

E).

Scho

ol t

rave

l pla

ns a

resu

ppor

ted

by In

tegr

ated

Tran

spor

t W

hite

Pap

er (D

ETR

1998

); ca

n be

inco

rpor

ated

into

a lo

cal t

rans

port

pla

n;lin

ks t

o lo

cal e

nviro

nmen

tal

conc

erns

(Com

mun

itySt

rate

gy, L

A21

).

Furt

her

info

rmat

ion

The

NH

SS id

entif

ies

crite

riaon

phy

sical

act

ivity

to

info

rmgo

od p

ract

ice

and

the

impl

emen

tatio

n of

a ‘w

hole

scho

ol’ a

ppro

ach

(NH

SS20

00).

NH

SS s

uppo

rt m

ater

ial o

nph

ysic

al a

ctiv

ity f

or p

rimar

yan

d se

cond

ary

scho

ols;

NH

SS p

hysic

al a

ctiv

ity,D

Han

d D

fEE

(200

0). L

ondo

n:H

DA

.

Briti

sh H

eart

Fou

ndat

ion

(BH

F) (2

000)

.

http

://w

ww

.wire

dfor

heal

th.

gov.

uk/

The

STA

G r

epor

t is

avai

labl

eat

: htt

p://w

ww

.loca

l-tr

ansp

ort.d

etr.g

ov.u

k/sc

hool

trav

el/in

dex.

htm

#199

8-19

99re

port

DET

R Sc

hool

Tra

vel P

lan

Best

Prac

tice

Gui

de:

http

://w

ww

.loca

l-tr

ansp

ort.d

etr.g

ov.u

k/sc

hool

tra

vel/b

pgla

/inde

x.ht

m

Scho

ol T

rave

l Str

ateg

ies

and

Plan

s C

ase

Stud

ies

Repo

rtca

n be

acc

esse

d at

:ht

tp://

ww

w.lo

cal-

tran

spor

t.det

r.gov

.uk/

scho

oltr

avel

/bpg

la/c

ases

tudi

es/in

dex

.htm

In t

his

guid

e, d

etai

ls ar

epr

ovid

ed f

or u

rban

and

rur

alsc

hool

s.

Sust

rans

SRT

S ca

n be

acce

ssed

at:

http

://w

ww

.sus

tran

s.or

g.uk

/f_

srs.

htm

Wh

o c

ou

ld b

ein

volv

ed?

Staf

f, pu

pils,

loca

led

ucat

ion

auth

ority

(LEA

), he

alth

y sc

hool

sne

twor

k, le

isure

serv

ices

, tra

nspo

rtde

part

men

t, N

GO

s(e

g Su

stra

ns).

Scho

ols

Impr

oved

env

ironm

ent

for

cycl

ing

and

wal

king

; cha

nges

in u

se o

f m

otor

ised

trav

el t

osc

hool

; red

uced

roa

d da

nger

.

Staf

f, pu

pils,

par

ents

,lo

cal t

rans

port

plan

ners

, NG

Os

(Sus

tran

s), s

choo

lgo

vern

ors.


51

Inte

rven

tion

’Gre

en‘ t

rans

port

plan

s (G

TPs)

Stai

r us

e pr

omot

ion

Evid

ence

Sche

mes

to

prom

ote

wal

king

to

wor

k ca

n be

eff

ectiv

e (W

alk

in t

ow

ork

out,

Mut

rie e

t al

. 199

9);

chan

ges

in t

rave

l mod

es w

hen

GTP

sha

ve b

een

impl

emen

ted.

Prom

otio

n of

sta

ir us

e w

as e

ffec

tive

in G

lasg

ow, u

sing

post

ers

(Bla

mey

et a

l. 19

95).

Ou

tco

me

Perc

enta

ge o

f em

ploy

ers

with

deve

lope

d tr

ansp

ort

plan

s;ch

ange

s in

wor

kpla

ce t

rave

l.

Skill

s an

d r

eso

urc

es

Prov

ide

safe

par

king

for

bicy

cles

and

sho

wer

s.

Poin

ts t

o c

on

sid

er

NSF

CH

D m

ilest

one:

‘By

Apr

il20

02 e

very

loca

l hea

lthco

mm

unity

will

… h

ave

deve

lope

d “g

reen

” tr

ansp

ort

plan

s’ (m

ilest

one

3).

Prom

otio

n of

GTP

s ne

ed n

otbe

con

fined

to

heal

th s

ervi

cesit

es. W

orkp

lace

cyc

ling

prom

otio

n in

par

ticul

arre

quire

s en

viro

nmen

tal

chan

ges

(in t

he w

orkp

lace

and

on t

he r

oad)

.

Che

ap in

terv

entio

n;ob

ject

ives

alli

ed w

ithen

viro

nmen

tal c

once

rns

(redu

ctio

n in

use

of

elec

tric

ity).

Furt

her

info

rmat

ion

Tran

spor

t 20

00 (1

998)

.

DET

R ad

vice

for

gov

ernm

ent

depa

rtm

ents

: ‘gr

een

tran

spor

t gu

ide’

http

://w

ww

.env

ironm

ent.

detr

.gov

.uk/

gree

ning

/flee

t/gc

ont.h

tm

DET

R (1

999,

200

0b).

Free

copi

es o

f th

e la

tter

(Sch

ool

trav

el s

trat

egie

s an

d pl

ans.

Abe

st p

ract

ice

guid

e fo

r lo

cal

auth

oriti

es) a

re a

vaila

ble,

tel

:08

70 1

2262

36 (q

uotin

g:99

ASC

S 02

40A

).

WH

O (1

998)

; web

site:

ww

w.w

ho.d

k/en

viro

nmen

t/pa

mph

lets

Wh

o c

ou

ld b

ein

volv

ed?

Staf

f, un

ions

, loc

altr

ansp

ort

plan

ners

,lo

cal p

ublic

tra

nspo

rtpr

ovid

ers.

Wor

kpla

ce in

terv

enti

ons

Stai

r us

e to

bec

ome

the

norm

; inc

reas

ed p

rom

inen

ceof

sta

irs in

bui

ldin

g de

sign

com

pare

d to

lift

s/es

cala

tors

;in

crea

sed

use

of s

tairs

.

Staf

f, un

ions

,em

ploy

ers,

arc

hite

cts.


52

Inte

rven

tion

Prom

otin

g us

e of

faci

litie

s

Thes

e in

clud

e le

isure

and

spor

ts c

entr

es,

com

mun

ity c

entr

es,

and

loca

l com

mun

ityin

terv

entio

ns f

orm

inor

ity g

roup

s.

Evid

ence

Acc

ess

and

cost

are

impo

rtan

tde

term

inan

ts f

or m

any

grou

ps.

Invo

lvin

g ‘h

ard

to r

each

’ gro

ups

islik

ely

to in

crea

se u

ptak

e an

dap

prop

riate

ness

of

proj

ects

.

Ou

tco

me

Skill

s an

d r

eso

urc

es

Aud

it an

d ev

alua

tion

skill

s,tr

ansla

tion,

kno

wle

dge

oflo

cal f

acili

ties;

com

mun

ityde

velo

pmen

t sk

ills;

sep

arat

ech

angi

ng a

reas

; pro

visio

n of

appr

opria

te f

acili

ties.

Poin

ts t

o c

on

sid

er

Cul

tura

l and

lang

uage

issu

esm

ay b

e im

port

ant.

‘Spo

rty’

conn

otat

ions

of

leisu

re a

ndex

erci

se c

entr

es c

an b

e of

fpu

ttin

g. H

LC f

undi

ng is

avai

labl

e. P

roje

cts

need

to

bead

ditio

nal t

o st

atut

ory

prov

ision

and

invo

lve

com

mun

ities

in d

evel

opm

ent

and

man

agem

ent.

Furt

her

info

rmat

ion

HEA

(199

7a,b

, 199

8b,

1999

a).

The

Con

fede

ratio

n of

Indi

anO

rgan

isatio

ns r

uns

anex

erci

se p

roje

ct t

o in

crea

sele

vels

of w

alki

ng in

the

Asia

n co

mm

unity

inLe

ices

ter

(con

tact

San

deep

Rohi

t, te

l: 01

16 2

25 9

299,

for

deta

ils).

Wh

o c

ou

ld b

ein

volv

ed?

Leis

ure

acti

viti

es

Iden

tific

atio

n of

gro

ups

not

part

icip

atin

g in

loca

lpr

ovisi

on; i

ncre

ased

part

icip

atio

n by

‘har

d to

reac

h’ g

roup

s; in

volv

emen

t in

desig

n an

d ru

nnin

g of

proj

ects

by

repr

esen

tativ

esfr

om s

peci

fic lo

cal g

roup

s,su

ch a

s ol

der

peop

le, b

lack

and

min

ority

eth

nic

grou

ps,

youn

g pe

ople

, peo

ple

with

disa

bilit

ies.

Leisu

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3.8 References

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Sonning Common health walks scheme. Oxford: Brookes University.

BHF, 2000. Active school resource pack. London: BHF.

Blamey, A., Mutrie, N. and Aitchison, T., 1995. Health promotion

by encouraging use of stairs. British Medical Journal, 311, 289–290.

Bovell, V., 1992. The economic benefits of health promotion in the

workplace. London: HEA.

Brownell, K.D., Stunkard, A.J. and Albaum, J.M., 1980. Evaluation and

modification of exercise patterns in the natural environment. American

Journal of Psychiatry, 137, 1540–1545.

Bull, F.C. and Jamrozik, K., 1998. Advice on exercise from a family

physician can help sedentary patients to become active. American

Journal of Preventive Medicine, 152, 85–94.

Coats, A., McGee, H. and Stokes. H., eds., 1995. British Association of

Cardiac Rehabilitation guidelines for cardiac rehabilitation.

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DETR, 1996. Vulnerable road users, Transport Committee, third report.


DETR, 1998. A new deal for transport: better for everyone. London:

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DETR, 1999. School travel: strategies and plans: a best practice guide

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DETR, 2000a. School travel strategies and plans: case study reports.

London: DETR.

DETR, 2000b. Encouraging walking: advice to local authorities.

London: DETR.

DH, 1996. Strategy statement on physical activity. London: DH.

Dishman, R.K., Oldenburg, B., O’Neal, H. and Shephard R.J., 1998.

Worksite physical activity interventions. American Journal of Preventive

Medicine, 15, 344–361.

Dunn, A., Marcus, B., Kampert, J., Garcia, M., Kohl, H. and Blair, S.

1999. Comparison of lifestyle and structured interventions to promote

physical activity and cardiorespiratory fitness: a randomised trial. Journal

of the American Medical Association, 281, 327–34.

Eakin, E.G., Glasgow, R.E. and Riley, K.M., 2000. Review of primary

care-based physical activity intervention effectiveness and implications

for practice and future research. Journal of Family Practice, 49 (2), 158–168.

Elder, P., 1996. Promoting physical activity in NHS workplaces. London:

NHS Executive and HEA.

Foster, C., 2000. Guidelines for health-enhancing physical activity

promotion programmes. Oxford: BHF Health Promotion Research Group.

Gordon, D., Shaw, M., Dorling, D. and Smith, G.D., eds., 1999.

Inequalities in health: the evidence presented to the independent inquiry

into inequalities in health, chaired by Sir Donald Acheson. Bristol: The

Policy Press.

Harland, J., White, M., Drinkwater, C., Chin, D., Farr, L. and Howel, D.,

1999. The Newcastle exercise project: a randomised controlled trial of

methods to promote physical activity in primary care. British Medical

Journal, 319, 828–832.

Harris, J., 1997. Physical education: a picture of health? The

implementation of health related exercise in the national curriculum in

secondary schools in England and Wales, doctoral dissertation.

Loughborough: Loughborough University.

HEA, 1995. Promoting physical activity: guidance for commissioners,

purchasers and providers. London: HEA.

HEA, 1997a. Physical activity ‘from our point of view’: qualitative

research among South Asian and black communities.

London: HEA.

HEA, 1997b. Guidelines: promoting physical activity with people

with disabilities. London: HEA

HEA, 1998a. Young and active? Young people and health enhancing

physical activity: evidence and implications. London: HEA.

HEA, 1998b. Guidelines: promoting physical activity with older people.

London: HEA.

HEA, 1998c. Transport and health: a briefing for health professionals

and local authorities. London: HEA

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HEA, 1999b. Making THE links: integrating sustainable transport, health

and environment policies: a guide for local authorities and health

authorities. London: HEA.


54

HEA, 1999c. Active transport: a guide to the development of local

initiatives to promote cycling and walking. London: HEA.

HEA, 2000. Health and lifestyle survey. London: HEA.

Hillsdon, M., Thorogood, M. and Foster, C., 1999. A systematic review

of strategies to promote physical activity. In: D. MacAuley, ed. Benefits

and hazards of exercise, Vol. 1. London: British Medical Journal

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Joint Surveys Unit, 1999. Health survey for England, 1998.


Killoran, A., Fentem, P. and Caspersen, C., eds., 1995. Moving on:

international perspectives on promoting physical activity. London: HEA.

Marcus, B.H., Owen, N., Forsyth, L.H., Cavill, N.A. and Fridinger, F.,

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print media and information technology. American Journal of

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Morris, J. N. and Hardman, A. E., 1997. Walking to health. Sports

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increasing active commuting in a workplace setting. Edinburgh:

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NHF, 1995. Physical activity: an agenda for action. London: NHF.

NHF, 1999. Looking to the future: making CHD an epidemic of the past.


