Research and analysis

Executive summary: learning from local authorities with downward trends in childhood obesity

Updated 15 February 2021

The National Child Measurement Programme

The National Child Measurement Programme (NCMP) was established in 2006 and involves measuring, on an annual basis, the height and weight of over a million children in reception and year 6 at state-funded schools, including academies, in England.

The purpose of the NCMP is to provide robust public health surveillance data on child weight status in order to understand and monitor obesity prevalence and trends at national and local levels, inform childhood obesity planning and commissioning and underpin the Public Health Outcomes Framework indicators on child excess weight in 4 to 5 year olds and 10 to 11 year olds. Public Health England (PHE) has responsibility for the overall management of the NCMP and provides operational guidance for the programme.

Childhood overweight and obesity in England

The NCMP 2018 to 2019 school year data showed that 22.6% or more than a fifth of children in reception and 34.3% or 1 in 3 children in year 6 were living with overweight or obesity, including severe obesity. NCMP data consistently shows that the prevalence of obesity doubles between reception and year 6 (from around 10% to around 20%).

The data for NCMP long-term trends from 2006 to 2007 and 2018 to 2019 shows an upward trend in the prevalence of severe obesity, obesity and excess weight for girls in reception and boys and girls in year 6. Data also shows that there are inequalities in terms of obesity prevalence in children from the most deprived compared with least deprived areas, and between children from different ethnic groups.

The government published the Childhood Obesity Plan in 2016. Chapter two, published in 2018, outlines the actions the government will take towards its goal of halving childhood obesity and reducing the gap in obesity between children from the most and least deprived areas by 2030. Chapter 3 of the childhood obesity plan, published as part of the 2019 prevention green paper, reinforced the government’s commitment to providing support for individuals to maintain a healthier weight. Tackling child and adult obesity is a renewed and strengthened priority for the government, as is shown in its recently published strategy. The NCMP results are used to monitor progress towards reaching these targets and are used in the Public Health Outcomes Framework Indicators on Excess Weight in children.

Children living with overweight or obesity are much more likely to become adults living with overweight or obesity. The COVID-19 review of disparities in risks and outcomes report emphasised that adults living with overweight and obesity are at an increased risk of serious COVID-19 complications and death, further demonstrating the need to reduce childhood obesity.

The NCMP and long-run trends in body-mass index data

In 2017, PHE published NCMP long-term trends in body-mass index (BMI) data from 2006 to 2007 and 2015 to 2016. Following this, PHE commissioned University College London (UCL) to research the approaches being taken by local authorities with significant long-term downward trends in childhood BMI data.

UCL identified local authorities that had demonstrated downward trends in the BMI z-scores^{[footnote 1]} of children in 3 of the 4 cohort groups (The 4 cohort groups are: reception boys, reception girls, year 6 boys, and year 6 girls). In addition to this, UCL investigated local authorities with a significant downward trend amongst the most deprived quintile.

Of the 31 local authorities that were identified as having a small but significant 10-year downward trend in the BMI z-scores, 25 agreed to be interviewed and this included one local authority with a downward trend in the most deprived quintile.

Findings

Using semi-structured interviews with directors of public health and childhood obesity leads, the main approaches taken by local authorities were thematically analysed. The 13 themes and examples of some approaches the local authorities used are shown in Table 1. These themes are discussed in detail in the main report and 24 practice examples have been published as part of this work – broken down into 5 regions:

• North of England
• Midlands
• South of England
• East of England
• London

The term ‘approach’ was used to describe all strategies and activities such as weight management services, childhood obesity policies and commissioned programmes that the local authority referred to in their interview with the researchers.

It’s important to note that the methods used in this research cannot show causality nor even association. All local authorities interviewed used more than one approach.

Table 1 (Theme A to M). Main themes of approach used by local authorities in order of commonality

Theme A: engagement with and integration of the NCMP

Approach (% of local authorities)	Examples of actions for this approach
School feedback (76%)	• provide NCMP results to schools (3 year aggregated data or annual feedback etc.) • provide deprivation information in school feedback
School nursing team (72%)	• deliver the NCMP Employ a childhood obesity lead within the school nursing team • send the PHE NCMP feedback letter home (using the PHE template) • follow up with parents and carers in a telephone call, text messages and/or additional letters • include signposting for local services in the NCMP feedback letter for parents
GP feedback (16%)	• provide NCMP feedback to GPs
NCMP Data (36%)	• use the NCMP data to monitor the prevalence of overweight and obesity, in reports and business plans, to inform the planning and delivery of interventions or for commissioning decisions

