Childhood Obesity Prevention

Programmes in Auckland

“It is not adequate to focus on the individual, especially the child, and expect them to

exercise self-control against a stream of socially endorsed stimuli designed to encourage

the consumption of excess calories” (1)

“We don’t need another diet. We need a way to make healthy eating (and exercise)

unavoidable” (2)

Dr Denise Barnfather

A study completed for the Auckland Regional Public Health Service

July 2004

ii

Executive SummaryThis report was undertaken for Auckland Regional Public Health’s Nutrition Service. Its objectives

were as follows:

� Present an overall picture of overweight and obesity in New Zealand children.

� Provide a summary of the proven causes for childhood overweight and obesity.

� Review the literature on the effectiveness of interventions to prevent childhood overweight

and obesity.

� Review Auckland programmes that may help prevent childhood obesity, including identifying

any gaps in, or barriers to, service.

� Based on the above review, recommend national and local actions that may help prevent

childhood obesity.

The Burden of Overweight and Obesity in New Zealand Children

Results from the National Children’s Nutrition Survey showed that 21.3% of NZ school children aged

between 5 and <15 years of age were overweight and 9.8% were obese. Overweight and obesity levels

were highest for Pacific males (33.9%; 26.1%) and females (32.9%; 31%), followed by Maori males

(19.6%; 15.7%) and females (30.6%; 16.7%), with the lowest levels in NZ European males (18.4%;

4.7%) and females (18.8%; 6%). Results were based on the International Obesity Task Force reference

and may have limited suitability for the NZ population given that NZ Maori and Pacific children have a

lower percentage of body fat than Europeans for any given BMI.

Few other NZ studies of childhood BMI have been done, with only one study examining longitudinal

trends in BMI. This study of Hawkes Bay children aged 11-12 years showed a doubling in percentage

of overweight children and a quadrupling of obese children between 1989 and 2000. International

statistics also show trends of rapid increases in prevalence of overweight and obesity with time, with

the prevalence of obesity increasing more quickly than the prevalence of overweight.

Obesity carries a significant associated burden of morbidity, mortality, and financial cost. It is the

main modifiable driver of the Type 2 diabetes epidemic which is predicted to increase 2.3-fold between

1996 and 2011. Paediatric obesity is also associated with an increased risk of cardiovascular risk

iii

factors, psychological morbidity, asthma, Type 1 diabetes, and early mortality. The direct cost alone of

obesity was calculated at $247.1 million in 200/01. This equated to 2.5% of total health expenditure, in

line with the global WHO estimate that obesity consumes 2-7% of developed countries’ annual health

budgets.

Causes of Overweight and Obesity

A persistent imbalance between the amount of energy consumed and the amount expended, in favour

of consumption, causes weight gain. However the causes of energy imbalance are more complex and

are due to a combination of biological, behavioural, and environmental factors, with environmental

factors being responsible for the rapidly evolving obesity epidemic. Environmental factors

significantly associated with the obesity epidemic include: inactivity and sedentary lifestyles, high

intakes of energy-dense food and drinks (especially non-diet soft drinks), marketing of energy-dense

food and drink to children (especially via TV advertising), and low socioeconomic status.

Effectiveness of Interventions to Prevent Childhood Overweight and Obesity

Current research lacks the power to set clear directions for obesity prevention activity at a time when

obesity prevention is a public health priority, as noted in the recent Cochrane Review of controlled

trials for childhood obesity prevention. Controlled trials of dietary education and/or physical activity

are few in number and have methodological and other limitations, with studies examining combined

dietary education and physical activity interventions showing no significant impact on BMI. However,

dietary education delivered by multimedia strategies to primary and kindergarten children, and

education designed to reduce soft drink consumption in primary school children, were significantly

associated with reductions in obesity prevalence. Physical activity interventions and interventions

aimed at reducing sedentary activity were also associated with significant reductions in BMI in two

studies and a trend towards significant reductions in BMI in two remaining studies. Evidence also

suggests that breastfeeding is protective, with the largest two studies showing a 20-37% reduction in

risk of childhood obesity. However, despite the paucity of evidence for interventions to prevent

childhood obesity, the seriousness of trends in childhood obesity suggests we must act now, using the

best available evidence, and “guard against nihilists and procrastinators who require top-level evidence

from randomised controlled trials before action is taken” (John Catford).

iv

Obesity Prevention Programmes Operating in Auckland

Interviews were conducted with 40 providers of children’s physical activity or nutrition programmes in

the Auckland region. Most of the physical activity and nutrition programmes currently operating in the

Auckland region do not have obesity prevention as a goal and do not measure weight-related outcomes,

although they might be expected to help prevent childhood obesity by increasing physical activity and

reducing the energy-density of food and snacks eaten. Programmes that had collected weight-related

measures i.e. Food With Attitude, Well Child, Kids In Action, and the Pacific Islands Heartbeat Church

project, had significant data collection/recording problems, with the possible exception of Kids In

Action where the 2003 evaluation showed that 70% of children had maintained or lost weight and 42%

had lost weight. In addition, Food With Attitude and Kids In Action, are both aimed at treatment of

obesity rather than prevention, the PI Church project targeted families rather than children, and the

Well Child programme had not reported any weight-related findings.

All of the remaining programmes had either increasing physical activity or improving nutrition as

goals, with one exception (the Adolescent Obesity & Diabetes Prevention Programme) having obesity

and Type 2 diabetes prevention as a specific goal. The Children and Young People’s Diabetes

Prevention & Management Project and two large planned obesity prevention trials (the Pacific Obesity

Prevention in Communities Trial in Auckland, and Activ8 in Waikato) have obesity prevention as a

goal and will measure weight-related outcomes.

Programmes currently reaching the greatest number of children and youth are as follows:

� School-based programmes such as those coordinated by Health Promoting Schools, National

Heart Foundation’s School Food and Jump Rope For Heart programmes, and 5+ A Day.

� Pre-school programmes such as the National Heart Foundation’s Healthy Heart Award, the

Well Child programme, and other services provided by Auckland District Health Board.

� Family programmes such as Food With Attitude and Young & Active.

� Community programmes provided by city councils particularly Walking School Buses and

Waitakere City Council’s youth programmes.

v

� Regional Sports Trusts physical activity programmes including two specific programmes

targeting children: Sport Waitakere’s Fitt Kidz and Harbour Sports’ More Kids More Active

More Often programmes.

Currently, primary care has only a small role in childhood obesity prevention with no programmes yet

developed by PHOs, although Procare has the Modified Green Prescription Project for adults that it

may develop to target children and youth in the future, and TaPasifika helps provide the Kids in Action

programme. However, both of these programmes involve targeting and treatment of overweight and

obese people, rather than prevention in the general population or at-risk groups. Various outstanding

service needs were identified by providers and from the literature, and these served to inform

recommendations for action.

National and Local Recommendations for Action

Recommendations focus particularly on environmental strategies relating to the physical and policy

environments, with lessons from other epidemics suggesting that environmental strategies are the most

powerful and sustainable. Vector-based strategies that increase the availability of low-energy, high-

nutrient foods while reducing the availability of high-energy snacks and drinks, and host-based

strategies that enable the development of lifeskills and individual competence to influence factors

determining health, are also needed.

National Recommendations

National recommendations focus on the areas of policy, research, and schools.

� National policy is recommended to prevent the advertising of high-energy snacks, fast foods

and soft drinks to children; control product labelling with health promotion messages;

introduce appropriate pricing +/- a fat tax on energy-dense foods of low nutritional value;

develop intersectoral policy on obesity control; remove non-diet soft drinks and high-energy

snacks/food from vending machines in schools and pre-schools; and ensure that school tuck

shops sell food and drink consistent with the National Nutrition Guidelines.

� NZ childhood obesity prevention research is needed that examines the association between

environmental factors and individual behaviours affecting energy balance, addresses various

methodological constraints, and identifies appropriate Body Mass Index standards according

vi

to ethnicity. In addition, government-supported surveillance and research is needed to

evaluate the effect of policy and macroenvironmental changes on nutrition, PA, body weight,

and health outcomes.

� It is recommended that the health of the wider school environment discourages access to junk-

food outlets, and that active transportation to school is encouraged by the establishment of

WSB, safe cycleways and walkways, and other innovations. The schools’ role in physical

activity and nutrition/lifestyle education needs to be reassessed and strengthened with a

curriculum-based approach being used to influence eating patterns, reduce soft drink

consumption, reduce sedentary behaviours (especially TV viewing), promote physical

activity, and provide daily structured physical activity.

Local Recommendations

Local recommendations focus on several areas.

� For families, identified barriers to eating fruit and vegetables need to be addressed, and

family-based obesity treatment programmes require more resources to help enhance parenting

skills.

� More public health dietitians are required in the Auckland region, particularly in the

Waitemata and Counties Manukau District Health Board areas.

� Primary Health Organisation plans are needed that target childhood overweight and obesity

prevention.

� Health Promoting Schools’ staff could take a more proactive role in monitoring HPS goals

and programmes, and providing regional links between programme providers.

� Existing childhood PA/ nutrition programmes could include obesity prevention as a goal and

weight-related measures as outcomes especially those based in schools or primary care, and

possibly some of those run by Regional Sports Trusts.

� Local environmental interventions such as school travel plans, safe walkways and cycleways,

school food policies, and school drinking fountains need to be established and supported.

� In addition to its other roles, Auckland Regional Public Health Service could have a lead role

in providing nutrition education workshops to tuck shop retailers, and working with the food

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industry on nutrition policy and health promotion messages. In addition, ARPHS could have

a role in advocating for environmental-level policies.

� There is a need to build collaborative relationships between providers in the area of childhood

obesity prevention, nutrition, and PA. This would be aided by maintaining up-to-date lists of

providers and programmes, and increasing provider awareness of, and access to relevant

programmes and providers. Whilst there is some co-ordination of providers through annual

meetings organised by ANA and MoH in conjunction with SPARC, it remains extremely

difficult for providers to be aware of all players as funding is widely dispersed.

viii

Acknowledgements

This project was only possible due to the support of the Auckland Regional Public Health Service

(ARPHS), the Nutrition Team at ARPHS, Public Health Consultant Supervision, and the Auckland

providers of childhood nutrition and physical activity services. Particular thanks are expressed below.

ARPHS

Special thanks to Monica Briggs and Bob Mack for Management support; Nick Sharp for IT assistance;

Ruth Moore for document formatting help, Jo Wall for passing on relevant literature, and all other

members of the ARPHS team.

Nutrition Team

Grateful thanks to Christine Cook, Kate Sladden and Elizabeth Stewart who managed to convert my

nutritional ignorance into a working knowledge of the subject! Christine Cook provided invaluable

help and guidance in: designing and writing the proposal for this project, providing an extensive list of

provider contacts, accompanying me to initial interviews, keeping me informed of new developments

in childhood obesity, providing valuable project feedback, and always being available to provide

exceptional help and guidance when needed. Elizabeth Stewart and Kate Sladden were always happy

to answer my queries and proved to be wonderfully accurate and intelligent sources of information.

Elizabeth provided me with weekly updates of the national and international nutrition news media that

proved invaluable.

Supervisor

Dr Nick Jones provided very valuable public health consultant support as co-supervisor of my project

with Christine Cook. He was available for help when needed and provided extremely useful feedback

during the write-up of my project.

Providers

During the course of this project, I interviewed over 90 people working in the arena of childhood

nutrition or physical activity. I can not name each person here but the details for each contributor are

available in Appendix Three. I wish to thank the providers for their unique contributions to this

project, for spending their valuable time speaking with me, and most of all for continuing to care

deeply about the wellbeing of children in their care. I hope that this project will go some way towards

allowing their concerns to be heard and acted upon.

ix

Table of ContentsEXECUTIVE SUMMARY ...................................................................................................................II

ACKNOWLEDGEMENTS ............................................................................................................. VIII

TABLE OF CONTENTS .................................................................................................................... IX

LIST OF TABLES............................................................................................................................... XI

LIST OF FIGURES............................................................................................................................XII

LIST OF APPENDICES.................................................................................................................. XIII

LIST OF ABBREVIATIONS ...........................................................................................................XIV

THE BURDEN OF OVERWEIGHT AND OBESITY IN NEW ZEALAND CHILDREN.............1

International Standards for Obesity ......................................................................................................1Ethnic Differences in Obesity in New Zealand Children .....................................................................1Results from the National Children’s Nutrition Survey........................................................................2New Zealand Studies of Childhood Obesity.........................................................................................3International Studies of Childhood Obesity..........................................................................................4Morbidity Associated with Obesity ......................................................................................................5Mortality Associated with Obesity .......................................................................................................7Monetary Cost of Obesity.....................................................................................................................7

CAUSES OF OVERWEIGHT AND OBESITY ..................................................................................9

Biological ...........................................................................................................................................10Behavioural.........................................................................................................................................10Environmental ....................................................................................................................................11

Inactivity.........................................................................................................................................15Energy-Dense Food and Drink .......................................................................................................15Marketing of Energy-Dense Food and Drink .................................................................................16Low Socioeconomic Status ............................................................................................................17Possible Causes of Obesity.............................................................................................................17

EFFECTIVENESS OF INTERVENTIONS TO PREVENT OVERWEIGHT AND OBESITY ..18

Breastfeeding......................................................................................................................................18Controlled Trials of Dietary Education and Physical Activity Interventions .....................................19

Dietary Education vs Control .........................................................................................................23Physical Activity/ Reduction in Sedentary Activity vs Control .....................................................24Dietary Education vs Physical Activity..........................................................................................26Combined Effects of Dietary Education and Physical Activity......................................................26

Summary ............................................................................................................................................32Planned Obesity Prevention Trials .....................................................................................................33Macroenvironmental Interventions.....................................................................................................33

OBESITY PREVENTION PROGRAMMES OPERATING IN AUCKLAND..............................34

Schools’ Setting: Multi-component Interventions..............................................................................35Adolescent obesity & diabetes prevention programme ..................................................................35Health Promoting Schools ..............................................................................................................37The Pacific Obesity Prevention in Communities (OPIC) Project...................................................40Waitemata DHB Wellbeing Schools’ Project.................................................................................41

Schools’ Setting: Nutrition Interventions ...........................................................................................42The School Food Programme .........................................................................................................425+ A Day ........................................................................................................................................43Breakfast in Schools .......................................................................................................................45Nutrition Education in Schools and Home Economics...................................................................47

x

Schools’ Setting: PA Interventions.....................................................................................................48Jump Rope for Heart ......................................................................................................................48More Kids, More Active, More Often ............................................................................................48

Pre-Schools’ Setting: Multi-component Interventions .......................................................................49Healthy Heart Award......................................................................................................................49

Pre-Schools’ Setting: Nutrition Interventions.....................................................................................51ADHB Services ..............................................................................................................................51

Family Setting: Multi-component Interventions.................................................................................52‘Food With Attitude’ and ‘Young and Active’...............................................................................52Kids in Action.................................................................................................................................55

Primary Care Setting: Multi-component Interventions.......................................................................56Primary Health Organizations (PHOs) ...........................................................................................56The Centre for Youth Health ..........................................................................................................61Children and Young People’s Diabetes Prevention and Management Project (CYPDPMP).........62

