Healthy Weight Plan for Knowsley 2018-2021 - Knowsley Council
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Healthy Weight Plan
for Knowsley
2018-2021
Produced by Public Health
May 2018
Revew date: April 2021
For advice and support around health and wellbeing please
visit www.healthyknowsley.co.ukContents
Introduction 3
SECTION 1
Policy and Partnership 7
SECTION 2
Excess Weight 10
SECTION 3
The Local Picture 12
Knowsley Adults 13
Knowsley Children 14
SECTION 4
Lifestyle Behaviours 16
SECTION 5
Evidence Base 20
Primary Care 20
Obesity Insight 20
SECTION 6
Knowsley Healthy Weight Plan 22
SECTION 7
The Action Plan 23
APPENDIX ONE
The Strategic High Impact Changes in Summary 30
APPENDIX TWO
Healthy Foundations by Demographics 31
APPENDIX THREE
Evidence Base 32
References 34
2Introduction
Overweight and obesity occurs when energy Being overweight or obese comes at a great
intake from food and drink is greater than financial cost to the NHS, costing an estimated
energy expenditure through the body’s £4.2 billion annually to treat people with health
metabolism and physical activity over a problems related to being overweight or obese.
prolonged period of time, resulting in the It also has implications for people’s health and
accumulation of body fat. Obesity is complex social needs, with obesity strongly linked to
with many factors influencing whether an major risk factors such as type 2 diabetes, some
individual will struggle with their weight. cancers, fatty liver disease and heart disease.
Broader impacts are seen in the psycho-social
impact on individuals, for example, prejudice,
Seven cross-cutting predominant themes have
discrimination, less chance of promotion,
been highlighted as essential factors that
increased chance of poverty, the economic
contribute to obesity in our populations1:
costs to society associated with co-morbidities
1. Biology: an individual’s starting point for (multiple ill-health factors), the cost of sickness
example, the influence of genetics and ill absence and unemployment. Emotional health
health. is also strongly linked to obesity with
2. Physical activity: the type, frequency and individuals more likely to experience bullying.
intensity of activities an individual carries Their self-esteem and social interaction may be
out, such as cycling vigorously to work impaired. They may have a poor body image,
every day. anxiety and depression1.
3. Activity environment: how the
environment influences an individual’s Body fat can be measured via a range of
activity behaviours. For example a decision different methods with the most common being
to cycle to work may be influenced by road the calculation of an individual’s body mass.
safety, air pollution and provision of a cycle The body mass index (BMI) tool measures height
shelter and showers. and weight to work out if weight is healthy,
overweight or obese. The BMI calculation divides
4. Food consumption: the quality, quantity
an adult’s weight in kilograms by their height in
(portion sizes) and frequency (snacking
metres squared, for example, a BMI of 25 means
patterns) of an individual’s diet.
25kg/m2. Drawbacks to this method include
5. Food environment: how the food indirect and imperfect measurement i.e. does
environment influences an individual’s food not distinguish between body fat and lean
choice. For example, a decision to eat more body mass. Waist circumference, waist-to-hip
fruit and vegetables may be influenced by ratio, skinfold thicknesses, and bioelectrical
the availability, cost and quality of fruit and impedance are generally more useful in clinics
vegetables near to home. and community settings, as well as in large
6. Individual psychology: For example, research studies2.
individual psychological drive for particular
food consumption patterns and/or
preference.
7. Societal influences: the impact of
society; including the influence of media,
education, peer pressure or culture.
3Healthy Weight Plan for Knowsley The story so far in Knowsley
2018-2021 Much work has been undertaken in recent years
This Healthy Weight Plan will provide; local around reducing obesity levels and increasing
data including recent health and lifestyle physical activity in an effort to stabilise and
surveys summarising emerging research and reduce the number of people with excess
new guidance, a summary of the work to weight. This is evident under the current Obesity
date and set out a refreshed set of actions. and Physical Activity Plans for the borough
The Healthy Weight Plan will also address the 2014-17 to 2015-18 respectively.
clear association between food consumption,
sedentary lifestyles and the impact of the We have seen good progress across several areas
commercial industry on the obesogenic as a result of the existing plans. For example,
environment that we now live in. The Healthy effective referral pathways now exist from local
Weight Plan will incorporate actions that are GP practices into the Healthy Knowsley Service.
crosscutting and will ensure a more collaborative This affords lifestyle advisors the opportunity
approach and propose a partnership delivery as and the time to triage and support or signpost
it is recognised that many of the factors which an individual on to other appropriate services,
impact on healthy weight are outside the control something GPs don’t have capacity for during a
of Public Health. 10 minute consultation.
There have also been a number of successful
campaigns such as This Girl Can; localising the
The Vision: national brand to increase the physical activity
levels of women in Knowsley, and Give Up
Through a concerted effort by all
Loving Pop (GULP) developed by Food Active to
partners there will be support for all encourage children and young people to pledge
people who live and work in Knowsley to give up sugary drinks for a 21 day challenge.
to address factors affecting lifestyle
behaviours that impact on achieving/ Following consultation with local residents,
maintaining a healthy weight across the green gyms have been installed in parks
life course, particularly for individuals and and green spaces across the borough as an
families most in need, in the early years innovative approach to provide free access to
and during school. Support will take gym equipment for all residents.
various forms (e.g. services, information,
face to face and online) and people will Knowsley also has a well-established cycling
network which meets regularly to share
be better informed and know where and
information and ideas for increasing cycling
how to access what they need when and walking locally. A community cycling
they need it. programme offers opportunity to all residents
This will ensure we create a borough including those with disabilities to experience
where those that know, are nudged to cycling safely with trained ride leaders from one
do, and those that don’t are enabled, of the four hubs across the borough.
therefore reducing health inequalities.