NHSS, 2000. National Healthy Schools Standard: physical activity. London: HDA.

Pieron, M., Cloes, M., Delfosse, C. and Ledent, M., 1996. An

investigation of the effects of daily physical education in kindergarten

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sedentary living habits: theoretical but realistic estimates. Medicine and

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London: HEA.

Sallis, J.F., Hovell, M.F., Hofstetter, C.R., Elder, J.P., Hackley, M.,

Casperson, C.J. and Powell, K.E., 1990. Distance between homes and

exercise facilities related to frequency of exercise among San Diego

residents. Public Health Reports, 105, 179–185

Sallis, J.F., Nader, P.R., Broyules, S.L., Berry, C.C., Elder, J.P., McKenzie,

T.L. and Nelson, J.A., 1993. Correlates of physical activity at home in

Mexican-American and Anglo-American pre-school children. Health

Psychology, 12, 390–398.

Shephard, R.J., Jequier, J.-C., Lavallee, H., La Barre, R. and Rajic, M.,

1980. Habitual physical activity: effects of sex, milieu, season and

required activity. Journal of Sports Medicine, 20, 55–66.

Shephard, R.J., 1990. Costs and benefits of an exercising versus a

non-exercising society. In: C. Bouchard, R.J. Shephard, T. Stephens,

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55

WHO, 1996. Guideline series for healthy ageing: No. 1. The Heidelberg

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56

4.1 Introduction

The prevalence of overweight and obesity has increasedin the United Kingdom in recent decades (see Box 4.1).The incidence of CHD is highest in obese men andwomen, especially in those under 50 years old. There is agraded, increased risk of cardiovascular and totalmortality in people with a body mass index (BMI) over 25kg/m2 (Nutrition and Physical Activity Task Forces 1995).Approximately 75% of non-insulin dependent diabeticpatients are overweight (Jung 1997). In women, a weightgain of about 10 kg can lead to a threefold increased riskof developing diabetes (Jung 1997). Women with a BMIover 35kg/m2 (compared with a BMI of 22 kg/m2) have a93 times higher risk of diabetes and men have a 42-foldincreased risk (Jung,1997).

Obesity in childhood is on the increase and predictsadolescent obesity and adult obesity (Parsons et al. 1999).Adolescent obesity is associated with an increased risk ofadult mortality and morbidity (Epstein 1995). Children aremore likely to be obese if they have an obese parent.

There are critical periods in the life course where weightgain is more likely. In women these are between the agesof 15 and 19 years, after marriage, pregnancy, themenopause and retirement. In men the categories arebetween ages 35 and 40 years, after marriage and afterretirement.

Although the causes of obesity are varied, energy intakeexceeds energy expenditure for weight gain to occur. Major weight gain tends not to occur over the short-term,and an energy imbalance of only 1–2% per day can leadto the trend towards overweight and obesity seen in theUK over the years. Daily energy consumption hasdecreased by approximately 20% since 1970, but obesity has increased over this period of time (Prenticeand Jebb 1995). The number of hours spent watching TV has increased since the 1960s and a more automated lifestyle (domestic appliances, use of a motor car) eliminates the amount of physical activityincorporated into daily life. The population is moresedentary with the result that the amount of energyexpended has reduced. The prevalence of obesity is

Chapter 4Reducing overweight and obesity

Reducing overweight and obesity

Box 4.1 Prevalence of overweight and obesity

Men % Women %

Overweight (BMI 25–29.9 kg/m2) 45% 33%Obese (BMI >30kg/m2) 17% 20%Overweight or obese aged 16–24 years 27% 28%Overweight or obese aged 55–64 years 74% 69%Over last 10 years, increase in obesity Increase by 50% Increase by 42%

25% of women in unskilled occupation are obese compared with 14% of women in professional jobs.

Source: Petersen et al. (1999)

57

increasing, despite decreasing energy intake (Barlow andDietz 1998).

Losing weight is in itself beneficial to reducing CHD riskbut increased cardiorespiratory fitness should also beencouraged. Normal weight men with low cardiorespiratoryfitness have a greater risk of cardiovascular diseasemortality than overweight or obese men who do nothave low cardiorespiratory fitness (Wei et al. 1999). Seebox 4.2.

4.2 Objectives of weight management

Prevention, identification and treatment of obesity, andsustainability of weight loss after the intervention are allimportant in a weight management strategy.

Specifically:

• To prevent an increase in prevalence of obesity inchildren and adults

• To promote a reduction of obesity in children andadults

• To support weight maintenance in young children andweight loss in children and adults

• To encourage weight maintenance and preventincreases of weight in individuals who havesuccessfully reduced their body weight.

The US National Heart, Lung and Blood Institute (1998) guidelines have suggested that weight loss programmes should aim initially to reduce body weightby 10% from baseline, at a rate of one or two pounds(approximately 0.5–1 kg) a week, for six months. TheScottish Intercollegiate Guidelines Network (SIGN 1996)recommend a period of 12 weeks of weight loss followedby 12 weeks of weight stabilisation in order for energyexpenditure to readjust.

US guidelines for the evaluation and treatment of obesity in children (Barlow and Dietz 1998) recommendthat children with a BMI greater than or equal to the85th percentile with complications of obesity or with aBMI greater than or equal to the 95th percentile, with orwithout complications, should undergo evaluation andpossible treatment.

Determinants of weight and weight gain aremultifactorial (Sherwood et al. 2000). The Pound ofPrevention study concluded that exercise, fat intake and total energy intake all contribute to successful long-term control of body weight (Sherwood et al. 2000).Energy consumption must be reduced. High calorie/lowvolume foods should be avoided and replaced with anincrease in complex carbohydrates (such as whole grainfoods) and an increase in fruit and vegetables. A reduced fat intake is also an important element of abalanced healthy diet. See the sections on promotinghealthy eating (Chapter 2), and increasing physical activity (Chapter 3) in this document for further details on the effectiveness of interventions for those risk factors.

4.2.1 Definitions of ‘lifestyle’ weightmanagement interventions

Behavioural therapyCognitive behaviour modification and behavioural skills training to modify eating and physical activity habits to prevent weight regain are often used with dietary therapy.


58 Box 4.2 Health benefits of weight reduction

A 10 kg reduction in body weight can lead to thefollowing health benefits:

Mortality >20% fall in total mortality>30% fall in diabetes related deaths>40% fall in obesity-related cancer deaths

Hypertension Approximately 10 mmHg systolic and diastolic blood pressure

Lipids 10% total cholesterol reduction15% low density lipoprotein cholesterol reduction30% triglycerides reduction7% increase in high density lipoprotein cholesterol

Diabetes Fall of 50% in fasting glucose

Source: Jung (1997)

Family therapyBehavioural therapy sessions involve all members of thefamily rather than individual counselling of the affectedmember (to be used in the prevention of obesity inchildren specifically).

Dietary therapyTwo main types of dietary therapy are a low calorie diet(800–1500 kcal daily), and a very low calorie diet (lessthan 800 kcal of energy daily), which usually consists of aprotein-enriched liquid.

Exercise therapyThe primary goal is to move sedentary people into anactive category (even if it is moderate levels of intensity)and to move moderate level individuals into morevigorous levels. Accumulation of daily physical activityshould be the key if 30 minutes at least five times a weekseems unobtainable. (See Chapter 3 on Increasingphysical activity for further information.)


A number of themes are emerging on what strategies arethe most effective in preventing obesity. These are: toreduce sedentary behaviour in obese children; to use diet,physical activity and behavioural strategies for adults, incombination where possible; and to use maintenancestrategies such as continued therapist contact. A gradual,incremental stepwise approach seems to have the mostbeneficial long-term effect. Evidence for the effectivenessof obesity prevention and treatment is inconclusive(Harvey et al. 2000).

Where possible, the intended target group or geographicarea should be consulted to establish what strategies aremost appropriate and it is important to monitor the impact.Accurate recording of baseline data at the local level andthe establishment of clear objectives can aid this. It isimpossible to measure the impact of an intervention wherethe aims and objectives are too vague and multi-faceted.

The overwhelming evidence is that overweight and obesepeople should be encouraged to integrate changes totheir lifestyle over a longer period of time to maintain thebenefit of initial weight loss (Tremblay et al. 1999). Acombination of decreased food intake and increasedphysical activity is more likely to lead to sustained weightloss (Sherwood et al. 2000).

• A combination of diet and physical activity (inconjunction with behavioural counselling) is probablymore effective in sustaining weight loss than diet orexercise alone in adults. The type of activity does notseem important.

• Family therapy is more effective than conventional diet and exercise in preventing weight gain in children (but not necessarily in treatment of obesity).Family therapy is essential in treatment with youngerchildren.

• Small, sustainable modifications in diet, exercise andcommunication are more effective than restrictivestrategies. With small steps, the family/individual canaccommodate the required lifestyle modifications.

• Maintenance of weight loss interventions (self-helppeer groups, relapse prevention strategies andcontinued therapist contact by phone and mail) mayrequire longer-term contact to promote sustainabilityof weight loss.

Further information is available from Glenny et al. (1997),NHS Centre for Reviews and Dissemination (1997) andEdmunds and Waters (2000). More detail can be found inTable 4.7 at the end of this chapter.

Modest, regular bouts of physical activity can lead tobenefits. The type of exercise is not important and shortbouts of walking can cumulatively be of much benefit.Walking a mile a day for a year is equivalent in energy tothat stored in 3 kg of adipose tissue (DH 1994). Habitualphysical activity can also help keep weight off afterweight loss has been achieved, and can reduce the threat of the post-weight-loss seesaw effect (DH 1994).Generally, it is agreed that the cumulative effect ofphysical activity can benefit weight loss (DH 1994)although this view has been questioned by some(Sherwood et al. 2000).

Very low calorie diets are not advisable in children(Epstein 1995) and they are not effective. In terms ofincreasing children’s physical activity, a more active daily lifestyle should be encouraged rather thanstructured aerobic exercise schedules (Epstein 1995). It appears to be more effective to promote less sedentary lifestyles (with less opportunity to eatexcessively while watching TV, for example) than simply attempt to increase activity.


59

Potential barriers to effective obesity management mayinclude lack of access to appropriate support services,lack of motivation by professionals due to negativeperceptions of overweight and obese people or theefficacy of treatments (Harvey et al. 2000). There is stillvery little information about how clinical practice in aprimary care setting or the organisation of care in thisarea might be improved (Harvey et al. 2000). A workbook has been published by the former HEA to guide health professionals in their weight management strategies (Cowburn and Foster 1998). It provides self-learning advice in counselling approaches.

4.3.1 Skills

A local assessment of the provision of weightmanagement services will be necessary. The PCGs will be carrying out a mapping/profiling exercise. Ifobesity management services are not considered, anequity profile (see p78) should be part of the localassessment. Groups at greater risk of obesity and related CHD illness should be identified and targeted. A local mapping exercise can help achieve this goal(population structure by age, ethnicity, employment and housing status as well as identification of foodsuppliers, access to parks/leisure facilities and specialist centres).

There will be a need for training of the professionals who will be delivering the services (primary care, specialist exercise and nutrition staff). This will involve providing information about what options andservices are available as well as equipping them with the skills to identify, treat and manage ‘at risk’overweight or obese people.


There are socioeconomic and ethnic differences in theprevalence of obesity. There is a higher level of obesity inthe more deprived groups (Gordon et al. 1999). Thisshould be considered when planning obesity preventionand treatment interventions. Studies have shown thatweight loss and prevention of weight regain are lesseffective in lower income groups (Jeffery and French1997; Hardeman et al. 2000).

Epidemiological evidence suggests that there are anumber of groups who are most at risk of gainingweight, and subsequently of suffering from co-morbidityassociated with obesity. These groups are:

• South Asians

• African-Caribbeans

• Those living in socially deprived areas

• Smokers planning to stop (need to liaise with smoking cessation planners)

• People with disabilities.

Identification of individuals or groups who are at risk of associated obesity co-morbidities must be anessential element of a strategy to reduce the increasedprevalence of overweight or obesity. Consideration mustbe given to disabled people who may suffer a range ofadditional barriers to managing their weight andparticipating in weight loss programmes. There is noevidence to suggest effective interventions in this area, but training in identifying and prescribing appropriatestrategies must be considered.


60


61

4.5 Further information

There is an obesity toolkit available from the Faculty of Public HealthMedicine, Tackling obesity: a toolbox for local partnership action. A numberof interventions are listed by setting (community, home, school andworkplace). It is divided into prevention, and weight management in thetreatment of obesity (Davis et al. 2000). A copy was sent out to all directorsof public health and all health promotion units.

Tel: 020 7935 0243;email: [email protected]

A comprehensive overview of obesity will shortly be available on the web aspart of the Health Care Needs Assessment Series. It covers the epidemiologicaldata, services available and the effectiveness of interventions of theprevention and treatment of obesity in adults and children.

http://hcna.radcliffe-online.com

A directory of projects of weight management compiled by the DH is availablein each regional office. Three main themes emerged: that weight loss israrely maintained, that multicomponent programmes are more successfuland that regular follow up is important (Hughes and Martin 1999) .