Theme B: working with schools and taking a ‘whole-school’ approach

Approach (% of local authorities)	Examples of actions for this approach
Partnerships with schools (76%)	• support local ‘Healthy Schools’ schemes • deliver physical activity and nutrition programmes in schools • work with schools to make school meals healthier • commission evidence-based programmes such as the Soil Association’s ‘Food for Life’
Whole-school approaches (33%)	• incorporate as a focus within a whole-systems approach • target schools with high levels of obesity • recognise and reward school efforts

Theme C: interventions in the early years

Approach (% of local authorities)

Examples of actions for this approach

Pre-school years (72%)

• promote and support breastfeeding • publish an Early Years Strategy • encourage Healthy Eating Standards for early years settings • provide programmes for pregnant women above a healthy weight • utilise children’s centres for cooking lessons or to deliver physical activity and healthy eating programmes • train health visitors on starting solids or on identifying children’s weight or in ‘Health, Exercise, Nutrition for the Really Young’ (HENRY) an evidence-based programme • work with childminders

Theme D: linking across family weight management programmes, the NCMP and schools

Approach (% of local authorities)	Examples of actions for this approach
Link family weight management services with the NCMP data or with schools (71%)	• signpost parents to local weight management services using the NCMP result letter • support the school nursing team to contact parents following the NCMP results and refer them to weight management programmes • use NCMP data to target weight management services to the schools in greatest need

Theme E: broader partnerships including academic links

Approach (% of local authorities)	Examples of actions for this approach
Partnerships within the community (68%)	• work with universities for research opportunities such as programme evaluation • partner with the third sector to work with charities or as part of a ‘Healthy Weight Network’ • work with the community through community-driven interventions or community-led projects in targeted areas

Theme F: having a published childhood obesity strategy

Approach (% of local authorities)	Examples of actions for this approach
Publish a childhood obesity strategy (68%)	• publish a strategy with sign off from council’s senior leadership • create a steering group to help develop the strategy • include public consultation as part of the strategy development

Theme G: increasing physical activity

Approach (% of local authorities)

Examples of actions for this approach

Focus on physical activity (68%)

• support initiatives to increase physical activity such as ‘Girls Active’, ‘Daily Mile’, junior ‘park runs’, active play, health walks, ‘Fit Kids’, ‘Skip4Life’, ‘Us Girls’, physical activity clubs and provision of outdoor gyms in parks • utilise the Sports Premium Initiative to develop sports clubs • work in partnership with leisure providers, libraries, schools, children’s centres, transport planning and charities to increase physical activity • focus on partnerships with the ‘Schools Sports Partnership’ • train early year’s settings staff in ‘Healthy Movers’ • consider alternative sports development programmes to engage children with special educational needs • consider how the environment can be made more conducive to physical activity by improving open spaces, footpaths and cycle routes • engage the community through an app (such as Lewisham Park Life) to encourage and facilitate park activities

Theme H: focus on food

Approach (% of local authorities)	Examples of actions for this approach
Focus on food (52%)	• sign a healthy food and drink declaration • provide a healthy food offer • sign up to the Sugar Smart campaign • consider programmes such as ‘field to fork’, ‘grow project’ or a holiday food programme • provide healthy food at council events • incorporate good oral health education

Theme I: active travel focus

Approach (% of local authorities)	Examples of actions for this approach
Incorporate active travel into schemes or initiatives (50%)	• publish an active travel plan or strategy • plan for sustainable transport such as cycling • work with partners to provide staff training and access to a cycling hub • employ an active travel team • promote walking to school

Theme J: spatial planning

Approach (% of local authorities)	Examples of actions for this approach
Involve spatial planning (48%)	• involve spatial planning as part of a whole-systems approach • encourage Environmental Health Teams to work with takeaway food businesses to create a healthier offer • limit new takeaway food businesses from opening close to schools or limit opening hours

Theme K: taking a ‘whole-systems’ approach

Approach (% of local authorities)	Examples of actions for this approach
A whole-systems approach (48%)	• bring together existing work from a number of different departments to avoid duplication and identify gaps in provision • link other Joint Strategic Needs Assessment topics such as mental health in a whole-systems approach • include a childhood obesity strategy