4The leisure centres in Knowsley offer discounted 2017, 448 people were referred onto weight
gold memberships for twelve weeks via management programmes and 260 to health
referral to the most inactive residents and they trainers for one-to-one support.
also deliver a free clinical 12 week exercise
programme (Knowsley Clinical Commissioning
Group funded) following GP referral for Healthy Weight Declaration
residents with long term conditions. The Health Equalities Group (a health charity
based in Liverpool) developed a Healthy Weight
Through the Council’s Working Well Programme, Declaration for adoption by North West local
grants are available to small/medium local authorities, which includes a number of key
businesses to improve the health and wellbeing pledges to underpin local plans to reduce
of the workforce, for example, purchasing cycles obesity. Knowsley Council signed up to the
for the staff to use. Slimming World vouchers Healthy Weight Declaration in December
(free for twelve weeks) are also on offer for 2016, many of the pledges contained in the
businesses and this initiative was recently offered declaration will contribute towards achieving the
to Council staff between September 2017 and Councils key objectives in the:
January 2018, which resulted in 87 Council staff
losing a total of 60 stone in weight. Strategy for Knowsley
The strategy commits the Council and its
The Council’s Healthy Knowsley website was partners to achieving the following goals
developed in 2014 as a one-stop-shop for advice by 2023:
and information on all lifestyle behaviours.
In 2017, the website was refreshed and now • Attractive, sustainable neighbourhoods
includes specific pages relating to healthy with a wide choice of housing and excellent
pregnancy across all trimesters. There are also community facilities.
links to relevant local and national websites, • Vibrant and welcoming town centres.
for example, further support around healthy
• Residents and local communities who are
eating, physical activity or information from NHS
able to make positive lifestyle choices.
Choices. It also has a self-referral option into
the Healthy Knowsley Service. The website quite • High quality employment areas which help
clearly supports the self-care agenda. to drive economic growth in the Liverpool
City Region.
The continued investment in the delivery of NHS
• Narrow the gap in deprivation levels both
Health Checks for 40 to 74 year olds has also
between different parts of the Borough and
seen a consistent upward trend in the uptake
between Knowsley and elsewhere.
of health checks in Primary Care since 2015. As
part of an NHS Health Check, BMI and levels
of physical activity are assessed and between
January and December 2017, 3,349 residents
had their BMI measured with 71% classified as
overweight/obese. Following a health check in
5Knowsley Council Corporate Plan
2017-2020
The vision of the plan is to make Knowsley a
place where all children have the best start
in life, where every family thrives and where
all young people aim high and achieve their
potential.
Priority two: Maximise the Council’s
contribution to the health and wellbeing of
Knowsley residents
Knowsley Joint Health and Wellbeing
Strategy 2016-2020
The vision of the strategy is to work together for
a healthier and happier Knowsley. The following
are the relevant priority and outcomes contained
in the strategy:
Priority: Promoting Healthy Living
Outcome: People living longer, healthier lives in
Knowsley
6SECTION 1
Policy and Partnership
National Context • 26% of adults consumed the recommended
• In 2015, 58% of women and 68% of five or more portions of fruit and vegetables
men were overweight or obese. Obesity a day in 2015. Women (27%) were more
prevalence increased from 15% in 1993 to likely to do so than men (24%).
27% in 2015. • In 2014, 52% of 15 year olds reported that
• In 2015/16, over 1 in 5 children in Reception, they consumed five or more portions of fruit
and over 1 in 3 children in Year 6 were and vegetables a day.
measured as obese or overweight. • In 2015/16, 26% of adults were classified
• In 2015/16 there were 525,000 admissions as inactive (fewer than 30 minutes physical
in NHS hospitals where obesity was recorded activity a week).
as a factor. • 449,000 items were prescribed for the
• In 2015/16, there were 6,438 finished treatment of obesity in primary care in 2016.
consultant episodes in NHS hospitals with a That is 7% less items than in 2015 and
primary diagnosis of obesity and a main or continues a downward trend from 2009.
secondary procedure of bariatric surgery. Despite the downward trend, Knowsley is
still one of the areas with the highest rates
• Over three quarters of bariatric surgery of prescribing for obesity medication - see
patients were aged between 35 and 54, and Figure 1 below3.
over three quarters of patients were female.
Figure 1
Knowsley is an area with high prescription rates for the treatment of obesity
Prescription items for the treatment of obesitya
Prescriptions per 1,000 population
By Clinical Commissioning Group (CCG) By NHS Commissioning Region
NHS Stoke on Trent 15 to 21 (12) North of England had the highest prescription rate with
and NHS Knowsley 10 toPolicy and Strategy Updates CONST identified the following four
There are a number of strategies and policies strategic high impact changes needed
that link into the obesity agenda: to tackle the growing trend of obesity
(See Appendix One):
The National Childhood Obesity Plan 20164 - is
the Government’s plan to reduce England’s rate 1. Building local intelligence;
of childhood obesity within the next 10 years by 2. Harnessing the contribution of
encouraging: existing community resources within
• Industry to cut the amount of sugar in food local healthy weight pathways;
and drinks. 3. Workforce development; and
• Primary school children to eat more healthily 4. Workforce health.
and stay active.
CONST identified five policies which can have
Healthy Lives, Healthy People - A Call to Action the greatest impact on levels of obesity across a
for Obesity in England (2011)5 gives a new range of scenarios6. These are:
direction for work around obesity, moving
beyond a focus on children towards a life course 1. Increasing walkability and cyclability of the
approach, setting out two national ambitions of: built environment.
• A sustained downward trend in the level of 2. Targeting health interventions for those
excess weight in children by 2020. at increased risk (dependent on ability to
identify these groups and if reinforced by
• A downward trend in the level of excess public health interventions at the
weight averaged across all adults by 2020. population level).
In 2011, the Department of Health published 3. Controlling the availability of and exposure
a report on the findings from the Childhood to obesogenic foods and drinks.
Obesity National Support Team (CONST), 4. Increasing the responsibility of organisations
established with the primary purpose to for the health of their employees.
improve the quality and impact of healthy
5. Early life interventions at birth or in infancy.
weight delivery systems and interventions.