The US National Institute of Health’s Clinical guidelines on the identification,evaluation, and treatment of overweight and obesity in adults (NationalHeart, Lung, and Blood Institute 1998) is available on the web. Usefulinformation for healthcare professionals working in obesity treatment andprevention can be located on their website.

http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.htm http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm

The appendices in the Clinical guidelines on the identification, evaluation,and treatment of overweight and obesity in adults list a number of usefulstrategies to help treat obesity. Examples of weight goal records, foodsubstitution ideas and food preparation leaflets, guide to behaviouralchange strategies and exercise programmes for gradual build up ofactivity/fitness are included. Consideration should be given to making thisavailable to health professionals.

http://www.nhlbi.nih.gov/guidelines/obesity/practgde.htm

An initiative Shape up America, designed for doctors, nurses, dietitians andother health professionals, has produced guidance on treating obesity. Itincludes ideas for weight gain prevention and weight loss. The appendicesmay be a useful practical toolkit for suggested approaches and includesuggestions for walking (including safety considerations and food diaries).

http://www.shapeup.org/professional/index.html

The US CDC has a report entitled Physical activity and health, which coversthe promotion of physical activity in our daily lives (US Department of Healthand Human Services 1996).

http://www.cdc.gov/nccdphp/sgr/summary.htm

CDC has published a set of guidelines on the promotion of physical activityin children and adolescents, with guidance on the benefits andconsequences of physical activity. There is a separate set of guidelines forthe promotion of healthy eating in schools.

Physical activity:http://www.cdc.gov/nccdphp/dash/physact.htmNutrition:http://www.cdc.gov/nccdphp/dash/nutraag.htm


62

Further information (continued)

WHO report Obesity: preventing and managing the global epidemic (1999). The executive summary can beviewed in the publicationssection at http://www.iotf.org/

There are two Cochrane reviews in progress on the prevention andtreatment of obesity in childhood.

Campbell et al. (2000a,b).

A community approach to behavioural change in the promotion of physicalactivity, published by the CDC, is aimed at all those interested in a community-wide strategy (central and local government, transport, health and communityplanners, exercise specialists and health professionals, community groups,businesses, schools, colleges and universities).

Community physical activityapproach:http://www.cdc.gov/nccdphp/dnpa/pahand.htm

The International Obesity Task Force (IOTF) has a web site with many linksto obesity related sites.

http://www.iotf.org/


63

Tabl

e 4.

6Su

gges

ted

acti

viti

es t

o su

ppor

t lo

cal a

ctio

n

Com

mun

ity

Inte

rven

tion

Evid

ence

Ou

tco

me

Skill

s an

d r

eso

urc

esPo

ints

to

co

nsi

der

Furt

her

info

rmat

ion

Indi

vidu

al w

eigh

tm

anag

emen

tin

tegr

ated

wit

hpo

pula

tion

inte

rven

tion

s

Indi

vidu

al s

trat

egie

s m

ay b

e m

ost

effe

ctiv

e al

ongs

ide

wid

eren

viro

nmen

tal i

nter

vent

ions

(Jef

fery

1995

; Nes

tle a

nd J

acob

son

2000

).

Incr

ease

in a

cces

sible

and

safe

set

tings

for

the

prom

otio

n of

phy

sical

act

ivity

;gr

eate

r ac

cess

to

affo

rdab

lean

d he

alth

y fo

od o

ptio

ns.

Aw

aren

ess

of t

heco

mpl

exiti

es in

the

aet

iolo

gyof

obe

sity

and

anun

ders

tand

ing

of t

he

mul

tifac

toria

l app

roac

h to

redu

cing

obe

sity.

Mas

s m

edia

has

lim

ited

shor

t-te

rm im

pact

on

phys

ical

activ

ity p

artic

ipat

ion

but

may

have

an

impa

ct in

enco

urag

ing

a cl

imat

e of

chan

ge (C

avill

1998

).

Smal

l but

ste

ady

chan

ge in

die

t an

dac

tivi

ty

Wei

ght

loss

abo

ut 1

–2 lb

/wee

k fo

ra

perio

d of

six

mon

ths.

In t

helo

nger

ter

m, w

eigh

t lo

ss c

an b

em

aint

aine

d. W

omen

who

did

som

efo

rm o

f m

oder

ate

exer

cise

on

are

gula

r ba

sis g

aine

d w

eigh

t m

ore

slow

ly t

han

thos

e w

ho w

ere

less

activ

e (S

herw

ood

et a

l. 20

00).

Wei

ght

redu

ctio

n by

abo

ut10

% o

f ba

selin

e w

eigh

t;pr

even

tion

of r

elap

se t

opr

evio

us w

eigh

t le

vel.

Skill

in e

ncou

ragi

ng p

atie

nts

who

may

bec

ome

disil

lusio

ned

with

slo

w lo

ss.

Ther

e is

cum

ulat

ive

bene

fit in

freq

uent

, but

sho

rt s

pells

of

phys

ical

act

ivity

.

Com

bine

die

t,ph

ysic

al a

ctiv

ity

and

beha

viou

ral

ther

apy

A c

ombi

natio

n of

inte

rven

tions

ism

ost

effe

ctiv

e (C

linic

al E

vide

nce

2000

). Ev

iden

ce s

ugge

sts

that

effe

cts

are

shor

t te

rm.

Impr

oved

link

s be

twee

nle

isure

fac

ilitie

s, c

ater

ers,

LA

san

d H

As.

Regu

lar

mee

tings

bet

wee

ndi

ffer

ent

sect

ors

will

be

requ

ired.

Iden

tify

lead

per

son

or o

rgan

isatio

n.

Freq

uent

ong

oing

con

tact

issu

gges

ted

to h

elp

mai

ntai

nth

e be

nefit

s.

Wh

o c

ou

ld b

ein

volv

ed?

HA

s, e

duca

tion

sect

or, l

ocal

envi

ronm

ent

plan

ners

.

Prim

ary

care

tea

m,

diet

itian

s,be

havi

oura

lth

erap

ists.

Nut

ritio

n an

dph

ysic

al a

ctiv

ityex

pert

s.


64

Inte

rven

tion

Seco

ndar

ypr

even

tion

insc

hool

s

Use

‘who

le s

choo

l’ap

proa

ch (G

oran

et

al. 1

999;

Sto

ry19

99).

Prim

ary

prev

enti

onin

sch

ools

Use

‘who

le s

choo

l’ap

proa

ch.

Supp

orti

ve a

ndre

spec

tful

app

roac

h

Evid

ence

Abo

ut a

10%

mea

n re

duct

ion

inov

erw

eigh

t w

as r

epor

ted

(Sto

ry19

99).

Youn

ger

(pre

-ado

lesc

ent)

inte

rven

tions

wer

e m

ore

succ

essf

ul.

This

resu

lt w

as b

ased

on

a sh

ort-

term

fol

low

up

(mos

tly le

ss t

han

sixm

onth

s).

App

roac

h sh

own

to b

e ef

fect

ive

(Sto

ry 1

999)

.

Qua

litat

ive

inte

rvie

ws

of U

S ch

ildre

n(S

tory

199

9); i

ncre

ased

adh

eren

ce if

appr

oach

ed in

a s

ensit

ive

man

ner.

Prev

ent

incr

ease

s in

wei

ght

inal

read

y ov

erw

eigh

t ch

ildre

n.

Prev

ent

beco

min

g ov

erw

eigh

tor

obe

se.

Build

sel

f-co

nfid

ence

and

sel

fes

teem

.

Skill

s an

d r

eso

urc

es

Acc

ess

to g

yms

and

play

ing

field

s. C

hild

ren

can

eat

up t

otw

o m

eals

per

day

in s

choo

ls;fa

mili

es a

re n

ot t

o in

cur

the

cost

(Gor

an e

t al

. 199

9).

Will

req

uire

tra

ined

you

thco

unse

llors

/die

titia

ns.

Poin

ts t

o c

on

sid

er

Nee

d lo

nger

-ter

m d

ata

to s

eew

heth

er w

eigh

t lo

ss c

an b

esu

stai

ned.

Pot

entia

l har

mfu

lef

fect

s (s

tigm

atisa

tion,

eat

ing

diso

rder

s, la

belli

ng) m

ayre

sult.

Pot

entia

l fra

mew

ork

for

PSH

E.

Prov

ide

a cu

ltura

llyap

prop

riate

inte

rven

tion;

incl

ude

clas

sroo

m h

ealth

educ

atio

n cl

asse

s; p

oten

tial

fram

ewor

k fo

r PS

HE.

Be a

war

e of

adv

erse

psyc

holo

gica

l im

pact

.

Furt

her

info

rmat

ion

Mor

e in

form

atio

n on

you

ngpe

ople

’s a

ttitu

des

to d

iet,

heal

th a

nd e

xerc

ise c

an b

efo

und

at:

http

://w

ww

.ex.

ac.u

k/~d

regi

s/Pu

bs/y

p98.

htm

l

A s

umm

ary

of t

he s

ide

effe

cts

of t

reat

men

t in

child

ren

can

be f

ound

in(E

pste

in e

t al

. 199

8).

A s

yste

mat

ic r

evie

w o

nhe

alth

pro

mot

ion

in s

choo

lsis

avai

labl

e (L

ister

-Sha

rpet

al. 1

999)

. It

can

also

be

acce

ssed

on

the

Web

:ht

tp://

hta.

nhsw

eb.n

hs.u

k

Ou

tco

me

Wh

o c

ou

ld b

ein

volv

ed?

Scho

ol n

urse

s,te

ache

rs, c

ouns

ello

rs,

loca

l hea

lthy

scho

ols

prog

ram

me.

Scho

ols

LAs,

foo

d se

ctor

,le

isure

fac

ilitie

sm

anag

ers,

tea

cher

s,sc

hool

bas

edco

unse

llors

, you

thw

orke

rs/y

outh

clu

bs,

pare

nts,

loca

l hea

lthy

scho

ols

prog

ram

me.

Teac

hers

, sch

ool

base

d co

unse

llors

,pa

rent

s, lo

cal h

ealth

ysc

hool

s pr

ogra

mm

e.


65

Inte

rven

tion

The

‘Sto

plig

ht D

iet’

for

trea

tmen

t of

pre-

adol

esce

ntch

ildre

n

It ha

s ‘re

d’ f

oods

for

best

avo

ided

, ‘am

ber’

for

food

s th

at c

an b

eea

ten

in m

oder

atio

nan

d ‘g

reen

’ for

ple

ntifu

l.

Regu

lar

daily

acti

vity

in c

hild

ren;

com

bine

die

t an

dex

erci

se

Enco

urag

e le

ssse

dent

ary

leis

ure

tim

e

Fam

ily g

roup

sess

ions

wit

hdi

etar

y ad

vice

, and

regu

lar

visi

ts t

o G

P

Evid

ence

Youn

ger

child

ren

achi

eved

bet

ter

wei

ght

loss

, and

mai

nten

ance

of

loss

(Eps

tein

et

al. 1

998)

.

Inte

grat

ing

regu

lar

activ

ity in

to d

aily

life

is m

ore

effe

ctiv

e th

an s

truc

ture

dae

robi

c ex

erci

se. T

he e

ffec

t w

asm

aint

aine

d at

a t

wo

year

fol

low

up

(Eps

tein

et

al. 1

998)

.

Tria

l of

redu

cing

TV

wat

chin

gre

sulte

d in

dec

reas

ed a

dipo

sity

(Rob

inso

n 19

99).

Tria

l of

a re

war

dsy

stem

for

dec

reas

ing

sede

ntar

ybe

havi

our

show

ed a

red

uctio

n in

perc

enta

ge o

verw

eigh

t (E

pste

in e

tal

. 199

5).

Prev

ente

d pr

ogre

ssio

n to

sev

ere

obes

ity in

ado

lesc

ence

in 1

0- a

nd11

-yea

r-ol

ds (F

lodm

ark

et a

l. 19

93),

but

no d

iffer

ence

at

one-

year

fol

low

up.

A t

rial w

ith a

10-

year

fol

low

up

show

ed t

hat

invo

lvem

ent

of p

aren

tan

d ch

ild w

as m

ost

effe

ctiv

e(E

pste

in e

t al

. 199

8). I

nclu

sion

ofm

aste

ry e

lem

ent

(taki

ng c

ontr

ol o

fow

n be

havi

ours

) and

use

of

rew

ards

wer

e fo

und

to b

e m

ore

effe

ctiv

e in

red

ucin

g w

eigh

t in

child

ren.

Wei

ght

loss

; mod

ifica

tion

ofea

ting

and

exer

cise

beha

viou

rs.

Regu

lar

phys

ical

act

ivity

inda

ily li

fe b

ecom

es t

he n

orm

.

Incr

ease

d ac

tivity

and

less

‘sna

ckin

g’ t

ime.

Enco

urag

e ch

ange

s in

habi

tual

life

styl

e by

all

fam

ilym

embe

rs.

Skill

s an

d r

eso

urc

es

Leaf

lets

on

diet

s.

Educ

atio

n fo

r pa

rent

s an

dch

ildre

n w

ill b

e re

quire

d.

Teac

hers

to

expl

ain

how

to

be s

elec

tive

in c

hoic

e of

TV

wat

chin

g; le

afle

ts t

o pa

rent

sab

out

reco

rdin

g ch

ild’s

activ

ities

; TV

mon

itorin

gbo

xes

coul

d be

con

sider

ed.

Poin

ts t

o c

on

sid

er

Ensu

re t

he c

hild

has

adeq

uate

nut

ritio

n fo

rgr

owth

. Mon

itor

psyc

holo

gica

l im

pact

on

child

ren.

Safe

ty is

sues

with

loca

l urb

anpl

anne

rs a

nd r

ecre

atio

nal

divi

sion

to e

nsur

e sa

fe p

lay

area

s.