Maori Provider Setting: Multi-component Interventions....................................................................64Te Hotu Manawa Maori .................................................................................................................64Hapai Te Hauora Tapui Ltd............................................................................................................65Te Whanau O Waipareira Trust......................................................................................................65Tuakau Homebuilders.....................................................................................................................66Raukura Hauora O Tainui...............................................................................................................67Aotearoa Maori Netball Oranga Healthy Lifestyle Trust Inc. ........................................................67

Pacific People Provider Setting: Multi-component Interventions ......................................................68Pacific Islands Heartbeat ................................................................................................................68Moto’otua Ltd.................................................................................................................................69

Community Setting: Physical Activity Interventions .........................................................................70MCC ...............................................................................................................................................70WCC...............................................................................................................................................71Walking School Buses (WSB) .......................................................................................................71Regional Sports Trusts....................................................................................................................74Fitt Kidz..........................................................................................................................................74

Community Setting: Nutrition Interventions ......................................................................................75ARPHS Community Services.........................................................................................................75Public Health Dietitians..................................................................................................................75Advocacy Groups ...........................................................................................................................76

Refugee and Migrant Health Setting ..................................................................................................78Asian Health Setting...........................................................................................................................79The Food Industry Setting ..................................................................................................................80Policy Setting......................................................................................................................................83Transportation and Town Planning Setting ........................................................................................85

RECOMMENDATIONS .....................................................................................................................87

National Strategies for Action ............................................................................................................88Host ................................................................................................................................................88Environment ...................................................................................................................................90Vector .............................................................................................................................................93

Local Strategies for Action.................................................................................................................93Host ................................................................................................................................................93Environment ...................................................................................................................................97

REFERENCES ...................................................................................................................................100

APPENDICES ....................................................................................................................................116

xi

List of Tables

Table 1: Relative risk of health problems associated with obesity (56) ..................................................7Table 2: International estimates of the direct costs of obesity.................................................................8Table 3: Environmental influences on food intake and physical activity (69) ......................................14Table 4: Summary of strength of evidence on factors that might promote or protect against weight gain

and obesity......................................................................................................................................15Table 5: Controlled trials evaluating childhood obesity prevention programmes. ................................20

xii

List of Figures

Figure 1: Overweight using international cut-off values (12) .................................................................2Figure 2: Obesity using international cut-off values (12)........................................................................3Figure 3: Obesity rates by BMI (>95%) and Body Fat Percentage (>35%) in Auckland School

Children (9) ......................................................................................................................................4Figure 4: The ecological model of the causes of obesity.........................................................................9Figure 5: Epidemiological triad as it applies to obesity. The circles refer to the predominant strategies

to address each corner of the triad. Source: (188). ........................................................................34Figure 6: Walking School Buses - schools by decile and TLA (Territorial Local Authority) (329). ....73

xiii

List of Appendices

Appendix 1: Auckland component of the Australasian school-based obesity prevention study forchildren in Years 9 to 12. .............................................................................................................116

Appendix 2: Key informant structured questionnaire..........................................................................119Appendix 3: List of Auckland providers interviewed (ordered by organisation). ................................121Appendix 4: List of programmes in Auckland having a role, or potential role, in childhood obesity

prevention. ....................................................................................................................................123

xiv

List of Abbreviations

ACC Auckland City Council

ADHB Auckland District Health Board

AIMHI Achievement in Multicultural High Schools

AMN Aotearoa Maori Netball Oranga Healthy Lifestyles Trust Inc

ANA Agencies for Nutrition Action

ARC Auckland Regional Council

ARPHS Auckland Regional Public Health Service

AUT Auckland University of Technology

BF Body Fat

BMI Body Mass Index ()2height(m

weight(kg))

C Control group

CCHD Community Child Health and Disability Service

CFYH Centre for Youth Health

CI Confidence Interval

CMDHB Counties Manukau District Health Board

CYPDPMP Children and Young Persons Diabetes Prevention and Management Project

DPT Diabetes Projects Trust

FAO Food and Agriculture Organization

FIS Food In Schools

FOE Fight against the Obesity Epidemic

FTE Full Time Equivalent

GEMS Girls’ health Enrichment Multisite Studies

HEHA Healthy Eating Healthy Action

HHA Healthy Heart Award

HPS Health Promoting Schools

NSCC North Shore City Council

HTHT Hapai Te Hauora Tapui Ltd

xv

I Intervention group

IOTF International Obesity TaskForce

JRFH Jump Rope For Heart

KIA Kids in Action

LINZ Life in New Zealand

MCC Manukau City Council

MHK Mangere Healthy Kai

MK More Kids More Active More Often

MoE Ministry of Education

MoH Ministry of Health

MTC Mangere Town Centre

n number of people in a defined group

NA Not Applicable

NEW Nutrition, Exercise and Weight working party

NGO Non-Governmental Organisation

NHF National Heart Foundation

NSCC North Shore City Council

NZ New Zealand

NZNF New Zealand Nutrition Foundation

OAC Obesity Action Coalition

OSCAR Out of School Care and Recreation

PA Physical Activity

PAC Physical Activity Coordinator

PE Physical Education

PHD Public Health Dietitian

PHO Primary Health Organisation

PI Pacific Island

PIH Pacific Islands Heartbeat

RH Raukura Hauora

RST Regional Sports Trusts

xvi

SD Standard Deviation

SFP School Food Programme

SPARC Sport and Recreation New Zealand

TH Tuakau Homebuilders

THMM Te Hotu Manawa Maori

TLA Territorial Local Authority

WCC Waitakere City Council

WDHB Waitemata District Health Board

WHO World Health Organisation

WSB Walking School Buses

YAA Young & Active

YMCA Young Men’s Christian Association

1

The Burden of Overweight and Obesity in New ZealandChildren

International Standards for ObesityResults from the 2002 National Children’s Nutrition Survey for overweight and obesity in NZ school

children aged between 5 and <15 years of age were based on international cut-offs. The reference cut-

off values used for determining the prevalence of overweight and obesity in children were as

determined by the International Obesity Task Force (IOTF) (Cole et al, 2000 (3)). The IOTF reference

is one of the two most widely used international BMI-for-age reference charts developed, the other

being the World Health Organisation (WHO)/US National Centre for Health Statistics reference (4).

The IOTF reference is used to classify overweight and obesity in young people of 2-18 years of age,

and is a series of age- and sex- specific BMI cut-off points based on population data collected from

Brazil, UK, Hong Kong, Singapore, the Netherlands, and the USA. The BMI cut-offs were derived

from sex-specific BMI age curves that pass through a BMI of 25 and 30 kg/m2 (the cut-off points used

in adults to define overweight and obesity, respectively) at 18 years of age.

Ethnic Differences in Obesity in New Zealand ChildrenThe suitability of using the IOTF BMI reference for NZ children is unknown. However, researchers

have compared ethnic differences in BMI and % BF (body fat) among Maori, Pacific, and European

populations, with several studies finding that Maori and Pacific adults tend to be leaner (i.e. have a

lower %BF and a higher fat-free mass) than NZ Europeans of the same body size (5-7). Similar results

have been observed in children, with one study finding that Maori and Pacific girls have 3.7% less BF

than European girls of the same body size (8). A similar finding, although small, was found in a study

of schoolchildren aged between 5-10 years (9). However, one small NZ study (n=79) of children aged

5-14 years found no difference in percentage BF between Maori Pacific, and European (10). A study

of NZ adults showed that when higher BMI thresholds were applied to Maori and Pacific people to

counteract their higher lean-to-fat mass ratio (26 and 32 kg/m2 for overweight and obesity,

respectively), these two groups remained twice as likely to be obese than the ‘European and Other’

group (11).

Asian ethnic groups have been largely neglected by NZ health and research policies. Despite the fact

that Asian adults comprise 12.5% of the Auckland population (Census 2001), in the 2002 National

2

Children’s Nutrition Survey Asian children were not over-sampled as were Maori and Pacific children,

and were not analysed separately but were grouped in with NZ Europeans (12). Overseas studies of

Asian children (13) and adolescents (14) have shown that they have a greater central fat mass

compared with Europeans and other ethnic groups, while studies of adult Asians have shown that they

also have higher levels of BF than Europeans for a given BMI (15, 16), thus putting them at greater risk

of obesity-related disease at relatively low BMI scores. One NZ study has shown that Asian Indian

children tended to have a higher %BF at a given BMI compared with NZ Europeans (9), and an

overseas study suggested that Chinese adolescents matured later than the IOTF reference populations

(17), thus providing another cause for misclassification in Asian children.

Results from the National Children’s Nutrition SurveyUsing the IOTF cut-off points, results from the National Children’s Nutrition Survey showed that

21.3% of NZ school children aged between 5 and <15 years of age were overweight and 9.8% were

obese (12). The proportion of overweight females remained constant throughout the three age groups

while the proportion of overweight males increased from 16.4% (5-6 years) to 23.7% (11-14 years)

(Figure 1).

0

5

10

15

20

25

5-6y 7-10y 11-14y

Age group (years)

Prop

ortio

n of

ove

rwei

ght

child

ren Males

Females

Figure 1: Proportion of overweight NZ children using international cut-off values (12)

The proportion of obese males was similar in the three age groups while the proportion of obese

females increased from 6.7% (5-6 years) to 11.6% (7-10 years) (Figure 2).

3

Figure 2: Proportion of obese NZ children using international cut-off values (12)

Overweight and obesity levels were highest for Pacific males (33.9%; 26.1%) and females (32.9%;

31%), followed by Maori males (19.6%; 15.7%) and females (30.6%; 16.7%), with the lowest levels in

NZ European males (18.4%; 4.7%) and females (18.8%; 6%) (3).

New Zealand Studies of Childhood ObesityA study of 2273 Auckland school children aged 5-10.9y showed that 14.3% of all children were obese,

with obesity rates higher in Pacific people (24.1%) and Maori (15.8%) than in European children

(8.6%) (9). Using a definition of obesity based on percentage body fat >30%, obesity rates were higher

in all ethnic groups (Figure 3). Youth2000, a national study of 12,934 Year 9 to 13 students,

discovered that a high proportion of female students had tried to lose weight in the previous year

(63.2%, 95% CI 61.3-65.2%) with the proportion increasing with age from Year 9 (52.2%, 95% CI

48.3-56.0%) to Year 13 (73.6%, 95% CI 70.6-76.5%) (18). This correlated with the finding that the

proportion of females participating in at least 20 minutes of moderate to vigorous physical activity on

at least three occasions in a week decreased with age from Year 9 (60.8%, 95% CI 57.3-64.3%) to Year

13 (51.4%, 95% CI 47.3-55.5%). BMI was not measured for the Youth2000 survey.

A recent study of Year 9 students at nine schools (eight of which were in South Auckland), conducted

as part of the AIMHI (Achievement in Multicultural High Schools) Healthy Community Schools

Initiative, revealed that 30% of children were obese (J Woolston, personal communication). One

recent NZ study of approximately 900 children aged 11-12 years in Hawkes Bay, examined changes in

BMI between 1989 and 2000, using the IOTF standard (19). The percentage of overweight children

0

2

4

6

8

10

12

14

5-6y 7-10y 11-14y

Age group (years)

Prop

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obe

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hild

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MalesFemales

4

increased from 11.0% in 1989 to 20.9% in 2000, and the percentage of obese children increased from

2.4% in 1989 to 9.1% in 2000. The absolute percentages in 2000 were higher for Maori (overweight

24.7%, obese 15.3%) and Pacific people (overweight 35.0%, obese 15.0%) than European (overweight

18.2%, obese 5.7%). However, the risk of being overweight or obese in 2000 compared to 1989 was

greatest among European children (RR overweight=3.0, 95% CI 2.2-4.0; RR obese = 8.3, 95% CI 3.0-

23.3).

Figure 3: Obesity rates by BMI (>95th percentile) and body fat percentage (>35%) in Aucklandschool children (9)

International Studies of Childhood ObesityThe WHO estimated that world-wide there were 200 million obese adults in 1995 and 18 million

children aged under five classified as overweight; by 2000 the number of obese adults had increased to

over 300 million (20). Internationally there is evidence that the prevalence of overweight and obesity

amongst children of all ages is also increasing rapidly (21-31). One study of English and Scottish

primary school children showed substantial increases in overweight and obesity between 1984 and

1994 (22). From 1984 to 1994 overweight increased from 5% to 9% and 9% to 13% in English boys

and girls, respectively, and from 6% to 10% and 10% to 16% in Scottish boys and girls, respectively.

The prevalence of obesity increased correspondingly, reaching 1.7% (English boys), 2.1% (Scottish

boys), 2.6% (English girls), and 3.2% (Scottish girls). An English study of pre-school children showed

a rise in prevalence of overweight (14.7% to 23.6%) and obesity (5.4% to 9.2%) between 1989 and

1998 (21). The 2002 Health Survey for England also noted deterioration in overall childhood statistics

with 21.8% of boys and 27.5% of girls being either overweight or obese (32). By projection of these

0

5

10

15

20

25

30

European Maori Pacific Other

Perc

enta

ge

BMI > 95th percentile

Body Fat>35%

5

statistics, it has been estimated that by 2020 the prevalence of childhood obesity will be >50% in the

UK (33).

In the USA, obesity in children and adolescents increased from 11 to 15% between the National Health

and Nutrition Examination Surveys conducted in 1988-94 and 1999-2000, and at the later date

approximately 30% of children were overweight, a figure that has doubled in 30 years (34, 35). In

Australia, figures published in 2001 show that 16.1-16.9% of boys (and 17.4-20.4% of girls) were

overweight, and 5.1-6.9% of boys (5.7-7.0% of girls) were obese (36). Spanish, Australian and

American data have shown that children’s BMI appears to be increasing most in the heavier BMI group

(23-26, 30). A comprehensive listing of the prevalence of child and adolescent overweight and obesity

in most countries, along with reference to how overweight and obesity were classified in each instance,

was recently published by the International Association for the Study of Obesity (37).

Morbidity Associated with ObesityObesity in childhood predicts adult obesity (38). In addition, increasing age of obesity in childhood

more strongly predicts obesity in adulthood, with an odds ratio for adult obesity of 1.3 at 1-2 years of

age rising to 17.5 at 15-17 years of age (38). In 2002, the Ministry of Health published a model

forecasting the prevalence and severity of adult obesity in 2011 (39) based on adult BMI1

measurements from three prior national surveys (11, 40, 41). The model estimated total population

mean BMI would increase from 25.5 in 1997 to 26.4 in 2011, while the prevalence of obesity would

increase from 17% in 1996 to 29% in 2011(39).

Obesity is the main modifiable driver of the Type 2 diabetes epidemic, although other factors such as

declining levels of physical activity have a smaller, independent effect (42). Globally, obesity and

Type II diabetes have reached epidemic proportions, with 120 million people affected by Type II

diabetes in 1997, and the number predicted to reach 216 million by 2010 (43). In New Zealand, the

number of adults with diagnosed (mainly Type 2) diabetes is predicted to increase 78% (1.8-fold) while

the annual number of new diagnoses will rise approximately 2.3-fold from 4700 in 1996 to about

11,100 in 2011 (39). One third of this forecast growth in the diabetes epidemic from 1996 to 2011 has

been attributed to obesity (39).