CONST completed 44 diagnostic visits across
The Healthy Weight Action Plan will focus
England and focused on those areas facing the
on the four strategic high impact areas
greatest challenges in positively influencing
identified by CONST in an effort to take
the health behaviours of the local population,
a systems wide approach to address the
Knowsley featured in the report.
spiralling levels of obesity in the borough.
They found that by adopting a structural and
The Chief Medical Officer published guidelines
systematic approach to tackling obesity, local
on physical activity (2011), ‘Start Active, Stay
areas can achieve system and scale and make
Active’7 which span the life course. They contain
significant and early progress in achieving better
information on suitable types and levels of
healthy weight outcomes.
physical activity depending on age and
present ability.
8Change4life is a Department of Health initiative Other strategies include; Turning the Tide of
aimed at encouraging and supporting people to Inactivity (UK Active, 2014) Get Everybody
‘Eat Well, Move More, Live longer’8. Although Active Every Day (PHE, 2014). Cycling and
originally aimed at addressing childhood obesity, Walking Investment Strategy (2017) - outlines
it now focuses on providing information, advice the Government’s ambition to make cycling and
and guidance across the life course. walking a natural choice for shorter journeys, or
as part of longer journeys by 204011.
The Public Health Outcome Framework9
identifies several outcome indicators which Locally, the Knowsley Children and Young
relate to obesity: People’s Plan 2017-2020 provides the strategic
direction for the delivery of positive outcomes
• Breastfeeding initiation and continuation
for children and young people in Knowsley.
at 6 weeks.
It includes a collective partnership vision and
• Proportion of children aged 4 to 5 a series of outcomes and priorities to guide
classified as overweight or obese. direction and focus as well as key actions to be
• Proportion of children aged 10 to 11 carried out by 202012.
classified as overweight or obese.
The plan includes:
• Excess weight in adults.
• Giving Children the Best Start in Life - this
• Proportion of adults achieving at least 150 relates to improving a child’s life chances
minutes of physical activity per week. from birth, promoting active healthy lifestyles
• Proportion of adults classified as inactive. and positive mental wellbeing.
• Utilisation of green space for exercise or • Maximising the council’s contribution to the
health reasons. health and wellbeing of Knowsley residents.
The National Institute for Health and Care The Healthy Weight Plan will also support the
Excellence (NICE) Guidance ‘Obesity: working delivery of Knowsley Green Spaces Plan and the
with communities, 2012’10 recommends Health Merseyside Local Transport plan.
and Wellbeing Boards ensure:
In line with national policy, the Healthy Weight
• A multi-agency approach is in place
Plan will aim to encompass the entire evidence
to address obesity prevention and
base in its life course approach with priorities for
management.
early years, children and increased interventions
• Activities are integrated within joint health in primary care. A life course approach can
and wellbeing strategies and broader help identify critical periods when people are
regeneration and environmental strategies. more likely to change behaviour, for example,
when starting school or becoming a parent, and
• Partners provide funding beyond one
ensure that action is taken within the context of
financial or political cycle as the challenges
people’s lives. It is also important to take actions
of obesity cannot be met in the short term.
that reach the whole population, as well as
adjusting the ‘intensity’ of activity to meet the
needs of specific groups.
9SECTION 2
Excess Weight
Figure 2
Public Health England; the annual cost of obesity
Obesity
medication Social care
£13.3m £352m
Cost to Obesity
Cost to
wider attributed
NHS
economy days sickness
£27bn £6.1bn £16m
Many things affect healthy weight including While most people understand that regular
lifestyle, living and working conditions, and exercise and healthy eating will promote a
access to food and leisure services. Most people healthy weight, even if just in the short term,
know the facts about healthy eating and many don’t have the knowledge or support
keeping active. However, as outlined in the to put it into practice. Evidence shows that
Foresight Report in 200713 making it happen increasing knowledge doesn’t necessarily lead
is more complex. We are all affected by social to behavioural change; the social, cultural and
norms and by our environment. The slimming financial context, all need to be understood and
and fitness industries and weight management carefully considered at a local level. There is
services have been the traditional approaches huge potential to influence behaviour, but the
to achieving a healthy weight. However, they capacity and capability of practitioners to deliver
haven’t worked for many people within our behaviour change at individual and population
communities and a broader approach is needed. level needs to be enhanced. The ability of
The Foresight Report 201014 concluded that individuals to respond to advice or information
preventing obesity is a societal challenge, will depend on the extent to which it can be
similar to climate change. It requires partnership incorporated into his or her personal system
between government, science, business and (lifestyle). While small scale interventions can
civil society, however, it is also part of a much have a limited positive impact on tackling
broader agenda. obesity, significant action is needed to tackle the
cultural and psychological context13.
10By 2050, the prevalence of obesity has been Over the past few decades advances in
predicted to affect 60% of adult men, 50% of technology have reduced the need for physical
adult women and 25% of children. The costs work. Therefore lives which were physically
of overweight and obesity to society and the demanding are now increasingly sedentary,
economy have been estimated at almost reducing energy expenditure. The built
£16 billion (2007 figure). If the increase in environment which has also changed in recent
obesity rates continues to be unchecked this has years has also led to a decrease in physical
the potential to be £50 billion by 2050. activity levels by decreasing the need to walk.
This can be particularly observed in how
Overweight and obesity are a direct methods of travel have changed, with car
consequence of eating and drinking more use increasing substantially since the 1950s.
calories and using up too few. This energy Physical activity is a particular issue for children
imbalance is driven by environmental, in today’s society because an increase in traffic
physiological and behavioural factors, all has prevented children from playing or travelling
of which interrelate and often reinforce independently. Play is crucial to health and
each other15. development throughout childhood. According
to research, school aged children and young
During 2016/17 there have been a number of people get more exercise from free play than
new studies and guidance documents published from most structured activities, excluding
providing further evidence for tackling the physical education classes. Therefore, it is
causes of obesity. A key feature emerging from worrying that children are being prevented from
research evidence is that too much sugar in playing. The availability of cheap and accessible
our diets is a key reason for increasing levels of electronic equipment has also made the home
overweight and obesity. an increasingly attractive and comfortable
place to be, which is reflected in the decreasing
A tax on sugary drinks has been introduced in levels of activity in childhood and increasing
April 2018 in line with the National Childhood prevalence of obesity15.