Long

-ter

m o

utco

me

not

yet

know

n.

One

stu

dy s

how

s th

at if

the

child

and

par

ent

are

coun

selle

d se

para

tely

, bet

ter

wei

ght

loss

is a

chie

ved.

Bot

har

e in

volv

ed in

the

pro

cess

,bu

t ar

e se

en a

part

.

Self-

mon

itorin

g an

d go

alse

ttin

g pr

aise

are

sug

gest

ed.

Gra

dual

beh

avio

ural

the

rapy

over

a lo

nger

per

iod

of t

ime

had

a be

tter

long

-ter

m e

ffec

tth

an in

tens

e se

ssio

ns (E

pste

inet

al.

1998

).

Furt

her

info

rmat

ion

Epst

ein,

L.H

. and

Squ

ires,

S.S.

, 199

8. T

he S

topl

ight

Die

t fo

r ch

ildre

n. B

osto

n,M

A: L

ittle

, Bro

wn

and

Co.

BHF

leaf

lets

for

par

ents

: Get

kids

on

the

go:

http

s://w

ww

.bhf

.org

.uk/

publ

icat

ions

/upl

oade

d_pd

fs/a

ctiv

echi

ldre

n.pd

f

Ou

tco

me

Wh

o c

ou

ld b

ein

volv

ed?

Scho

ol b

ased

hea

lthca

rers

(die

titia

ns a

ndsc

hool

nur

ses)

, PE

teac

hers

, fam

ily.

Child

ren

Scho

ol, p

hysic

aled

ucat

ion

(PE)

teac

hers

, exe

rcise

spec

ialis

ts, f

amily

,lo

cal p

arks

and

recr

eatio

n ar

eas;

loca

l hea

lthy

scho

ols

prog

ram

me.

Pare

nts,

tea

cher

s,yo

uth

wor

kers

, loc

alhe

alth

y sc

hool

spr

ogra

mm

e.

Cou

nsel

ling

serv

ices

,di

etiti

ans,

PC

Gs,

scho

ol n

urse

s.


66

Inte

rven

tion

Indi

vidu

alis

edad

vice

and

ris

kas

sess

men

t

Prov

ide

regu

lar

follo

w u

p co

ntac

t.

Exer

cise

as

inte

gral

part

of

inte

rven

tion

Enco

urag

e fr

iend

san

d fa

mily

to

acco

mpa

nypa

rtic

ipan

t (m

aybe

abu

ddy

sche

me

whe

repa

rtic

ipan

ts c

an li

nkup

with

ano

ther

mem

ber

of t

hegr

oup)

.

Ener

gy-r

estr

icte

ddi

et (

1,00

0–2,

000

kcal

/day

) ra

ther

than

fat

res

tric

ted

diet

(22

–26

g/da

y)

Spec

ialis

t w

eigh

tlo

ss c

linic

wit

hin

aG

P pr

acti

ce

Evid

ence

Gro

up s

essio

ns a

ppea

red

mor

eef

fect

ive

(Hug

hes

and

Mar

tin 1

999)

.Su

stai

ned

wei

ght

loss

in p

rimar

yca

re s

ettin

gs is

unc

omm

on (H

ughe

san

d M

artin

199

9).

Mod

erat

e (s

hort

-ter

m) e

ffec

ts o

fpr

imar

y ca

re b

ased

cou

nsel

ling

and

inte

rven

tions

tai

lore

d to

par

ticul

arne

eds

with

writ

ten

mat

eria

ls ha

d a

stro

nger

eff

ect

(Eak

in e

t al

. 200

0).

Rand

omise

d co

ntro

lled

tria

l (RC

T)sh

owed

gre

ater

wei

ght

loss

in t

heen

ergy

res

tric

ted

diet

, at

18 m

onth

follo

w u

p (C

linic

al E

vide

nce

2000

).

A w

eekl

y cl

inic

(with

a h

ealth

visit

or) a

chie

ved

wei

ght

loss

eve

n at

a on

e-ye

ar f

ollo

w u

p; 3

3%ac

hiev

ed a

10%

wei

ght

redu

ctio

nan

d 6%

mai

ntai

ned

this

loss

at

one

year

(Sle

ath

1999

).

App

ropr

iate

ly t

ailo

red

inte

rven

tions

for

par

ticul

argr

oups

lead

to

bett

erco

mpl

ianc

e an

d ef

fect

ive

outc

omes

; can

be

used

for

high

er r

isk g

roup

s su

ch a

set

hnic

min

ority

or

disa

bled

grou

ps.

Incr

ease

d ac

tivity

as

part

of

ever

yday

livi

ng; b

ette

rba

lanc

e of

ene

rgy

inta

ke a

ndex

pend

iture

.

Mai

nten

ance

of

wei

ght

loss

thro

ugh

regu

lar

follo

w u

p.

Skill

s an

d r

eso

urc

es

Link

with

loca

l com

mun

itygr

oups

wor

king

with

eth

nic

min

oriti

es; l

angu

age

skill

s,re

cogn

ition

of

cultu

ral a

ndre

ligio

us r

equi

rem

ents

; see

Impr

ovin

g di

et a

nd n

utrit

ion

(Cha

pter

2) f

or in

terv

entio

ns.

Trai

ning

for

prim

ary

care

team

s ab

out

the

role

of

phys

ical

act

ivity

; see

Incr

easin

g ph

ysic

al a

ctiv

ity(C

hapt

er 3

).

Trai

ning

for

hea

lthpr

ofes

siona

ls (s

ee Im

prov

ing

diet

and

nut

ritio

n,

Cha

pter

2).

Room

in t

he p

ract

ice;

tra

inin

gfo

r a

heal

th v

isito

r (w

hich

coul

d be

sha

red

betw

een

prac

tices

in t

he a

rea)

.

Poin

ts t

o c

on

sid

er

Ass

essin

g re

adin

ess

toch

ange

is im

port

ant

whe

nre

com

men

ding

a w

eigh

tre

duct

ion

prog

ram

me

(Die

tz19

99).

Iden

tify

barr

iers

(acc

ess

to a

ffor

dabl

e,nu

triti

ous

food

, chi

ld c

are

arra

ngem

ents

, ope

ning

hou

rsof

fac

ilitie

s).

A m

otiv

ated

coo

rdin

ator

and

supp

ortiv

e te

am m

ay im

prov

eou

tcom

es.

Patie

nts

shou

ld b

e gi

ven

choi

ce o

f ac

tivity

(inc

ludi

ngho

me

base

d) (H

illsd

on 1

998)

.Ex

erci

se r

efer

ral s

chem

es c

anid

entif

y su

itabl

e ca

ndid

ates

and

esta

blish

the

resp

onsib

ilitie

s w

ithin

apr

ogra

mm

e be

twee

n th

epa

rtie

s (H

ughe

s an

d M

artin

1999

), bu

t re

crui

tmen

t an

dad

here

nce

may

be

fairl

y lo

wan

d no

t re

ach

thos

e w

ithm

ost

to g

ain

(Hill

sdon

199

8)

Furt

her

info

rmat

ion

A f

ram

ewor

k ha

s be

ende

velo

ped

that

run

s th

roug

hth

e st

ages

of

prom

otin

gex

erci

se f

or w

eigh

tm

anag

emen

t fr

om a

sses

sing

read

ines

s to

cha

nge

to t

hepr

oces

s of

cha

nge

and

inte

rven

tions

(Bid

dle

and

Fox

1998

).

See

Impr

ovin

g di

et a

ndnu

triti

on (C

hapt

er 2

).

Ou

tco

me

Wh

o c

ou

ld b

ein

volv

ed?

Prim

ary

care

tea

ms,

GPs

, com

mun

itydi

etiti

ans,

com

mun

ity(e

thni

c gr

oup)

link

wor

kers

, hea

lthvi

sitor

s.

Prim

ary

care

leve

l

PCG

s, p

ract

ice

nurs

es, l

eisu

re f

acili

type

rson

nel;

som

ehe

alth

visi

tors

hav

eth

is ro

le.

Die

titia

ns, p

ract

ice

nurs

es.

PCG

, hea

lth v

isito

r,co

mm

unity

die

titia

n.


67

Inte

rven

tion

Freq

uent

con

tact

over

long

ter

m

Prov

isio

n of

hom

eex

erci

se e

quip

men

t

Also

sup

ervi

sed

exer

cise

ses

sions

with

simpl

e be

havi

oura

lth

erap

y (S

BT) a

t on

eye

ar c

ompa

red

with

SBT

and

simpl

eex

erci

se (C

linic

alEv

iden

ce 2

000)

.

Com

mer

cial

wei

ght

loss

pro

gram

mes

Evid

ence

Syst

emat

ic r

evie

w s

how

ed t

hat

any

type

of

freq

uent

con

tact

led

to le

ssw

eigh

t ga

in (C

linic

al E

vide

nce

2000

). In

terv

entio

ns s

houl

d la

st f

orle

ast

six m

onth

s an

d in

corp

orat

eco

ntin

uing

con

tact

to

prev

ent

wei

ght

rega

in (N

atio

nal H

eart

, Lun

gan

d Bl

ood

Inst

itute

199

8). F

ace

tofa

ce c

onta

ct (h

ouse

visi

ts) w

ere

show

n to

be

effe

ctiv

e in

red

ucin

gw

eigh

t re

gain

in o

ne R

CT

(mor

e so

than

pho

ne o

r le

tter

con

tact

)(C

linic

al E

vide

nce

2000

).

Impr

oved

wei

ght

loss

ach

ieve

d w

ithpr

ovisi

on o

f ex

erci

se e

quip

men

t fo

rth

e ho

me

com

bine

d w

ith a

dvic

e on

cont

inuo

us e

xerc

ise (v

ersu

sin

term

itten

t) (C

linic

al E

vide

nce

2000

). Su

perv

ised

exer

cise

ses

sions

(thre

e tim

es a

wee

k fo

r 12

wee

ks)

plus

SBT

was

mor

e ef

fect

ive

inw

eigh

t lo

ss a

t on

e ye

ar, b

ut a

noth

erfo

und

that

sup

ervi

sed

wal

ks o

r a

pers

onal

tra

iner

res

ulte

d in

less

wei

ght

loss

tha

n SB

T al

one

(Clin

ical

Evid

ence

200

0).

Evid

ence

tha

t be

tter

wei

ght

loss

isac

hiev

ed in

gro

up s

ettin

gs (D

avis

etal

. 200

0).

Redu

ce w

eigh

t ga

in.

Cum

ulat

ive

daily

act

ivity

can

be o

f be

nefit

in a

wei

ght

cont

rol p

rogr

amm

e an

d ca

nim

prov

e ad

here

nce

(Jaci

cic

etal

. 199

5).

Impr

ove

psyc

holo

gica

l wel

l-be

ing.

Mak

e th

e pr

oces

s of

losin

g w

eigh

t m

ore

enjo

yabl

e.

Skill

s an

d r

eso

urc

es

Reso

urce

s to

fol

low

up

over

long

er t

ime

perio

d re

quire

d(s

taff

/pho

ne c

alls/

lett

er);

freq

uent

or

long

-ter

m f

ollo

wup

may

req

uire

ext

ra p

ract

ice

reso

urce

s.

Supe

rvise

d se

ssio

ns r

equi

reex

tra

reso

urce

s. L

iaiso

n w

ithle

isure

fac

ilitie

s or

loca

lsu

pplie

rs m

ay m

ake

it ea

sier

to p

rovi

de h

ome

base

deq

uipm

ent

(con

sider

are

ntin

g sc

hem

e?).

Mot

ivat

ed c

lass

lead

er m

aybe

impo

rtan

t.

Poin

ts t

o c

on

sid

er

Self-

help

pee

r gr

oups

, sel

f-m

anag

emen

t te

chni

ques

and

fam

ily o

r sp

ousa

l inv

olve

men

tm

ay a

ll be

of

som

e he

lp(C

linic

al E

vide

nce

2000

).

App

roac

h ca

n en

cour

age

sede

ntar

y pe

ople

to

beco

me

mor

e ac

tive.

Sm

alle

r bo

uts

ofac

tivity

may

app

ear

mor

eat

tain

able

. Aim

to

accu

mul

ate

abou

t 30

min

utes

of a

ctiv

ity p

er d

ay (N

atio

nal

Hea

rt, L

ung

and

Bloo

dIn

stitu

te 1

998)

.

Eval

uatio

n to

ols

for

com

mer

cial

wei

ght

loss

prog

ram

mes

are

nee

ded

(Con

ley

1998

).

Furt

her

info

rmat

ion

Ou

tco

me

Wh

o c

ou

ld b

ein

volv

ed?

GP,

pra

ctic

e nu

rse

orw

eigh

t sp

ecia

list.

Mai

nten

ance

of

wei

ght

loss

Phys

ical

act

ivity

advi

sor,

coun

selli

ngse

rvic

es.

4.7 References

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expert committee recommendations. Pediatrics, 102, E29.

Biddle, S.J.H. and Fox, K.R., 1998. Motivation for physical activity

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Campbell, K., Waters E., O'Meara, S. and Summerbell, C., 2000a.

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Campbell, K., Summerbell, C., O'Meara, S. and Waters, E., 2000b.

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Cavill, N., 1998. National campaigns to promote physical

activity: Can they make a difference? International Journal of

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the best available evidence for effective health care. London:

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Conley, R., 1998. The commercial sector: marketing and fitness

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Cowburn, G. and Foster, C., 1998. Managing weight: a workbook

for health and other professionals. London: HEA.

