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APPENDIX 3 TO ITEM NO. 5 (b)
Scrutiny Topic: Healthy Eating
Life Chances and Employment PPB
6th March 2006
REPORT OF THE
HEALTH SCRUTINY
TOPIC TEAM
ON
HEALTHY EATING
IN HALTON
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Executive Summary
Considerable evidence has been provided to and considered by the Health Scrutiny Topic
Team. Overall the Topic Team has been impressed with the commitment of those who are
working in services around food with Halton Borough. The food available to children within
our schools has improved markedly over the last few years with increases in the use of fresh
ingredients and decreases in processed ingredients. The Halton Healthy Schools Standard has
clearly supported progress. Many schemes and initiatives have been and are being undertaken
to improve healthy eating within the borough, through the HFP, SureStart and Healthy Living
Programme to name but a few.
There are also some structural issues that are mitigating against further progress. The Topic
Team has particularly identified areas around the overall strategic direction and co-ordination
of services, that if improved could improve how exiting resources are deployed more
effectively. This requires a change in the current decision-making structures, with a group to
provide clear strategic direction and one reporting that delivering operational implementation.
The strategic group need to provide leadership and direction, based on evaluation, best
practice and understanding of the effectiveness of current arrangements against an overall
view of where we want to be in the 5 to 10 years.
In the absence of clear understanding of what is the best pattern of services locally against
which to commission it is difficult for this committee to make informed decisions. Although
much of the evidence… The principal recommendation of this committee is that this stating of
a clear baseline, assessing Halton’s position against it and what should be commissioned and
de-commissioned should be report back in September 2006.
The resources available to staff within the system were raised in a number of submissions and
there is clearly heavy reliance on short term funding. However without effective mapping we
are not convinced that the overall level of resource is insufficient.
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INTRODUCTION
AND
EVIDENCE
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1.
Introduction
1.1
Diet and Nutrition
Diet is central to health throughout life. A healthy and varied diet can help to maintain a
healthy body weight, enhance general wellbeing and reduce the risk of a number of diseases
including heart disease, stroke, cancer, diabetes and osteoporosis.
A balanced, healthy diet is one based on a wide variety of foods, including at least five
portions of fruit and vegetables a day and plenty of starchy foods (such as bread, potatoes and
cereals), and a minimum amount of salt and foods containing fat and sugar. No single food
can provide all the essential nutrients that the body needs. Therefore, it is important to
consume a wide variety of foods to provide adequate intakes of vitamins, minerals and dietary
fibre, which are important for health.
This type of diet can help reduce the risk of coronary heart disease, type II diabetes,
overweight and obesity, stroke and some cancers. A good diet is also important during
pregnancy for the healthy development of the growing baby and impacts on the health of the
person in later life (including the need for folic acid to reduce risk of neural tube defects).
Breastfeeding provides vital nutrients for babies and there is also evidence to suggest that
babies who are breastfed are less likely to become obese in later life.
In addition, a balanced diet during childhood helps ensure that children grow well and
develop good eating habits. Taken together with physical activity, a healthy diet can enhance
not just the length but also the quality of life.`
1.2
Diet and Nutrition in Halton
Halton has some of the worst Standardised Mortality Ratios (SMRs) for Major Causes of
Death in the country for some of the major causes of death. Some of the worst SMRs are for
cancers (particularly lung cancer), circulatory diseases, accidents and suicides.
Other key facts about diet and nutrition:

One in ten men in Halton eat the recommended five pieces of fruit and vegetables per
day
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Women do slightly better, with three in twenty eating five pieces a day.
More people eat their “5 a Day” in Halton than in Liverpool and Merseyside, but less
than in Southport and Wirral (Heart of Mersey Lifestyles Survey 2004).
In Halton more than half of men and women are overweight for their height. One in
ten men and women are actually obese.

An independent team from Lancaster University conducted a study into health in the borough,
and compared Halton to other boroughs around the country in terms of healthcare,
environmental pollution and lifestyle.
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Consultation and research with local people before and during the time that the health study
was being conducted, showed that many felt that pollution and Halton’s industrial legacy
were responsible for the high levels of poor health in the borough. The findings of the study
itself however, demonstrated that social, economic and lifestyle factors account for high rates
of illness and death. The study acknowledged that although pollution is an issue, there are no
significant environmental effects on health that can be demonstrated across Halton, or within
smaller local areas.
Since the Lancaster University baseline report of 2001, effort has been made to begin to
implement actions to address some of the policy areas identified. It is recognized, however,
that this is about long-term investment, especially around prevention, if we are to see a real
difference in the long-term health of the population.
It is also about recognizing the need to work in partnership to address health inequalities, as
we said earlier, by improving educational attainment, access to employment opportunities and
reducing deprivation.
Since the baseline report of 2001 we have moved on significantly in understanding “what
works”. Preventive interventions affect mortality and morbidity rates and the demand for
NHS and other services. There is a large body of evidence to support preventive measures,
which proves them to be as sound, or better than many treatment interventions.
At a national level better treatments for heart disease have made a big impact (for example,
using aspirin to prevent a second heart attack, treating blood pressure and making heart
surgery more widely available). But the biggest impact has been from how much we smoke
and how much fat and salt we eat: these account for 71% of the decline in heart disease.
The Halton Health Baseline report identified that in order to achieve maximum impact on
health improvement in Halton policy development work needs to focus on.
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1.3
The need to reduce death rates from some of the major causes of death in Halton by
reducing smoking levels, increasing exercise and physical activity, improving diet and
improving the early detection and treatment of disease.
“Building” healthy individuals from the earliest stages of life.
Addressing the needs of older people, enabling them to lead longer, active and healthier
lives.
Nutrition and general health
Although questions may remain on some of the details, the general link between diet and
health is now well established through numerous studies.
People are reasonably informed about the kind of things they ought to be eating, although
lower socio-economic status links with less information. Putting this general knowledge into
practice requires two major hurdles to be overcome:
a) Shopping habits/buying healthy food/ingredients in the first place, and
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Making the right food buying decisions often means resisting the messages put out
through multi-million convenience food marketing/advertising campaigns
Parents may have preconceived and excessively limited notions of what children
can/will eat so that they are not exposed to an adequate range of healthy options and
do not ‘discover’ new healthy foods
There is a tendency to buy ‘what you fancy’ at the expense of what’s healthy
Time/convenience and price may push shoppers towards less healthy options,
particularly if they have limited experience/skills in preparing healthy meals.
Accessibility and/or transport issues are important here, including distance to travel
for quality fresh produce.
b) Knowing what to do with it and taking the time/effort to create healthy meals.