Obesity Plan as a way to address obesity and oral
health. This approach incentivises manufacturers
to use less sugar in products and provide options
for consumers to buy sugar free alternatives.
Success has been significant across these areas
however restrictions on the advertising of foods
high in sugar and fat to children, particularly
pre-watershed, are slow and demonstrate little
or no progress so far.
A range of toolkits for action on local nutrition
and food poverty have been developed by the
National Heart Forum, Faculty of Public Health
and Public Health England amongst others
which aim to impact on healthy weight.
11SECTION 3
The Local Picture
Knowsley Adults What are we doing to reduce
overweight/obesity in adults?
• Over half of adults in Knowsley are classed There are a number of initiatives commissioned
as being overweight (37%) or obese (22%), around the healthy weight and obesity agenda:
which mirrors the national picture and
marginally higher than across the whole of • Tier 3 Specialist Weight Management Service
Merseyside (21%). (Figure 3). - includes children and adults.
• The 2012/13 Merseyside Adult Health and • Healthy Knowsley Service - includes lifestyle
Lifestyle Survey16, aggregating individuals’ courses and Tier 2 weight management
fruit and vegetable consumption in Knowsley programme for adults.
shows that 35% consume at least five • Delivery of Making Every Contact Count
portions per day. On average, people in (MECC) training for all frontline staff.
Knowsley consume 3.9 portions of fruit
• Physical activity - community cycling,
and vegetables per day, which is slightly
cycling and walking to work programme,
below the average across Merseyside of
community wellbeing (physical activity)
4.1 portions.
programme, green gyms, green spaces
• Just fewer than three in ten adults in rangers service.
Knowsley (28%) engage in moderate-
• Working with students at Liverpool John
intensity activity, defined as sports, fitness
Moore’s University and local hot food
or recreational activities that cause a small
takeaways to change current practices and
increase in breathing or heart rate such as
to consider creating healthier options.
brisk walking, cycling or swimming; lower
than the average across Merseyside. • Several campaigns have also been developed
and implemented, for example, This Girl Can
• People in Knowsley are more likely to
(physical activity campaign) and GULP for
have a hot food take-away from a local
young people and early year’s (campaigns
non-chain outlet (22%), than from a large
aimed at reducing the number of sugary
chain restaurant such as McDonalds, KFC
drinks consumed).
or Burger King (14%)16.
Figure 3
Knowsley residents classed as obese
England* 25% 18-24 9%
Merseyside 21% 25-34 17%
Knowsley 22% 35-44 22%
45-54 30%
Male 21% 55-64 28%
Female 23% 65+ 20%
12Knowsley Children all secondary school children reported doing
moderate physical activity five or more times
There is a growing concern that children’s diets in the last week.
contain too much sugar, salt, saturated fat and • Nationally, 8% of children aged 11 to 18
too few vegetables. These are contributing met the 5-A-Day recommendation of fruit
factors to Knowsley’s higher than average and vegetables between 2012/13-2013/1417.
childhood obesity rates amongst children. Of the 23 Local Authorities in the North
• Data from the 2016/17 National Childhood West, Knowsley is ranked 23rd (worse) for
Measurement Programme (NCMP) show that both reception and year 6 obesity.
12.6% of reception year children (aged 4
and 5) in Knowsley were classified as obese,
which is a reduction on 2015/16 data. What are we doing to support
• The proportion of obese children in reception overweight/obesity in children?
year from Knowsley was still higher than • Continued participation in the NCMP,
the North West region (10.3%), England as participation rate is currently >98% which
a whole (9.6%), the Liverpool City Region is higher than North West and England at
average (11.5%) and Knowsley’s Statistical 94%18.
Neighbour Group average (10.4%).
• Primary School Aged Children and Families
• In contrast the proportion of children Programme which builds on the Primary
classified as obese in year 6 has increased to Healthy School Weight Programme.
27.8% (an increase on 2015/16 data), with
only 56% in the healthy weight range. • Healthy Child Programme for children, young
This is also higher than the North West people and families which focuses on early
region (20.8%), England as a whole intervention and prevention.
(20.0%), Liverpool City Region average • Supporting schools around utilising the
(22.9%) and Knowsley’s Statistical school sports premium, for example, the
Neighbour Group average (22.5%). Rangers creating a ‘Daily Mile’ route which is
• In the 2017 annual schools survey the both easy to do and informative.
proportion of Knowsley primary school • Campaigns, for example; Change4Life and
children who consumed five or more Give Up Loving Pop (GULP).
portions of fruit and vegetables on the day
before the survey was 16%, with 49% of
pupils stating that they eat fresh fruit ‘on
most days’. 38% of year 6 children reported
School Meal Provision
The School Meals Service operates in 59 of
doing moderate physical activity five or more
the 61 schools (Primary, Secondary and Special
times in the last week.
Sector) in the borough and offers a varied menu
• The proportion of all secondary school that caters for a wide range of different tastes
children who consumed five or more fruit and is compliant with the School Food
and vegetables on the day before for the Standards.
2017 annual schools survey was 7%. 9% of
13Figure 4
Childhood Obesity in Knowsley
30
Year 6
Reception
25
20
% of obese children
15
10
5
0
1998/99
1999/00
2000/01
2001/02
2002/03
2003/04
2004/05
2005/06
2006/07
2007/08
2008/09
2009/10
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
2016/17
School year
The School Meals Service recognises that for Reviews of menu design are carried out with
some of the borough’s pupils, a school meal colleagues from public health on a periodic
may be the only significant and nutritious daily basis. This is in an effort to make incremental
meal they have and will continue to work with changes to menu design by swapping out
colleagues from across the council to promote options that could potentially be replaced by
and encourage this. The aim is to reach the goal healthier options, whilst balancing the need
of children consuming five portions of fruit and for maintaining popular choices that pupils,
vegetables a day by providing a wide ranging parents and schools want to see that maintain
and attractive menu that maximises the take up an economically viable level of uptake across all
of school meals. the sites.