Davis, A., Giles, A. and Rona, R., 2000. Tackling obesity: a toolbox for

local partnership action. London: Faculty of Public Health Medicine.

DH, 1994. Nutritional aspects of cardiovascular disease: report of the

cardiovascular review group of the Committee on Medical Aspects of

Food Policy. London: The Stationery Office.

Dietz, W., 1999. How to tackle the problem early? The role of

education in the prevention of obesity. International Journal of Obesity

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Eakin, E.G., Glasgow, R.E. and Riley, K.M., 2000. Review of primary

care-based physical activity intervention studies. The Journal of Family

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Edmunds, L. and Waters, E., 2000. Childhood obesity. In: V.A. Moyer, E.J.

Elliot, R.L. Davis, R. Gilbert, T. Klassen, S. Logan, C. Mellis and K. Williams,

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Epstein, L.H., 1995. Management of obesity in children. In:

K.D. Brownell and Fairburn, C.G., eds. Eating disorders and obesity.

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Epstein, L.H., Valoski, A.M., Vara, L.S., McCurley, J., Wisniewski, L.,

Kalarchian, M.A., Klein, K.R. and Shrager, L.R., 1995. Effects of

decreasing sedentary behavior and increasing activity on weight change

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Epstein, L.H., Myers, M.D., Raynor, H.A. and Saelens, B.E., 1998. Treatment

of pediatric obesity. International Journal of Obesity and Related

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Flodmark, C.E., Ohlsson, T., Ryden, O. and Sveger, T., 1993. Prevention

of progression to severe obesity in a group of obese schoolchildren

treated with family therapy. Pediatrics, 91, 880–884.

Glenny, A.M., O’Meara, S., Sheldon, T. A. and Wilson, C., 1997.

The treatment and prevention of obesity: a systematic review of the

literature. International Journal of Obesity and Related Metabolic

Disorders, 21, 715–737.

Goran, M.I., Reynolds, K.D. and Lindquist, C.H., 1999. Role of

physical activity in the prevention of obesity in children. International

Journal of Obesity and Related Metabolic Disorders, 23 (suppl 3),

S18–S33.

Gordon, D., Shaw, M., Dorling, D. and Davey Smith, G., eds., 1999.

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inquiry into inequalities in health, chaired by Sir Donald Acheson.

Bristol: The Policy Press.

Hardeman, W., Griffin, S., Johnston, M., Kinmonth, A.L. and

Wareham, N.J., 2000. Interventions to prevent weight gain:

a systematic review of psychological models and behavioural change

methods. International Journal of Obesity and Related Metabolic

Disorders, 24, 131–143.

Harvey, E. L., Glenny, A., Kirk, S.F.L. and Summerbell, C.D., eds.,

2000. Improving health professionals’ management and the

organisation of care for overweight and obese people. Oxford:

Update Software.

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care. International Journal of Obesity and Related Metabolic Disorders,

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Jacicic, J.M., Wing, R.R., Butler, B.A. and Robertson, R.J., 1995.

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effects on adherence, cardiorespiratory fitness, and weight loss in

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21, 457–464.

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treatment of obesity. Effective Health Care, 3, 1–12.

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increasing problem of obesity in England. London: DH.

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S1–S107.

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sloth? British Medical Journal, 311, 437–439.

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obesity. Journal of the American Medical Association, 282, 1561–1567.

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D.M., 2000. Predictors of weight gain in the Pound of Prevention study.

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sustained? An evaluation of a general practice based weight control

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weight maintenance. International Journal of Obesity and Related

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Paffenbarger, R.S. and Blair, S.N., 1999. Relationship between low

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69

5.1 Establishing a local CHD implementation team

As outlined in the NSF CHD, every HA should make contact with all local NHS organisations, LAs and other partner agencies to establish animplementation team. This will work on behalf of thelocal health community with members representingrelevant stakeholders, including users and carers (DH2000a, Chapter 3.7, p63). Partnership working, both for strategy development and implementation will be crucial to success.

5.1.1 Milestones and goals

Organisational and health promotion milestones and goals are set out on pp57–60 of the NSF CHD mainreport (DH 2000a). These include responsibilities for NHS organisations and LAs as employers (smokingpolicy, ‘green transport’ policies, and employee-friendlypolicies) and responsibilities for implementing thepreventive aspects of the NSF. In particular, by April 2001 all NHS bodies, working closely with LAs, will have agreed and be contributing to the delivery of local programmes of effective policies (DH 2000a, p57;DH 2000b, p18) on:

• Reducing smoking • Promoting healthy eating• Increasing physical activity• Reducing overweight and obesity.

5.2 Developing local delivery plans

The local implementation team is responsible forproducing a local delivery plan for implementing the NSFCHD. Local delivery plans should be in place and agreedby all the relevant players by October 2000 (DH 2000a,Chapter 3.38, p70).

The key elements of NSF CHD delivery are:

• Identifying service developments – what needs to be done differently?

• Identifying organisational and systems developments – how will the service developments be delivered?

• Professional and personal development – what skillsare needed and who needs them? (DH 2000a, pp64–65).

The NSF CHD should be delivered within the context of the overall HImP and the National PrioritiesGuidance. The plan should be consistent with thedevelopment plan for clinical governance and be reflected within the service and financial frameworks. The plans should also link and be consistent with primarycare investment plans (DH 2000c), and the emerging LAcommunity strategies. Teams should identify other localstrategies and plans to which the delivery plan should belinked and map the contribution that they currently maketo CHD prevention.

Chapter 5Developing a local strategy

Developing a local strategy

73

74

It will be important to consider local plans in the contextof regional health strategies. Box 5.1 identifies localinitiatives which are relevant to CHD prevention.

In order to develop their local implementation plans,teams need to develop partnerships, involve their localcommunities and assess local needs. The planning processfollows a number of key stages as outlined in Figure 1.

5.3 Building effective partnerships

Local implementation of the NSF CHD is intended to be partnership based. There are three broad objectives for local partnerships to prevent CHD:

• improving the coordination and integration of policies (eg integration of the CHD prevention strategy with relevant health and other policies such as health at work and healthy schools policies; environmental, regeneration and leisure policies)

• developing innovative and high quality services by bringing together the contributions and expertise of all partners

• increasing and maximising the financial and other resources available for local services bydeveloping joint ventures between statutoryorganisations, the voluntary sector and the private sector (such as healthy living centre approaches, health at work initiatives).

The development of effective policies and interventions to prevent CHD requires the involvement of the NHS, LAs, voluntary organisations, businesses and the local community in the strategic reshaping of service provision. In many areas this will mean building on alliances and partnerships, which already exist. Existing localpartnerships should be reviewed. They may be able to take on this responsibility, or new partnerships may need to be formed to deliver the NSF locally.

5.3.1 New freedoms to promote and support joint working

New powers to enable HAs and LAs to work together more effectively came into force on 1 April 2000 (DH 2000d). Pooled budgets, integrated provision and lead commissioning are operational flexibilities, which enable services to be developed according to need, irrespective of the boundaries between organisations.


Figure 1. Suggested framework for local plans.

Box 5.1 Local plans and initiatives linking to CHD prevention

All areas should include:• HlmP• Primary care investment plans• Community strategy• LA 21/sustainable development/environment

strategy• LTP.

Those areas covered by the following (eg):• HAZ• Healthy cities/health for all• HLCs• School health plans• Sports and leisure strategies• Anti-poverty strategies• Existing health topic strategies• Secondary prevention strategies (including

coronary rehabilitation services, open accesschest pain clinics)

• Regeneration initiatives and plans (eg New Dealfor Communities).

5.3.2 Making the partnership effective

Effective partnership working should include (Geddes1998; Plamping et al. 2000; Watson et al. 2000):

• Leadership and vision – the management anddevelopment of a shared realistic vision for thepartnership’s work through the creation of commongoals

• Involvement and commitment – the commitment oflocal players and particularly the involvement ofcommunities as equal partners. Senior levelcommitment and involvement from NHS, LAs andother partner organisations

• Resources – the contribution and shared utilisation ofinformation, financial, human and technical resources.LAs and HAs should report the proportion of theirbudgets to be given to health promotion, includingheart health promotion (DH 2000b, p15).

Box 5.2 provides examples of a range of people andorganisations who could be involved in different aspectsof CHD prevention.

5.4 Involving local communities

A community development approach enablescommunities to make their own decisions about how toachieve better health for themselves, their families andthe wider community. Professionals are required to act asfacilitators, rather than imposing an agenda on thecommunity. Community development projects do notusually have a focus on disease prevention; however,many address at least one of the lifestyle risk factors forCHD and/or its broader social determinants.

The NSF requires that there is at least one communitydevelopment project with a focus on CHD in one of themost deprived communities in every LA area. Healthvisitors will be a vital resource in securing successfulcommunity development (DH 2000a, p19). HLCs, whichare funded through the NOF, can provide a focus forcommunity development initiatives(http://www.nof.org.uk).

Consulting and involving communities is a key part ofgovernment policy which service providers are required


75

Box 5.2 Who could be involved in the CHD prevention partnership?

From the NHS:• Community Health NHS Trusts• Community nurses, health visitors and midwives• Hospitals and staff• GPs (Local Medical Committee and/or GP Forum)• HAs• Health promotion• Nutrition and dietetic services• Occupational health• Physiotherapy• PCGs/PCTs• Public health• Smoking cessation services• Ambulance trusts• NHS Direct• Community pharmacistsFrom LAs:• Community development• Education• Environmental health• Highways• Housing• Leisure• LA 21• Regeneration and planning• Social care services• Schools• Transport, roads and highways• Youth and community servicesFrom the voluntary sector:• Local voluntary organisations with a remit for CHD

prevention or which address relevant CHD risk factors• Local voluntary organisations who have links with

local target groups (eg groups who work witholder people, black and minority ethnic groups)

From the local community:• Schools and colleges• Groups which work with relevant local target groupsFrom private sector:• Food retailers and local businesses• Medium to large size local employers (for health

at work policies)• Private sector leisure providers• Restaurateurs, caterers and other local food outlets• Private transport companies

to implement and is a key part of many local initiatives (eg NHSE 1998, 1999; DETR 2000). Involving localcommunities in developing strategies and action plansimproves the quality and effectiveness of programmes(Nichols 1999).

Local communities should be actively involved in CHDpartnerships at every stage to include strategy development,action planning, delivery and review and evaluation.

Local people are able to provide insights into the natureof health and social issues and the appropriateness andacceptability of policies and strategies (Rogers et al.1997). Actively involving local communities in needsassessment research processes, ensuring theirrepresentation within planning and managementarrangements and providing training and resources forvolunteers and local networks are key factors for successin initiatives to improve health and well being (Gillies 1998).

5.4.1 Consulting local communities

The Audit Commission (1999) has identified principles ofgood practice in this area. Consultation should:

• Be related to a decision that the organisations intendto take

• Have clear objectives• Be competently carried out• Be inclusive• Be used in practice.

Effective consultation is not easy to achieve. It needs tobe carefully planned, effectively carried out andthoughtfully used. Communities contain many different

interests and interest groups and it is important to try toestablish whom a representative is representing, and towhom in the community the representative is accountable.Findings from community consultations have to bebalanced with other factors such as other stakeholderpriorities, available resources and statutory requirements.There are many different consultation methods, eachwith their own advantages and disadvantages. Theseinclude: meetings, surveys, focus groups, user groups,citizens’ juries, citizens’ panels, neighbourhood fora,youth councils, community visioning/mapping exercises,and participatory appraisal and participatory actionresearch. A broad spectrum of approaches should beused and selection of those which are relevant to thepurpose of the consultation, and suitable for those whoare being consulted, is recommended.

Public participation and consultation occurs at differentlevels, and the degree of control local people experiencerelates to the level of involvement (see Box 5.3).

When planning community consultation it is important to:

• Identify information from consultation that has alreadytaken place through existing initiatives such as LA 21

• Work with other partners to agree a joint approach to consultation and to agree the most appropriatemethods (this will avoid consultation overload, andmake the best use of available resources)

• Present the exercise realistically to avoid raisingunrealistic expectations

• Plan feedback to the participants.


76

Box 5.3 Level of involvement

Less involvement High involvement

Source: Audit Commission (1999)

One off polls(eg referendum, publicopinion survey)

Regular surveys of views(eg panel survey)

One off deliberativeexercises(eg citizens’ jury,community visioningevents)

Ongoing consultationgroups(eg neighbourhoodforum)

Once the consultation is completed consider who elsewould find the results useful in planning and deliveringtheir services, and disseminate the findings accordingly.

5.4.2 Developing capacity

To support effective community development andinvolvement, consideration needs to be given to capacitybuilding on three levels (Russell and Killoran 1999):

• Individual development

• Capacity building within local groups (eg throughtraining, support workers, skills development,administrative resources)

• Developing the local community infrastructure.

Capacity building enables individuals in communities to develop knowledge, skills and self-efficacy that mayhelp them to continue to be involved with preventioninitiatives and to sustain programmes and activities within the community.

5.4.3 Engaging ‘excluded’ groups

As a first step it is vital that the implementation team has a clear picture of those who take part. A participation profile may include:

• Demographic analysis (age, ethnicity, gender, disability)

• Geographical breakdown (town, ward, enumerationdistrict)

• Economic background (employment status, occupation).