1 Adult BMI: obesity is defined as a BMI�30kg/m2; overweight is defined as 25<BMI<30kg/m2.

6

Obesity is also a risk factor for other chronic diseases including heart disease, hypertension, stroke,

gallstones, some cancers (endometrial, colon, and breast), osteoarthritis, obstructive sleep apnoea, and

psychological problems such as depression, low self-esteem, and social stigmatisation (Table 1). In

children, as mentioned above, the later the weight gain in childhood and adolescence, the greater the

persistence of overweight and obesity into adulthood with its attendant risks for chronic disease (38,

44, 45). In fact, more than 60% of overweight children also have at least one additional risk factor for

cardiovascular disease such as raised blood pressure, hyperlipidaemia or hyperinsulinaemia, and more

than 20% have two or more risk factors (46). Many studies have observed significant clustering of

cardiovascular risk factors with paediatric obesity and, as with adults, the extent of asymptomatic

atherosclerotic lesions in childhood and adolescence is predicted by the number of cardiovascular risk

factors present (47).

In addition to cardiovascular risk factors, a recent international review of the health consequences of

childhood obesity showed that obese children are more likely to experience psychological or

psychiatric problems than non-obese children, that girls are at greater risk than boys, and that risk of

psychological morbidity increases with age (48). Paediatric obesity has also been significantly

associated with risk of asthma and severity of asthma (49-52), a more than two-fold risk of developing

Type 1 diabetes (53), and a marker of chronic inflammation (54).

Studies have also shown that obesity in adolescence/ young adulthood has adverse effects on social and

economic outcomes in young adulthood such as income and educational attainment, and there is some

evidence that these effects are more marked in women than in men (55).

7

Table 1: Relative risk of health problems associated with obesity (56)Greatly increased

(relative risk greater than 3)*Moderately increased

(relative risk 2-3)*Slightly increased(relative risk 1-2)*

� Type 2 diabetes� Gallbladder disease� Dyslipidaemia� Insulin resistance� Breathlessness� Sleep apnoea

� Coronary heart disease� Hypertension� Osteoarthritis� Hyperuricaemia

� Cancer (breast cancer inpostmenopausal women,endometrial cancer, coloncancer)

� Reproductive hormoneabnormalities

� Polycystic ovary syndrome� Impaired fertility� Low back pain due to

obesity� Increased anaesthetic risk� Foetal defects associated

with maternal obesity*All relative risk estimates are approximate

Mortality Associated with ObesityEvery year 1,000 New Zealanders die of obesity-related diseases, which is double the annual road toll

(57). Evidence, although scant, indicates that obese youth are at increased risk of early mortality

independent of the risk conferred by adult obesity (58, 59). A Dutch cohort study found that a BMI of

>25kg/m2 at 18 years of age was associated with a significantly increased risk of mortality within 20

years of follow-up (58). At 32 years of follow-up the relative risk of mortality was 1.95 compared with

those who had had a BMI of 19kg/m2 at 18 years of age. Similarly, Must and colleagues found that

adolescent overweight had adverse effects on long-term morbidity and mortality (59). Among men, the

RR of all-cause mortality was 1.8 (95% CI 1.2 to 2.7) and coronary heart disease mortality was 2.3

(95% CI 1.4 to 4.1).

Monetary Cost of ObesityAs well as causing excess morbidity and mortality, obesity imposes an important financial burden on

New Zealand society. In 1991, the direct annual cost of obesity was estimated at $135 million, which

was 2.5% of the total 1991 health expenditure (60). This equated to an annual cost attributable to

obesity of $247.1 million in 2000/01 (61). This figure excluded the downstream costs from chronic

diseases that result from obesity. For example, the annual cost of diabetes alone has been estimated at

$280 million and the cost of coronary artery disease was estimated at $306 - $467 million in the early

1990s (57). In the Pacific Islands, the economic consequences of non-communicable diseases, chiefly

obesity and type 2 diabetes, have been dramatic, consuming US$1.95 million, almost 60% of the health

budget of Tonga, and US$13.6m, 39% of the health budget of Fiji (62).

8

In the United States, obesity consumed a whopping US $118 billion of the national healthcare budget

in the late 1990s, more than double the US $47 billion costs for smoking (63, 64). More recently, the

combined direct and indirect costs to the USA have been reassessed at $123 billion in 2001 (65). In

1998, the direct cost of treating obesity in England was estimated at £480 million and indirect costs

(loss of earnings due to sickness and premature mortality) amounted to £2.1 billion (66). In Australia,

the direct cost of obesity was estimated at $680 - $1239 million in 1995-96 (67). Globally, the WHO

has estimated that the cost of obesity for a country is 2-7% of the annual health budget (31).

International comparisons of the direct costs of obesity as a proportion of the total healthcare

expenditure are presented in Table 2.

Table 2: International estimates of the direct costs of obesity (12, 68-73)

Prevalence of obesity (BMI>30kg/m2)Country Year of estimate

Proportion of totalhealthcare

expenditure due toobesity

At time of estimate Latest

USA

Netherlands

Canada

Portugal

New Zealand

Australia

England

France

2000

1981-89

1997

1996

1991

1989/90

1998

1992

8.5%

4%

2.4%

3.5%

2.5%a

>2%

1.5%

1.5%

30.5%

5.0%

14.0%

11.5%

11.1%b

10.8%

19.0%

6.5%

30.5%

10.3%

13.9%

14.0%

17.0%c

22.0%

23.5%

9.0%

a2.5% of the healthcare budget was equal to $135 millionbPrevalence of adult obesity from the LINZ Survey, 1989 (70)cPrevalence of adult obesity from the National Nutrition Survey, 1997 (11)

9

Causes of Overweight and ObesityAt first consideration, the cause of obesity seems simple: too much energy consumed for energy

expended. However, the reasons why energy imbalance is common in our society, and indeed in all

Western countries, are complex. Greg Critser, renowned author of the recently published book ‘Fat

Land: how Americans became the fattest people in the world’ describes some of this complexity well

when pondering the socio-economic factors responsible for his success in losing weight by their

influence on his environment and behaviour (74):

‘Yet the more I contemplated my success, the more I came to see it not as a triumph of will,

but as a triumph of my economic and social class. The weight loss medication Meridia, for

example, had been effective not because it is such a good drug; even its purveyors freely admit

it is far from effective for most people. What made the drug work for me was the upper-

middle-class support system that I had brought to it: a good physician who insisted on seeing

me every two weeks, access to a safe park where I could walk and jog, friends who shared the

value of becoming slender, healthy home-cooked food consumed with my wife, books about

health, and medical journals about the latest nutritional breakthroughs. And money. And

time.’

This complexity is captured by Swinburn’s ‘ecological model’ of the causes of obesity (Figure 4) that

regards obesity as a normal response to an abnormal environment. It proposes three main influences on

level of body fat (biology, behaviour and environment), mediated through energy intake and energy

expenditure, and moderated by physiological adjustments during periods of energy imbalance (75).

This places obesity in an ecological context that clearly calls for multi-sectorial involvement to impact

on the problem.

Figure 4: The ecological model of the causes of obesity (75)

Equilibriumfat stores =

Energy EnergyIntake Expenditure-

Physiologicaladjustment x

Biology Behaviour Environment

Mediators

Influences

Moderators

10

Influences

Biological: The main biological influences on weight are genetic through ethnicity, gender, hormonal

and other heritable factors, while biological ageing is also often associated with weight gain (75). In

addition, several studies have found an association between various measures of abdominal obesity in

childhood or adult life and low birth weight, malnutrition during early gestation, or early weight gain

(76-83). Obesity in childhood has also been associated with maternal overweight status (38, 84),

maternal gestational diabetes (85), and high birth weight (84, 86-88). Research on the foetal origins of

disease hypothesis has shown that coronary heart disease (89-96), chronic renal disease (97, 98), Type

2 diabetes (99, 100), and hypertension (101, 102), are all possible outcomes associated with low birth

weight or body leanness at birth +/- followed by poor or rapid infant growth. Obesity in childhood or

adulthood would exacerbate these poor outcomes.

Most of these biological influences on weight are not modifiable except for the prevention of small

birth weight babies and rapid early weight gain. However, small birth weight does not only depend on

modifiable factors such as maternal nutrition, smoking, and level of social deprivation, but also on

mother’s body composition, size and nutrient stores, which are influenced and established during her

own foetal life in addition to her nutritional experiences in childhood and adolescence (103). However,

while biological factors explain much of the variance in body fat between individuals within a given

environment, they do not explain the large population increases that represent the obesity epidemic

itself (75).

Behavioural: Behaviours leading to overeating and/or inactivity are the result of a complex mix of

psychological, cognitive, biological and environmental influences (75). A number of psychological

models have been proposed as possible causes of obesity, although currently, personality and emotional

factors are thought to play only a minor role in the aetiology of obesity (104, 105). Binge-eating

disorder is linked to obesity with a prevalence of 20-30% in obese patients and 2.5% in the general

population (106, 107). Emotional eating is a less severe form of binge eating caused by disinhibition of

restraint resulting from emotional arousal. A recent study of 153 girls from the USA, showed that girls

at risk for overweight (>85th percentile BMI) at 5 years of age had higher levels of dietary restraint2,

2 Dietary restraint is defined as the tendency to restrict intake as a means of maintaining or losing body weight.

11

disinhibited overeating, weight concern, and body dissatisfaction, and higher weight gain from 5 to 9

years of age (108). This, and similar studies, suggests that children’s attempts to control weight may

result in weight gain, and that positive alternatives to dietary restriction may be needed, such as

encouraging PA, healthy foods, and appropriate portion sizes (109-111). Body image dissatisfaction is

highly correlated with obesity, particularly obese binge eaters (112, 113). In addition, a profile of

psychosocial factors has been identified in adolescents and adults that are closely associated with non-

participation in organised sport and exercise that may predispose individuals to developing obesity. By

late adolescence, physical self-perceptions of fitness and skill strongly predict the degree and type of

involvement in sport and exercise (114, 115). Similarly, social physique anxiety (a fear of displaying

the body in public settings) presents an additional barrier to attendance at exercise settings (116).

Attitudes, beliefs and intentions about exercise also comprises the mental ‘set’ that predicts inactivity

(117, 118), and the obese score particularly low on such profiles (119, 120).

Cognitive influences on behaviour include factors such as willpower based on knowledge and are

considered to have only a minor effect on behaviour (75). Environmental influences are discussed

below.

Environmental: The environmental influences on the amount and type of food eaten and the amount

and type of physical activity undertaken are rarely understood and thus vastly underrated. This is

understandable given the large and subtly interconnected network of obesogenic environmental

influences impacting on the population. However, an attempt must be made to understand

environmental influences as they potentially explain the rapidly evolving obesity epidemic. Greg

Critser has described this influence well by detailing how changes in the American environment, that

were replicated to some degree throughout most of the developed world, led to upsizing of the

population (74). The environmental factors identified by Critser are discussed below (italicized

section) to aid understanding of the concept that such factors are pervasive and powerful forces driving

the obesity epidemic. A similar historical analysis that links the obesity epidemic with environmental

factors has not yet been carried out for NZ.

12

In 1970s America, economic factors that led to changes in agriculture resulted in a surplus of cheap

fats (121, 122) and sugars (123, 124) that allowed affordable super-sizing of energy-dense fast foods

(125-128). Huge variety in cheap fast-food and energy-dense snacks exploited the human drive for

novelty – the same drive that supported our hunter-gatherer forebears in gaining a variety of energy-

poor and micronutrient-rich foods to improve survival now supports overconsumption of energy-dense

commercial foods that ultimately limit survival (129).

Critser also describes how the roles of society, schools and parents as custodians of caloric intake

were eroded in the 1980s. Societal changes led to parenting changes: both parents were now working,

parents were left with less time or inclination to supervise their children’s meals, and more meals were

being eaten outside the home with loss of control over portion sizes and the nutritional content of meals

(130). New ideas about food and children came into vogue in society: research suggested children

should eat more frequently than three times a day and that children should be allowed to self-moderate

their food intake (131) – this was associated with an increase in snacking on energy-dense

micronutrient-poor foods which was most prevalent among the poor (132).

In public schools, the in loco parentis rights of teachers were eroded by legal, economic and cultural

changes (133). Moves to limit taxation in the late 1970s (134, 135) left schools competing for money

with other public services and led to budget cuts that curtailed physical education, stopped

subsidisation of school cafeterias (thus leading to an entrepreneurial rather than a nutritional food

environment), and saw public schools’ middle-class parental support disappearing to private schools.

Super-sized and fat-laden fast foods and soft drinks entered schools in this new entrepreneurial

environment (136-139). Coke purchased ‘pouring rights’ in schools by providing them with monetary

remuneration in return for selling and advertising rights (140-142). This led to children drinking Coke

and other soft drinks in place of milk and nutrient-rich foods, often without properly compensating for

liquid calories consumed by eating less at other meal times (143, 144). In addition, from the 1980s,

meat became affordable for most individuals on a daily basis. This combined with a publishing drive

for new diet books that could compete with Atkins’ very low carbohydrate diet, resulted in an

outpouring of Atkins’-like diets and many “all you can eat diets” that were, however, all missing any

mention of the concept of ‘self-control’ (145-147).

13

Nevertheless, increases in calorie consumption were not matched by compensatory increases in

physical activity; instead many of the existing social constructs supporting physical activity were

eroded. The decline of physical exercise in schools across the USA was an important societal change.

In early twentieth century California, four years of PE were required for graduation along with a daily

dose of formal PE (148). However, the future climate of budgetary constraints, declining national

productivity and job growth coupled with declining school math and science scores, parents’ collective

‘bad memories’ of failure and humiliation in PE, and a societal change towards individualised rather

than group exercise with the advent of private gyms and ‘aerobics’, led to PE teachers being sacrificed

in favour of ‘higher’ academic priorities (149). The remaining fitness opportunities for children

(children’s sport clubs and safe parks and neighbourhoods) depended greatly on socioeconomic status,

as such opportunities were contingent upon parental time, money or residence (150).

Television viewing hours rose in the 1980s and a strong inverse association between duration of TV

viewing and weekly exercise was observed (151). TV viewing time was also positively correlated with

increasing body fat percentages (152). Between 1966 and 1994, youth obesity jumped from 7 to 22%.

Television was being used as a baby-sitter and advertising of fast foods increased rapidly. Children

and parents were sitting watching hours of TV full of billion-dollar cues to eat even when one was not

hungry. In addition, the socioeconomically disadvantaged were viewing most TV and exercising least,

and this was found to be associated with poorer neighbourhoods affording less safe environments for

physical activity (152).