14Table 1
Health inequalities faced by Knowsley residents
Indicator / Area England Knowsley
Healthy life expectancy at 65 years - male 2013-15 63.4 59.1
Healthy life expectancy at 65 years - female - 2013-15 64.1 59.0
Life expectancy at birth males - 2013-15 79.5 76.8
Life expectancy at birth females - 2013-15 83.1 80.4
Mortality rate per 100,000 population from all causes 184.5 262.4
preventable (persons) 2013-15
% Excess weight in 4 to 5 year olds (2015/16) 22.1 27.8
% Excess weight in 10 to 11 year olds (2015/16) 34.2 39.2
% Excess weight in adults (2013-15) 64.8 70.1
% of physically active adults (2015) 57.0 53.0
% of physical inactive in adults (2015) 28.7 35.1
% Utilisation of outdoor space for exercise/health (2014/15) 17.9 9.3
Self-reported wellbeing (% of people with low satisfaction) 2015/16 4.6 7.1
Self-reported wellbeing (% of people with low worthwhile) 2015/16 3.6 5.6
Self-reported wellbeing (% of people with low happiness) 2015/16 8.8 11.8
Self-reported wellbeing (% of people with high anxiety) 2015/16 19.4 23.6
Injuries due to falls in people aged 65 and over, Standard rate 1012.0 1548.0
per 100,000 population (2014/15)
% of adult social care users who have as much social contact as they 45.4 42.7
would like (2015/16)
15SECTION 4
Lifestyle Behaviours
Current lifestyle choices represent a risk to the
How many calories are in our food?
health of the population and while there have
been some improvements in lifestyle risks across 260 in a typical burger with cheese in a bun.
the population, the greatest improvements
are still in higher socio-economic groups. 880 in a 10-inch takeaway pizza.
This section looks at the factors that impact on
achieving/maintaining a healthy weight. 237 in a Krispy Kreme chocolate iced ring
doughnut.
338 in a Greggs tuna mayonnaise white sub
Diet roll.
Diet can have a major impact on health.
Many people are eating more saturated fat, 244 in a 400g tin of Heinz spaghetti.
salt and added sugar than the Government
recommendations, and too little fruit,
Eating Disorders
vegetables, oily fish and fibre. A healthy diet
Eating disorders are also an important factor
should be based on the principles of the Eat
when looking at healthy weight. The National
Well Guide19. According to Health Officials it is
Institute for Health and Care Excellence (NICE)
estimated that people are consuming an extra
estimate that 1 in 250 females and 1 in 2,000
200-300 calories a day. The recommended
males will experience anorexia nervosa in
calorie intake per day to maintain a healthy
adolescence or young adulthood and that
weight is 2,500 for men, 2,000 for women and
bulimia nervosa is about five times more
between 1,600-2,500 for children20.
common. The management and treatment
of eating disorders is primarily through
As a nation, our food culture has changed
psychological therapies22. These are not explored
over recent decades. This has resulted in a shift
within this plan although any developments
from the more traditional routine of shopping,
or public messages on healthy weight need to
food preparation and cooking to an increased
consider the impact on people who are both
reliance on the convenience of processed foods
overweight and underweight. The commissioned
many of which are higher in fat, sugar and salt.
specialist obesity service offers an eating disorder
More than one-quarter (27.1%) of adults and
service and from April 2017 will include a Young
one-fifth of children eat food from out-of-home
People’s Community Eating Disorder Service, for
food outlets at least once a week. These meals
children and young people aged 8 to 18 who
tend to be associated with higher energy intake;
are referred by GP’s, teachers, school nurses,
higher levels of fat, saturated fats, sugar, and
social workers and other health professionals.
salt, and lower levels of micronutrients21.
These trends in food consumption together
with the high levels of obesity in Knowsley Malnutrition
present a compelling case for interventions to Malnutrition can have significant adverse effects
improve access to healthy food, control the on health and wellbeing, however it can be
proliferation of takeaway food establishments managed by assessing the level of risk, medical
and improve the quality of food served in management, treating the underlying cause
commercial catering premises. and access to a multidisciplinary team including;
16Dieticians, Occupational Therapists, Speech and Food is often a flexible element of family
Language Therapists, Community Matrons and finances and when funding is tight families may
Community Pharmacists. Management options prioritise high energy dense food. Families on a
include fortification of food, assistance with limited budget may not be able to risk wasting
eating, addressing social issues for example food that has a limited shelf life such as fresh
assessing the ability to shop both physically fruit and vegetables and rely on processed foods
and financially and the preparation of food. instead. Some families are affected by food
Knowsley’s Community Dietetic Service security and the rise in food banks in the UK is
provides services to support residents, including testament to the number of families for whom
one-to-one assessments and treatment plans having the basics can be a challenge at times.
along with training for health and social care Cooking skills and facilities also impact on how
staff on MUST which is a malnutrition universal families eat and how healthy their overall diet
screening tool23. is. Feedback from residents from lower income
households suggests that preparing and eating
fresh and healthy food is viewed positively.
Food Poverty However, intentions of parents to feed their
Knowsley is the second most deprived area children healthy foods can become strained and
in England. There is a steady rise in obesity difficult to maintain after a child reaches the age
prevalence with increasing deprivation for both of two24.