Comparing this with the profile of the whole populationwill enable the identification of those who are not yetinvolved, and allow efforts to be targeted to includethem. A first step is to ascertain whether there are anyspecific reasons preventing participation, and to addressthem. Reasons may include:

• Language barriers• Time• Lack of awareness of the consultation or project• A feeling that ‘it isn’t for us’.

Implementation teams need to know the composition of their communities and have targets and strategies toensure they are included in the process. Capacity building will be particularly important with groups who are less likely to be involved. A traditionally‘excluded’ group may be an appropriate focus for a community development project.

5.5 Health needs assessment

Assessing local need, and profiling the local community is the first step towards developing a local delivery plan. Different areas will be at differentstages. As part of the HImP and Director of PublicHealth’s Annual Report, many places will have welldeveloped local needs assessment for CHD andcommunity profiles will already have been undertaken. In other places more work will need to be done. LocalPublic Health and Health Promotion experts provide an important resource for local implementation groups.

This guidance concentrates on prevention activities only, but consideration should be given to needsassessment as part of planning the delivery of other parts of the NSF CHD. Needs assessment isintended to inform local plans: to look at unmet need for services and to provide information that will allow services to be tailored to local populations.Successful local strategies to address CHD risk will take a broad approach to needs assessment, involving a wide range of partners and ensuringcommunity involvement.

5.6 Community profiling

A community profile describes the local area in terms of local populations (eg ethnicity, age, gender) and characteristics of the local environment (eg employers and employment; parks and open spaces; housing and estates) of importance in planning local CHD preventionstrategies.

Assessing health needs of the local population involves:

• Defining the different ’segments‘ or target groupswithin their local population


77

• Describing these different groups according to theirneeds and preferences using a variety of data.

Target groups can be distinguished in two ways:

• Geographical groups bound together by locality

• Social groups bound together by some other attribute,such as age, gender, ethnic origin, health status orsocio-economic status (and combinations of these).

Consultation with local communities will identify factors that local people consider are important, which should be included in the profile.

A well developed community profile would include local data (qualitative and quantitative) on the burden of CHD disease, and on risk factors (smoking prevalence, physical activity, diet, and weight);perceptions of health, service and facility provision and use, socio-economic information. Examples of data items to include are presented on p82 on local indicators. Where local data do not exist, riskprofiles may be derived from national data sets (byapplying risk profiles based on the total population to alocality). Consideration should be given to collectingmissing local data, relevant to the local action plan.Sources of local data can be found in Box 5.4. As part ofthe development plan, identify gaps in current data whichneed to be filled to enable better targeting andmonitoring of local implementation.

5.7 Equity profiling

The incidence of CHD is not uniformly distributed among the population. CHD risk is stratified by sex, age, social class, ethnic origin, and region of residence.The NSF highlights the importance of developing a local equity profile, with equity targets. Directors of public health are charged with producing the profile. The equity profile is intended to identify inequalities in heart health and in access to preventive and treatmentservices. It will concentrate on the needs of individualsand groups, especially those for whom specialconsideration is warranted (poorer people, children,pregnant women, women of childbearing age, minority ethnic groups, other vulnerable groups). Theequity profile should identify the inequalities which exist locally in terms of CHD mortality and morbidity. The equity targets are local targets to reduce theseinequalities. As part of the prevention strategy equityprofiling should cover smoking, nutrition, physical activity and weight management, with associated targets.

5.7.1 Audit of current provision

Local needs assessment requires a comprehensive audit of activity relevant to the four areas for prevention (smoking, physical activity, nutrition andoverweight and obesity). An example for physical activity is presented in Box 5.5. This type of audit willallow the identification of gaps and in conjunction with the equity profile, will identify unmet need forinterventions.

5.7.2 Personal and professional development audit

A local skills audit is an important aspect of needsassessment. There will be a need for appropriate personal and professional development for a wide range of people. This will include not just healthprofessionals, but other professional groups involved in planning and delivering services (eg LA officers, teachers, social workers, youth leaders, voluntary sector staff) and members of the public involved in needs assessment and in delivering community-based programmes.


78

Box 5.4 Local sources of data

• The annual reports of the Director of PublicHealth

• HlmPs and other local plans and profiles (eg poverty profile)

• LA data sets• Socio-economic data derived from the census• Neighbourhood statistics• Regional data sets (eg health and lifestyle

surveys)• Public health observatories• Local surveys (eg by LAs, HAs and local colleges

or universities)

5.8 Monitoring progress

Monitoring is a review of progress towards goals. To do this it is important to set targets and relatedindicators. Targets are an expression of the goals of theprogramme and indicators track movement towards oraway from them. The NSF CHD identifies priorities and uses milestones, which set out the time by which the recommendations should be implemented. Thesemilestones should be used to set local targets and bereflected in HImPs and other local plans.

The broad performance indicators for CHD fit within theareas of the national Performance Assessment Framework

(PAF) and are designed to track progress. The PAF issummarised in the main NSF document (DH 2000a, p74).There will be additional performance indicators for CHD and these are also set out in the main NSF CHD (DH 2000a, pp81–82). Chapter 1 of the NSF CHDincludes a framework for the preventive aspects of theprogramme, and highlights data items that should becollected locally (DH 2000b, p16). A technical supplement to follow the white paper Saving lives: ourhealthier nation (DH 1999) is currently being drafted andwill set out the scientific basis for target setting and the indicators available for the assessment of progress atboth national and local level. See further sources ofinformation on p88.


79

Box 5.5 Audit of local provision of services and facilities for physical activity

Group/locality

How many? Where? How accessible to group?

FacilitiesSwimming poolsSports facilitiesHealth clubsSchool facilitiesCommunity facilities

Conducive environmentsCycle routes/tracksWalksParks/playing fieldsOther open spaces

Active local groupsSports clubsSports promotion unitsPrimary careHealth promotionLocal resources

Workplace facilities

NHSLALocal business

Source: HEA (1995)

80

5.8.1 Developing local targets

A target is usually expressed numerically (quantitative).Targets should be feasible in the timeframe and berevised according to changes in the policy environment.They should be measurable – that is, it must be possibleto measure them and to collect the required data items.There is a national target for reducing the death ratefrom CHD: stroke and related diseases in people under75 years should be reduced by at least two-fifths by 2010 (DH 1999). The NSF CHD emphasises the need forintervention with other sections of the population such as children and pregnant women that will have an impact on CHD long after the 2010 deadline.

Local targets can be based on national targets for CHDrisk factors, modified to take into account the populationprofile. They can be set in terms of long-term disease risk,risk factors or be focused on areas or groups at particularrisk. Local targets need to take into account past trendsand performance. Baseline measures for the target in questionneed to be collected (although initially, national data canbe adapted while local data are collected). An example,focusing on physical activity, is presented in Box 5.6.

Equity targetsThe government intends to set national targets forreducing inequalities in health (DH 2000c). However, asdiscussed above, local plans should include an equity


Box 5.6 Example of local targets for physical activity

*The recommendation is that adults build into their daily routine half an hour of moderate intensity physical activity.

Note: For each target baseline values should be established. If data exist the trend over time should be looked at to

help set achievable targets. Sources of data for measuring progress should be identified, and plans made to collect missing

data items.

Local targets for physicalactivity

Description Example

Long-term disease or healthstatus

Mortality and morbidity A reduction in CHD mortality rates by 32%by 2010

Risk factor Relating to physical activity An increase in the proportion of thepopulation taking the recommendedamount of physical activity* to 45% by 2003(from 37% of men and 25% of women)

Process/Intermediate Policy An increase in the number of employerswith more than 100 employees with aworkplace physical activity policy by 20%by 2003

Groups or areas at particularrisk

A decrease in the proportion ofBangladeshi people who are sedentary(from 52% men and 56% of women to30% by 2005)

Access and delivery An increase in young women from Xlocality accessing leisure services from 10%to 20% by 2004

profile and equity targets. Equity targets should addressthe wider determinants of health and specify the need forlevelling up (Kendall 1998). Those setting equity targetsshould be aware that differential targets may be requiredto take account of differential causes and effects indifferent population groups. Improving the potential forhealth amongst the most vulnerable could mean areduction in services for other sections of the population.

ObjectivesObjectives are the methods used to achieve the targetsand are usually expressed in the form of desired changes.For example, if the aim were to increase access to leisureprovision, objectives could include: to set up a special busservice to take people to facilities; to make facilitiesavailable more cheaply to certain groups; and to increaseopening hours.

IndicatorsIndicators measure the movement towards or away fromobjectives. They are used to assess progress againstbaselines and for comparative purposes. A small numberof indicators will be collated nationally as part of the NSFCHD, but local implementation teams will need to assessperformance using a wider range of appropriate localindicators.

Indicators can be based on the input, process, output andoutcome (Ziglio 1996).

Input measures of resources and action

Process also known as formative or intermediateindicators. These relate to the implementationof the actions defined in the delivery plan.

Output also known as impact indicators. Thesemeasure the immediate impact of the work onits target group.

Outcome also known as summative indicators. Thesefocus on the end product and look at theextent to which the objectives have beenachieved. It is a measure of the long-term goal, such as the improvement in health status.

The NSF CHD notes that most local indicators will relateto inputs and processes where it will be important toassess the level of progress, and where data can beanalysed at a local level. Output indicators can also be

defined and assessed locally. Outcome measures, on thewhole, can be assessed only regionally and nationally,where the numbers will be large enough to show trendsover time (DH 2000a, p77).

All performance indicators should relate to evidence-based changes towards the achievement of the desired outcomes. Not all will be quantifiable. Indicators can be quantitative or qualitative or acombination of the two.

• Quantitative indicators can use standardised measuring instruments to collect data systematicallyover time. The size of the effect can be measured andcompared over time with baselines (Hawe et al. 1990).A list of local sources of data is presented on p78. A CD-ROM resource, Health and lifestyles guide tosources (HEA 1997) is available, which provides anoverview of quantitative health and lifestyle surveys ofsound methodological design available at a nationallevel. It presents details of these surveys, indicatinginformation that could be usefully collected at a locallevel and used to support policy development andplanning.

• Qualitative indicators assess non-quantifiable aspects of the intervention that contributed to its impact.These indicators are generally assessed throughquestionnaires, observational studies, interview studies,focus groups and other forms of communityconsultation. Qualitative indicators can be a series ofcriteria that need to be fulfilled in order for theintervention or programme to be deemed a success or failure.

See boxes 5.7 and 5.8 on p82.

Challenges in setting indicators in public health• Limited data and resources (can lead to availability

driving the indicator rather than the other way around)

• Setting robust indicators for non-quantifiable outputs

• Need to define short-, medium- and long-term goals(health promotion is usually evaluated in the shortterm but the objectives are often long-term)

• Attributing cause and effect – interventions are oftenmulti-agency and multi-intervention


81

• Changes over time may occur for reasons independentof the intervention or there may be a long chain ofevents between intervention and effect.

5.8.2 Monitoring frameworks

A series of monitoring frameworks could be developed asa management tool for project planning. The frameworksshould:

• Enable the identification of the local targets in relationto the national NSF CHD goal

• Specify objectives set as a contribution to the target

• Outline the interventions planned to achieve it

• Derive indicators to monitor change.

Illustrative monitoring frameworks are provided in Table5.9 (pp83–86).


82

Box 5.7 Checklist for setting local indicators

• Define target/problem/standard or criteria• Establish aim – defined by clients or institution

concerned with needs/rights• Define who is responsible for the achievement of

the move towards the target• Define whose interventions are you measuring• Set a timeframe – devise framework in which the

indicator is to be targeted• Assess availability and quality of data • Formulate a monitoring system to collect data• Decide on form (eg a rate of change expressed

as a proportion or the setting of a standard as away of assessing the quality of a service orinteraction)

• Set baseline or reference data to standardiseindicator

• Test indicator, if possible, or set date for review

Box 5.8 Examples of indicators used in public health

• Shifts in policies or practices such as policystatements

• Awareness among the public, NHS and LA employees• Access to services, equity• Participation or drop out rate• Levels of client satisfaction • Changes in individual knowledge, awareness and

self efficacy• Changes in behaviour • Health status, quality of life (QOL) and quality

adjusted life years (QALYs) • Community changes (eg decrease in fear of local

crime, reduced levels of racial or sectarian violence)• Environmental changes (eg increase in the

number of cycling routes) • Partnership working (eg evidence of partnerships

with the community and evidence of increasedinvolvement over time, equitable involvement ofdifferent community groups)

• Advocacy (eg unpaid media coverage, policysetting and implementation)

• Quality of services eg interaction between healthprofessional and client

• Quality of life and sustainability indicators (LA 21indicators)


83

NSF

CH

D G

OA

L an

d O

HN

TA

RGET

Con

trib

ute

to t

he t

arge

t re

duct

ion

of d

eath

s fr

om c

ircul

ator

y di

seas

e of

up

to 2

00,0

00 li

ves

in t

otal

by

2010

LOCA

L TA

RGET

bas

ed o

n CO

MA

(19

91, 1

994)

To in

crea

se t

heav

aila

bilit

y of

heal

thie

r fo

odpr

oduc

ts t

o th

elo

cal p

opul

atio

n

OBJ

ECTI

VE

Com

preh

ensiv

e an

d re

gula

rsu

pply

of

frui

t an

d ve

geta

bles

to

all s

ectio

ns o

f th

e po

pula

tion

with

loca

lly o

rgan

ised

initi

ativ

esan

d co

mm

unity

ow

ned

reta

iling

(food

co-

ops)

.