A significant proportion of adults have very limited experience/skills in how to make
the most of cheap/healthy basic ingredients to create healthy meals for their families.
This applies to both
-
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Cooking skills, and
Budgeting
Along with skills and knowledge, households need to have the essential basic
equipment needed for cooking, and this is not always the case.
Especially in bringing up children, it is important to create a physical and social
environment that is conducive to healthy eating (e.g. proper sit-down meals where a
family comes together to share and talk).
A good diet should help reduce sickness generally. Healthier eating will help to reduce
important types of diet/weight-related illnesses such as obesity, heart disease, type two
diabetes etc. which are currently on the increase. In the case of young families, healthier
children enjoying a healthy diet will need less time off sick from school and parents will need
to take less time off work to care for them. Good diet also has an impact on children's
behaviour in school and can help promote a calmer atmosphere if children are not filling up
on fast releasing, high energy foods at lunchtime.
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2.
Population Specific information
2.1
Pre-school Children
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Encouraging pre-school children to eat a healthy, varied diet will provide all the
nutrients they need for healthy growth and development and help to establish good
eating habits for life.
Young children who are growing and are usually very active have high energy and
nutrient requirements in relation to their size.
A good supply of protein, calcium, iron and vitamins A and D are important during
this time.
Young children have small stomachs and may not be able to obtain all the energy and
nutrients they need if their diet contains too much fibre. Such diets can sometimes
reduce the amount of minerals they can absorb, such as calcium and iron.
By the time they are 5 years old, children should be eating family food and consuming
a diet that corresponds with the Balance of Good Health model.
Healthy Eating Guidelines
Healthy eating guidelines are not intended to apply in full to pre-school children (1-5 years of
age). A diet which is low in fat and high in fibre may not supply enough energy for a young
child. However, a healthy family approach to diet and lifestyle will encourage a child to eat
more healthily, as food preferences are often established during this early stage of life.
Energy And Nutrient Requirements
Children’s energy requirements increase rapidly because they are growing quickly and
becoming more active. They have a high energy requirement for their size. To achieve this
energy intake, foods which are high in energy (and also rich in nutrients) and eaten as part of
small and frequent meals may be necessary for younger children, who do not have large
enough stomachs to cope with big meals.
Young children should not be put on weight reduction diets. However, developing a healthy
family approach to food and physical activity is important in the weight management of
children.
A good supply of protein, calcium, iron and vitamins A and D is also necessary during this
time. Calcium is needed for healthy tooth development and, together with vitamin D, helps
make bones stronger. Childhood is an important time for tooth and bone development.
Whole cows’ milk is recommended for children over the age of 12 months as a main drink as
it is a rich source of a number of nutrients. Semi-skimmed milk can be introduced after the
child is two, as long as the diet provides enough energy. Skimmed milk is not suitable for
children under five years of age, as it does not provide enough energy and vitamin A for the
growing child.
Children should be taught to think about dental hygiene and ways of preventing dental caries.
They should be encouraged to reduce the number of times a day that they have foods and
drinks containing sugar and, if possible, to have them only at meal times. Brushing teeth
regularly with a fluoride toothpaste and regular visits to the dentist should also be encouraged.
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Children from the age of 6 months should be given supplements of vitamins A, C and D (in
the form of liquid drops). These should be continued until the child is 5 years of age if
considered to be at risk of deficiency, e.g. poor eaters or those who do not have much
exposure to sunlight. These drops are free for children under 5 years for families receiving an
income-based Job Seekers Allowance or Income Support.
Iron deficiency anaemia is common in certain groups of young children such as those who are
not receiving a good supply of iron from solid foods and who are given cow’s milk as a main
drink too early (i.e. before 12 months of age).
Iron deficiency anaemia is associated with frequent infections, poor weight gain and delay in
development. Red meat is the best source of easily absorbable iron and can be offered to
children from 6 months of age. Iron rich foods, such as liver and red meat, may not be
popular with young children, so other ways of providing this nutrient must be found, e.g.
offering mildly flavoured liver pate (for children 1 year or older) or minced meat hamburgers
(paying attention to the salt content). Children who are vegetarian must have alternative
sources of iron, such as green vegetables and pulses. Other useful sources include bread and
some breakfast cereals. Iron from plant sources is less well absorbed than iron from animal
sources but can be improved by consuming vitamin C rich foods or drinks (such as orange
juice) with a meal.
Young children need plenty of calcium in their diets for healthy bones and teeth. Dairy
products such as milk, cheese and yogurt are good sources of calcium. Other foods such as
white bread, dark green leafy vegetables, pulses (e.g. baked beans) and fortified cereals can
also contribute to calcium intake.
Free Milk
Children attending day care (including nursery and child minder) sessions of two hours or
more are eligible to receive a third of a pint of free milk on each day they attend. This is
known as the Nursery Milk Scheme and is operated by the Department of Health.
Children under five whose parents receive Income Support or income-based Jobseekers
Allowance are currently eligible to receive a free pint of milk daily under the Welfare Food
Scheme. This scheme is currently under review.
Common Diet-Related Problems
Constipation is quite a common problem in young children and can usually be dealt with by
gradually increasing the amount of fibre in the child’s diet. Try increasing the amount of
vegetables and wholemeal bread in the diet plus other fibre-rich foods that are popular with
children such as baked beans and high fibre white bread. Constipation can also result from too
low a fluid intake - encourage children to drink more plain (e.g. tap) water.
Toddler diarrhoea is also quite common and may arise because the gut isn’t fully developed.
It may also be linked with allowing the child too many sugary drinks and fruit juice,
particularly between meals. This type of pattern can also make the child too full at meal-times
to eat a balanced diet and can be harmful to teeth. Encourage an eating pattern based on minimeals and snacks selected from the four main food groups. At least one food from each of the
four main groups should be eaten at each meal. Restrict sweetened drinks to meal-times. In
families who follow a high fibre diet, it may be worthwhile initially reducing the amount of
fibre a young child receives.
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2.2
Children
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A varied diet containing adequate energy and nutrients is essential for normal growth
and development, which at times can be very rapid.
National survey data suggest that there has been a reduction in the percentage of
energy derived from fat (with average intakes of total fat in line with
recommendations for adults), with a corresponding increase in the proportion of
energy derived from protein and carbohydrate.
Average intake of saturated fatty acids still exceeds government targets for adults,
while some children (e.g. older girls) have low micronutrient intakes or status.
A large proportion of children are inactive, spending less than one hour a day
participating in activities of moderate intensity.
A varied diet containing adequate energy and nutrients is essential for normal growth
and development, which at times can be very rapid.
Energy And Nutrient Requirements
The energy requirements of children increase rapidly because they are growing quickly and
becoming more active. They have a high energy requirement for their size. To achieve this
energy intake, foods which are high in energy (and also rich in nutrients) and eaten as part of
small and frequent meals may be necessary for younger children (e.g. 4-6 year olds), who do
not have large enough stomachs to cope with big meals.
Despite this need for a high energy intake, however, the 2002 Health Survey for England
found that about 1 in 5 boys (21.8%) and over 1 in 4 girls (27.5%) were either overweight or
obese. These children should not be expected to lose large amounts of weight. They should be
encouraged to remain at a constant weight or increase weight slowly while their height
increases, so that they grow to be an acceptable weight for their height. Developing a healthy
family lifestyle is important in the weight management of children.
A good supply of protein, calcium, iron and vitamins A and D is also necessary during this
time. Calcium is needed for healthy tooth development and, together with vitamin D, helps
make bones stronger. Childhood is an important time for tooth and bone development.
Children should be taught to think about dental hygiene and ways of preventing dental caries.
They should be encouraged to reduce the number of times a day that they have foods and
drinks containing sugar and, if possible, to have them only at meal times. Brushing teeth
regularly with a fluoride toothpaste should also be encouraged.
Iron deficiency anaemia is associated with frequent infections, poor weight gain and delay in
development. Iron rich foods, such as liver and red meat, are not always popular with
children, so other ways of providing this nutrient may need to be found, e.g. offering paté or
minced meat burgers. Children who are vegetarian must have alternative sources of iron, such
as dark green leafy vegetables, pulses and nuts. Other useful sources include bread and some
fortified breakfast cereals. Iron from plant sources is less well absorbed than iron from animal
sources. Consuming vitamin C rich foods or drinks such as orange juice with a meal can
increase iron absorption from plant sources.
Current Intakes
National survey data suggest that over recent years there has been a reduction in overall
energy intake and in the percentage of energy derived from fat, with a corresponding increase
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in the proportion of energy derived from protein and carbohydrate (comprising starch and
sugars). The average fat intake of children is in line with recommendations for adults,
although their average intake of saturated fatty acids still exceeds government targets for
adults. Whilst an increase in starchy carbohydrate-rich foods is to be welcomed, sugar intakes
were also high in many children. Salt intakes were also above the recommended targets.
The recent national survey of young people aged 4-18 years found:
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Children eat less than half the recommended five portions of fruit and
vegetables a day. In an average week, one in five 4-18 year olds ate no fruit at
all.
Over 80% of the group surveyed ate white bread, savoury snacks, potato chips,
biscuits, boiled, mashed and jacket potatoes, and chocolate confectionery.
Chicken and turkey were the most popular types of meat with over 70% of the
sample eating these foods.
Under half the boys and just over half the girls ate raw and salad vegetables
(excluding tomatoes and carrots) during the 7-day study period, whilst 40% ate
cooked leafy green vegetables and 60% consumed other types of cooked
vegetables.
4% of the sample did not consume any vegetables during the 7-day survey
period.
The most commonly eaten fruits, consumed by over half of the sample, were
apples and pears, followed by bananas.
Carbonated soft drinks were the most popular drink, with three-quarters of the
group consuming standard versions and less than half drinking low calorie
versions.
Generally, the quantities of foods eaten increased with age with the exception
of whole milk and vegetables, which both decreased with age.
There was evidence of low micronutrient intakes or status in some subgroups,
especially the older age groups.
Healthy Eating Guidelines
Children over 5 years of age are beginning to take responsibility for their own food intake so
it is important that they understand the need for a healthy diet. However, their eating habits
will have been influenced by the family earlier in life, and it is difficult to change these once
they are established. It is therefore important that the whole family adopts a healthy lifestyle.
The Food Standards Agency has recently provided information on the safe maximum
consumption levels for oily fish. It recommends that boys and girls under the age of 16 should
not eat marlin, shark or swordfish. Boys under 16 can have up to 4 portions of oily fish a
week and girls up to 2 portions (with a portion weighing 140g). The lower recommendation in
girls is because substances found in oily fish e.g. dioxins can accumulate in the body and high
levels may be detrimental in later life to an unborn baby.
School Meals
School meals can make an important contribution to the energy and nutrient intake of