Reception and year 6 children. Key research
shows that households/individuals who are in
poverty or are socially disadvantaged have worse Oral Health
dietary-related outcomes and that nationally Oral health is an important aspect of the overall
children growing up in poverty are less likely to health status of children. A major cause of
have a healthy weight. Food poverty is more tooth decay is juices and fizzy drinks, which
likely amongst those; who have a low income, can be high in sugar and have few nutrients.
are unemployed, have a disability or are a In Knowsley, children are being admitted to
member of a black or minority ethnic group. hospital for tooth extraction at a younger age
Whilst there is some emerging evidence that than the national average. Of the number of
national child obesity levels have plateaued, children admitted for tooth extraction,
rates in the more deprived areas continue to rise. three-quarters were aged under 10, compared
to 57% aged under 10 across England25.
According to the latest available figures (2013),
there are 10,205 children living in poverty
in Knowsley, which represents 28.9% of all Alcohol
children living in the borough (higher than the Alcohol contains calories and many people who
England average of 18%). Knowsley has the are watching their weight forget to count these.
ninth highest proportion of children living in In Knowsley, 58% of adults drink alcohol, which
poverty out of all local authorities in England, is consistent with the Mersey Cluster (59%)
and the second highest in the Liverpool City but slightly lower than England (62%). Men
Region. Of the 23 Local Authorities in the North are more likely to drink alcohol than women
West, Knowsley is ranked 23rd (worse) for both (65% compared to 52%) and people aged 18
reception and year 6 obesity.
17to 24 are the most likely cohort to drink alcohol average of 57% (representing 66,918 of the
(70%). Research also suggests that alcohol population) this would equate to 4,696 more
consumption is higher in the more affluent people being physically active.
groups of the population with 67% of people
in full time work drinking alcohol compared to The design of where we live and access to
53% who are not in work26. good quality facilities or areas which encourage
activity either formally or informally also
influence our activity rates. The planning system
Breastfeeding has a key role to play in ensuring that new
Based on the available evidence, breastfeeding development encourages active travel and
appears to provide some level of protection provides sufficient green space (or facilitates
against childhood overweight and obesity. access to existing green space) for residents to
Together with other targeted nutrition enjoy for leisure and recreational purposes.
interventions, breastfeeding can therefore be an Promotion of active travel greatly contributes
important component of strategies to reduce to increasing activity levels as part of daily life
the risk of overweight and obesity in children22. as transport is important for people to access
Breastfeeding rates in Knowsley are increasing education, training or employment. Evidence
slowly although they are still much lower than suggests that families with low incomes who live
regional and national rates. Breastfeeding in deprived neighbourhoods are more adversely
initiation in Knowsley is currently 47.7% with affected by the impacts of poor transport access
18% of mothers continuing after 6 to 8 weeks, than others in more affluent neighbourhoods.
compared to 43.2% continuation average Feedback from local residents tells us that high
for England27. transport costs is a growing concern for many
young people24.
Active travel is lower in Knowsley compared to
Physical Activity other Merseyside areas with 29% of residents
While the benefits of physical activity on general
reporting they do not spend any time walking
health are widely known it is diet that has the
or cycling for travel26. According to Natural
greater overall effect on weight loss (80%)
England 2015/16, Knowsley’s utilisation of
with physical activity accounting for 20%.
green spaces for exercise and/or health reasons
However, achieving 150 minutes of moderate
has seen a sharp increase to 21% from 9.3%
intensity physical activity a week for adults helps
in 2014/15, compared to 17.5% for the North
prevent and manage over 20 chronic conditions
West and 17.9% nationally29.
including coronary heart disease, stroke, type
2 diabetes, cancer, obesity, mental health
problems and musculoskeletal conditions28.
The Local Population
The over 16 year’s population of Knowsley The 2012 Lifestyle Survey30 found that people
is approximately 117,400 based on 2016 in Knowsley value good health highly with 9 in
estimates. According to the Active People 10 people agreeing that there is nothing more
Survey, to achieve a shift from Knowsley’s important than good health (93%). However,
current activity rate of 53% (representing many people in Knowsley are relatively fatalistic
62,222 of the population) to the national with 58% of people thinking if a person is
18meant to get ill, it doesn’t matter what a doctor Local Assets
tells them to do, they will get ill anyway. Assets can be described as the collective
resources which individuals and communities
The survey identified population segments have at their disposal, which protect against
(Appendix 2) for Knowsley, which helps negative health outcomes and promote health
us to understand different attitudes and status. Asset based approaches recognise that
motivations to health and how we need to sustained positive health and social outcomes
tailor our approach. Groups which are very will only occur when people and communities
resistant to traditional health messages require have the opportunities and facility to control and
intensive support, community led solutions manage their own futures.
with peer support playing a vital role. The
influence of family, friends and peer support Knowsley has some excellent assets that can
is well established in Knowsley as a key driver impact upon inactivity. This includes physical
for achieving behaviour change. The Target assets with a significant proportion of green
Wellbeing Programme31 in Knowsley which space including green gyms and modern leisure
ran between 2008 and 2012 showed the facilities as well as community led activities such
impact and capability that the third sector and as walking and cycling groups32.
community groups have in reaching population
groups and developing partnerships that
sometimes traditional services cannot do alone.
19SECTION 5
Evidence Base
In 2016 an obesity evidence review was
conducted by Knowsley Public Health that Obesity Insight
looked at the evidence base for effective To inform the design and take up of healthy
interventions in the treatment of obesity. weight services, local insight was gathered in
A summary of the National Institute for Health 2017 with a focus on better understanding
and Care Excellence (NICE) guidance and further the attitudes, behaviours and awareness of
emerging evidence can be found at Appendix 3. childhood obesity and oral health.
The period between a child’s universal
developmental health check (2 to 2.5 years old)
Primary Care and starting school (approximately 5 years old)
has been identified as a key time when problems
It appears that GPs are nervous of telling people
relating to obesity and oral health occur.
they are overweight and worry that initiating
any discussion will lead to a long, fruitless
As with other health issues there are many
conversation about failed diets and eating
factors that can affect positive behaviour change
habits that will go on long beyond a 10 minute
in relation to obesity.
consultation. However, a recent study has shown
that GPs who raise the issue of their patients’
The insight identified three ‘typical’ families in
obesity in the surgery will not offend them and
Knowsley:
are likely to help them reach a healthy weight.
