Reducing childhood obesity: evaluation of an Early Years

Population, Policy Practice Department, UCL Great Ormond Street Institute of Child Health, University College London, London, WC1N 1EH, UK GKT School of Medical Education, King's College London, London, SE1 1UL, UK Whittington NHS Trust, London, N19 5NF, UK Director of Public Health (2015-2018), Newham Council, London, UK Department of Epidemiology and Public Health, University College London, London, WC1N 1EH, UK Aceso Global Health Consultants Limited, London, UK

This article is included in the UCL Child Health gateway.

Introduction
Obesity in childhood has a significant impact on an individual's lifelong health and well-being. The associated risks of excess weight in childhood include an increased risk of becoming overweight as an adult, and of developing serious health conditions 1 . Although childhood obesity is considered as one of the most serious challenges of the 21st century, policy and research efforts have not been successful in halting the rise of overweight and obesity, resulting in almost a 20% rise in obese and overweight children in the UK over the past two decades 2 .
The UK government introduced its childhood obesity strategy 'A Plan for Action', in 2016 3 . This plan acknowledged that 'Long-term, sustainable change will only be achieved through early intervention and active engagement of communities, families, schools and individuals.' One such effort is the Early Years Nutrition programme, a local strategy in a London borough (Newham). Newham has an ethnically diverse population and the third highest rate of childhood obesity amongst all London boroughs, which is increasing steadily 4 . In light of this, Newham's Childhood Obesity Action Plan was introduced in 2017 to define the borough's vision for addressing childhood obesity 5 . The current study aimed to assess the implementation of this programme through an evaluation of services offered in Newham's children's centres and provide recommendations for wider implementation of similar programmes.

Methods
All Newham's children's centres were invited to participate in this study (n=11). Our objectives were to conduct a service evaluation of what information about healthy eating (topics) is provided on display boards in early years settings against set standards by National Institute for Health and Care Excellence (NICE) guidelines. In addition, we aimed to determine what sessions the centres offer in their timetable for parents and whether centres are displaying the UNICEF's 'you are welcome to breastfeed here' logo to promote breastfeeding 6 .
Data collection occurred from January 1, to March 31, 2018. Information about healthy eating topics was collected through photographs and field notes of the display boards of each of the centres, while information about parent sessions was collected from the centre staff and available information pamphlets at the centres.
Additionally, we assessed whether nutrition activities (both parent sessions and nutritional topics) of each centre complied with the maternal and child nutrition guidelines (PH11) from the NICE 7 . These guidelines set out the key recommendations for proper nutrition during pregnancy and for children under five years of age and highlight interventions aimed at optimising nutrition for children. The initiatives within Newham's early years nutrition programme were identified by the research team and mapped/ classified against the 22 NICE recommendations for maternal and child nutrition to determine where Newham's offerings were compliant and to identify areas for improvement.
Since this study was a routine service evaluation, we used the Health Research Authority decision tool to confirm that Research Ethical Committee approval was not required 8 .

Results
Out of the eleven centres in Newham, eight (72.7%) centres participated ( Table 1). The three remaining centres failed to respond when approached to participate. Of the remainder, one was newly opened and therefore did not have display boards. Findings from assessing the display boards revealed that the most frequently displayed topics were related to generic health and wellbeing (4 centres, 50.0%), and breastfeeding (3, 37.5%) ( Table 1).
On assessing the parent sessions offered, we observed that they were varied, with no single session topic widely offered across centres ( Table 1). The most frequent sessions offered were oral health (4, 50.0%) and nutrition (3, 37.5%) workshops. Three centres (37.5%) did not offer any relevant sessions during this period.
All centres displayed the UNICEF breastfeeding logo.
Assessment of the centres' display information revealed that the Early Year Nutrition programme is meeting the NICE recommendations for child nutrition, achieving all recommendations within the scope of this study (Table 2).