Societal attitudes to exercise were also changing – exercise was no longer seen as a way to better

one’s performance in everyday life but as a means to reduce the risk of chronic diseases, with only

moderate exercise prescribed by the latter, replacing more vigorous exercise prescribed by the former

(153). Unfortunately, the moderate exercise prescription of the 1990s coincided with a time of

unparalleled opportunity to be both sedentary and consume huge amounts of cheap calories. In

addition, given the permissiveness of American culture and the way that information was presented by

the media, the moderate prescription was often interpreted as an excuse not to exercise rather than as

a ‘doable’ goal. In effect, an exercise prescription to reduce a lazy man’s chance of a heart attack had

14

turned into a national prescription for fitness. In addition, medical research, some of it flawed,

combined with media spin had given rise to the erroneous widespread beliefs that it was okay to gain

weight as one aged (154) and that fat people were healthy (155).

As exemplified above and noted by Swinburn (75), environmental influences represent the public

health arm of the obesity problem (Table 3) with obesogenic macroenvironments overriding the more

limited effect of programmes aimed at individual behaviour. Table 3 lists aspects of the physical,

economic, social and cultural environment that affect foods consumed and physical activity

undertaken.

Table 3: Environmental influences on food intake and physical activity (75)Physical Environment Economic environment Sociocultural environmentType of

environment Food Activity Food Activity Food Activity

Macro Food laws andregulationFood technologyLow fat foodsFood industrypolicies

Labour savingdevicesCycleways andwalkwaysFitness industrypoliciesTransport system

Food taxes andsubsidiesCost of foodtechnologyMarketing costsFood prices

Cost of labourversusautomationInvestment inparks andrecreationalfacilitiesCosts of petroland carsCosts ofcycleways

TraditionalcuisineMigrant cuisinesConsumerdemandFood status

Attitudes torecreationNational sportsParticipatingversus watchingcultureGadget status

Micro Food in houseChoices atschool cafeteriasFood in localshopsProximity of fastfood outlets

Local recreationfacilitiesSecond carsSafe streetsHousehold rulesfor watching TVand video

Family incomeOther householdexpensesSubsidisedcanteensHome grownfoods

Gym or club feesOwningequipmentSubsidised localeventsCosts of schoolsport

Family eatingpatternsPeer attitudesPressure fromfood advertisingFestivities

Peers’ activitiesFamily recreationSchool attitude tosportsSafety fears

The WHO recently compiled a list of the environmental factors that research has shown to promote or

protect against weight gain and obesity, divided according to the strength of the available evidence

(Table 4) (156).

15

Table 4: Summary of strength of evidence on factors that might promote or protect againstweight gain and obesitya (156).

Evidence Decreased risk No relationship Increased riskConvincing Regular physical activity

High intake of dietaryfibreb

Sedentary lifestylesHigh intake of energy-dense micronutrient-poorfoodsc

Probable Home and schoolenvironments that supporthealthy food choices forchildrend

Breastfeeding

Heavy marketing ofenergy-dense foods andfast-food outletsd

High intake of sugars-sweetened soft drinks andfruit juicesAdverse socioeconomicconditions (in developedcountries, especially forwomen)d

Possible Low glycaemic index foods Protein content of the diet Large portion sizesHigh proportion of foodprepared outside the home(developed countries)”Rigid restraint/ periodicdisinhibition” eatingpatterns

Insufficient Increased eatingfrequency

Alcohol

aStrength of evidence: the totality of the evidence was taken into account. The World Cancer Research Fundschema was taken as the starting point but was modified in the following manner: randomised controlled trials(RCTs) were given prominence as the highest ranking study design (RCTs were not a major source of cancerevidence); associated evidence and expert opinion was also taken into account in relation to environmentaldeterminants (direct trials were not usually available).bSpecific amounts will depend on the analytical methodologies used to measure fibre.cEnergy-dense and micronutrient-poor foods tend to be processed foods that are high in fat and/or sugars. Lowenergy-dense (or energy-dilute) foods, such as fruit, legumes, vegetables, and whole grain cereals, are high indietary fibre and water.dAssociated evidence and expert opinion included.

InactivityThe studies showing increased evidence of risk for overweight and obesity (i.e. potentially causative

factors) include sedentary lifestyles, with convincing evidence that the inactivity associated with

sedentary occupations and TV watching promotes weight gain (157, 158). A recent longitudinal study

of 1000 New Zealanders followed up over 26 years, showed that in 26 year-olds, population-

attributable fractions indicated that 17% of overweight and 15% of poor cardiovascular fitness could be

attributed to watching TV for more than 2h a day during childhood and adolescence (159).

Energy-Dense Food and DrinkA high intake of energy-dense foods (high in fat and generally low in water, micronutrients and fibre),

and consumption of energy-dense drinks (usually high in sugar) are the main candidates for the so-

called “passive overconsumption” of calories that occurs when the energy density of the diet is high

(144, 158, 160). There is also increasing evidence that the high intake of sugars in beverages promotes

weight gain (143, 144, 157, 161-163) and it has been estimated that every additional glass or can of

sugar-sweetened drink drunk per day by children increases the risk of becoming obese by 60% (164).

16

Soft drink intake amongst USA children is increasing with consumption doubling over the last two

decades and now adding 188 kcal/day to the energy intake of children who drink them (165, 166). In

NZ, 45% of children aged 5-14 years of age drink carbonated drinks at least weekly, with the highest

consumption by Maori and Pacific people and those in the lowest NZDep01 (12).

Marketing of Energy-Dense Food and DrinkThe WHO report on diet and nutrition concluded that there was sufficient indirect evidence that the

heavy marketing of fast foods and soft drinks to young children causes obesity (156). Certainly, the

consistent strong relationships between TV viewing and obesity in children may relate in part to the

advertising to which they are exposed (162, 167-169). Since release of the WHO report on diet and

nutrition, the Hastings report, a UK report prepared for the FSA (Food Standards Agency) that

reviewed all research on the effect of food promotion to children, was published (170). This report

concluded that although results from research into a topic of this nature could not amount to proof of

causality, sufficient evidence existed to conclude that an effect exists, with the research showing that:

� There is a lot of food advertising to children.

� The advertised diet is less healthy than the recommended one. A NZ study showed that two-thirds

of food advertisements targeted at children were for food high in fat and/or sugar (171).

� Children enjoy and engage with food promotion.

� Food promotion is having an effect, particularly on children’s preferences, purchase behaviour and

consumption.

� This effect is independent of other factors and operates at both a brand and category level.

Not surprisingly, the Hastings’ report was quickly followed by an analysis of the report commissioned

by the UK Food Advertising Unit (FAU) that concluded, “we do not believe the Hastings Review has

the robustness to be used for policy development” (172). Despite the fact that the Hastings Review

admitted that current research was unable to demonstrate proof of causality between advertising and

children’s food consumption behaviour, the FAU analysis chose to concentrate on this lack of

causality, and the results of one study that showed that parental influence affected children’s behaviour

more than food advertising (173), rather than the evidence showing that an effect existed. More

recently, WHO commissioned a report to review regulations on food marketing to children as part of its

global strategy on diet and physical activity (174).

17

Low Socioeconomic StatusAs the obesity epidemic has progressed, lower socioeconomic status has been consistently associated

with higher rates of obesity in higher income countries (175). The mechanisms by which

socioeconomic status influences food and activity patterns are probably multifactorial and need

elucidation. However, the WHO report suggests that people living in circumstances of low

socioeconomic status may be most at the mercy of obesogenic environments. This is because their

eating and activity behaviours are more likely to be the “default choices” on offer e.g. the cheapest or

geographically most available food/activity sources (156). In NZ, rates of overweight and obesity are

highest amongst Pacific and Maori children who also have the highest rates of low socioeconomic

status (see ‘burden of overweight and obesity in NZ children’). Similarly, data from the Medical

Research Council of England has shown that Asian children are four times more likely to be obese than

those who are white (176). In the USA, black girls and their mothers are heavier than their white

counterparts (177), and the largest concentrations of the obese reside in the poorest sectors of society –

the chronically impoverished (from Appalachia to the rural South), working poor (from L.A. barrios to

New York’s Little Puerto Rico), and ‘structurally’ poor (from Detroit’s housing projects to reservation-

tied Native Americans) (74). As in other heterogeneous and affluent societies, in the USA there is a

strong inverse correlation between socioeconomic status and obesity (178).

Possible Causes of ObesityResearch suggests that possible causes of overweight and obesity include diets comprised of a high

proportion of high glycaemic foods (179-182), large portion sizes (with evidence that people do not

adequately compensate for large meals by subsequently eating less) (183, 184), and eating a significant

proportion of calories from meals prepared outside the home (185). In the USA, it has been shown that

those who most often eat outside the home have higher BMIs than those who tend to eat at home (185).

In addition, the energy, total fat, saturated fat, cholesterol and sodium content of foods prepared outside

the home is much higher than in home-prepared food (185).

18

Effectiveness of Interventions to Prevent Overweight and

Obesity

Reviews examining the evidence for the effectiveness of childhood obesity prevention interventions

have used different frameworks for presenting the evidence. Generally, these frameworks have been

based on either type of interventions (dietary education and/or physical activity), as in the latest

Cochrane review (186, 187) or, more commonly, the setting of interventions (188-195). A settings

approach for grouping interventions is based on places where people gather and where food or physical

activity is involved e.g. schools, homes, neighbourhoods, primary care settings and communities (194).

The following review of the effectiveness of interventions to prevent childhood obesity is organised

under the headings listed below, in order to capture findings from the best available evidence:

� Breastfeeding

� Controlled Trials for Dietary Education and Physical Activity Interventions

� Dietary Education Interventions

� Physical Activity Interventions

� Macroenvironmental interventions.

The WHO summary shown in Table 4, above, listed regular physical activity and a high intake of

dietary fibre as the two factors that most convincingly prevented excess weight gain. However, dietary

fibre studies were conducted with adults rather than children (196, 197), as were most physical activity

trials (198) - except for the controlled trials of physical activity +/- dietary interventions conducted with

children in educational institutions or family settings, discussed below. In adults, the majority of

dietary fibre studies have demonstrated increased satiety, reduced hunger, reduced energy intake, and

body weight loss during consumption of high-fibre diets (196, 197). Thus, there is considerable reason

to conclude that fibre-rich diets containing non-starchy vegetables, fruits, whole grains, legumes, and

nuts, may be effective in the prevention and treatment of obesity in children.

BreastfeedingAs shown in Table 4, studies suggest that breastfeeding probably protects against childhood obesity.

Five of approximately 20 studies found a protective effect (199-203), two found that breastfeeding

predicted obesity (204), and the remainder found no relationship (156). Although there were probably

multiple confounding effects in these studies, the three largest studies did show a protective effect (200,

19

201, 203). In addition, it has been calculated that the reduction in risk of developing obesity observed

by two of these studies was substantial (20-37%) (201, 203). The mechanism by which breastfeeding

may protect against overweight or obesity remains uncertain, although suggested possible mechanisms

include the following: breastfed infants may have more control over the amount of milk they consume;

differential endocrine responses to formula and breast milk may promote more body fat deposition in

the formula-fed infants; and food preferences subsequent to breastfeeding may be affected by the mode

of infant feeding (205). A NZ study of approximately 1000 infants monitored up until 21 years of age

showed that breastfeeding for >6 months showed a reduction in risk of overweight during late

childhood and adolescence which became nonsignificant after adjusting for sex, birthweight, maternal

education, and parents’ being overweight (206). Nevertheless, the ORs were comparable to those

found in other large studies (201-203).

Controlled Trials of Dietary Education and Physical Activity InterventionsThe latest Cochrane Database of Systematic Reviews on interventions for preventing obesity in

children included all randomised controlled trials and non-randomised trials with concurrent control

group that observed participants aged less than 18 years for a minimum of three months (186). Ten

studies were identified from which it was concluded that there is currently limited quality data on the

effectiveness of obesity prevention programmes and as such no generalisable conclusions could be

drawn. It was suggested that a concentration on strategies that encourage a reduction in sedentary

behaviour and an increase in physical activity could be fruitful. It also concluded that at a time when

obesity prevention is a public health priority, the current research lacks the power to set clear directions

for obesity prevention activity. These, plus four school-based studies and one community/family-based

study published since the Cochrane Review that fit the same inclusion criteria (207-211), are

summarised below according to type of intervention(s) and are listed in Table 5. The International

Association for the Study of Obesity recently published a list of controlled trials undertaken to prevent

childhood obesity that also includes several trials that did not meet the Cochrane Review’s criteria for

inclusion, but is less up-to-date than the list shown below (Table 5) (212).

20

Table 5: Controlled trials evaluating childhood obesity prevention programmes.Author,Country,

Year

Participants Interventions Results Comments

Dietary EducationEpsteinUSA2001

Non obese children fromfamilies with at least oneobese parent.Mean age: I=8.6 yrs,C=8.8 yrs.65% female

Both groups received same 6-month treatment and followed the 'traffic light'diet, but targeted different dietary goals. Treatment meetings were facilitated bytherapists:I: increased fruit and vegetable intake (n=13)C: decreased intake of high fat/high sugar foods (n=13)Follow-up: one year.

Percentage of overweight:Parents in the increased fruit and vegetable group showed significantly greaterdecreases (p<0.05) in percentage of overweight than parents in the decreasedhigh-fat/high-sugar group, while children showed a stable percentage ofoverweight over time.

Random allocation: method not described.Blinding:*children: unclear*providers: unclear*outcome assessors: unclear

SimonettiItaly1986

Children aged 3-8 yrs inkindergarten or primaryschool.

Two school groups received dietary education interventions that differed inintensity, and there was one control school as follows:School 1: multimedia action strategy (MA), n=367.School 2: written action strategy (WA) - pamphlet only n=358.School 3: control, n=596.Follow-up: one year.

A 12.2% reduction in obesity and a 12.1% reduction in overweight was foundin the MA school. There were no significant changes in overweight or obesityin the WA or control schools.

Non-randomised allocation.Did not adequately describe attrition, the potential ofcontamination between study groups or thegeneralisability of the study.

JamesUK2004

Children aged 7-11 yrs inprimary schools.

Twenty-nine classes from six primary schools were randomized into theintervention group (15 classes) or control group (14 classes).Intervention group: 4X 1 hr educational sessions to reduce the consumption ofcarbonated drinks (n=325).Control group: no sessions (n=319).Follow-up: one year (the end of the intervention).

A drop in consumption of carbonated drinks was observed in the interventiongroup of 0.6 glasses over 3 days compared with an increase of 0.2 glasses inthe control group (mean difference 0.7, 95% CI 0.1-1.3).There was an increase of 7.5% in overweight and obese children in the controlgroup compared with a decrease of 0.2% in the intervention group (meandifference: 7.7%. 95% CI 2.2-13.1%).

Random allocation: randomisation of classes stratifiedby school.Blinding:*children: at time of consent*outcome assessors: unclear

Physical ActivityMo-SuwanThailand1998

Kindergarten children.Mean age: 4.5 yrs44% female.

Intervention: Kindergarten-based physical activity programme conducted byspecially trained staff and including a 15 minute walk and a 20 minute aerobicdance session 3x a week (n=158 baseline, 147 at end of study).Control: no intervention (n=152 baseline, 145 at end of study).Follow-up: 29.6 weeks (the end of the intervention) and 29.6 weeks + 6 months.