According to research published in the Lancet • Young Chaotic Families - low educational
Medical Journal33, a trial 30 second intervention attainment and poor understanding of
in which the GP suggests the patient’s weight healthy lifestyles, often have substance
may be affecting their health and offering them misuse problems;
a place on a weight-loss programme revealed • Hardworking Parents - both parents busy
advice can make a major difference. will have good knowledge of healthy living
and support networks in place, but struggle
Physical activity brief advice in healthcare is also with time and issues with overweight can go
effective at getting individuals active. It has been unnoticed;
suggested that one in four people would be
more active if advised by a GP or nurse, but as • Information Hungry Parents - typically
many as 72% of GPs do not discuss the benefits want the ‘best start’ for their children and
of physical activity with patients. A nationwide will do everything possible to do this.
study has revealed that 80% of GP’s in England Often start with breastfeeding.
said they were unfamiliar with the national
physical activity guidelines, and more than 1 in 7
said they were not confident in raising the issue
of physical activity with their patients34.
20Key Findings From this insight we can see that by ‘joining
A key theme that kept coming up, was being up the dots’ for people; for example less silo
unable to recognise overweight and obesity, working and services working more collectively
particularly when children are perceived as to ‘push’ the correct messages and information
being physically active, and wanting the best out at the right time we can go a long way
start or life for their children was seen as a key to influencing the capability, opportunity and
motivator for change Overall there was a lack motivation for parents and carers. This could be
of knowledge and understanding when making through effective commissioning of appropriate
the connection between healthy eating and how services, targeting those in need, and harnessing
a poor diet affected teeth and weight. the contribution across all sectors, by recognising
and utilising the opportunity to reach vulnerable
The findings also noted that having the right families through third sector organisations such
capability, opportunity and motivation at the as Homestart.
right time are key factors that drive positive
engagement and action in overcoming barriers During the foundation years (children aged 2 to
and excuses that arise. 5 years) it is essential to be proactive and create
the right environments for parents/carers to ask
It is essential that people are encouraged to questions around weight and NCMP. Increasing
make positive choices by ensuring people: the number of trained staff who can recognise
the signs of overweight early and who feel
• Have the necessary knowledge, skills confident enough to raise the issue in a
and capacity to make positive choices. non-judgmental way will ensure issues are
(Capability) addressed much earlier in the child’s life.
• Have sufficient opportunity to do these
things - easy and convenient access to The delivery of well-structured local behaviour
relevant services; encouragement and change campaigns such as Change4Life and
support and/or sufficient triggers and GULP can also support increases in personal
opportunities to engage in positive motivation and help people to see the
behaviours. (Opportunity) importance of healthy weight to them and
their family.
• Recognise that it is relevant to them and
their family and believe it is an important
thing to do. (Motivation)35
21SECTION 6
Knowsley Healthy Weight Plan
There are many challenges associated with The action plan for Knowsley will focus on the
reducing obesity levels and while these four overarching strategic high impact changes
challenges are not exclusive to Knowsley, as identified by CONST (See Appendix One) and
significant health inequalities exist across the we will aim to demonstrate significant progress
borough and are starker in an area of such across all the development areas. The Local
deprivation. We understand this and that’s Authority will provide the strategic leadership
why the plan, although having a life course to ensure that healthy weight is central to
approach, will have a greater emphasis on early Knowsley’s locality strategic plans, policies and
years. Obesity, particularly amongst children in commissioned contracts.
the foundation years is becoming a growing
concern. We will also aim to exploit the contact There is no extra budget associated with the
opportunities in primary care to act as a catalyst delivery of the Healthy Weight Plan; all actions
for change much earlier, as evidence has will be agreed and achieved using a collaborative
suggested a fear and lack of confidence in this approach with key partners and stakeholders
area from GPs. combining areas of good practice to start
reducing the prevalence of excess weight in the
The plan will be effective by applying the borough by 2021 and beyond.
principles of behaviour change to raising
awareness and training with cross sector A Healthy Weight Steering Group will be
workforces. Population level behaviour change established to take the action plan forward.
requires a system wide approach which will This will involve senior partners from across
support to reduce the barriers and enable various teams, agencies and organisations
people to lead healthier lives; from changes in coming together, taking ownership and being
policy, the physical environment, organisations accountable for their actions. For example,
and institutions leading the way and the social increasing early identification of overweight /
environment; increasing knowledge and skills obesity.
within communities.
We know that transformational change will
not be delivered by a top down approach.
Knowsley Council sets out the plan, but is
reliant on everyone across the system and within
communities to recognise the critical role that
they can play in bringing about positive change.
The most successful examples of person and
community centred approaches in practice are
those developed by people and communities,
working with and alongside commissioners,
providers and policy makers, who co-design and
co-deliver solutions that work36.
22SECTION 7
The Action Plan
The local authority together with key partners will work on:
1. Building Local Intelligence
Objectives
• Make best use of resources and funding.
• Identify local variations and better targeting of resources.
• Ensure that all data, intelligence and evaluation is shared.
• Identify gaps and reduce areas of duplication.
• Adopt robust evaluation methods to assess whether or not the particular service or project is
delivering the desired/intended outcome.
Actions Who When
Continue to provide the rationale for investment in cycling KMBC: Ongoing
and walking infrastructure. For example, including Public Health,
programmes to support active travel, by ensuring that the Planning,
needs of people walking and cycling are factored into all Highways
transport infrastructure investment. This includes ensuring Knowsley Chamber
that our streets and neighbourhoods are walking and of Commerce
cycling friendly.
Utilise evidence of best practice around collaborative working Local Authority Ongoing
to support pooling of budgets locally and across borders.