children. They are thought to be the best option when compared with food brought from other
sources such as cafés and take-aways, although there is considerable variation in the
nutritional quality of school meals. Although the Education Act of 1980 removed the
obligation for schools to provide meals of a set nutritional standard, the government has
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recently recognised the importance of the contribution that school lunches can make to the
health of children and has now re-introduced regulations on national minimum nutritional
standards for schools who opt to provide lunches. These became compulsory on 1st April
2001 across England and Wales in both primary and secondary schools. Details can be found
below. Separate school lunch standards have been developed in Scotland. Full details for
Scottish Nutrient Standards for School Lunches are available at the link below. Children
whose parents receive Income Support or Income-based Jobseeker’s Allowance are eligible
for free school meals.
Some schools now offer parents guidance on the content of packed lunches, which are
becoming more popular. This advice is offered as part of a ‘whole school approach’ to
healthy eating through which the food consumed at school is in harmony with the principles
of healthy eating taught in the classroom.
School Milk
Subsidised school milk can be made available to children in primary schools via the EC
School Milk Subsidy Scheme. This scheme allows children to purchase 250ml of milk daily
at a reduced price. Details of the scheme are available from the Dairy Council.
Physical Activity
National data suggests that, with the exception of very young children (4-6 year olds),
between 40-69% of children in Britain are largely inactive, spending less than one hour a day
participating in activities of moderate intensity. The 2004 report At Least Five a Week,
Evidence on the impact of physical activity and its relationship to health from the Chief
Medical Officer recommended that children and young people have at least 60 minutes of at
least moderate intensity exercise every day. It also recommended that activities that increase
muscle strength and flexibility and also improve bone strength should be included at least
twice a week.
Exercise and sleep
There are also benefits for concentration if adequate nutrition is combined with a period of
exercise before starting lessons. This helps to ‘wake up’ people and their system. Exercise is
also important in achieving a good balance and rhythm of eating, activity and sleeping. Too
little sleep or sleeping/feeling sleepy at the wrong times has obvious spin-offs for
concentration and ability to learn.
2.3
Young families and families-to-be
There are several reasons for focussing on this group:
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Deciding to have a family is an important milestone in most people’s lives and for
many may be a point at which they reflect on their lifestyle and make changes e.g. to
diet
Mothers-to-be in particular need to be at the peak of good health when conceiving and
carrying a baby, in order to give it the best chance of a healthy life
Young children don’t control what’s available for them to eat at home so their parents’
knowledge and skills regarding food are essential for the children to have access to a
healthy diet.
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2.4
Young adults setting up home
If young adults have not acquired the skills and knowledge needed to ensure a healthy diet
before they set up their first home independently, a pattern of consuming take away and
convenience food may become established. It is suggested that agencies and organisations
involved in developing life-skills amongst this group of young adults should include healthy
eating, cooking skills and domestic budgeting in their programme/’curriculum’
2.5
The needs of adults
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Nutritional requirements do not change much between the ages of 19–50 years,
except during pregnancy and lactation, but energy requirements vary depending on
age, gender and activity level of the individual.
On average, the diet of UK adults provides more than enough of most nutrients,
although subgroups of the population appear to have low intakes of some vitamins
and minerals.
The percentage of energy derived from saturated fatty acids is higher than
recommended (although fat intake is close to recommendations), and the average
diet contains too little fibre and too much salt.
Several nutrients may be of particular relevance for women’s health, including
iron, calcium and folate, and for men selenium, zinc and lycopene.
Energy And Nutrient Requirements
Nutritional requirements do not change much between the ages of 19 and 50 years, except
during pregnancy and lactation. Energy requirements are reduced when growth stops but
requirements vary depending on the age, gender and activity level of the individual
concerned.
Requirements for energy usually decrease further after the age of 50 as activity levels fall.
Adults should aim for a body weight that is appropriate for their height. This can be assessed
by determining body mass index (BMI).
The ideal BMI range for adults is 20–24.9, although these cut-offs may not be appropriate for
athletes and some ethnic groups (as BMI does not distinguish between fat and fat free mass).
In Britain, 41% of men and 33% of women are overweight (BMI 25 or more). Obesity is a
growing problem, with 25% of men and 20% of women being obese (BMI over 30).
Weight is gained when more energy is taken in than is used up. Weight reduction methods
tend to focus on achieving a well balanced, reduced energy diet together with increasing
physical activity. Regular physical activity is also important for the maintenance of healthy
bones (especially weight-bearing exercise) and to reduce the risk of chronic diseases such as
heart disease, stroke and type 2 diabetes.
Current Intakes
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Surveys in the UK have shown that, on average, the diet of UK adults provides more than
enough of most nutrients, although subgroups of the population seem to have low intakes of
specific nutrients. Average total fat intakes is now close to the target of 35% of energy from
fat but the percentage of energy derived from saturated fatty acids is higher than
recommended and the average diet contains too little fibre and too much salt.
A healthy, well balanced diet is one which contains plenty of fibre-rich starchy foods and fruit
and vegetables, moderate amounts of meat or its alternatives, milk and milk products and only
small amounts of foods and drinks containing fat and/or sugar.
Eating a varied diet, not smoking, keeping physically active, drinking alcohol in moderation
only and keeping body weight within the healthy range for height are all factors which are
thought to play a part in reducing the risk of certain diseases such as cardiovascular disease
and some cancers.
An increasing number of people are developing non-insulin dependent diabetes (type 2
diabetes). This is more common among people who are overweight.
Women’s Health
Several nutrients may be of particular relevance for women’s health, including iron, calcium
and folate.
Iron – women have higher requirements for iron compared to men, mainly because of the
losses of iron that occur during menstruation. Requirements fall (to the levels estimated for
men) when menstruation ceases (menopause). Recent UK statistics show that many women of
child-bearing age have low iron intakes.
Calcium – calcium is one of the nutrients important for bone health. Intakes of calcium during
childhood and adolescence are known to be important for determining peak bone mass but
having an adequate calcium intake during adulthood (700 mg/day) is also an important
determinant of later bone health, as is being physically active.
Folate – folate is involved in the formation of red blood cells and deficiency causes anaemia.
Women of child-bearing age are recommended to take folic acid supplements and consume a
folate-rich diet. This is because a high folate intake before conception and during the first
twelve weeks of pregnancy reduces the incidence of neural tube defects (e.g. spina bifida) in
babies.
Folate is found in liver, yeast extract, green leafy vegetables (e.g. sprouts, spinach, green
beans, peas), potatoes, fruit (especially oranges), milk and dairy products. Breakfast cereals
and bread are examples of foods that may be fortified with folic acid (the manufactured form
of folate).
Premenstrual syndrome
Premenstrual syndrome (PMS) describes a range of symptoms that some women experience
between the middle and end (luteal phase) of their menstrual cycle. The most frequently
reported symptoms include water retention, irritability, depression, backache and breast
tenderness. These usually disappear soon after menstruation begins.
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Although the underlying mechanisms leading to the symptoms of PMS are unknown, several
aspects of diet have been considered. Although there is general advice to women who suffer
from PMS (e.g. maintaining a healthy body weight), there has been interest in specific
nutrients.
It has been suggested that vitamin B6 may be involved as it is needed for the synthesis of
some neurotransmitters (e.g. serotonin and dopamine) which can affect mood. Several studies
have been conducted and women have been encouraged to act on the results. Some take large
doses which can lead to nerve damage. Recently the Food Standards Agency’s Expert
Committee on Vitamins and Minerals advised that people should limit their intake of vitamin
B6 from dietary supplements to no more than 10 milligrams per day, unless acting on medical
advice.
Several minerals such as zinc and magnesium, are also involved in the production of
neurotransmitters in the body and have been studied in relation to PMS. Although there is
little convincing evidence of any benefit of these supplements, there is evidence to suggest
calcium supplementation may alleviate some (mainly mood) symptoms.
There has also been interest in a particular fatty acid that is found in evening primrose oil,
GLA (gamma-linoleic-acid). Some women report relief from symptoms when they take GLA,
while others perceive no benefit. Because of the lack of consistent information from scientific
studies, the efficacy of evening primrose is uncertain.
Current advice to women who suffer from PMS includes:
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Exercising several times a week
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Maintaining a healthy body weight
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During symptoms of PMS, eat little and often.
Men’s Health
Men are more prone to carry extra weight in the abdominal area (known as central obesity).
Excessive weight gain puts them at increased risk of developing heart disease and type 2
diabetes. African-Caribbean and Asian men have a high risk of developing type 2 diabetes,
high blood pressure and heart disease and this is likely to be related to a genetic tendency to a
carry excess weight in the abdominal area.
Drinking too much alcohol can increase weight, particularly around the abdominal area, and
lead to other long-term health problems such as high blood pressure. Men are advised not to
drink more than 3 to 4 units of alcohol a day. A unit is half a pint of standard strength beer,
lager or cider, or a pub measure of spirit.
Nutrients that may be of particular relevance to men’s health include:
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Zinc which has a role in fertility as it is involved in sex hormone production and
selenium which is involved in sperm motility and has been suggested to have a
possible beneficial role in prostate cancer prevention. Good food sources of both these
nutrients include brazil nuts, seafood, meat and poultry. Wheat has traditionally been a
major source of selenium, with bread contributing a large proportion of the daily
selenium intake. However, levels are now lower (as flour from Europe has a lower
selenium content compared to that from the US) but bread still accounts for about 12%
of total selenium intake due to the amounts eaten.
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2.6
Lycopene, a carotenoid, abundant in red fruits such as watermelon, red grapefruit, and
tomatoes and tomato products. People who have high intakes of lycopene appear to
have lower risk of developing prostate cancer, although whether this association is
causal remains to be established.
The needs of older people
By 2010, 22.5% of Halton’s population will be made up of older people. Therefore, policies
need to be implemented to ensure that a positive approach to ageing is employed by all
agencies. This should not just be about the provision of health and social care services,
although this is important, but it is also about developing “healthy ageing” strategies to focus
on prevention, quality of life and well-being. For example, these could include social
activities, community education and learning, developing links between the older and younger
generations within the borough, employment opportunities for older people, good neighbour/
visiting services. All of these activities promote both physical and mental well- being and can
help to reduce the demand for social care and health services.
The National Diet and Nutrition Survey: people aged 65 years and over revealed that most
older people are adequately nourished and their intakes of most vitamins and minerals are
generally sufficient. There is, however, cause for concern about the nutritional status of some
subgroups, in particular those without their own teeth, those living in institutions, older age
groups and low socio-economic groups.
Three particular public health issues were highlighted: bone health and vitamin D; folate
status in relation to cardiovascular disease; oral health.