Discussion
The display boards were designed to encourage parents to visit the centre and join discussions about health topics displayed. Existing research has demonstrated that training staff from children's centre in delivering key evidence-based healthy eating and physical activity messages results in an increase in adoption of formal nutrition and physical activity policies within the early years setting 9 . It is also evident that, in addition to the adoption of such policies, staff training has resulted in key benefits for children, such as improved nutrition and increased energy levels 10 .
In general, we recommend that the children's centres should aim to offer more workshops, ideally a schedule with topics standardised across all boroughs to ensure consistency in the information delivered to parents. These sessions should also cater to specific age groups in children. Programmes targeted at families with children under age five that aim to promote healthy choices, have demonstrated positive outcomes in terms of improved health behaviours 11 . Furthermore, a previous study suggests that home-based interventions delivered to target families can reduce the Body Mass Index (BMI) status for children under the age of two 12 . Therefore, programmes aimed at increasing health visitor capacity to intervene around nutrition and obesity issues through increased parental engagement may be a potential method of reducing later childhood obesity in the UK. However, there is little longitudinal evidence about the role of the UK's health visitors in reducing childhood obesity at older ages, and thus further research into their significance in preventing and reversing childhood obesity is required.
Although conducting parental interviews was not within the scope of our study, we recommend developing nutritional programmes that focus on building a bridge between community centres or service providers and parents, with a goal of improving communication about child nutrition and promotion of child health. This should include regular engagements with parents and young individuals in the community to educate them and gather essential feedback regarding the services and knowledge offered. Previous studies have proved the importance of service user feedbacks as these are pivotal in enforcing changes and improving the delivery of programmes 13,14 . A 2010 systematic review also concluded that parental engagement resulted in increased health-related behavioural change, with better outcomes associated with increased parental engagement compared to controls 15 . Furthermore, we recommend programme planners take a 'participatory learning approach' to intervention design, as there is evidence suggesting its benefits in communities for the success of such interventions 16 . This approach involves members from the community and increases the chances of adherence to promoted advice, as they are specifically developed with the community in question, thus making them socially and culturally acceptable 16 .
Displaying the UNICEF breastfeeding logo is a simple intervention to support UNICEF's Baby Friendly Initiative and promote breastfeeding both in the children's centre and in general by encouraging mothers and families to pursue this as a feeding choice. Since the Initiative was established, breastfeeding initiation rates have increased by 20% 17 and there is evidence suggesting a correlation between breastfeeding and decreased risk of childhood obesity 18 . This is especially important as the UK has a relatively low breastfeeding rate, which is amongst the worst in Europe 19 . Currently there aren't any studies exploring the strength of displaying breastfeeding logos, but given the benefits of breastfeeding, further research is warranted that looks at the impact of local supportive initiatives, and particularly if displaying such logos in public places can actually influence breastfeeding behaviour on a local level.
Overall, the Early Years Nutrition programme is meeting the NICE recommendations for child nutrition, with efforts to address all recommendations within the scope of this study (Table 2). These evidence-based guidelines highlight the key recommendations for optimal nutrition for children 7 and should form the basis for the benchmarking of activities to monitor what services are available within the boroughs and assess if they meet NICE guidance.

Limitations
Due to no response, some children's centres were excluded from the study. It is possible that non-responders may have had poor adherence to guidelines and hence did not reply to our request. Private and voluntary settings providing similar services were not included. In addition, it was not possible to assess the nutritional quality of the food provided in the children's centres. Furthermore, parental feedback on the Early Years Nutrition programme was not collected.

Conclusion
This evaluation indicates that the Early Years Nutrition programme is consistent with NICE guidelines, addressing all 18 relevant recommendations. However, there are several important key areas for development for programme planners delivering such services. These include improved staff training to ensure accuracy and standardisation of promoted information, consistency in sessions delivered to parents, not just within the borough, but within all similar services across the country and further exploring the role of health visitors in promoting nutritional and lifestyle changes to reduce childhood obesity. In addition, we suggest further engagement with parents and young people regarding the services offered, and the potential for applying the participatory approach to intervention design for the success of such programmes in communities. This may further strengthen delivery of the programmes, and contribute to their efficacy and further implementation of similar childhood obesity programmes in other settings.

Key messages and recommendations
1. Childhood obesity is rising; 2. Effective early interventions are key to prevent the rise of childhood obesity; 3. Targeting parental perceptions with appropriate knowledge around early nutrition acknowledging their cultural beliefs and practices is required; 4. Routine service evaluations of community health programmes are essential to improve programme delivery; 5. Improved staff training and increased community engagement is key for a successful programme

Data availability
All data underlying the results are available as part of the article and no additional source data are required.