Continue to identify trends, drivers and patterns of the KMBC: Ongoing
physical activity behaviour of different cohorts and people Policy Impact and
living in different parts of the borough. For example, increase Intelligence,
understanding of the individual, social, environmental and Public Health,
policy factors that influence physical activity behaviours by Volair
exploring the evidence of what works to support active lives.
Consistently share evidence, data and local intelligence with KMBC: Ongoing
key partners, for example, Local Authority, Clinical Policy Impact and Identify key
Commissioning Group, Primary Care and schools, by Intelligence, contact across
identifying a named contact in each area. This would include Public Health areas in Year 1
sharing ward level data and intelligence around NCMP.
Work with partners to continue to develop and utilise local Local Authority and Ongoing
and national insight findings to direct targeting of resources. relevant partners
For example, local obesity insight findings in early years.
23Actions Who When
Maximise co-creation opportunities across sector workforces All providers of Ongoing
to embed meaningful evaluation in all interventions and commissioned
initiatives. This should include; an evaluation of approaches services
which enable the capture of the invisible outcomes, such as, All relevant
social change, community strength and economic growth. Council directorates
Work with partners to gather insight that will provide local KMBC: Workforce Year 1
data to further understand: Development, Public
• How the workforce can positively influence the behaviour Health, Occupational
of less active people across Knowsley. Health,
• The priorities and requirements to support and develop NHS providers
a healthy workforce for the future. Knowsley Chamber
of Commerce
2. Harnessing the Contribution
Objectives
• Drawing out the specific and expected contribution to this agenda by using existing community-
based programmes and services.
• Developing the necessary mechanisms to ensure that effective local signposting through
partnership working is in place.
• Maximising the opportunities presented to engage families, For example, Primary Care, through
the Healthy Child Programme, contact points with frontline staff, and the NCMP process.
Actions Who When
Ensure that healthy weight is integrated into locality working KMBC: Whole Life Year 2
around health and social care, transformational locality plans Commissioning
and local care organisations. For example, supporting ‘age Team,
friendly community’ approaches across the whole system, to Communities Team,
reduce social isolation, and the risk and effects of long term Knowsley CCG
conditions through active ageing.
Continue to work collaboratively with local authority KMBC Partners Ongoing
partners to take forward the healthy weight declaration
pledges. For example, support a wide-ranging workforce
from planners to developers to understand and embed active
design principles in their work, showcasing excellent practice
that demonstrates how places designed for active lives are
also more appealing and commercially viable.
24Actions Who When
Work with partners to embed physical activity at the heart of Knowsley CCG, Year 2
broad approaches to social prescribing across Knowsley. Primary Care,
KMBC: Public Health
Continue to work with a range of diverse providers to ensure KMBC: Public Health Ongoing
that there is a focus on physical activity and sport provision Commissioned
which engages inactive people, challenges and addresses services e.g. Volair,
stubborn inequalities in participation and helps to support Falls and Wellbeing
people to maintain an active lifestyle through the key and Community
transitions throughout their life. Including supporting a social Cycling,
movement towards healthy weight as the norm, for example, Communities Team
increasing activities for people with disabilities through
funding via the Council’s Better Together Fund.
Continue to explore and apply for external funding to KMBC: Public Health Ongoing
increase physical activity, for example, Sport England and Knowsley Chamber
Merseytravel. of Commerce
Engage with and support all education settings to explore KMBC: Public Health, Year 3
innovative ways to take forward the National Childhood Schools Team,
Obesity Plan by implementing the recommended amount of Commissioned
physical activity per day. For example, embracing approaches services e.g. Rangers
like the ‘Daily Mile’, along with developing school governors
as healthy weight champions for each setting.
Create effective working partnerships with early year’s KMBC: Public Health, Year 2
providers to take forward initiatives to tackle obesity. Early years providers,
For example, exploring opportunities to pre-empt the NCMP Commissioned
programme by piloting weighing and measuring in the 0-5 service
foundation years (3 to 5 years), implementing the ‘Daily
Toddle’ and signposting parents to Healthy Knowsley
Website to assist with meal planning for families.
Working with Knowsley Community & Voluntary Sector KMBC Communities Year 3
partners to develop a coordinated approach to volunteering Team
to increase and retain those engaged and ensure the Knowsley
volunteering workforce is more diverse and representative of Community &
Knowsley communities. For example, creating healthy weight Voluntary Sector
champions in areas of greater need.
25Actions Who When
Maximise the opportunity presented by other programmes, KMBC: Public Health, Year 2
for example, NHS Health Checks delivered by all GPs to Primary Care
further embed healthy eating and physical activity messages
for priority population groups.
Explore the opportunity with the Local Pharmaceutical KMBC: Public Health, Year 1
Committee for Healthy Living Pharmacies to engage with Local Pharmaceutical
residents around healthy weight. For example, MECC Committee
training and assessing BMI.
Increase the scope of the multi-agency cycling network to KMBC: Public Health Year 1
include walking. For example, to co-ordinate communication
and cross promoting for all local cycling and walking
opportunities, in a joined up way wherever possible.
Develop and deliver effective social marketing campaigns KMBC: Public Health Ongoing
locally and collaboratively which aim to raise awareness and
change behaviours around healthy weight. For example,
early years campaign based on the findings from obesity
insight and an NHS health checks awareness raising campaign
to increase uptake across the 40 to 74 years population.
Redesign and launch the Healthy Knowsley Website to KMBC: Public Health, Year 1
enable residents the opportunity to self-care. Working in North West
partnership with the provider of the Healthy Knowsley Boroughs Healthcare
Service to develop a recognisable brand for the website and NHS Trust
the service.
3. Workforce Development
Objectives
• Ensuring that all staff who have a contribution to make to the healthy weight agenda understand
what that contribution is and that they are competent, confident and effective when delivering
interventions.
Actions Who When
Continue to deliver training and champion the principles of North West Ongoing
Making Every Contact Count (MECC) to integrate healthy Boroughs
weight into every conversation including policy makers as Healthcare NHS
well as front line health professionals. Trust
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