Theme L: increasing parental engagement to tackle childhood obesity

Approach (% of local authorities)	Examples of actions for this approach
Target parents as part of child and family weight management services (48%)	• promote national campaigns such as Change4Life and One You • request parental attendance at group weight management programmes • utilise the workforce through Make Every Contact Count (MECC) and train staff in how to raise the issue of overweight and/or behaviour change techniques

Theme M: linking obesity with mental health

Approach (% of local authorities)	Examples of actions for this approach
Tackle mental health issues as part of obesity work (21%)	• link mental health and physical activity messages • use the Joint Strategic Needs Assessment topics for obesity work including mental health and wellbeing, physical activity and nutrition • deliver programmes that promote physical and mental health

Discussion

The results from this research support previously published PHE documents and guidance on evidence-based practice for preventing and reducing childhood obesity.

1. Health inequalities (all local authority themes)

Health inequalities are unfair and avoidable differences in health across the population, and between different groups within society. Health inequalities arise because of the conditions in which we are born, grow, live, work and age. The NCMP data can be used to identify health inequalities in order to understand the local population’s needs and inform planning and commissioning using a place-based approach.

Of the local authorities interviewed, 76% focused on deprivation in their area. For some this was a focus when they provided NCMP feedback to schools, Redbridge, for example, included deprivation information when they printed school results letters using the PHE template.

However, Lewisham, the only local authority included with a downward trend in the most deprived quintile for at least 3 out of the 4 cohorts, delivered most of their interventions or initiatives universally, because there was widespread deprivation with only one affluent ward and others with varying degrees of deprivation.

2. The life-course approach (Themes A, B, C, D, I, L)

A life-course approach considers the critical stages, transitions and settings where large differences can be made in promoting or restoring health and wellbeing. A life-course approach values the health and wellbeing of both current and future generations.

Many of the local authorities interviewed offered programmes and services aimed at different life stages to help reduce childhood obesity. This included:

• pregnancy (Theme C)
• infancy and early years (Theme C)
• childhood and adolescence (Themes A, B)
• adults (Themes D, I, L)

Several local authorities also referred to involving the whole family in their approaches. For example, at group weight management programmes for children, 12 of the local authorities interviewed requested parental attendance as well.

A life-course approach requires a skilled workforce and this research shows the importance of supporting those working in different settings to help reduce childhood obesity. Local authority approaches targeting infancy and the early years referred to midwives, health visitors and infant feeding teams. Approaches targeting children and adolescents mostly referred to the school nursing team who are responsible for delivering the NCMP, as well as GPs.

3. Whole-systems approach to obesity (Theme K)

A local whole-systems approach responds to complexity through an ongoing, dynamic and flexible way of working. In 2019, PHE published their guide and set of resources to support local authorities with implementing a whole-systems approach to address obesity and promote a healthy weight.

Although this research took place before PHE published the guide, 12 of the local authorities interviewed said that they took a whole-systems approach and this overlapped with some of the other themes including D (childhood obesity strategies).

4. Childhood obesity resources to support local authorities

Local authorities in this study referred to some of the PHE guidance and resources that they had used to help reduce childhood obesity and deliver the NCMP in their area. Since this research was undertaken, PHE has published additional evidence-based documents and tools for local authorities on the ‘All Our Health’ childhood obesity interactive townscape.

Many of the local authorities who had “engagement with and integration of the NCMP” (Theme A) had used the following NCMP letter templates for schools and parents found. These templates are updated annually based on feedback the NCMP team receive and can be amended to include signposting for local services. In addition to this, Public Health Outcomes Framework data was also mentioned by some local authorities.

Conclusion

Although this research took place in 2017, sharing the learning from these local authorities remains important, since it shows that those with small but significant downward 10-year trends in BMI z-score in children were using a highly diverse set of approaches and initiatives.

The commonality of these approaches across local authorities suggests that these may be important in reducing childhood obesity. Although the methods do not attribute causality, all local authorities interviewed used more than one approach to reduce childhood obesity. These common approaches also aligned with some of PHE’s priorities including reducing health inequalities, understanding the life-course approach and applying a whole-systems approach to obesity. This learning will be of interest to local authorities and to other strategic leaders who have an interest in preventing and reducing childhood obesity.