Although energy requirements generally decrease as we get older, the general dietary
guidelines still apply.
It is important for older people to keep physically active.
People aged 65 years and over should take a vitamin D supplement as well as
regularly eating food sources (e.g. oily fish, cod liver oil and margarine).
Some older people, especially those living in institutions, may have low intakes or low
blood levels of a range of micronutrients.
National survey data have highlighted potential areas of change that could improve the
nutrient intake of older people but it is important to take into account other factors
which may affect older people’s dietary intakes (e.g. illness, poor dentition, drugnutrient interactions).
Currently about 20% of the UK population is over 65 and the proportion of the
population in this age group is increasing rapidly as people live longer.
Energy And Nutrient Requirements
Energy requirements continue to fall with advancing age. This is due to a decrease in lean
body tissue (muscle), leading to a fall in basic metabolic rate. Older people also tend to be less
active. It is important that older people continue to enjoy their food and that they keep active
(e.g. walking, gardening, dancing, climbing stairs) in order to maintain a good appetite,
maintain mobility and prevent obesity.
15
In the UK, dietary recommendations for fat, fibre and carbohydrate are the same for older
people as for the rest of population. There is a lack of specific recommendations for older
people for many of the micronutrients, although it is known that the ability to digest, absorb,
metabolise and excrete nutrients changes with age (e.g. vitamin B12 absorption is decreased
because the intrinsic factor needed for its absorption is thought to decrease with age). There
are, however, specific recommendations for vitamin D. Vitamin D is necessary for calcium
absorption and is mainly obtained from the action of sunlight on the skin. People who are
housebound or live in institutions may be at risk of deficiency. It is recommended that
everyone over the age of 65 takes a supplement of vitamin D, and dietary sources such as oily
fish and margarine (which is fortified with vitamin D) should be eaten regularly.
It is also important that older people eat enough food to cover their energy requirements and
that the food they eat are nutrient dense, i.e. a small portion of the food contains a lot of
nutrients. Many older people have to modify their diets to help control illnesses such as
diabetes and heart disease but if an older person is in good health, it is recommended that they
follow the general dietary guidelines for the population.
Current Intakes
National survey data show that average daily energy intakes are below the estimated average
requirements for adults (although this may reflect lower physical activity levels of older
people), with the largest contribution coming from cereals and cereal products. Intakes of
fibre, which can help prevent constipation, were below the population recommendation.
Average daily protein intakes were well above the recommendation, with meat and meat
products, cereals and cereal products, and milk and milk products being the main sources of
protein. Intakes for total fat matched those population averages set but intakes of saturated
fatty acids were above these recommendations.
National survey data show that a proportion of older people, especially those living in
institutions, have low intakes or low blood levels of a range of vitamins and minerals. This
may be in part due to the differences in fruit and vegetable consumption among those older
adults living in their own homes (who on average consumed about 400g/day) and those living
in institutions (who consumed only about 260g/day).
National survey data also highlight aspects that could improve the nutrient intake of older
people. For example, by changing from ordinary white bread to white bread with added fibre
or wholemeal bread, fibre intake could be increased; using a margarine or other spread instead
of butter would decrease saturates intake, as would substituting semi-skimmed milk for whole
milk. Increasing the types and amounts of fruits and vegetables eaten, particularly among
those older adults living in institutions, may help improve intakes of some micronutrients
such as vitamin C and potassium as well as increasing dietary fibre intakes.
Factors Affecting Dietary Intake And Nutritional Status In Older People
A range of factors may influence the nutritional status of older people including:

Ill health and other medical conditions. Many older people modify their diets to help
control illnesses such as diabetes and heart disease or conditions such as osteoporosis
and rheumatoid arthritis which are more common in old age. There is also interest in
the potential of an increased intake of antioxidants to benefit eye health. There is some
evidence to suggest that oxidative damage may be involved in the formation and
16






2.7
progression of cataracts and age-related macular degeneration, two conditions that can
lead to loss of vision. There appears to be a link between these condition and
antioxidant nutrients (e.g. vitamin C and E links), with the highest risk of cataract
occurring among those with low intakes of antioxidants. As there is yet no consistent
evidence that any particular nutrient makes a special contribution, the most practical
advice is to increase vegetable and fruit consumption and to eat a wide variety of
types.
Poor dentition. National survey data found those older adults with no natural teeth or
few natural teeth ate a more restricted range of foods, influenced by their perceived
inability to chew. For example, they were less likely to choose foods that need
chewing such as apples, raw carrots, toast, nuts and oranges.
Drug-nutrient interactions
Mobility and physical activity (e.g. people with arthritis, for example, have difficulty
shopping, preparing and cooking food). 15% of over-85s are unable to prepare a main
meal for themselves, with 38% of these denied regular help or access to hot food.
Poverty and economic uncertainty. One in five pensioners lives in poverty and many
find it hard to afford basics such as food.
Poor diet means people are more prone to infections and will take longer to recover
from illness.
Hydration. Gradual, steady loss of body water is a factor of ageing and older people do
become dehydrated more easily. Dehydration can then be a major complicating factor
of illness and can have a negative effect upon recovery prospects. Fear of the
likelihood of urinary incontinence and the need for visits to the toilet, will also mean
that many older people will be reluctant to drink as much as they should. This frame
of mind is, of course, made worse when diuretic medications (‘water tablets’) have
been prescribed. Water intake is vital, as dehydration can result in illness, mental
confusion, and can speed the ageing process generally. It is recommended that older
people should drink at least 8 cups of fluids a day. It is worth noting that tea, coffee,
fizzy drinks or worse, alcohol, actually contain dehydrating agents.
The focus of the scrutiny review
As can be seen from the above information there is an enormous body of knowledge and
information covering nutrition and health from cradle to grave, and too much to fully cover in
a scrutiny review. As the body of evidence was considered it became increasingly clear that
the focus needed to be on the eating behaviour of children, and their parents, as that is where
the greatest impact can be had in terms of future health. However this is not undermine the
importance of eating in adulthood and older age and some recommendations will identify
actions in these areas.
17
3.
What is already happening in Halton?
Below are some examples of projects and services already in operation in Halton, that have
begun to address some of our health priorities. (This is not an exhaustive list)
Children and Young People

Healthy Schools Standard – All schools in Halton are now signed up to the standard
and most have chosen to look at healthy eating early on in the accreditation.

Recipe for Schools – promotes physical activity in schools and is helping to develop
sport facilities in Halton.

Extended Schools - As part of the extended schools programme operating in the Park
Primary School in Runcorn, the health of pupils and their families is high on the
agenda. As part of the food and nutrition projects, free fruit and milk is provided to all
3 – 11 year olds every day, together with a free salad bar at lunchtime. In addition a
low fat, sugar and salt lunch menu has been introduced, together with healthy midmorning snacks. A full time home economist has also been employed to work with
children and parents to improve nutrition and food preparation/ cooking skills. This
includes providing taster sessions to introduce new ingredients and recipes and
different ways of preparing food. By involving both parents and children in these
sessions a positive experience of food is encouraged, that can hopefully be used in the
home.
Allotments are also used to promote the “seed to plate” concept. This enables children
to develop an interest in food, where it comes from and the type of food that can be
harvested depending on the season. It is also good physical exercise.
School Meals

The recent media focus (Jamie Oliver’s campaign was during the evidence gathering
of the review) on the nutritional standards of school meals is one that Halton has
already recognised and seeks to address. School meals are being improved
nutritionally by regularly reviewing menus and introducing more freshly prepared
food onto the menu. The frequency of high fat/ high salt foods has also been reduced.
Tasting sessions of the new recipes have been carried out with children and parents to
encourage children to choose the healthier option.