Prevalence of obesity (triceps-skinfold thickness):Baseline: I=12.9%, C=12.2%.29.6 weeks: I=8.8%, C=9.4%.26.6 weeks + 6 months: I=10.2%, C=10.8%

Random allocation: randomisation of classes stratifiedby school.Blinding:*children: unclear*providers: unclear*outcome assessors: unclear

FloresUSA1995

School children (aged 10-13 yrs).Mean age: 12.6 yrs54% female.

Intervention: Thrice weekly aerobic dance classes plus health education in placeof regular school physical education programme (n=43).Control: Usual physical activity (n=38).Follow-up: 12 weeks.

Girls:Change in BMI: I=-0.8, C=0.3, p<0.05.Change in heart rate (beats per minute): I= -10.9, C=-0.2, p<0.01.Boys:There were no differences between I and C groups.

Random allocation: randomisation of classrooms.Blinding:*children: unclear*providers: unclear*outcome assessors: unclear.Generalisability of study outcomes not considered;follow-up numbers of participants (n) not reported.

RobinsonUSA1999

School children (aged 8-10yrs).Mean age: 8.9 yrs47% female.

Intervention school: 18 lessons aimed at reducing sedentary behaviours (TV,videotape and videogame use) (n=92).Control school: usual school curriculum.Follow-up: 6 months (the end of the intervention).

Intervention vs control change:*BMI: intervention vs control change: 18.38 to 18.67 kg/m2 vs 18.10 to 18.81kg/m2, respectively, adjusted difference -0.45kg/m2 (95% CI -0.73 to -0.17),p=0.002;*Triceps skinfold thickness: intervention vs control change: 14.55 to 15.47mmvs 13.97 to 16.46mm, respectively, adjusted difference, -1.47mm (95% CI, -2.41 to -0.54), p=0.002;*Waist circumference: intervention vs control change: 60.48 to 63.57 cm vs59.51 to 64.73cm, respectively, adjusted difference, -2.30cm (95% CI, -3.72 to-1.33), p<0.001); and*Waist to hip ratio: intervention vs control change: 0.83 to 0.83 cm vs 0.82 to0.84 cm, respectively; adjusted difference, -0.02 (95% CI,-0.03 to -0.01),p<0.001.*Intervention group watched significantly less TV (p<0.001) and played fewervideo games (p<0.01).*Groups did not differ for videotape viewing, daily servings of high fat foods,

Random allocation of schools.Blinding:*children: unaware of primary hypothesis*providers: unaware of primary hypothesis*outcome assessors: blinded

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physical activity levels, or cardiorespiratory fitness.

RobinsonUSA2003

Sixty-one African-Americangirls (and their parents/guardians) aged 8-10 yrsfrom low-incomeneighbourhoods. Girls hadBMI>50th percentile forage and/or at least oneoverweightparent/guardian.

Intervention: after-school dance classes at community centres, and fiveeducational sessions at family homes designed to reduce sedentary behaviours(TV, videotape and videogame use).Control: newsletters and health education lectures.Follow-up: 12 weeks (the end of the intervention).

Intervention vs control change:Trends towards -*Lower BMI: adjusted difference = -0.32 kg/m2, 95% CI -0.77 to 0.012.*Lower waist circumference: adjusted difference = -0.63 cm, 95% CI -1.96 to0.67.*Increased after school activity: adjusted difference = 55.1 counts/minute, 95%CI -115.6 to 225.8.*Reduced TV, videotape and video game use: adjusted difference = -4.96hours/week, 95% CI -11.41 to 1.49.*Improved school grades: Cohen's d=0.51, p=0.07.Significantly -*Reduced household television viewing: d=0.40, p=0.007.*Fewer dinners eaten while watching TV: adjusted difference = -1.60meals/week. 95% CI -2.99 to -0.21.*Less concern about weight: d=0.60, p=0.03.

Random allocation.Blinding:*children: unclear*providers: unclear*outcome assessors: blinded

Combined Dietary Education and Physical ActivityGortmakerUSA1999

School children (year 6-8).Mean age: 11.7 yrs.48% female.

Intervention: school-based interdisciplinary intervention focused on decreasingTV viewing, decreasing consumption of high-fat foods, increasing fruit andvegetable consumption and encouraging increases in physical activity (n=641).Control: no intervention (n=654).Follow-up: 18 months (2 school years).

Change in prevalence of obesity in girls (%):C=2.2, I=-3.3Adjusted OR=0.47 (95% CI: 0.24 to 0.93, p=0.03).Change in prevalence of obesity in boys (%):C=-2.3, I=-1.5Adjusted OR=0.85 (95% CI: 0.52 to -1.39, p=0.48).

Random allocation: ten schools matched according totown, size and ethnic composition, randomised usingrandom number table.Blinding:children: unclearproviders: unclearoutcome assessors: unclear.

DonnellyUSA1996

School children (years 3-5).Mean age: 9.2 yrs.% female: not given.

Intervention: school-based multi-component programme of nutrition education,modified school lunches and increased physical activity (n=102).Control: no intervention (n=236).Follow-up: two yrs (the end of the intervention).

No impact on obesity (BMI C vs I baseline (SD): 18.1(2.6):17.9(3.8); C vs I at 2yrs: 19.3(3.2):18.9(4.3)).There was a statistically significant decrease in total energy and fat content ofschool foods and an increase in carbohydrate and fibre content and physicalactivity during school hours. However, over 24 hrs there were no significantdifferences in diet and physical activity between intervention and controlgroups.

Random allocation: unnamed number of primaryschools paired according to ethnicity, level of socialdisadvantage, and baseline characteristics randomisedto intervention or control. Poor rates of follow-up.Blinding:children: unclearproviders: unclearoutcome assessors: unclear.

SahotaUK2001

School children (aged 7-11yrs).Mean age: I=8.36 yrs,C=8.42 yrs.Sex: I=49% female,C=41% female.

Intervention: Active Programme Promoting Lifestyle in Schools (APPLES).Programme designed to influence diet and physical activity and not simplyknowledge. Targeted at the whole school community including parents,teachers and catering staff. The programme consisted of teacher training,modifications of school meals and the development and implementation ofschool action plans designed to promote healthy eating and physical activity(n=301 baseline, n=292 follow-up).Control: no intervention (n=312 baseline, n=303 follow-up).Follow-up: one year.

Weighted mean difference in BMI (I-C):Overweight children: -0.07 (95% CI: -0.22 to 0.08).Obese children: -0.05 (95% CI: -0.22 to 0.11).All children: 0 (95% CI: -0.1 to 0.1).

Random allocation: ten schools paired according tosize, ethnicity and level of social disadvantage,randomised by coin toss.Blinding:children: unclearproviders: nooutcome assessors: no.

MuellerGermany2001

School children.Mean age: 11.7 yrs.48% female.

Intervention: 8-hour school course of nutrition education including 'active' breaksgiven by a skilled nutritionist and a trained teacher. Included the followingmessages: 'eat fruit and vegetables every day', 'reduce intake of high fat foods','keep active at least 1 hr each day', 'decrease TV viewing to <1 hr per day'.(Additional family-based intervention plus a structured sports programme wereoffered to families with overweight or obese children and to families with normalweight children but obese parents), n=136.Control: no intervention (n=161).Follow-up: one year.

Median BMI (baseline, 1 yr):I=15.2, 16.1C=15.4, 16.3p=ns.Median triceps skinfold (mm) (baseline, 1 yr):I=10.9, 11.3C=10.7, 13.0p<0.01.

Random allocation: method not described.Blinding:Children: unclearProviders: unclearOutcome assessors: unclear

StolleyUSA1997

African-American girls(aged 7-12 yrs) and theirmothers.Mean age: I=9.9 yrs,C=10.0 yrs.62% of mothers and 19%of daughters were obese.

Intervention: 12-week culturally specific obesity prevention programme, focusedon adopting a low fat, low calorie diet and stressing the importance of increasedactivity (n=32).Control: general health programme, focused on communicable disease control,effective communication skills, relaxation techniques, and stress reduction(n=33).Both groups led by either a doctoral clinical psychology student or registered

Significant between group differences with treatment mothers consuming lessdaily saturated fat (-2.1 oz, p<0.05) and a lower percentage of calories from fat(-7.9%, p<0.001). Weight remained unchanged. Differences amongtreatment and control groups were noted for the daughters' percentage of dailycalories from fat (-3.9%, p<0.05).

Random allocation: method not described.Blinding:Children: unclearProviders: unclearOutcome assessors: unclear

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dietitian.Follow-up: 12 months (only 12 week data reported).

CaballeroUSA2003

American Indian schoolchildren (aged 7-9 yrs).Mean age: 7.6 yrs48% female.

Intervention: Pathways intervention to school children with four components:change in diet, increase in physical activity, classroom curriculum focus onhealthy eating and lifestyle, and a family involvement programme (n=879baseline, n=727 follow-up).Control: no intervention (n=825 baseline, n=682 follow-up)Follow-up: three yrs (the end of the intervention).

Intervention vs control change:*No significant reduction in percentage body fat (-0.2 kg/m2, 95% CI: -0.84 to1.31, p=0.004).*No significant difference in total energy intake (5.8 kcal, 95% CI: -40.0 to51.5, p=0.80).*No significant difference in physical activity (20.43 average vectormagnitude/min, 95% CI: -19.05 to 59.92, p=0.31).*Significant reduction in % energy from fat in school meals (-4.2%, 95% CI: -7.1 to –1.3, p=0.005).*Improved knowledge, attitudes and behaviours.

Random allocation of schools: stratified randomisationbased on % body fat.Blinding:*children: unclear*providers: unclear*outcome assessors: blinded

Neumark-SztainerUSA2003

Mainly overweight highschool girls who performedlittle daily activity.Mean age: 15.4 yrs.

Intervention: New Moves intervention instead of regular PE classes 5 days aweek for 4 months. Physical activity four times a week, and nutrition and socialsupport education sessions every other week. Each component consisted ofseveral interventions based on a framework of Social Cognitive Theory. Theintervention was followed by a two month maintenance component consisting ofweekly healthy-lunch meetings and discussions.Control: written materials on healthy eating and physical activity that weredistributed at baseline assessment.Follow-up: eight months.

Intervention vs control BMI:*No difference in mean BMI (I:C BMI: 26.64:26.65 kg/m2, p=0.96).*Significant progression in stage of change for physical activity in theintervention (38% progressed, 11% regressed) compared with the control girls(20% progressed, 24% regressed), p=0.0004.

Random allocation of 6 schools.Blinding:*girls: unclear*providers: unclear*outcome assessors: unclear.

SallisUSA2003

School children in grades 6to 8.Ages: 12-14 years.49% female.

Intervention: Daily PE; promotion of PA at school during leisure times; morelow-fat food choices at all school food sources; and policy changes to createhealthier school environments that support these interventions (n=12 schools).Control: No interventions (n=12 schools).Follow-up: two years (the end of the intervention).

Intervention vs control BMI:*Boys: significant difference in mean change in BMI between the interventiongroup (20.12 to 19.84 kg/m2) and control group (19.68 to 20.04 kg/m2) forbaseline and 2-yearly measurements, respectively (F=4.6).*Girls: no significant difference in mean change in BMI between theintervention group (19.76 to 19.88 kg/m2) and control group (19.52 to 19.73kg/m2) for baseline and 2-yearly measurements, respectively (F=0.0).

Random allocation of 24 schools.Blinding:*children: unclear*providers: no*outcome assessors: unclear.

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Dietary Education vs ControlThe Cochrane Review identified two studies, described as long-term on the basis that the period of

observation was one year or longer, that evaluated the effect of a dietary education intervention versus

control (186). One further study was identified that was of one year’s duration (208). These studies

are described further below.

Epstein et al (213) evaluated the effect of an increased fruit and vegetable intake dietary intervention

(n=13) against a control group which decreased intake of high fat/high sugar foods (n=13)(213). The

study focussed on 6 to 11 year old children from families with at least one obese parent. The

intervention was delivered to the parents. The changes in percentage of overweight in the children

after 12 months were -1.10% +/- 5.29 in the increased fruit and vegetable group and -2.40%+/-5.39 in

the decreased fat and sugar group. The differences in percentage of overweight were not statistically

significant.

A study by Simonetti et al (214) assessed the effectiveness of two levels of intensity of dietary

education aimed at reducing the prevalence of obesity and overweight in 1,321 kindergarten and

primary school pupils in the 3-9 year age bracket. Therefore, one school (n=367) received a high

intensity Multimedia Action (MA) strategy. MA involved the use of printed pamphlets, audio-visual

aids and the use of qualified staff who promoted the project within the school. Another school (n =

358) received a lower intensity "Written Action" (WA) strategy which involved the distribution of

printed pamphlet only. A further school (n=596) acted as a control school. At twelve-month follow-

up, Simonetti reports a 12.2% reduction in obesity and a 12.1% reduction in overweight in the MA

school with no significant changes in WA or Control schools. No further statistical analyses were

reported. Overall, smaller weight changes were found in obese students compared to overweight

students.

The latest study by James et al (208) assessed the effectiveness of dietary education aimed at

discouraging the consumption of fizzy drinks and hence reducing the prevalence of overweight and

obesity in 644 school children aged 7-11 years. Fifteen classes (n=325) received the intervention

consisting of 4x one-hour sessions spaced throughout the school year involving: good health education,

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promoting drinking water, composing music for a song with an anti-soft drink message, art

presentations and a classroom quiz. Fourteen control classes received no intervention (n=319). At the

end of the school year consumption of carbonated drinks over three days had decreased by 0.6 glasses

(average glass size 250ml) in the intervention group and increased by 0.2 glasses in the control group

(mean difference 0.7, 95% CI 0.1-1.3). Furthermore, the percentage of overweight and obese children

had increased in the control group by 7.5% compared with a decrease in the intervention group of 0.2%

(mean difference 7.7%, 95% CI 2.2-13.1%).

Physical Activity/ Reduction in Sedentary Activity vs ControlThe Cochrane review identified one long-term and two short-term studies (≥3 months and <1 years

duration) (215-217). One further short-term study was also identified by Robinson et al, 2003 (210).

These are discussed in detail below.

The single long-term study by Mo-Suwan et al, 1998 (216) evaluated a physical activity intervention

versus control. Specialists delivered a specific regimen of exercise (15 minutes of walking plus 20

minutes of aerobic exercise) to Thai kindergarten children (mean age 4.5 years, n=292), for 29.6 weeks.

Follow-up measures were taken at this time. At this initial evaluation at 29.6 weeks Mo-Suwan found a

reduction of the prevalence of obesity in the intervention pre-school children that nearly reached

statistical significance (P = 0.057). The study showed that intervention girls had a lower likelihood of

having an increased BMI slope than control girls (odds ratio 0.32; 95%CI, 0.18 - 0.56), while the

opposite was true for boys (odds ratio 1.08; 95% CI, 0.62 - 1.89). Data at 6 months post-intervention

has now been collected. Overall prevalence of obesity, using 95th percentile National Centre for

Health Statistics triceps-skinfold thickness cut-offs, in the control group decreased from 12.2% at

baseline to 9.4% at completion of the intervention at 29.6 weeks, and was 10.8% at 29.6 weeks plus 6

months. In the exercise intervention group, the prevalence of obesity was 12.9% at baseline, 8.8% at

29.6 weeks and 10.2% six months later. It is not known (information not available) if the changes at

29.6 weeks plus 6 months are statistically significant, but such small differences between groups are

unlikely to be clinically significant.