INTE

RVEN

TIO

N

To r

educ

e th

e av

erag

e pe

rcen

tage

of

tota

l foo

d en

ergy

der

ived

by

the

popu

latio

n fr

om s

atur

ated

fat

ty a

cids

to n

o m

ore

than

10%

and

tot

al f

at t

o no

mor

e th

an 3

5% b

y 20

05. T

o in

crea

se t

he c

onsu

mpt

ion

of f

ruit

and

vege

tabl

es t

o fiv

e po

rtio

ns a

day

by

2005

.

Loca

l sur

vey

2000

Obs

erva

tion/

loca

lsu

rvey

Focu

s gr

oups

SOU

RCE

2000

: 54%

2001

: 58%

2002

: 62%

RESU

LT

Perc

enta

ge o

f pe

ople

who

agr

ee t

hat

they

can

fin

d fr

uit

and

vege

tabl

es a

t an

aff

orda

ble

pric

e lo

cally

.

Incr

ease

in a

war

enes

s an

d ac

cess

to

loca

lly g

row

npr

oduc

e fr

om c

omm

unity

allo

tmen

t an

d gr

owin

gsc

hem

es b

y 10

%.

Incr

ease

in p

ropo

rtio

n of

com

mun

ity o

wne

d re

taili

ngsc

hem

es e

stab

lishe

d (e

g, b

asel

ine

2000

: one

in f

ive

loca

litie

s; 2

002:

one

per

loca

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.

Evid

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tha

t pe

ople

on

low

inco

mes

fin

d fa

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s’m

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sefu

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IND

ICA

TOR

Tabl

e 5.

9Ill

ustr

ativ

e m

onit

orin

g fr

amew

orks

To e

ncou

rage

the

cons

umpt

ion

ofta

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s, in

clud

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frui

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dve

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ong

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are

abl

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t le

ast

thre

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the

fol

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way

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achi

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heal

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1) e

at lo

ts o

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vege

tabl

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sal

ad, (

2) c

ut d

own

on f

atty

or

frie

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eat

gril

led

food

, (3)

eat

lots

of

fibre

, cer

eals,

who

lem

eal f

ood

and

(4) e

at lo

ts o

f st

arch

y fo

ods

such

as

brea

d, p

otat

oes,

past

a or

ric

e.

Incr

ease

in c

onsu

mpt

ion

of f

ruit

and

vege

tabl

es a

ndst

arch

y fo

ods,

dec

reas

ed c

onsu

mpt

ion

of f

ats

amon

gso

cial

cla

sses

IV a

nd V

.

Prev

ious

nat

iona

lex

ampl

es:

HEM

S (1

996,

199

8)

Nat

iona

l Foo

d Su

rvey

1996

:M

ales

14%

Fem

ales

17%

1998

:M

ales

15%

Fem

ales

17%

Base

:16

–74

year

s ol

d


84

NSF

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of d

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s fr

om c

ircul

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seas

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up

to 2

00,0

00 li

ves

in t

otal

by

2010

LOCA

L TA

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To d

evel

op a

‘who

le s

choo

l’ap

proa

ch t

ohe

alth

y ea

ting

OBJ

ECTI

VE

The

scho

ol in

clud

es e

duca

tion

on h

ealth

ier

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g, p

ract

ical

cook

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skill

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safe

ty p

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in t

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augh

tcu

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ulum

.

Polic

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idel

ines

for

eat

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heal

thy

snac

ks in

sch

ools.

Prov

ision

of

brea

kfas

t cl

ubs

inse

lect

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choo

ls.

INTE

RVEN

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N

To r

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tota

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ated

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cids

to n

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than

10%

and

tot

al f

at t

o no

mor

e th

an 3

5% b

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05. T

o in

crea

se t

he c

onsu

mpt

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of f

ruit

and

vege

tabl

es t

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day

by

2005

.

Liai

son

with

loca

lhe

alth

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hool

spr

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mm

e co

ordi

nato

r

Aud

it

Feed

back

and

dat

afr

om t

each

ing

staf

f,pu

pils,

cat

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g st

aff

and

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nts

Obs

erva

tion

Dat

a fr

om L

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and

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Obs

erva

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audi

t

SOU

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RESU

LT

An

incr

ease

in t

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r of

sch

ools

with

a p

olic

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heal

thy

eatin

g (in

clud

ing

snac

ks) a

t sc

hool

.

Evid

ence

of

revi

ew a

nd e

ffic

ient

use

of

reso

urce

s.

Incr

ease

in n

umbe

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sch

ools

selli

ng f

ruit

in t

uck

shop

sto

6–1

1 ye

ar o

lds

and

11–1

6 ye

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sal

es d

ata:

fru

itas

a p

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all

snac

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ms

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in s

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ls.

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t in

itiat

ives

are

sus

tain

able

.

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in t

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umbe

r of

sel

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s w

hopr

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ast

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n in

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se in

the

num

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ofsc

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ren

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ted

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akfa

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perc

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thy

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roug

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‘who

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Qua

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IND

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RVEN

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N

To im

prov

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alth

of

peop

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ged

65–7

5 ye

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the

num

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ofye

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fro

m il

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201

0.

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alita

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adap

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ques

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; H

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(199

8).

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lvem

ent

of o

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port

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ofol

der

peop

le w

ho h

elp

out

with

:•

Mea

ls on

whe

els

•D

ay c

entr

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or t

he e

lder

ly r

un b

y co

unci

l or

volu

ntar

yor

gani

satio

ns•

Volu

ntar

y or

gani

satio

ns•

Hel

p at

ano

ther

ser

vice

.

Qua

lity

of li

fe m

easu

rem

ent.

Evid

ence

tha

t ol

der

peop

le f

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sen

se o

f co

ntro

l and

invo

lvem

ent

with

initi

ativ

es.

Perc

enta

ge o

f ol

der

peop

le w

ho s

tate

tha

t th

ey a

re a

ble

to e

njoy

day

to

day

activ

ities

.

Perc

enta

ge o

f ol

der

peop

le w

ho f

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it di

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for

at le

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15 m

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inut

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IND

ICA

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86

NSF

CH

D G

OA

L an

d O

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Con

trib

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to t

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t re

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ion

of d

eath

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in t

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crea

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l of

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s am

ong

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onth

e am

ount

and

type

of

phys

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acti

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nee

ded

for

a be

neft

to

heal

th

Sou

rce:

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d f

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rgan

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nd

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rd, K

., 19

98.

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s o

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Perc

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invo

lved

in t

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rogr

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to w

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to w

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afte

r six

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the

pro

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of t

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eden

tary

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by 5

% f

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27%

(men

) and

28%

(wom

en).

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incr

ease

in t

he p

olic

ies

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as

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stria

n pr

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ains

.

The

num

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and

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avai

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uch

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alki

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aths

,pu

blic

sw

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s; in

crea

se in

the

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alki

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5.10 Further sources of information

Partnerships

Advice and information is available from the Health and Social Care

Joint Unit in the Department of Health and information is available at

http://www.doh.gov.uk/jointunit/partnership.htm

Audit Commission, 1998. A fruitful partnership: effective partnership

working. London: Audit Commission (may be ordered on tel: 0800 50

20 30).

Geddes, M., 1998. Achieving best value through partnership. London:

DETR.

NHSE, 1998. Health improvement programmes: planning for better

health and better health care. HSC 1998/167 LAC 98(23). London: NHS.

NHSE, 1999. Planning for health and health care: incorporating

guidance on health improvement programmes, service and financial

frameworks, joint investment plans and primary care investment plans.

HSC 1999/244 LAC 99(39). London: NHS.

Plamping, D., Pratt, J. and Gordon, P., 2000. Practical partnerships for

health and local authorities. British Medical Journal, 320, 1723–1725.

http://www.bmj.com/

Pratt, J., Plamping, D. and Gordon, P., 1998. Partnerships: fit for

purpose?. London: King’s Fund.

Russell, H. and Killoran, A., 1999. Public health and regeneration:

making the links. London: HEA.

Watson, J., Speller, V., Markwell, S. and Platt, S., 2000. The Verona

benchmark: applying evidence to improve the quality of partnership

working. International Journal of Health Promotion and Education, 7,

17–23.

Best value

The Audit Commission publishes a number of reports on best value.

Some of these can be directly accessed through their website:

http://www.audit-commission.gov.uk

Local Government Improvement and Development Agency (IDeA)

has placed many resources relating to best value on line:

http://www.idea.gov.uk

Community and public involvement

Audit Commission, 1999. Listen up! Effective community consultation.

London: Audit Commission (may be ordered on tel: 0800 50 20 30).

Summary and management paper available from:

http://www.audit-commission.gov.uk/ac2ss.first.htm

Useful wallchart included in the main publication but can be obtained

by tel: 020 7828 1212.

Cohen, J. and Emanuel, J., 2000. Positive participation: consulting and

involving young people in health-related work. A planning and training

resource. London: HEA.

DH, 1999. Patient and public involvement in the new NHS.

London: DH. http://www.doh.gov.uk/involve.htm

DETR, 2000. Preparing community strategies: draft guidance to local

authorities from the Department of Environment, Transport and the

Regions. London: DETR.

Local Government Improvement and Development Agency (IDeA) has

placed many resources relating to best value on line. This includes a

document dealing with consultation:

http://www.idea.gov.uk/bestvalue/consult/main.htm

National Consumer Council, Consumer Congress and Service First Unit,

1999. Involving users: improving the delivery of healthcare. London:

Cabinet Office.

National Consumer Council, Consumer Congress and Service First Unit,

1999. Involving users: improving the delivery of local public services.

London: Cabinet Office.

Northern and Yorkshire Region NHS Executive, 1999. NHS primary care

group’s public engagement toolkit. Durham: Northern and Yorkshire

Region NHS Executive.

http://www.doh.gov.uk/pub/docs/doh/toolkit1.pdf

Rifkin, S., Lewando-Hundt, G. and Draper, A., 2000. Participatory

approaches in health promotion and health planning.

London: HDA.

Service First Unit, 1999. An introductory guide: how to consult your

users. London: Cabinet Office.

Service first publications can be found through the Cabinet Office

website: http://www.cabinet-

office.gov.uk/servicefirst/index/publications.htm#policy


87

Health needs assessment

HEA, 1999. Indicators of good practice: an organisational self-

assessment tool. London: HEA.

Sustain, 2000. Reaching the parts. Community mapping: working

together to tackle social exclusion and food poverty. London:

Sustain, in association with Oxfam’s UK Poverty Programme.

Indicators and monitoring

Bowling, A., 1991. Measuring health: a review of quality of life

measurement. Milton Keynes: Open University Press.

Buck, D., Godfrey, C. and Morgan, A., 1997. The contribution of

health promotion to meeting health targets: questions of measurement,

attribution and responsibility. Health Promotion International, 12 (3),

239–250.

Cheadle, A., Sterling, T., Schmid, T. and Fawcett, S., 1995.

Evaluating community based nutrition programmes: comparing

grocery store and individual level survey measures of program

impact. Preventive Medicine, 24 (1), 71–79. The indicators are shown on

http://www.faculty.washington.edu/cheadle/cli/

Funnell, R., Oldfield, K. and Speller, V., 1995. Towards healthier

alliances: a tool for planning, evaluating and developing healthy

alliances. London: HEA.

Hawe, P., Degeling, D. and Hall, J., 1990. Evaluating health

promotion. Sydney: Maclennan and Petty.

Kendall, L., 1998. Local inequalities targets. London: Kings Fund.

Macleod Clark, J., Latter, S., Maben, J. and Franks, H., 1997.

Promoting health through primary health care nursing. London: HEA.

Morgan, A., Buck, D. and Godfrey, C., 1996. Performance indicators

and health promotion targets. York: Centre for Health Economics,

University of York.

Mutrie, N., Blamey, A. and Whitelaw, A., 1999. A randomised

controlled trial of a cognitive behavioural intervention aimed at

increasing active commuting in a workplace setting. Edinburgh: Chief

Scientist’s Office of the Scottish Executive.

Ziglio, E., 1996. Indicators of health promotion policy: directions for research.

In: B. Bandura and I. Kickbush, eds. Health promotion research: towards

a new social epidemiology. Copenhagen: WHO Regional Office for Europe.

The HDA has commissioned the Office for National Statistics to develop

and validate a module of questions to measure a range of components

of social capital. These questions will be used to measure social capital

at a national level in the General Household Survey 2000/2001. The

questions will investigate areas such as the strength of voluntary

organisations, norms of neighbourliness, reciprocity and trust and

infrastructure resources, community networks and attitudes to

community involvement. Some HAZs are using this questionnaire in

their local surveys to enable them to make comparisons between

their local area and the national average. Further information on this

project can be obtained from Antony Morgan (antony.morgan@hda-

online.org.uk) or Caroline Mulvihill (caroline.mulvihill@hda-

online.org.uk) at the HDA.

The National Centre for Health Outcomes Development

(http://nww.nchod.nhs.uk/) provides relevant data and information on

measurement tools for public health. It is a key source of information on

assessment of health and outcomes of health interventions at individual,

HA, Hospital and Community Trust, PCG/PCT and LA levels for the

English NHS and the government. The website contains information on

a range of indicators relevant to CHD, for example fat consumption,

mean adult BMI and smoking statistics.

HEA, 1997. Health and lifestyles: guide to sources. London: HEA.