In spite of the constraints placed upon the existing school meals budget in Halton,
funding from other sources has meant that schools have benefited from a range of
healthier eating initiatives. These have included, Free salad bars in all Primary and
Special schools one day per week funded through NRF, “Flying” cooks who work
with the schools to develop healthy eating child friendly recipes, offering tasting
sessions to children and their parents and Fresh broccoli in all schools - At present
the school meals budget can only provide frozen vegetables but research shows that
children prefer fresh vegetables. In Halton, broccoli and sweet corn are the two most
popular. Fresh broccoli was provided to all Primary and special schools from January
to March 2005 using NRF under spend.
18
Halton schools also benefit from a number of national initiatives including:

Fruit in Schools - This means that all children in Key Stage 1 are entitled to one piece
of fruit every day funded by the Department of Health until March 2006. Junior school
pupils are currently not entitled to free fruit, however, there is a mid morning break
service operated by the school meal service in 49 schools in the borough where half a
piece of fruit can be purchased for 10p. 75% of schools who participate in the mid
morning break service have received a gold award for serving milk, toast and fruit.
There are also a handful of junior schools that sell fruit to children in the afternoon in
order
to
boost
concentration
levels.

Free School Milk -Children under the age of five are entitled to free school milk, if
the school chooses to participate in the scheme. At present there are only eleven
schools that participate in Halton. However, schools that have a mid morning break
service sell milk at 10p per glass.

Pilot projects have been introduced in ten Primary schools, where the amount of
freshly prepared food on the menu has increased:
The Park
Weston Primary
Beechwood
Palacefields
Windmill Hill
Brookvale Primary
St Michaels
Our Lady Perpetual Seccour
Farnworth CE
Fairfield Infants
This pilot has now been extended to all schools in the Borough as the Government
provided an additional 5p per meal per child directly to the school meals service. The
school meals menu has significantly improved nutritionally since September
including:
- Purchasing improved quality Roast Beef, Pork, Ham, Welsh Farm Sausage with a
70% pork content, diced chicken breast and fish fingers with a 50% white fish content
plus omega 3.
- Increasing the frequency of salad and fresh fruit.
- Introducing homemade vegetable soup and French bread on to the menu
- Decreasing the amounts of processed food on the menu.
In some schools almost all processed food has been removed from the menu. Changes
to the menu need to be made slowly to introduce healthy options incrementally. A
“whole” school approach is required to encourage children to make healthy choices
and there is an increase in food cost in these schools of about 10p per day. The pilot
schools have demonstrated that if the menus are changed too quickly children will
bring a packed lunch from home that frequently has little nutritional content.
19

Healthier Eating Activities in Schools – During 2003/4 the school meals service
arranged various different activities in schools to try to encourage children to choose a
wider range of healthier options and be more physically active. These activities
included, fruit, vegetable, salad and new recipe tasting sessions, themed meals, health
days, competitions and links with the Vikings RL Team in promoting a good diet and
exercise.

Pricing Policy Structure in Secondary Schools – Halton Borough Council has had a
pricing policy for the past five years of increasing the selling prices of high fat and
high sugar foods e.g. chips, sausage rolls, doughnuts etc and maintaining the price of
healthier options e.g. filled jacket potatoes, pasta dishes, fruit, vegetables, milk,
yoghurt etc, by way of encouraging children and young people to choose healthy
options.

The Five A Day programme encourages local people to increase their consumption
of fruit and vegetables. The programme a number of strands including schools,
workplaces and communities.

Halton is also part of the Heart of Mersey Programme. The programme aims to
reduce the rates of heart disease across Merseyside (almost 2 million people) through
area wide programmes such as Healthy Sports Stadiums and using mass media.

Recipe For health – This is an exercise on prescription scheme, whereby the GP or
practice nurse may prescribe up to 20 free activity sessions for people with certain
health conditions. This scheme is used as both a method of prevention (e.g. helping to
reduce high blood pressure, obesity etc. which can then lead to further more serious
health conditions) and as a method of rehabilitation. The scheme is very popular and
heavily subscribed.

Healthy Living Centre – This project offers a range of activities aimed at improving
physical and mental well- being. For example these include arts and complimentary
therapies,
physical
activity
sessions
and
healthy
eating.

Halton Association of Food Coops – run a mobile shop that sells fresh, affordable
fruit and vegetables to local people, and a door to door delivery service.

Allotments – Halton has 15 allotment sites with 286 plots. The Council’s allotment
officer and the Healthy Living Project has been working with local groups to make
allotments an easier way to get more exercise, get outdoors and grow your own fresh
fruit and vegetables. The role of allotment officer ends March 2006.

Community Food Workers provide community events including Cook and Taste
sessions, fun days and talks on healthy eating. As well as various activities, the
workers are on hand to provide general information on healthy eating.

Cook & Taste activities, parents and children cooking together session, advice on
weaning infants, weight management programmes (including exercise) and cooking
skills sessions for teenage parents.
20

There is a Domiciliary Visiting service for which referrals are received from Sure
Start
Programmes,
Health
Professionals
and
Social
Services.