A short-term study by Flores, 1995 (215) also evaluated the effect of physical activity interventions

versus control. In this study, a 50 minute dance oriented physical activity curriculum replaced the

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regular physical activity sessions of 110 African American and Hispanic boys and girls aged 10-13

years. In all, students received 150 minutes of dance per week (over three sessions), and the

intervention ran for 12 weeks. Follow-up measures were taken at this time. Flores reports significant

reductions in BMI between intervention (I) and control (C) girls (BMI: -0.8 kg/m2(I), 0.3 kg/m2(C),

p<0.05), and in fitness (heart rate -10.9 beats/min (I), -0.2 beats/min (C); P<0.01). Results beyond 12

weeks are not available.

A further short-term study by Robinson, 1999 (217), evaluated the effect of an intervention aimed at

reducing sedentary behaviours (rather than promoting physical activity), versus control. Specifically,

the intervention aimed to reduce television, videotape and video game use in elementary school

children (mean age 8.9 years). This was undertaken by existing school staff and consisted of 18 (30-50

minute) lessons delivered over six months. Follow-up measurements were taken at this time. In this

study, after adjustment by mixed-model analysis of co-variance for the baseline values, age, and sex,

the intervention group (both boys and girls) had statistically significant relative decreases in all

measures of body fatness:

� BMI: intervention vs control change: 18.38 to 18.67 kg/m2 vs 18.10 to 18.81 kg/m2, respectively,

adjusted difference -0.45kg/m2 (95% CI -0.73 to -0.17), p=0.002;

� triceps skinfold thickness: intervention vs control change: 14.55 to 15.47mm vs 13.97 to 16.46mm,

respectively, adjusted difference, -1.47mm (95% CI, -2.41 to -0.54), p=0.002;

� waist circumference: intervention vs control change: 60.48 to 63.57 cm vs 59.51 to 64.73cm,

respectively, adjusted difference, -2.30cm (95% CI, -3.72 to -1.33), p<0.001); and

� waist to hip ratio: intervention vs control change: 0.83 to 0.83 cm vs 0.82 to 0.84 cm, respectively;

adjusted difference, -0.02 (95% CI,-0.03 to -0.01), p<0.001.

In addition, relative to controls, intervention group changes were accompanied by statistically

significant decreases in children's reported television viewing (p<0.001) and number of meals eaten in

front of the television (p<0.02). There were no statistically significant differences between groups for

changes in high-fat food intake, moderate-to-vigorous physical activity, and cardio-respiratory fitness.

Given that there was no assessment beyond six months post-intervention, it is not possible to

extrapolate the findings of this study to longer-term outcomes.

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Recently, Robinson et al, 2003 (210) completed a 12-week randomised controlled trial in California

that aimed to both increase physical activity and decrease sedentary activities, and was one of four pilot

studies for the GEMS (Girls’ health Enrichment Multisite Studies). The GEMS is a multisite obesity

prevention trial programme targeting 8-10 year-old African-American girls, sponsored by the National

Heart Lung and Blood Institute (218, 219). The pilot study intervention involved 61 girls and their

parents/ guardians from low-income neighbourhoods and consisted of after-school dance classes at

three community centres, and a five-lesson intervention delivered in participants’ homes that was

designed to reduce television, videotape, and video game use. The active control intervention consisted

of disseminating newsletters and delivering health education lectures. Goal rates of retention were

exceeded and participation rates were high except where transportation was lacking. At the end of the

twelve-week interventions, girls in the treatment group, as compared to the control group, exhibited

trends towards:

� Lower BMI: adjusted difference = -0.32 kg/m2, 95% CI -0.77 to 0.012, Cohen’s d=0.38 SD units.

� Lower waist circumference: adjusted difference = -0.63 cm, 95% CI -1.96 to 0.67, d=0.25.

� Increased after school activity: adjusted difference = 55.1 counts/minute, 95% CI -115.6 to 225.8,

d=0.21.

� Reduced TV, videotape and video game use: adjusted difference = -4.96 hours/week, 95% CI -

11.41 to 1.49, d=0.40.

� Improved school grades: d=0.51, p=0.07.

Significant changes were reported in the treatment group compared with the control group for:

� Reduced household television viewing: d=0.40, p=0.007.

� Fewer dinners eaten while watching TV: adjusted difference = -1.60 meals/week. 95% CI -2.99 to

-0.21, p=0.03.

� Less concern about weight: d=0.60, p=0.03.

Dietary Education vs Physical ActivityNo studies were found to match the Cochrane Review criteria for inclusion that compared a physical

activity intervention group with a dietary education intervention group.

Combined Effects of Dietary Education and Physical ActivityThe latest Cochrane Review identified four long-term studies (220-223) and one short-term study (224)

that examined the combined effects of interventions aimed at dietary education and physical activity.

27

Three more studies were also identified that had been published since the review and met the same

criteria for inclusion (207, 209, 211). These studies are discussed in more detail below.

One programme entitled "Planet Health", Gortmaker et al, 1999 (221), examined a behavioural choice

intervention which targeted school boys and girls in years 6 to 8 (ages 10 to 13). This programme

concentrated on the promotion of physical activity, modification of dietary intake and reduction of

sedentary behaviours (with a strong emphasis on reducing television viewing). Evaluation at two years

post intervention showed that the prevalence of obesity among girls in the intervention schools was

reduced compared with controls, controlling for baseline obesity (OR 0.47, 95%CI 0.24-0.93; p=0.03).

Among boys obesity declined among both control and intervention students however, after controlling

for co-variates, there was no significant difference in outcome (OR 0.85, 95%CI 0.52-1.39; p=0.48). In

addition, there was greater remission of obesity among intervention girls vs control girls (OR 2.16;

95%CI 1.07-4.35; p=0.04). Gortmaker reports that the intervention reduced television hours among

both girls (-0.58 hours; 95%CI -0.85 to -0.31; p=0.001) and boys (-0.4 hours; 95%CI -0.56 to -0.24;

p<0.001). In addition, the authors report an increased fruit and vegetable consumption in girls (0.32

serves/day; 95%CI 0.14 to 0.5; p=0.003), resulting in a smaller daily increment in total energy intake

among girls (-575 kJ; 95%CI -1155 to 0; p=0.05). Gortmaker concludes that reductions in television

viewing predicted obesity change and mediated the intervention effect (in girls but not boys). Among

girls, each hour of reduction in television viewing predicted reduced obesity prevalence (OR 0.85; 95%

CI 0.75-0.97; p=0.02). Of additional interest was the finding that measures of extreme dieting

behaviour remained unchanged (and low) throughout the intervention and were not different between

intervention and control schools.

In contrast, a study targeting elementary school children (years 3 to 5), that aimed to attenuate obesity

and promote physical and metabolic fitness via a nutrition and physical activity intervention

implemented over a two year period, found that while there were some positive changes in targeted

behaviours, on follow-up at the end of the two years, the intervention had no impact on obesity

(Donnelly et al, 1996) (220). However, the intervention resulted in statistically significant and positive

changes in food provided at intervention schools (decreases in total energy and fat, and increases in

carbohydrate and fibre (p<0.05)), and statistically significant differences in food provision, between

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intervention and control schools. In addition, this intervention resulted in small, but statistically

significant increases in the amount of activity undertaken in class (no p-values given). Unfortunately,

there appeared to be compensation outside school for these changes in diet and physical activity.

Therefore, over 24 hours there appeared to be no statistically significant differences in dietary intakes

between intervention and control groups, and the intervention group were actually less physically

active outside of the class than were the control group (no p-values given).

The APPLES study, Sahota et al, 2001 (223), assessed the impact of a primary school based

intervention which included teacher training, modification of school meals, and the development of

school action plans targeting the curriculum, physical education, tuck shops, and playground activities.

Ten primary schools in Leeds, UK, were randomised to either the intervention or control group. Data

were collected on 634 children aged 7-11 years. At 1 year, there was no difference in change in BMI

between the children in the two groups, nor was there any difference in dieting behaviour. However,

children in the intervention group reported higher consumption of vegetables (weighted mean

difference 0.3 portions/day, 95% CI 0.2 to 0.4), but fruit consumption was lower in obese children in

the intervention group (-1.0, -1.8 to -0.2). Sedentary behaviour was higher in overweight children in

the intervention group (0.3, 0.0 to 0.7). Global self worth was higher in obese children in the

intervention group (0.0, 0.3 to 0.6), but there was no difference in other psychological measures

(dietary restraint, body shape preference, self-perception). Process evaluation showed that the

APPLES intervention was successful in producing changes at the school level, in terms of changing the

ethos of the schools and the attitudes of the children, but had little effect on children's behaviour other

than a modest increase in the consumption of vegetables.

The fourth study which looked at the combined effects of dietary education interventions and physical

activity interventions was the Kiel Obesity Prevention Study (KOPS), Mueller et al, 2001 (222). This

differed from the other three studies as the same behavioural and educational messages were given to

all children AND their parents. The key messages were to i) eat fruit and vegetables each day, ii)

reduce high fat foods, iii) keep active at least one hour a day, and iv) decrease TV viewing to less than

1 hour a day. Data were collected on 1,640 children aged 5-7 years. At one year, there was no

difference in change in BMI between the children in the two groups. The median BMI of children at

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baseline was 15.2 in the intervention school and 15.4 in the control schools. At one year follow-up the

corresponding data were 16.1 and 16.3. Contrary to BMI, the one-year changes in fat measured by

triceps skinfold thickness (TSF) or sum of 4 skinfolds did reach statistical significance in favour of the

intervention group. (Overweight was defined by TSF >90th centile of a child reference population

from Germany). At baseline, the mean % overweight was 24.1 in the intervention school and 27.7 in

the control schools. At one-year follow-up there was no change in these figures.

Stolley et al, 1997 (224), trialed the efficacy of a culturally specific obesity prevention programme

designed for low-income inner-city African American girls and their mothers. This eleven-week (one

hour per week) programme focussed on culturally appropriate modifications of diet and activity, and

had a strong emphasis on experiential learning. On assessment at 12 weeks, results showed significant

differences between the treatment and control mothers, with treatment mothers consuming less daily

saturated fat (ounces) (-2.1oz, p<0.05) and a lower percentage of calories from fat (-7.9%, p<0.001).

However, weight remained unchanged. Differences among treatment and control groups were also

noted for the daughters' percentage of daily calories from fat (-3.9%, p<0.05). Longitudinal data has

been collected in this study, however, it has not been analysed and remains unreported.

The Pathways study was a randomised controlled trial involving a multicomponent, school-based

intervention for the primary prevention of obesity in public schools serving American Indian

communities (207). A total of 1704 children (school years 3 to 5, mean age 7.6 yrs) from 41 schools

were involved for three consecutive years. Interventions consisted of four components:

� Classroom curriculum: regular lessons designed to promote healthy eating and regular exercise.

� Food service: providing lower-fat school meals.

� Physical education: minimum of 3x 30-minute PE sessions per week plus exercises during recess

of 2-10 minutes duration.

� Family involvement: educational material designed to promote healthy eating and physical

activity, and family events at schools such as cooking demonstrations and healthy lifestyle

activities.

Results showed no significant change in % body fat in the intervention group compared with controls

(mean difference in BMI: 0.2 kg/m2, 95% CI: -0.84 to 1.31, p=0.004). There was a significant

30

reduction in the percentage of energy from fat in the intervention schools compared with controls

(mean difference % energy from fat: -4.2%, 95% CI: -7.1 to –1.3, p=0.005). However, there was no

difference in directly observed total energy intake (mean difference in total energy intake: 5.8 kcal,

95% CI: -40.0 to 51.5, p=0.80) despite results from 24-hr dietary recall that showed a significant

reduction in total energy intake (mean difference in total energy intake: -265 kcal, 95% CI: -437 to -94,

p=0.003). Motion sensor data showed similar activity levels in intervention compared with control

schools (mean difference in physical activity: 20.43 average vector magnitude/min, 95% CI: -19.05 to

59.92, p=0.31). Several components of knowledge, attitudes and behaviours were positively and

significantly changed by the Pathways intervention.

The New Moves study was a randomised controlled trial involving a multicomponent, school-based

intervention for the primary prevention of obesity in overweight adolescent girls who did very little

daily physical activity (209). Six high schools were randomised to control or intervention conditions

with 89 girls in the intervention group and 112 in the control group, averaging 15.4 years of age. The

intervention school participants received the New Moves programme for five days a week for four

months in place of the regular physical education class for academic credit. The interventions aimed to

bring about positive changes in physical activity and eating behaviours for weight loss/maintenance,

avoid unhealthy weight control behaviours and feel good about themselves. The main components of

the programme included physical activity four times a week, and nutrition and social support education

sessions that were offered every other week. Each component consisted of several interventions based

on a framework of Social Cognitive Theory (225). The intervention was followed by a two-month

maintenance component consisting of weekly healthy-lunch meetings and discussions.

Control school participants received written materials on healthy eating and physical activity that were

distributed at baseline assessment. At eight months, a final follow-up assessment was completed. At

baseline there was no significant difference in BMI between intervention and control girls (mean BMI

26.7 kg/m2); similarly, at four months (postintervention), there was no difference in mean BMI between

the intervention or control girls (I:C BMI: 26.64:26.65 kg/m2, p=0.96). In fact, there were no

significant changes in any of the outcome variables apart from a significant progression in stage of

31

change for physical activity in the intervention (38% progressed, 11% regressed) compared with the

control girls (20% progressed, 24% regressed), p=0.0004.

Sallis et al, 2003 (211) performed a randomized controlled trial of the effect of physical activity,

nutrition, and school policy change interventions on students in 12 middle schools3 compared to

students in 12 non-intervention middle schools in California. Students were aged from 12 to 14 years

with a mean enrolment of 1109 students per school of whom 49% were female. The primary aims of

the study were to increase total energy expenditure at school and decrease total dietary fat purchased at

schools. Reduction in mean BMI was a secondary aim. Intervention schools received daily physical

education and physical activity was encouraged during leisure time at school by providing equipment,

organised activities, and supervision. School food sources were regulated to provide more low-fat

choices and children were assisted and encouraged to bring lower fat lunches to school. Results

showed a greater increase in physical activity in intervention schools compared with control schools,

no significant difference in fat intake, and a significant reduction in BMI in intervention compared with

control boys although no effect was observed for girls.

Some of the major problems with study methodology are commented on briefly in Table 5. In

addition, measures of diet and physical activity are relatively weak estimates of actual behaviour. For

example, in these studies, dietary data were usually collected by recall of the past 24 hours' food intake

or by food frequency checklists. In ideal situations, dietary data should be collected over at least three

days, including one weekend day to provide best estimates of actual intake (226, 227). Furthermore,

while food frequency questionnaires are valuable in the clarification of major dietary patterns (228),

they are considered to be methodologically inappropriate for measurement of usual intake in

individuals (226, 227, 229, 230). A further problem with dietary records is the tendency for

respondents to under-report energy intake, with under-reporting of energy intake observed to be greater

in the obese and overweight (231, 232). The measurement of physical activity is similarly problematic

(233).