A technical supplement to follow the white paper, Saving lives: our

healthier nation (DH, 1999), is currently being drafted. It will suggest

some measures of progress to monitor the strategy, draw together

information on data sources, and signpost relevant initiatives and

references which may be helpful to those involved in monitoring

progress at national or at local level. A short draft version is currently

available on the OHN web site, situated at http://www.ohn.gov.uk (look

under ‘OHN’, then ‘Technical’), which will be regularly updated and

supplemented with additional material as appropriate.

StatBase ® http://www.statistics.gov.uk/statbase/mainmenu.asp

StatBase ® is an on-line database which holds a large selection of

Government statistics. It also provides descriptions of all the UK

Government Statistical Service’s data sources, derived analyses, all its

statistical products and services and all the relevant contact points.

Social Exclusion Unit, 2000. Measuring deprivation: a review of indices

in common use.

http://www.cabinet-office.gov.uk/seu/2000/pat18/Depindices.htm

This Working Paper was produced to inform, and support the work of

the Social Exclusion Unit’s Policy Action Team (PAT) 18 on Better

information. It reviews the most commonly used deprivation measures

and highlights some of the issues surrounding their use.

Social Exclusion Unit, 2000. Report of PAT 18: Better information.



88

OHN indicators

Data to measure progress towards OHN indicators are collected by

local directors of public health. Many of these are also applicable

to the NSF CHD indicators. The OHNiP database:

(http://www.ohn.gov.uk/database/database.htm) holds information on a

wide range of projects and initiatives that in different ways contribute

to the aims of the OHN health strategy. The database can be searched

by health keyword, target audience, government initiative or zone and

setting.

The Health Survey for England has covered cardiovascular disease (1998)

and ethnic minority groups (1999), published by The Stationery Office.

The full text of the CHD survey is available at http://www.official-

document.co.uk/document/doh/survey98/hse-00.htm and information

on the ethnic minority survey is at

http://www.doh.gov.uk/public/hs99ethnic.htm

In 2000 the survey will focus on older people.

Health Education Monitoring Survey (HEMS)

The 1998 HEMS includes a measurement of social capital. The survey

contains six questions whereby a neighbourhood social capital score can

be calculated (Rainford L., Mason V., Hickman M. and Morgan, A.,

2000. Health in England: investigating the links between social

inequalities and health. London: The Stationery Office).

HAZnet: http://www.haznet.org.uk

Evidence is a key feature in the work of HAZs and HAZnet works

towards creating and disseminating an evidence base for new ways

of working. HAZnet has a database of area-based initiatives, local

evaluation projects and other research specific to HAZs, which may

also be of relevance as case studies for the NSF CHD.

LA 21. Local indicators of sustainable development.

http://www.environment.detr.gov.uk/sustainable/localind/nutshell/index.htm

The DETR has recently launched a handbook, Local quality of life counts,

which offers ideas for measuring sustainable development and quality of

life in local communities. The handbook gives a menu of 29 indicators

from which local authorities may wish to consider using a selection for

reporting in their LA 21 and community strategies. A number of these

indicators are also applicable to the NSF CHD. These include 15 headline

indicators that are intended to make up a ‘quality of life barometer’,

which will be used to measure overall progress, including success in

tackling poverty and social exclusion and expected years of healthy life.

The handbook also provides advice on indicator development for:

• Access to key services (i.e. medical services and shops)

• Mode and average distance of travel to work

• Percentage of school children travelling to and from school by

different modes

• Recorded crime per 1,000 population, fear of crime, social

participation, community well being and social and community

enterprises (social capital).

Neighbourhood statistics

Following the recommendations of the Social Exclusion Unit’s Policy

action team 18: better information, a set of standard neighbourhood

statistics covering the social exclusion characteristics of a neighbourhood

will be collated annually. This work will be led by the Office for National

Statistics and will be coordinated across Government departments and

with local government and other public, private and voluntary sector

organisations who collect relevant information so as to avoid duplication

and minimise costs. It is envisaged that this information will be available

down to ward level. Information will be collected within nine suggested

domains which include access to services, community well being/social

environment, crime, economic deprivation, education, skills and

training, health, housing, physical environment and work deprivation.

Evaluation

The HDA has produced a practical toolkit on evaluation. It outlines the

purpose and principles and describes the variety of approaches to

evaluation. In addition it provides guidance on quantitative and

qualitative research methods, developing recommendations and

dissemination of findings. This toolkit will be available on Evidence Base

2000 on the HDA website (http://www.hda-online.org.uk/evidence) in

autumn 2000.

Funnell, R., Oldfield, K. and Speller, V., 1995. Towards healthier

alliances: a tool for planning, evaluating and developing healthy

alliances. London: HEA.

Meyrick, J. and Sinkler, P., 1999. An evaluation resource for healthy

living centres. London: HEA.

Thorogood, M and Coombes, Y., 2000. Evaluating health

promotion: practice and methods. Oxford: Oxford University Press.

5.11 References

Audit Commission, 1999. Listen up! Effective community consultation.

London: Audit Commission.

DETR, 2000. Preparing community strategies: draft guidance to local

authorities from the Department of the Environment, Transport and

Regions. London: DETR.


89

DH, 1999. Saving lives: our healthier nation. London:

The Stationery Office.

DH, 2000a. National service framework for coronary heart disease:

main report. London: DH.

DH, 2000b. National service framework for coronary heart disease:

Chapter 1. Reducing heart disease in the population. London: DH.

DH, 2000c. The NHS plan. A plan for investment. A plan for reform.


DH, 2000d. Implementation of Health Act partnership arrangements.

HSC2000/10 LAC2000/09. London: DH.

Geddes, M., 1998. Achieving best value through partnership.

London: DETR.

Gillies, P., 1998. Effectiveness of alliances and partnerships for health

promotion. Health Promotion International, 13 (2), 99–121.

Hawe, P., Degeling, D. and Hall, J., 1990. Evaluating health promotion.

Sydney: Maclennan and Petty.

HEA, 1995. Promoting physical activity: guidance for commissioners,

purchasers and providers. London: HEA.

HEA, 1997. Health and lifestyles: guide to sources. CD ROM.

London: HEA.

Kendall, L., 1998. Local inequalities targets. London: King’s Fund.

NHSE, 1998. Health improvement programmes: planning for

better health and better health care. HSC 1998/167 LAC 98(23).

London: NHS.

NHSE, 1999. Planning for health and health care: incorporating

guidance on health improvement programmes, service and

financial frameworks, joint investment plans and primary care

investment plans. HSC 1999/244 LAC 99(39). London: NHS.

Nichols, V., 1999. The role of community involvement in health

needs assessment in London. London: HEA.

Plamping, D., Pratt, J. and Gordon, P., 2000. Practical partnerships for

health and local authorities. British Medical Journal, 320, 1723–1725.

Rogers, A., Popay, J., Williams, G. and Latham, M., 1997.

Inequalities in health and health promotion: insights from the

qualitative research literature. London: HEA.

Russell, H. and Killoran, A., 1999. Public health and regeneration:

making the links. London: HEA.

Watson, J., Speller, V., Markwell, S. and Platt, S., 2000. The

Verona Benchmark: applying evidence to improve the quality of

partnership working. International Journal of Health Promotion

and Education, 7, 17–23.

Ziglio, E., 1996. Indicators of health promotion policy: directions for

research. In: B. Bandura and I. Kickbush, eds. Health promotion

research: towards a new social epidemiology. Copenhagen: WHO

Regional Office for Europe.


90

This guidance has been developed in consultation with a range of professionals through a workshop and criticalreview. The HDA would like to thank them for their cooperation.

Researched and written by

Health Development Agency

Hugo Crombie Public health adviser, physical activity Karen Ford Head of public health advice and learning Caroline Mulvihill Research and development specialist Lesley Owen Public health adviser, smoking Karen Peploe Public health adviser, food and nutritionHilary Whent Head of public health advice and learning Patti White Public health adviser, smoking Tricia Younger Head of action zone development

London School of Hygiene and Tropical Medicine

Dalya Marks Research fellowMargaret Thorogood Reader in public health and preventative medicine

Freelance consultants

Isobel Bowler Health policy consultantLynn Stockley Nutrition consultant

AppendixContributors

Appendix

91

Reviewers

Waqar Ahmad Professor of primary care research, Nuffield Institute, University of LeedsDanila Armstrong Health development manager, NHS Executive, LondonAmanda Avery Community dietitian, Community Nutrition Group, British Dietetic AssociationJanet Baker Deputy regional director of public health, NHS Executive, West MidlandsClive Bates Director, Action on Smoking and HealthYve Buckland Chair, Health Development AgencyJennie Carpenter Head of public health strategy and function in and through the NHS, DHGill Cowburn Senior researcher, Health Promotion Research Group, BHFAdam Crosier Research and development specialist, HDAAliya Darr Research fellow, Nuffield Institute, University of LeedsMike De Silva Policy officer, DHNick Dean Acting head, Health Strategy Branch, DHElizabeth Dowler Public health nutritionist, University of WarwickLaurel Edmunds Senior researcher, Health Promotion Research Group, BHFClaudette Edwards Public health adviser, black and minority ethnic groups, HDACarl Evans CHD/smoke prevention team, DHCharlie Foster Senior researcher, Health Promotion Research Group, BHFMollie Foxall HAZ CHD lead, Manchester Health AuthorityJeff French Director of planning, partnerships and communication, HDAAlison Giles Policy development officer, NHFMadeline Garraway Public health adviser, older people, HDALucy Hamer Development adviser, HImPs, HDALesley Hammond Health promotion officer, Environmental Services Division, Wycombe District CouncilDominic Harrison Regional health development specialist, HDA (northwest region)Nick Hicks Strategy unit team member, DHMelvyn Hillsdon Lecturer in health promotion, London School of Hygiene and Tropical MedicineJane Huntley Head of workplace health, HDAPaul Lincoln Director, NHFRichard Longbottom Senior planning manager, Bradford Health AuthorityJeanette Longfield Coordinator, SustainSusan Martin Deputy branch head PH2, DHAnn McNeill Freelance consultantDawn Milner Senior medical officer, DHAntony Morgan Head of health information, HDAMike Rayner Director, Health Promotion Research Group, BHFSheela Reddy Nutrition division, Food Standards AgencyImogen Sharp Branch head, CHD/stroke prevention, DHDave Shields Health development manager, Southampton City CouncilViv Speller Director of health improvement, HDACathy Stillman-Lowe Public health adviser, oral health, HDACarolyn Summerbell Reader in human nutrition, School of Health, University of TeesideCatherine Swann Research and development specialist, HDAMarilyn Toft Head of schools and young people, HDANikki Wade Health development specialist, Cambridgeshire Health AuthoritySheila Webb Consultant in public health, Bradford Health AuthorityJean Woodhouse Health promotion officer, Northumberland Health AuthorityLynn Young Community health adviser, Royal College of Nursing


92

ACoP Approved Code of PracticeAGPNM Association of General Practitioners of

Natural MedicineASH Action on Smoking and Health

BHA British Hypnotherapy AssociationBHF British Heart FoundationBMEG Black and minority ethnic groupsBMI Body mass indexBSH British Society of Hypnotherapists

CA Consumers’ AssociationCDC Center for Disease Control and PreventionCHD Coronary heart diseaseCOMA Committee on the Medical Aspects of Food

and Nutrition Policy

DETR Department of Environment, Transport andthe Regions

DfEE Department for Education and EmploymentDH Department of Health

EAZ Education action zoneEH Environmental healthEHO Environmental health officerEU European Union

FLI Food and low income (database)

GP General practitionerGSL General sales listGTP ‘Green’ transport plan

HA Health authorityHAZ Health action zoneHDA Health Development AgencyHDL High density lipoproteinHEA Health Education Authority

HEMS Health education monitoring surveyHEPA Health-enhancing physical activityHLC Health living centreHlmP Health improvement programmeHSC Health Services CircularHSE Health and Safety Executive

ICM Institute of Complementary MedicineIDeA Improvement and Development AgencyIOTF International Obesity Task Force

LA Local authorityLACA Local Authority Caterers’ AssociationLA 21 Local Agenda 21LDL Low density lipoproteinLEA Local education authorityLGA Local Government AssociationLTP Local transport plan

MAFF Ministry of Agriculture, Fisheries and Food

NGO Nongovernmental organisationNHF National Heart ForumNHS National Health ServiceNHSE National Health Service ExecutiveNHSS National Healthy Schools StandardNOF New Opportunities FundNRT Nicotine replacement therapyNSF National Service FrameworkNSF CHD National Service Framework for Coronary

Heart Disease

OFSTED Office of Fair Standards and Training in Education

OHN Our Healthier NationOHNiP Our healthier nation in practice (database)OTC Over the counter

Glossary

Glossary

93

PAF Performance Assessment Frameworkp&p Postage and packingPAT Policy action teamPCG Primary care groupPCT Primary care trustPE Physical educationPHC Primary health carePR Public relationsPSHE Personal, social and health educationPTA Parent–teacher association

QALY Quality adjusted life yearQOL Quality of life

RCT Randomised controlled trialRDA Regional Development AgencyRPHNutr Registered Public Health Nutritionist

RSA Retail Services Association

SACN Scientific Advisory Committee on NutritionSBT Simple behavioural therapySCOTH Scientific Committee on Tobacco and HealthSIGN Scottish Intercollegiate Guidelines NetworkSMAP School Meals Assessment PackSNAG Schools Nutrition Action GroupSRTS Safer routes to schoolSTAG School travel advisory group

UK United KingdomUSA United States of America

VIRSA Village Retail Services Association

WHO World Health Organization


94

Health & Medicine

NICE Coronary heart disease