Connecting for Health scheme providing Fruit & Vegetables on prescription from
Castlefields Health Centre – project undertaken by Dr Matt Kearney.
21
FINDINGS
AND
RECOMMENDATIONS
22
4.
Policy and Co-ordination
4.1 A new strategic food partnership to be developed to improve co-ordination of
thinking and activity in relation to healthy eating.
Strategic Food
Commissioning Group
(Council appointed chair)
Key objectives
Shared Priorities
Needs authorisation from Strategic Health Forum
PCT
HLP
Community
Local
Traders
Sure
Start
Area
Panels
School
Governors
School
Heads
Rep from Health
and Life Chances
PPBs
GP
Community
Development
Health
visitors
Voluntary
sector
School
Nurses
The direction of travel for food policy and the overall vision of what Halton will do over the
next 10 years is unclear. Current co-ordination between services is also not strong, and
appears to be due to an operationally focussed partnership without clear lead from
commissioning agencies, resulting in duplication of some service responses. Terms of
reference are needed for a new strategic food partnership and should include (in line with
Choosing Health and Wanless):
(i)
(ii)
(iii)
(iv)
(v)
to provide effective leadership and coordination of food initiatives/programmes
to performance manage the delivery of healthy eating strategy and policy
to raise the profile of the importance food as a determinant of health, and
to improve diet/eating habits and related health outcomes (e.g. obesity rates)
to receive reports of evidence and make recommendations as to future service changes
It is also clear that the overall determinants of health are many and varied. It would not be
helpful for a food strand to be siloed outside of the overall approach to improving health (as
highlighted in the health baseline report).
The existing Halton Food Partnership has itself identified a need for improved direction and is
looking to re-launch itself into a group that is capable of providing the leadership and
coordination needed to direct healthy eating initiatives/activity in Halton and can command
the resources required.
23
Priorities are not always clear and this can lead to a fragmentation of effort reflecting simply
operational realities rather than strategic overview. The linkage back to wider determinants of
health and the priorities the Health Strategic partnership has established for itself need to be
reflected in the focus of the group. On that basis it is suggested that the focus of the
partnership should prioritise:
 Very young children/toddlers
 Teenagers
 People with mental health needs
 Older People
4.2 The partnership will need to establish a clear set of coherent and mutually
supporting policies in relation to healthy eating that, amongst other things:
 Identify and address any significant gaps in coverage for high need
areas/groups
 Ensures consistency and continuity through various key transitional stages
(e.g. from SureStart to school) so that the benefits of good work on healthy
eating are not lost but are sustained and developed.
 Ensure initiatives are evaluated and that evidence influences policy.
 Value for money
Despite the obvious commitment of the staff involved food activity/initiatives are somewhat
fragmented with no clear view on what is really delivering value for money, what constitutes
best practice and where we as a ‘whole’ system need to focus. At present the Halton Food
Partnership is essentially made up of food initiative ‘deliverers’ and there are questions about
the clout and capacity of HFP members to commit resources on behalf of their respective
organisations.
4.3 A senior lead officer and/or lead member to be identified as a lead for healthy eating
(suggest operational director level) and chairs the strategic healthy eating group.
Given the importance of childhood experiences it is suggested that be within children’s and
education portfolio.
4.4 Officer support to the strategic group should be identified from corporate policy
team to support lead member/officer.
4.5 The strategic food group needs to operate within a clear governance framework so
that it is able to influence and advise partner agencies.
Members of the commissioning body should be empowered to make decisions on behalf of
their organisations. They therefore need to be senior enough and have routes through to senior
management teams to inform decision-making.
4.6 The operational implementation of strategy should be separated out from the
strategic role. A separate operational group should be formed and report to the
strategic group to agreed standards.
24
5 Performance Standards
Standards are agreed upon values used to measure quality, to evaluate products and services
and identify non-conformance. Standards are yardsticks for measuring quality, performance,
duration, and so forth.
5.1 A clear performance framework is needed for the new groups, based on agreeing
measurable outcomes and clear, SMART targets so the current position and changes
in it can be monitored.
Differences between secondary and primary school settings are of concern. Primary schools
are generally more compliant with SMS menus. Without clear measures judgements on
effectiveness and progress can become arbitrary and based on opinion.
Sure Start Food and Dietetic Service has done some work in this area. Appendix one is an
extract from the joint Service Level Agreement (SLA) that is in place for the Food and
Dietetic work. This work is commissioned from Halton and Chester Hospitals Trust, by all of
the Sure Start programmes in Halton. The outputs and outcomes identify exactly what areas of
work are required. These should then be measured annually, against the outcomes.
5.2 The Halton Health Schools Standard – Healthy Eating theme should be updated
(and reviewed annually) to include current evidence and good practice.
The Halton Healthy Schools Standard (HSS) put Halton ahead of many areas on encouraging
healthy eating within schools and set a standard higher than previous national guidance e.g.
use of processed foods. As national guidance moves so to does Halton’s approach need too.
This standard needs wide ownership of parents, schools and pupils. This standard should be
used in commissioning the school meals service.
5.3 Within the new HSS clear definitions of the exact meaning of terms is needed.
In the evidence provided to the Topic Team some of the terms such as ‘freshly made’,
‘processed’, ‘home made’, ‘balanced diet’, ‘low fat’, ‘low sugar’ etc were used to mean
different things. This made a full understanding of the actual quality of food provided
difficult. The committee expects this reflects a wider issue for parents and teachers as to what
healthy eating really means.
Interestingly the effect of processing food on its nutritional value is not always obvious. For
example, because of the very short time from field to freezer with most frozen food, it is
likely to better nutritionally than its ‘fresh’ equivalent unless very freshly picked. The journey
from farm to market/ wholesaler or supermarket depot and thence to the shops is likely to take
at least several days, during which the nutritional value of fresh food is gradually
deteriorating.
5.4 A consistent approach to changing eating behaviour is needed and should form part
of the work programme of the strategic group.
At present schools and the meals service are concerned about the impact of losing customers
if menus made ‘too healthy’ as children will not purchase them, this applies to both cooked
and packed lunches. Competition from ‘chippies’ needs to be considered but there was some
25
view that a policy decision should be considered of restricting children to school premises at
lunch time. Again this points to the need for ownership of and engagement with parents.
Home/parental eating habits are very influential on the development of children’s diet etc. and
this persists into adulthood.
The extended school experience of Park School has trialled a number of initiatives. These
need to be considered further and evaluated for extension to all schools.
Tasting sessions were referred to by a couple of witnesses as encouraging behaviour change
in children and parents. Funding was obtained from NRF temporarily. Without an evaluation
and evidence on their impact it is impossible to weigh such initiatives against each other or
overall outcomes sought. A number of other initiatives including food co-operative, 5-a-day,
free milk for under 5’s , free fruit for under 7’s, community cafes, Sure Start food strand,
HLC, SMS were also described and views offered about their effectiveness to the Topic
Team. Without comparative information on what outcomes they produce within an overall
understanding of the range of service needed to achieve improve health, definitive
recommendations as to what should continue and what should not were not felt to be helpful.
However there is clearly some duplication in the roles these groups and services fulfil, and
some schemes that need to be given thought as to whether they continue. There is also uneven
coverage across the borough, which partly reflects existing infrastructure such as location of
community facilities. The service a population receives should not depend on existing
facilities, as that will perpetuate existing inequalities.
5.5 The need for and role of the food co-operative needs to be evaluated
In relation to the food co-operative, the service effectively offers subsidised fresh fruit and
vegetables to some 300 Halton residents and organisations, and there was clearly some
support for the role it fulfils. The Topic Team however did question why such a service has
not become self-sustaining after 6 years. It was also questioned whether it was still needed, as
since its inception the availability of fresh fruit and vegetables has increased markedly, as
have home delivery options. Again there has been no evaluation of the service and whether
the investment is value for money compared to alternatives.
Many 5-a-day strands nationally indicate the value of food co-operatives, the role of the
Halton scheme therefore also needs to be considered against national good practice.
5.6 Standards for food need to refer not only to quality of ingredients but also the eating
environment and the presentation of food. Minimum standards in terms of proper
meal times (to support proper digestion), ‘sit down’ meals with laid tables are also
required. Teachers should also be encouraged to eat with the children.
Although ‘domestic science’ has fallen out of favour in many schools amidst all the other
pressures on the curriculum, schools provide the obvious environment in which to teach
young people about healthy eating, cooking knowledge and skills, domestic budgeting and
generally how to maintain good health. Consideration should be given as to how these
subjects can be adequately covered at school. This links to need to develop a ‘whole school’
approach (the evidence suggests that in schools where there was a comprehensive and welldeveloped health education programme, backed up by effective cross-curricular links, pupils
26
were knowledgeable about nutrition and could discuss basic principles of healthy eating). The
role of head teachers in developing such an approach cannot be understated.
Recent publicity, such as the Jamie Oliver school meals TV series, has highlighted the
importance not only of providing healthy food, but how vital other aspects such as the way
food is presented and how the children are involved can be in successfully promoting healthy
eating.
Erosion of school mealtimes is also a concern and there is some indication that mealtimes are
getting squeezed by pressures on time to deliver the curriculum, meaning there is little time to
eat properly and that meals tend to be hurried leading to indigestion etc.
Teachers are also less likely to eat with pupils (Only 6 - 12 staff / head teachers eat school
meals in Primary school dining rooms), which is leading to ill-developed eating habits. Only 7
out of 262 households at one Halton school sit down at a table to eat together.
Queuing for meals is a factor in take up (according to survey of customers) and card payment
(rather than cash) system have been introduced elsewhere with some success. That idea
should be explored further.
This may also support take up of free milk in under fives (which is low) and fruit for under
sevens. Free fruit & milk will change to free fruit or milk under Healthy Start for under fives.
Therefore free milk could be obtained from Health Start and fruit from fruit in schools
campaign. Healthy Start is not likely to happen in Halton until autumn / winter 2006.
5.7 Leadership and policy setting need to develop ways of more closely involving
parents, schools, councillors and governors to achieve an overall agreed approach
that best serves future interests of children.
Training for governors needs to include healthy eating. Many councillors are also school
governors and may be in a position to raise the profile of healthy eating within schools.
There is scope for further improvement in food presentation. This would support improved
take up.
5.8 Schools need to evaluate the dining space available and consider within school
priorities capital bid submissions / development bids to improve the facilities.
Space/physical environment for dining can be a barrier to providing variety/healthy meals.
Wade Deacon system works very well where they have two kitchens and have hot and cold
food bars offering different food and settings/atmosphere for eating.
This would not only improve the dining experience, but allow greater choice and an
environment conducive to improving eating choice.
5.9 Greater evaluation and evidence of impact is needed for food initiatives. This
evidence needs to be considered by the strategic body leading food policy.
27
There have been and continue to be creative approaches to improving healthy eating within
the borough. The evidence of the efficacy of some of the food initiatives and activities
currently in place was neither convincing nor robust. There was some evidence of use of
benchmarking and best practice however this was not consistent. Effective commissioning
requires an understanding of what works, linked to an investment and disinvestment strategy.
Otherwise all initiatives carry on in perpetuity regardless of whether they are the best use of
available (and limited) resources.
5.10 A healthy aging strategy should be developed for Halton Borough that
incorporates food and nutrition as a key dimension.
The needs of older people are less well served than those of children, with most initiatives
focussing on children. Rightly emphasis has to be on the future because early and family
dietary habits have a life shaping influence on children and tend to be sustained into
adulthood. However healthy eating in older age does have measurable health benefits and
reduces the likelihood of needing more specialist or intensive services.
28
6 Finance and resources
There was a range of information about resources provided to the Topic Team, and some of
that was contradictory. However what was clear, was that there are a range of activities from a
range of organisations, and that those activities are not always well co-ordinated.
It was also clear that there are not many dedicated resources working on food policy and
practice within Halton.
Dedicated food workers within Halton include:
 Community Food and Health Team, managed by 5 A DAY Co-ordinator which
comprises
1 x full time, 2 x part time Community Food Workers funded by Healthy Living
Programme
1 x full time staff member for the shopping service, funded by Vulnerable Adults Task
Force
 Four Sure Start food workers overseen by the Paediatric Dietician, who work in the
Sure Start areas.
There are also those with some wider roles such as Community Development workers who
don't focus on food although they support food projects and within the public health team one
officer supporting the Halton Healthy Schools Standard focusing on physical activity and
healthy eating.
Much of the resourcing appears to be worryingly short term. Base budget commitment to food
and healthy eating policy and practice is very limited across all organisations and is a matter
of concern. However without clear strategic direction we are not convinced that the resources
currently being deployed within schools and the system more generally are being used to best
effect.
6.1 A system wide financial strategy should be developed.
Challenging current investment emerged as an issue in the baseline report of 2001 and still
remains an issue in 2005. Unfortunately many of the initiatives referred to earlier rely upon
short term funding and in many cases there is little or no possibility of them being integrated
into mainstream services.
Since the baseline report of 2001 we have moved on significantly in understanding “what
works”. Preventive interventions affect mortality and morbidity rates and the demand for
NHS and other services. There is a large body of evidence to support preventive measures,
which proves them to be as sound, or better than many treatment interventions.
At a national level better treatments for heart disease have made a big impact (for example,
using aspirin to prevent a second heart attack, treating blood pressure and making heart
surgery more widely available). But the biggest impact has been from how much we smoke
and how much fat and salt we eat: these account for 71% of the decline in heart disease. This
reemphasises of not seeing food health policy in isolation from overall health improvement.
29
6.2 Additional funds that are passported through to SMS must go to improving the food
‘on the plate’.
Additional government funding for school meals is welcome but unless that money is spent to
have best impact on the plate, Halton will not make the qualitative leap in improving the diets
of our young people.
There are financial disincentives to SMS to only include healthy options, as the service may
then move into a deficit position.
Such factors can be reflected in an SMS business plan.
6.3 Future investment of NRF should be based on some match from funding
organisations.
In the case of the health strategy and action plan many projects receive little and in some
cases no match funding. The concept behind NRF was to encourage innovation, to pump
prime initiatives and to allow partnerships to test initiatives before investing large sums of
mainstream funding into projects. In terms of this health action plan, there are a number of
initiatives that continue to rely on NRF for their survival.
The Halton Strategic Partnership Board (HSPB) is encouraging partnerships to taper the
investment of NRF and to increase the mainstream contribution where projects are proving to
be effective. This goes back to the earlier point made about investment in preventive
interventions. Many of the projects we refer to are based around prevention.
6.4 The strategic group are to undertake that mapping to feed back to the healthy eating
Topic Team in 6/9 months.
The strategic food group need to identify an overall approach so that resources are allocated
based on evidence. Usually commissioning activity is built on an understanding of the ideal
situation in comparison to the current position i.e. what is working and what is not, and
where resources are allocated. It in then possible to commit (wherever possible permanent)
appropriate levels of funding to sustain cost-effective measures to promote healthy eating.
 The strengthening of evaluation of food initiatives will help to ensure good
decisions/allocation of resources, support for effective practice and achievement of
value for money.
 Explore relative merits and scope for employing fewer food workers permanently
rather than a larger number on temporary contracts with all the turnover /
discontinuities / demands on management time etc. that that implies.
The direct costs of meals do not account for the indirect benefits in terms of the health gain,
behaviour, academic achievement of children, for evidence has been provided.
6.5 In order for mapping to make changes the Partnership should also establish the
current funding and resource baseline for Halton.
Resources need to targeted where they will have an impact. The view of this topic team is that
this has not been linked clearly to levels of deprivation. It is children for example in the most
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deprived wards who life chances are most negatively impacted by the opportunities they have
in terms of food early on in life.
One approach that can help with focus is use of targeted voucher schemes for local residents.
7 Communication and participation
7.1 A marketing and information strategy should to be developed identifying the groups
who need to be reached, the information they need to have and effective ways of
disseminating that information.
Key within the evidence is that home/parental eating habits are very influential on the
development of children’s diet etc. and this persists into adulthood. Local people are often
confused by contradictory messages about food (e.g. are eggs healthy or not healthy to eat)
and from commercial marketing versus public health promotion. Access to information on
food is inadequate. Therefore tackling eating within the school environment, while necessary
is not sufficient to achieve lasting change and therefore health impact.
Access to information about where to obtain good food/products at reasonable cost can also
be difficult.
In assessing the ‘reach’ of healthy eating initiatives, the extent to which key messages (and
recipes) are passed from hand to mouth (e.g. amongst friends and neighbours) by individuals
who have had direct contact with ‘food workers’, should be neither exaggerated nor ignored.
A coherent ‘system’ is needed that identifies clear and consistent healthy eating messages,
promotes and establishes healthy eating habits throughout childhood and ‘embeds’ where
there is contact with young people (schools etc.). For example the evidence on Cancers and
Circulatory Disease identifies the importance of:


Promoting a healthy diet that is rich in cereals and fruit and vegetables, low in salt and
fat and by increasing access, availability and affordability of these foods.
Promoting a healthy start in life to parents, children and young people to maximize the
take up of healthy options.
An agreed message owned by all stakeholders is therefore key to reducing confusion and
proving a single source of information. The topic team were also concerned to reinforce the
importance of not patronizing people. People are experts in their own lives(which is the
emphasis of Choosing Health). Schemes have to meet people, listen to their experiences and
be sensitive as to how they can appropriately influence and support them in making decisions
on eating behaviour.
7.2 The marketing and information strategy needs to be owned by stakeholders and the
strategic body that leads food strategy.
In order to make a real difference to Halton’s poor health record, (attaining what Derek
Wanless referred to as “The maximum attainable shift in behaviour and attitude”) effective
community participation in health improvement issues will need to be achieved. As we have
already pointed out a lot of work is already being carried out to engage local people in healthy
lifestyle opportunities. However, if we are to make a real difference a community engagement
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strategy for health will need to be developed. This will need to look at a range of issues
including the role of social marketing, individual choice, barriers to healthy lifestyles, joint
working across all sectors and community champions for health.
Effective marketing of food/healthy eating is critical for changing eating habits. There are
opportunities to look at links to other types of venue outside of schools, such Halton Stadium
and look at unused advertising space etc for promotional purpsoes.
Involving parents/adults, especially with the development of extended schools, school-based
initiatives provide a good opportunity to engage and involve parents in healthy eating. (The
Park School in Runcorn has a number of good examples of what can be achieved in this area.
It has also achieved significant improvements in pupils’ behaviour following changes in
eating arrangements within school e.g. after introducing a mid-morning snack.)
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8 School Meals Service
The role of the School Meals Service in influencing the health of children cannot be
overstated. It is therefore considered in its own right as well as within other sections.
8.1 The SMS should continue to provide meals for schools. However it should be
properly commissioned and accountable to strategic food partnership and schools
for delivering an agreed menu. An annual business case should be presented to the
strategic group.
8.2 The mission of the SMS should be ‘to promote the health of children’.
The service has modernised and applied the HSS, improving fresh ingredients and decreasing
processed. However SMS operates in a complex environment and it needs to model changes
in demand and what is being commissioned so that its costs are transparent and can be
understood at the beginning of each year linked to strategic priorities. A business plan would
aid consensus and agreed targets linked to agreed resources for the year.
It is acknowledged that only a proportion of meals consumed by school age children are eaten
at school. However, with the move towards a longer school day including breakfast clubs,
after school clubs and all-day provision to fit in with the lives of working parents, it is likely
that the amount of food consumed at school will loom larger in the children’s overall diets.
There are few, if any, things that contribute more directly to good health than a healthy diet,
and schools have a significant and probably increasingly important role in ensuring that the
Borough’s children eat well, develop good eating habits, have essential knowledge/skills
about healthy food and enjoy the related health benefits.
Starting from an assumption that the food provided by schools (both at lunchtime and other
points in the day – breakfast, mid-morning, after school…) is good quality and nutritious,
schools may need to be more robust in managing what it eaten during the school day. The
idea is to provide a choice between a number of healthy options and to reduce or eliminate the
opportunities to eat less healthy foods:
 Ensure school meals menus are healthy
 Discourage or bar unhealthy foods from home-packed lunches and snacks
 Ensure any food/drink vending machines only offer healthy choices.
Schools need to create an environment that is conducive to healthy eating e.g. where there’s a
pleasant environment in which to eat and adequate time to do so. (Queuing time was also an
issue highlighted by SMS staff, from pupil feedback)
Where practicable, the eating environment should also promote ‘sociable’ eating, where
people sit down together (e.g. with staff or older children), are encouraged and have a good
example of how to eat properly, and have opportunities to ask questions and learn about food
and healthy eating.
Schools with SMS need to exploit and develop techniques for making healthy food more
acceptable/attractive to pupils e.g. ‘hidden’ in soups and sauces, integrated into child-friendly
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dishes such as pizza…, and by improving presentation e.g. fruit in fruit salads or serving
packs rather than simply presented as whole fruit, where such tactics have been shown to
improve uptake.
Reference is made above to the benefits to children of a healthy mid morning/break time
snack. Consideration should be given to boosting the proposed provision of free milk or a
free piece of fruit to children up to the age of 7 to providing both plus the option of, say a
piece of wholegrain bread/toast mid-morning, and making it available to all primary school
children in the Borough and where practicable to pre-school children. Free fruit and milk is
already provided for all children under seven years of age in Wales.
As indicated above, simply providing good food is not enough. Consideration also needs to
be given to the environment and the way in which the food is provided to ensure take
up/consumption of the healthy options on offer.
Several of the healthy eating initiatives offered through schools (e.g. free salad bar),
depend(ed) on special, short term funding. Given that health is one of the Council’s strategic
priorities and that a good diet is a central plank in efforts to improve health in Halton, it seems
unsatisfactory that funding of such an important aspect of provision should remain so
insecure.
The price charged by SMS is relatively high in comparison to other local authorities. The
picture has been a complex one with reduction in free school meals revenue. The service is
expected to break even in 2005/06 and future ‘profit’ will be ploughed back into the service.
However if numbers fall the service revenue falls, the service needs the active support and
engagement of head teachers within a co-ordinated approach to healthy eating.
School meals are funded through Central Government with many LAs choosing to contribute
some element of subsidy. In Halton SMS ingredients cost:
Primary
- 48p av. spent per meal on ingredients
Secondary
- 67p av. spent per meal on ingredients
£1.60 a day is charged to parents for a SM or packed lunch
Evidence suggested investment on the plate would have significant gain in terms of healthy
options available.
There is a clear commitment to training within the SMS.
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9.
Nutrition and its effects on learning
Evidence was presented of 4 main things that need to be right nutritionally for effective
learning and which all affect the ability to concentrate:
 the importance of breakfast
 availability and consumption of water throughout the day
 Omega 3 fatty acids in the diet (or supplements)
 Iron in the diet
9.1 A number of primary schools should be invited to volunteer to pilot the nutritional
recommendations which are designed to improve concentration and behaviour, and
the impact of these measures on behaviour, health, pupil achievement etc. should be
properly evaluated.
9.2 Subject to the outcome and learning from the pilots, the recommended practice
should be shared/rolled out across primary schools in the Borough where they are
not already in place.
9.3 So far as is practicable and with the support of parents and governors, schools
should adopt a robust approach to eliminating ‘junk’ and highly processed
ingredients/products from food and drink consumed at school (e.g. items from
vending machines, tuck shops and from packed lunches such as sugary drinks,
biscuits/cake, crisps, reconstituted protein and other products high in preservatives
and additives).
9.4 Schools should support and implement emerging Government proposals for pupils to
be weighed and measured annually, and advice on diet, exercise etc. should be
offered where appropriate and shared with parents.
9.5 A nutritious breakfast should be made available for children where this is not
provided at home (i.e. breakfast clubs).
After a night without food, if a child has no proper breakfast, the body starts to react with a
‘starvation’ response. Metabolism slows down and this impairs a person’s powers of
concentration. (It may seem counter-intuitive, but evidence also indicates that this
‘starvation’ eating pattern also tends individuals to greater obesity in later life.)
Modern diets tend to include too much protein, so a good, nourishing breakfast doesn’t
necessarily need to include it. Breakfast should:
 be a regular part of the daily routine and ideally take place at home with a family sitting
down to eat together
 include complex carbohydrates e.g. some form of unrefined or wholegrain carbohydrate(s)
 include calcium and vitamin D in combination. [Milk products are good sources of
calcium, but non-dairy sources include almonds, broccoli, canned salmon or sardines (with bones), collard
greens, kale, navy beans, spinach and turnips. Calcium needs vitamin D and other trace elements, including magnesium
and zinc, for proper absorption. Many foods are fortified with vitamin D. Other sources are egg yolks, liver, saltwater
fish and sunshine.]
A cola and a sausage roll is NOT a suitably nourishing breakfast!
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Where the home environment is unable or unwilling to provide a nourishing breakfast, a
nursery, school or other breakfast club may offer an opportunity to give a child a good
nutritional start to the day.
The role of school breakfast clubs in so far as some were being attended by adults receiving
subsidised toast/tea needs further discussion within a strategic framework of how we achieve
the overall objectives of the partnership. Where a parent comes to a breakfast club
themselves, possibly accompanied by other children, this may provide an opportunity either to
involve the parent in helping with preparing the food for others and/or to share key healthy
eating messages and develop the parent’s skills around healthy eating – possibly as a
condition for attendance.
Similarly after school clubs are set to become more widespread in the future. Given the
concerns about the loss of cooking skills amongst young (and not so young) people, there may
be a role for these in helping re-establish these skills amongst a new generation (subject to
essential facilities being available).
9.6 Water should be readily available for children at school and they should be
encouraged to drink enough to remain properly hydrated throughout the day.
People cannot concentrate so well if they are not adequately hydrated (have drunk enough
fluids). There are various good practice initiatives in place around the country that could
inform any approach taken by Halton to promote this. The school meals service offers free
water coolers to schools. Other measures could also be considered to encourage water
consumption during the nursery/school day and generally in Council-run or influenced
establishments.
One other important aspect of adequate water consumption is its effect in reducing
constipation, which can be a significant problem for some children.
9.7 Pupils’ intake of Omega 3 fatty acids should be enhanced to recommended levels
either through approved supplements or otherwise through changes to the diet.
There is growing evidence of the importance of omega 3 fatty acids in brain functioning.
Modern diets are often deficient in omega 3 and a number of research studies have shown
remarkable improvements - e.g. in concentration and behaviour - can be achieved by suitable
supplementation or otherwise enriching the diet in this regard.
Most studies have been on adults or school age children, but very recently, a study on children
between 20 months and 3 years old has been started in Durham (copy of article attached).
Early indications are that the impact amongst this age group is also marked and could play an
important part in ensuring that more children are equipped to take full advantage of early
learning opportunities and to fulfil their potential.
9.8 Pupils’ intake of iron (in combination with vitamin C to enable effective absorption)
should be enhanced to recommended levels either through approved supplements or
otherwise via an iron-fortified diet.
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Iron also plays an important part in enabling people to concentrate properly, however, it is not
easily absorbed in some forms. Generally speaking, except in the case of iron in red meat, it
needs to be consumed in conjunction with vitamin C e.g. fruit or fruit juice. Many cereals and
a variety of other foods are fortified with iron, but this linkage with vitamin C is needed if
consumption is to make a difference.
Iron and calcium are key nutrients particularly for those of secondary school age. (High
intake of vitamin C is needed to enable absorption of iron)
9.9 A healthy mid-morning/break time snack should be made available for primary
school children (typically wholemeal bread/toast, milk and fruit).
To sustain concentration it is a good idea to a top up the intake of complex carbohydrates at
intervals during the day. A good case can be made for offering children bread/toast midmorning. This could be combined with the milk and fruit that will becoming available for
some with the roll-out of the Healthy Start scheme due to reach Halton in late 2005/early
2006.
9.10
Plan to promote take up of the Healthy Start initiative when it reaches Halton.
‘Healthy Start’ scheme provides £2.60 voucher that can be exchanged for milk or fruit and
vegetables. Initiative started in SW England and expected to be available in Halton late 2005.
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Glossary
Abbreviation Meaning
HSS
Healthy School Standard
HFP
Halton Food Partnership
HLC
Healthy Living Centre
PCT
Primary Care Trust
SMR
Standardised Mortality Ratio
SMS
School Meals Service
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Appendix 1
Sure Start Food and Dietetic Service joint Service Level Agreement for the Food and
Dietetic work.
OUTPUTS:











To run a minimum of 2 Cook and Taste sessions (2x6 week courses) promoting
healthy eating, low cost but healthy food and cooking skills.
To run a minimum of one Feel Good Type Group per week. (This would incorporate
healthy walks and exercise and would be doubled where there is a fulltime food coordinator in a programme).
To co - organise one Fun day per year (Where there is a full time food co-ordinator in
post they will be responsible for organizing one event each year).
To develop links with Sports Development and promote physical activity
programmes.
To Promote Sure Start to Families
To complete Sure Start registration form with new families
To provide contact statistics on a monthly basis to Sure Start programmes
To carry out an evaluation of all elements of the service provided
To provide an annual report based on evaluation.
To undertake a minimum of 5 home visits each week to offer individual support to
families with nutrition difficulties
To offer up to 4 training courses (related to nutrition) per year for Sure Start and other
agency staff and Sure Start parents
OUTCOMES:







Parents and children will report an increased understanding of the improvement of
healthy eating/exercise
Parents and children will report an increase in the use of healthy foods
There will be an increase number of parents using the food co-op
There will be an increase in the number of parents participating in physical activity
groups
There will be a reduction in the reported number of children under 4 who have: Dental caries
Teeth extracted
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