3 Middle school is equivalent to Forms 1-3 in NZ (Years 7-9). American children start school 1 year later than NZ children.

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SummaryIn summary, as discussed above and shown in Table 5, studies examining combined dietary education

and physical activity interventions in children have thus far failed to demonstrate any significant impact

on BMI or obesity. Dietary education delivered by multimedia strategies to primary and kindergarten

children, and education designed to reduce soft drink consumption in primary school children, were

significantly associated with reductions in obesity prevalence. Physical activity interventions and

interventions aimed at reducing sedentary activity were also associated with significant reductions in

BMI in two studies and a trend towards significant reductions in BMI in the remaining two studies.

However, the public health implications of these findings are less certain for the following reasons:

� Only 14 studies were found for inclusion in this review.

� No studies have compared the relative efficacy of dietary vs physical activity interventions.

� There were multiple differences between studies in terms of study design and quality, target

population, theoretical underpinning of intervention approach, delivery of interventions, and

comparable outcome measures, making it impossible to combine results.

� The generalisability of study results is limited as most studies were done in the USA on children

aged 7-12 yrs. In addition, the characteristics of nonparticipants and those lost to follow-up was

not documented.

� Studies used different methods to estimate overweight and obesity, although Cole, 2000 (3),

proposed standardised international definitions/cut-points that are now being used globally.

� As discussed above, measurement of dietary intake and physical activity has been flawed.

� The effectiveness of interventions and delivery of interventions is likely to be limited by poor

understanding of the interface between individuals’ behaviour and the environment.

� Obesity prevention interventions may be considered too difficult to pursue in societies where the

complex socio-political environment overwhelmingly supports our driving physiological goals to

be sedentary and well fed.

Therefore, the difficulties in conducting research or interventions in this area and hence the limited data

at hand, makes it difficult to conclude that one strategy or combination of strategies is more important

than others in the prevention of childhood obesity. While existing literature suggests that limiting

33

children’s sedentary behaviours, increasing physical activity, reducing soft drink consumption, or

dietary education delivered by multimedia strategies may be effective in certain groups of children,

there remains an urgent need for well-designed studies in the area. The Cochrane Review group have

suggested that future studies should attempt to overcome the problems listed above, and also examine

the importance and effectiveness of those behaviours that could be targeted by obesity prevention

interventions. In addition, study designs should be based on the best and most appropriate available

theoretical models of behavioural change (186).

Planned Obesity Prevention TrialsInternationally, there are a number of major childhood obesity prevention trials currently planned or

underway that will add important information to the evidence base (186, 218, 234-237). In New

Zealand, there are currently two major trials being established that aim to prevent overweight and

obesity in children. The first is part of an Australasian study, the Pacific Obesity Prevention in

Communities trial, being co-ordinated by Boyd Swinburn (Deakin University, Australia) and Robert

Scragg (Auckland University, NZ). This study is a multi-component, randomised controlled trial

involving Years 9-12 children from eight high schools in South Auckland, and is scheduled to begin in

Term 2, 2005, and is discussed in more detail below (Appendix One). The second study, ‘Activ8’, is a

randomised-controlled trial that involves 65 primary schools in Waikato in a two-year physical activity

programme, with 65 comparison primary schools (238). The study will be funded by Waikato District

Health Board and begins in August 2004.

Macroenvironmental InterventionsCurrently, there are no studies that have directly examined the effects of changes in the physical/

political, economic, or sociocultural macroenvironments (Table 3), on the population prevalence of

overweight and obesity. However, most authors agree that action at societal level is required to counter

the macroenvironmental influences on physical activity and dietary intake, and changes are being

considered and implemented in policy, transportation/town planning, and the food industry at global

and national levels. Internationally, the International Obesity TaskForce (IOTF) has recently held a

workshop to develop an international framework for guiding decision-making in obesity prevention

that acknowledges both the paucity of evidence available for obesity prevention interventions, and the

importance of macroenvironmental factors (239). Macroenvironmental interventions that are proposed

or underway are discussed at the end of the next section.

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Obesity Prevention Programmes Operating in Auckland

Swinburn’s ecological model (Figure 4) was used as the framework for describing the aetiology of

obesity, and was valuable in identifying the influence environmental factors have on energy balance.

The elements of the ecological model could be rearranged into the classic epidemiological triad of host,

vector and environment (Figure 5) (75, 240). This can be used as a framework for strategies of action

to prevent weight gain, within the broader framework of a settings or interventions approach. A

settings approach is used below to present the existing programmes in Auckland that may help prevent

obesity. It is useful to consider the components of the triad represented by the interventions delivered

for programmes within each setting, as this helps ensure that all targets for intervention activities are

addressed. In addition, the triad has the advantage of providing a framework for obesity prevention

interventions that could allow comparisons with interventions used to control other epidemics e.g.

smoking, coronary heart disease, injuries and infectious diseases (241-243), and is described in detail

below. Similarly, the triad has been used to structure the final chapter outlining recommended

strategies for action.

Figure 5: Epidemiological triad as it applies to obesity. The circles refer to the predominantstrategies to address each corner of the triad. Source: (194).

Host factors for weight gain include biological, behavioural and cognitive factors, while host-based

interventions to prevent obesity at a population level primarily consist of educational strategies. As

shown in Figure 5, vectors for over-consumption are predominantly energy-dense foods and drinks,

Policy, socialchange

Education,behavioural &

medicalinterventions

Technology

HOST(biology, behaviour, physiological adjustments)

ENVIRONMENTS(physical, economic,

policy, socio-cultural)

VECTORS(energy-dense food and drinks,

large portion size, energy-saving& entertainment machines

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and vectors for low energy-expenditure include machines/devices that are labour-saving or promote

passive recreation. Many vector-based strategies for preventing obesity involve technical/engineering

solutions, for example, reducing the energy density of manufactured foods. The environment

incorporates the physical, economic, policy and sociocultural environments. Environmental changes

generally need a strong lead from policy and/or social change. As detailed by Swinburn (194), lessons

from other epidemics suggest that environmental strategies are often the most powerful and sustainable.

In addition, serious investment in media campaigns and systemic changes are usually needed; social

attitudes often follow policy changes, and broader government policies that impact on socioeconomic

status gradients affect the risk for obesity and opportunities for interventions among low SES groups.

An important lesson from other epidemics is that all three corners of the triad need to be addressed

simultaneously i.e. individual, environment, and food/activity vehicles (194).

Appendix Two shows the questionnaire that was used to structure interviews with providers in the

Auckland region. Appendix Three gives the list of Auckland providers interviewed for this project. A

summary of results for each programme is presented in Appendix 4. As discussed previously, evidence

for the effectiveness of interventions is sparse and sometimes lacking. In addition, a number of the

programmes currently operating in Auckland might be expected to help prevent childhood overweight

and obesity, but do not have obesity prevention as a goal and do not measure weight-related outcomes.

However, all programmes have been included as some could possibly be altered to include obesity

prevention as a primary aim and weight as a primary outcome. Auckland programmes are listed in

Appendix 4 and described below, ordered according to the settings of interventions. Any gaps in

services or barriers to services identified by providers have also been described. Several of the

providers interviewed were able to suggest roles that ARPHS could or should take in the prevention of

childhood obesity, and these are also summarised below.

Programmes

Schools’ Setting: Multi-component Interventions

Adolescent obesity & diabetes prevention programmeThe AIMHI (Achievement in Multicultural High Schools) Project was an initiative of the Ministry of

Education established in 1995 to improve the educational achievement of students in schools that serve

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low socio-economic communities and have a high percentage of Maori and Pacific students (244). It

involved students in nine Decile One urban secondary schools, eight of which were in South Auckland

and one in Porirua. A survey of needs of the AIMHI students was carried out from which it was

determined that children were eating a high proportion of junk food during school with associated

significant behavioural and health outcomes noted by teachers, such as headaches, faintness, fatigue,

and inattentiveness (245). In addition, Year 9 (ages 13-14 years) assessments of AIMHI school

children revealed that >30% were obese (Jude Woolston, personal communication).

This resulted in the establishment of the NEW (Nutrition, Exercise and Weight) working party,

consisting of a group of concerned stakeholders in South Auckland, with the aim of assessing,

developing, and producing a programme to encourage healthy lifestyles in Year 9 AIMHI school

children. The NEW working party subsequently collaborated with the Diabetes Projects Trust (DPT)

in South Auckland to produce the ‘adolescent obesity & diabetes prevention programme’. This

programme is currently operating in two South Auckland schools, McAuley and Southern Cross

colleges, with plans to extend to three other Auckland AIMHI schools (Mangere, Hillary Collegiate

and Tongaroa). The multi-component intervention consists of the following:

� A roadshow to explain the interventions, including a healthy eating/ PA video developed by DPT.

� Workshops one morning a month on aspects of healthy lifestyles including nutrition, Type 2

diabetes, and physical activity education. These educational sessions include guest speakers,

videos, quizzes, spot prizes, free apples etc, and are currently being run by DPT staff (dietitian,

public health nurses) and the school nurse. DPT have also produced three written educational

aides, leaflets on the prevention of Type 2 diabetes, a comic strip on diabetes prevention, and a

school diary with information about Type 2 diabetes.

� Lunch-time physical activity classes 3x a week. For example, Southern Cross College did a survey

of year 9 students to determine, amongst other things, whether children would attend a lunch time

exercise session (81.3% answered ‘yes’) and what activities they would prefer to do. Currently

they have Hip–Hop and Taebo classes supported by Manukau City Council (MCC).

� A healthy tuck-shop contract between the provider and the school Board of Trustees. For example,

the Southern Cross contract stipulates that food must conform to the National Heart Foundation’s

(NHF) guidelines.

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� Removal of all food and soft drink vending machines, although Southern Cross has two remaining

that now contain healthy food snacks only.

� School health councils run by students for assessing and instigating ongoing health activities.

With respect to the epidemiological triad, this programme targets the host through physical activity and

workshop interventions, the vector through provision of healthy food and removal of vending

machines, and the environment by making unhealthy food less accessible through a healthy tuckshop

policy.

Interventions are planned to continue for one year. Sustainability and expansion to other AIMHI

schools will depend on obtaining further funding (for PA services and for DPT services as they are

currently unfunded). Evaluation of the roadshow video is planned. Currently there are no formal

evaluations of the interventions or any assessment of their effect on BMI. Other needs were also

identified, such as the need for written information primarily targeting obesity prevention and for other

providers to complement the limited resources of the DPT. There was also an identified need for a

coordinator to manage and sustain the programmes operating in schools, and for a coaching/mentoring

programme to help children set, achieve and maintain goals.

DPT suggested that ARPHS could take a role in coordinating community PA/ nutrition demonstrations.

ARPHS could also keep an up-to-date inventory of effective childhood obesity prevention interventions

and keep providers informed of new developments in the research literature. In addition, ARPHS

could provide sound nutritional advice/education to school tuck shop retailers, aide in the formulation

of a generic school tuck-shop food policy, and provide BMI charts by age for overweight and obesity to

providers.

Health Promoting SchoolsThe Health Promoting Schools (HPS) programme commenced in Auckland primary schools in 1997. It

is part of an international movement originating from the promotion of healthy schools and the

development of the Ottawa Charter for Health Promotion by WHO (246, 247). HPS take a community

development, health promotion approach focusing on the needs and priorities identified by each

individual school, with activities in three main areas: providing health education, implementing health-

related policies, and involving outside agencies and professionals in the planning and delivery of health

38

programmes. Recently, the Tipu Ka Rea three-level model was introduced by CMDHB (Kidz First) as

a framework for developing HPS in a step-wise, sustainable fashion (248).

Various facilitators from governmental agencies and non-governmental service providers in the

community are involved in supporting HPS. Facilitators in Auckland are based at ARPHS, CMDHB

(Kids First, Pukekohe Public Health Nurses’ Office), MCC, ADHB (Auckland District Health Board,

Community Child Health and Disability Service), and WDHB (Community Child and Family

Services). Three facilitators are developing a Maori focus in Central and West Auckland. Providers

involved in delivering HPS services include: NHF (School Food Programme, Jump Rope for Heart),

ADHB (Food With Attitude = FWA, public health nurses - two public health nurses also provide

nutritional support for developing food policies in secondary schools), Physical Education NZ (Te Ao

Kori), SPARC (Sport and Recreation NZ), Sport Auckland (Young and Active, the PA programme run

in conjunction with FWA), Harbour Sport (More Kids More Active More Often programme pilot),

MCC (Food in Schools, School Gardens Project, annual mini olympics), AUT (research with HPS in

North Auckland looking at how BMI varies with activity level, measured by pedometer, and ethnicity –

not an ‘intervention’ per se), YMCA (Massey, Henderson), Pasifica Healthcare PHO (Primary Health

Organisation) etc.

Initiatives taken within schools are variable as they are dependent on the priorities identified by

individual schools. Initiatives aimed at preventing obesity are not yet operating and BMI has not been

assessed as an outcome for any existing HPS programme, with the exception of FWA, which is aimed

at treating rather than preventing obesity. A physical activity pilot programme is currently being run at

Stanmore Bay school by Harbour Sport and the Ministry of Education that aims to increase children’s

PA (see ‘More Kids More Active More Often’, below for details). These, and similar initiatives, such

as plans for a dietitian and HPS facilitators to meet with school tuckshop operators to encourage the

introduction of healthier food into schools, the development of Tii Raakau and Kapa Haka dance, and

changes to how the school Health and Physical Education curriculum is taught, are not being evaluated

as obesity-preventing interventions. Various other examples of HPS initiatives for increasing PA or

improving nutrition are available on the HPS website (249).

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Some of the programmes being run in HPS have been evaluated, i.e. FWA, the NHF School Food

Programme and WSB, and these are discussed below. However, the effect on weight outcomes has

only been assessed for FWA. HPS evaluations are available on the HPS website (250). While some

programme outcomes were evaluated, for example, the change in profitability of tuckshops following

the introduction of healthier foods, no obesity prevention programmes were identified or evaluated

(251). Ongoing funding is provided by the Ministry of Health.

Problems were identified in focus, coverage, communication, sustainability, and programme delivery

of HPS.

� (1)Focus: There is a need for schools prioritising obesity prevention to state their objectives

clearly, and measure appropriate outcomes.

� (2)Coverage: The coverage of HPS is currently limited: many primary schools are not HPS, there

is no equivalent programme running in Secondary schools apart from the limited coverage of

AIMHI school programmes, and Kura Kaupapa have effectively been excluded due to a lack of

exclusively Maori resources, for example, the School Food Programme is not exclusively in

Maori. Similarly, Asian children are being excluded due to a lack of Asian resources and a lack of

understanding of issues unique to Asians. For example, Asian children at North Shore HPS have

been observed to be reluctant to bring traditional Asian food to school, with school lunches being

replaced with less healthy bought food.

� (3)Communication: Communication between HPS Facilitators and their HPS/ community PA and

nutrition providers was identified as a problem by Facilitators. Facilitators did not have current

lists of HPS, their identified health priority needs, or details of programmes/activities being

implemented in HPS. Facilitators also lacked a comprehensive overview of the Auckland

providers working in childhood PA and nutrition.