Appendix

Local authority practice examples grouped by themes of approach

Themes of approach (% of local authorities)	Examples of local authorities using this approach (in alphabetical order)
A Engagement with and integration of the NCMP	School feedback (76%): Central Bedfordshire, Derbyshire, Redbridge, South Gloucestershire, Surrey, West Sussex School nursing team (72%): Central Bedfordshire, Coventry, Derbyshire, Oxfordshire, Peterborough, Redbridge, Shropshire GP feedback (16%): Hertfordshire, Hounslow, Shropshire, Somerset, South Gloucestershire, Portsmouth Methods of feedback: Hertfordshire, Lewisham, Luton, Portsmouth, Somerset NCMP data (36%): Coventry, Luton, Oxfordshire, South Gloucestershire
B Working with schools and taking a ‘whole-schools’ approach	Partnerships with schools (76%): Cambridgeshire, Cheshire East, Coventry, Derbyshire, Essex, Hounslow, Lewisham, Lincolnshire, Luton, North Yorkshire, Nottinghamshire, Peterborough, Portsmouth, Somerset, South Gloucestershire, St Helens, Wakefield, West Sussex, Yorkshire East Riding Whole-school approaches (33%): Cambridgeshire, Derbyshire, Essex, North Yorkshire, Peterborough, Portsmouth, St Helens, West Sussex
C Interventions in the Early Years (72%)	Cambridgeshire, Cheshire East, Hertfordshire, Hounslow, Lewisham, Lincolnshire, Luton, North Yorkshire, Nottinghamshire, Oxfordshire, Portsmouth, Redbridge, Shropshire, Surrey, Somerset, South Gloucestershire, St Helens, West Sussex
D Linking across family weight management programmes, the NCMP and schools (71%)	Bedfordshire, Cambridgeshire, Central West Sussex, Cheshire East, Coventry, Essex, Hertfordshire, Lewisham, Luton, North Yorkshire, Nottinghamshire, Peterborough, Shropshire, Somerset, South Gloucestershire, Surrey, Yorkshire East Riding
E Broader partnerships including academic links (68%)	Cambridgeshire, Central Bedfordshire, Coventry, Derbyshire, Essex, Gloucestershire, Hertfordshire, Hounslow, Luton, Oxfordshire, Peterborough, Redbridge, Shropshire, Somerset, South Surrey, St Helens, West Sussex
F Having a published childhood obesity strategy (68%)	Cambridgeshire, Central Bedfordshire, Hertfordshire, Lewisham, Luton, North Yorkshire, Nottinghamshire, Oxfordshire, Peterborough, Portsmouth, Redbridge, Shropshire, South Gloucestershire, St Helens, Surrey, West Sussex
G Increasing physical activity 68%	Central Bedfordshire, Derbyshire, Essex, Gloucestershire, Hertfordshire, Hounslow, Lewisham, Lincolnshire, Luton, North Yorkshire, Nottinghamshire, Portsmouth, Shropshire, Somerset, South West Sussex, St Helens, Yorkshire East Riding
H Focus on food (52%)	Derbyshire, East Riding, Essex, Gloucestershire, Hounslow, Lincolnshire, Luton, Shropshire, Somerset, South Lewisham, St Helens, West Sussex, Yorkshire Redbridge
I Active travel focus (50%)	Cambridgeshire, Essex, Lewisham, Lincolnshire, Nottinghamshire, Oxfordshire, Peterborough, Redbridge, South Gloucestershire, St Helens, Surrey, West Sussex
J Spatial planning (48%)	Cambridgeshire, Central Bedfordshire, Coventry, Derbyshire, Lewisham, Nottinghamshire, Oxfordshire, Peterborough, Portsmouth, Redbridge, Surrey, West Sussex
K Taking a ‘whole-systems’ approach (48%)	Central Bedfordshire, Coventry, Hounslow, Lewisham, Oxfordshire, Peterborough, Portsmouth, Redbridge, Somerset, St Helens, Surrey, West Sussex
L Increasing parental engagement to tackle childhood obesity (48%)	Cambridgeshire, Cheshire East, Coventry, East Nottinghamshire, Essex, Hertfordshire, Luton, Peterborough, Portsmouth, Redbridge, Somerset, St Helens, West Sussex
M Linking obesity with mental health (21%)	Hertfordshire, Nottinghamshire, Shropshire, Somerset, Yorkshire East Riding

1. Body-mass index(BMI) z- scores (also known as BMI standard deviation (s.d.) scores) are measures of relative weight adjusted for child and sex. A BMI z-score (or equivalent BMI-for-age percentile) can be determined by a child’s sex, age, BMI, and an appropriate reference standard. ↩