� (4)Sustainability: School-based activities that run during school time need to be related to the

curriculum if they are to receive Ministry of Education support. Teachers are unable to provide

‘extra’ services and often lack competency in nutrition and PA education. Collaboration and

communication between community service providers and HPS is often fraught by different

objectives and short-term funding/planning goals.

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� (5)Programme delivery: A comprehensive approach is needed in HPS to inform and involve

parents, staff, children, and providers. Where schools have prioritised childhood obesity

prevention, nutrition and PA components both need to be included.

HPS staff suggested that ARPHS could market/profile HPS to make other providers aware of the

potential role that they could play in HPS. It was also suggested that ARPHS could take a more

proactive role in keeping and distributing up-to-date lists of HPS, programmes and providers in HPS,

and potential providers that could play a role in HPS. ARPHS could provide nutritional information to

schools and their ‘stamp of approval’ for programmes meeting sound nutrional criteria.

The Pacific Obesity Prevention in Communities (OPIC) ProjectThis trial resulted from collaboration between The Wellcome Trust biomedical research charity and the

governments of Australia and NZ to tackle preventable diseases in the Asia-Pacific region.

Researchers in NZ (Associate Professor Robert Scragg at the University of Auckland) and Australia

will look at the effectiveness of a range of interventions to prevent childhood obesity in Fiji, Tonga,

NZ, and Australia (252). Funding of ₤2,350,000 for the OPIC project trial was provided by the

Wellcome Trust biomedical research charity, the Australian National Health and Medical Research

Council and the NZ Health Research Council. As mentioned previously, this trial begins in Term 2 of

2005 and involves eight Decile 1 or 2 High Schools in Mangere, South Auckland, that have a high

proportion of Pacific children. It is a multi-component, randomised-controlled trial involving Years 9

to 12 children, and will run for 30 months. The details of school-based interventions have not yet been

released but will incorporate activities from a number of provider groups including: MCC (HPS), the

adolescent obesity & diabetes prevention programme mentioned above, Counties Manukau Sport, and

5 Plus a Day. A new curriculum package aimed specifically at obesity prevention that will target Years

9 to 11 and include a component on decreased TV viewing, will also be developed. In addition to the

schools-based setting, 26 Pacific churches in Mangere will be targeted by the diet and activity

programme developed for Pacific churches by the NHF Pacific Islands Heartbeat Programme.

Outcome measures for school children will include BMI, abdominal circumference, and bio-impedance

to measure body fat, individual measures of diet and PA, and audits of the school environment. In

addition, the level of church-based activities that might affect the target age group will be assessed and

41

used to develop a score of church exposure to interventions to rank students. This study was calculated

to involve an effective sample size of approximately 1500 students.

Waitemata DHB Wellbeing Schools’ ProjectThe WDHB Wellbeing Action Group grew from WDHB’s involvement in the cardiovascular

prevention project for which it receives funding for public health interventions. In 2003, the prevention

of childhood obesity was identified as a major aim and the Waitemata Wellbeing Action Group,

consisting of various stakeholders (e.g. WDHB coordinator, local Sports Trusts and SPARC, local

councils and ARC, NHF, local PHOs, ARPHS public health dietitian, HPS, public health nurses, DPT,

and AUT) was developed and organised by the WDHB public health coordinator. From this group,

the Wellbeing Schools’ Project was developed which is a proposed collaborative model for schools in

the Waitemata district that aims to improve nutrition and physical activity to prevent an increase in the

prevalence of obesity. Currently, the groups involved in programme delivery include: Harbour Sport,

NHF SFP, HPS, Team Solutions (Auckland College of Education, for teacher education and curriculum

support), and the North Shore City Council (for school travel plans and WSB).

A three-tiered approach to interventions is proposed that will allow schools to progress through the

different levels as they feel able (this 3-tiered approach is similar to the Tipu Ka Rea three-level model

introduced by CMDHB (Kidz First) as a framework for developing HPS in a sustainable fashion

(248)). A 2-3 year plan has been proposed that will allow all 172 schools in the Waitemata district to

be approached and assisted with at least one Level, with the planning, marketing and recruiting of

schools to take place between July 2004 and January 2005. Level 1 involves awareness-raising

concerning health issues, wellbeing issues, and available programmes, and school-initiated change.

Level 2 involves schools engaging in three main interventions: the NHF’s SFP, the SPARC-led

SportsMark programme, and curriculum-based education workshops led by Team Solutions. The

SportsMark for schools is a mark of quality in the delivery of sports services to young people. It is

about best practice and uses a self-review tool that is based on the principles of the National Junior

Sport Policy (253). Level 3 involves programme extensions/innovations and becoming leader schools

used as examples for others. In addition, WDHB is looking at an initiative to schools, at principal/

school board CEO level, to get schools to agree to remove sweetened carbonated drinks from vending

machines. Other initiatives could also be discussed and introduced over time.

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There are plans to evaluate the project by AUT or the University of Auckland, although the specific

measured outcomes sought are not yet available. Funds are required to cover 3 FTEs (one each for

Sports Trusts, Team Solutions, and NHF), marketing, project management, and project evaluation. The

Waitemata Wellbeing Action Group identified several problems with service delivery to schools, which

it has sought to address through its schools project, as follows: schools want increased coordination

between programme providers to schools with a central organiser; schools want PA programmes to be

delivered by sports bodies rather than by teachers who are already overstretched; there is a need for one

or more dietitians working in health promotion as there are currently none employed by WDHB;

despite their health promotion brief, PHOs currently have a patient-oriented approach to health

promotion interventions rather than the community or population focus needed for obesity prevention

efforts.

Schools’ Setting: Nutrition Interventions

The School Food ProgrammeThe NHF School Food Programme (SFP) was introduced to NZ primary and secondary schools in

1989. The SFP is a health promotion programme which aims to improve the health of the school

community by increasing children’s access to, and knowledge of, healthy foods. Recognition of

achievement and motivational support is provided by a four-levelled Heartbeat Award that is awarded

to schools meeting criteria in the following areas:

� Providing food choices consistent with the Food and Nutrition Guidelines (254) by ensuring that

an appropriate school food and nutrition policy is implemented.

� Promoting/marketing healthy foods to students, staff, parents and caregivers.

� Nutrition education in the classroom using units developed from the ‘Health and Physical

Education’ school curriculum.

� Promoting nutrition to the wider school community.

The annual cost of the SFP nationally is $700,000 per annum and is funded largely by the Ministry of

Health (MoH).

Although the original SFP design did not incorporate evaluation measures and therefore did not collect

baseline data or establish a control group, three outcome evaluations have been undertaken since its

43

inception, in 1992, 1999, and 2004. The 1992 outcome evaluation showed that participation in the SFP

had influenced sales with schools reporting increased sales of low-fat, low-salt, low-sugar items and

decreased sales of high-fat, high-sugar, high-salt items (255). A study done in 1999 measured the

impact of the SFP on food sales in NZ schools (256). Increasing level of participation in the SFP was

found to be significantly associated with a reduction in sales of doughnuts and cream buns (p=0.01),

pies and sausage rolls (p=0.009), crisps (p=0.0065) and sweets (p=0.004). Sales of sandwiches and

filled rolls increased (p=0.0005). Although this study was limited by the use of self-reported data,

results indicated that the SFP was successful in achieving its aim of influencing the school food

environment by improving healthy food choices.

The SFP was reviewed and rewritten in 1998 following the identification of a number of key issues,

including a lower than expected uptake of the SFP, and limited flexibility within the programme to

differentiate between variable effort by schools. A pilot of the modified programme was trialed in

1999-2000, and involved revising the Heartbeat Award criteria to link closely with the achievement

objectives outlined in the Physical Education Curriculum, and introducing the four-levelled Heartbeat

award system (257). It was externally evaluated in 2000 by Holibar-Fidler (258), with results

suggesting that the SFP was fulfilling its aims of improving the school food environment and raising

awareness of healthy eating amongst staff and students. Results from the 2004 evaluation will not be

available until July 2004. Obesity prevention was not an aim of the SFP and weight-related outcomes

have not been measured.

The main problem identified with service delivery has been with obtaining long-term support for the

SFP. This was thought to be largely determined by the school principal’s attitude to the programme

and the existence of competing needs and priorities within the school.

5+ A DayFive-Plus A Day is an international programme that began in the USA in 1991 as a partnership between

the vegetable and fruit industries and the US Government. It aims to increase the average consumption

of fruit and vegetables to at least five or more servings every day (one serving fits in the palm of a

hand), with the long-range goal of reducing the incidence of cancer and other chronic diseases by

eating at least five servings per day of fruit and vegetables (259). The NZ Children’s Nutrition Survey

44

showed that 60% of NZ children ate three or more vegetables per day and 40% ate two or more

servings of fruit per day (12). Of older children (11-14 years-old), 39% of males and 36% of females

ate fruit at least twice a day compared with 46% and 55%, respectively, of younger children (5-6 years-

old). Fried hot potato chips were included in ‘vegetables eaten’ and were the most frequent vegetable

eaten by 65% of children. As discussed above, there is reason to conclude that fibre-rich diets

containing non-starchy vegetables, fruits, whole grains, legumes, and nuts, may be effective in the

prevention and treatment of obesity in children (196, 197). In addition, WHO has endorsed 5+ A Day

as a tool in the fight against obesity following the International 5+ A Day Conference in 2003 (260).

Nevertheless, prevention of obesity is not a primary aim of the 5+ A Day programmes, and children’s

BMI or other weight-related outcomes have not been measured.

Interventions for children are targeted at educators in early childhood centres and primary schools, and

have been in operation since 1994 in primary schools and 1998 in preschools. Recruitment of schools

and preschools usually occurs during an annual week-long campaign which results in approximately

1000 schools enrolling; 1405 preschools enrolled in 2003. Subsequently, a further 100-200 kits per

month are requested by schools and preschools. A resource kit is provided to each teacher in enrolled

schools which includes nutrition activities that have cross-curricular links, posters, CDs, stickers, and

website-based resources (http://www.5aday.co.nz/news/index.html). Resource materials are also being

sent to the NHF, Cancer Society, and secondary schools’ food technology educators etc. Further

intervention in secondary schools is limited by a lack of familiarity with other parts of the secondary

school curriculum that could usefully incorporate the 5+ A Day resource.

Baseline data for 5+ A Day was collected in 1995. This was followed by an evaluation in 1999,

conducted by Research International, which showed that the average number of servings eaten per day

had increased to 4.4 compared with 3.9 in 1995, with 44% eating 5+ a day compared with 31% in 1995

(261). Subsequently, a telephone survey (of adults only) identified Pacific people as having the lowest

intake of fruit and vegetables, followed by Maori (261). It also identified key barriers to eating fresh

fruit and vegetables in these groups, viz knowledge concerning the relationships between food and

health, and knowledge of the cost, planning, and preparation of fresh foods. More recently, ACNielsen

conducted a questionnaire-based survey (8163 respondents) of New Zealand adults’ PA and nutrition

45

on behalf of the Cancer Society of NZ Inc (262). This showed that the most common perceived

barriers to eating fruit and vegetables were the cost of fruit (34%) and vegetables (30%), and the rapid

spoilage of fruit (28%) and vegetables (24%). In addition, low fruit and vegetable intake was

associated with a greater proportion of obesity (20%) than those with recommended or higher intakes

(14%), and a lower proportion of regular activity (35% vs 47%).

Consumer research of school children in 2001 showed that 73% of children had daily fruit or

vegetables in their lunchboxes (263). A further external evaluation was done recently to assess the

impact of the 5+ A Day campaign on consumer knowledge and behaviour, and results are currently

being analysed by Massey University, Albany. Two research projects have also been undertaken by

Massey University, Albany: (1) a trial to compare the acceptability and intake of fruit in children from

ten primary schools receiving free fruit, with children from ten primary schools not receiving free fruit.

The trial was funded by the MoH, with approximately 2000 children from low decile primary schools

involved. Results showed a significant increase in fruit intakes in those who received free fruit

although the effect of the intervention had disappeared within six weeks of the intervention ceasing (Dr

Ashfield-Watt, personal communication). (2) An ongoing study to compare the knowledge and food

habits of children in schools which have received 5+ A Day teachers’ resources, with schools which

have not received these resources.

Funding for the 5+ A Day programme in NZ comes from the MoH and the fresh fruit and vegetable

industry, United Fresh NZ Inc, which owns the 5+ A Day brand in NZ. The programme costs

approximately $400,000 per year. Identified gaps in service include a lack of staff for visiting schools

and other settings as the 5+ A Day programme consists solely of 1.5 FTEs. In addition, further work

with secondary schools is needed to identify opportunities for incorporating the 5+ A Day programme.

Public health dietitians have also noted that 5+ A Day does not promote tinned or frozen fruit and

vegetables although they are equivalent to fresh fruit and vegetables with respect to nutrition and health

benefits (Kate Sladden, personal communication).

Breakfast in SchoolsResearch shows that breakfast is intimately linked with health. It has been shown to improve attention,

concentration, and test scores for memory, cognition, and verbal fluency (264-270). In addition,

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regular nutritious breakfasts can help control body weight by decreasing dietary fat consumption and

minimising impulsive snacking (271). Studies have also shown that people who consume breakfast are

less likely to have excess body fat, and those who are overweight have been shown to eat less breakfast

than their leaner counterparts (266). Furthermore, the NZ Children’s National Nutrition Survey

showed that children from ethnic groups containing the greatest proportion with lower socioeconomic

status (Maori and Pacific), were also the least likely to eat breakfast at home before school, and the

most likely to be overweight or obese (12).

The NZ Nutrition Foundation (NZNF) has been running a national healthy breakfast in schools

campaign in August every year, since 1997. Targeted primary schools and preschools are supplied

with healthy breakfasts provided by the food industry. Breakfasts are accompanied by a breakfast

resource kit for teachers that links with the schools’ ‘Health and Physical Education’ curriculum. Low-

decile primary schools are selected preferentially although schools are also targeted to achieve good

geographic and population-based spread. Maori and Pacific are also targeted through preschools and

Pacific churches. The programme reaches approximately 6,000 children annually with up to 250

children per school receiving breakfasts. Cost is approximately $200 for 30 children. Programmes in

schools are operated by Public Health nurses, teachers etc; schools provide the required utensils,

community sponsorship sometimes provides extras, and the NZNF organises the programme. This has

often led to schools developing their own breakfast programmes, and Manukau City Council also

operates its own breakfast in schools programme.

Evaluation of the campaign was performed in 2002 by a dietetics student who assessed qualitative

information gained from focus groups involving 34 children aged 6-13 years (272). Results showed

that 70% of participants always ate breakfast, 12% sometimes, and 18% never. However, there was no

baseline data to compare results with. Nor were results directly comparable with those from the

National Children’s Nutrition Survey which measured the proportions of children who usually ate

breakfast (86.2% of males and 79.2% of females) (12). Seventy-one percent of participants reported

changes in their eating habits including having breakfast and choosing cereals in place of left-over

dinner. Barriers to eating breakfast were also assessed. Teachers noted that on the day of breakfasts,

children appeared calmer and there were no reports of hunger. However, it was also reported that

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unless families were involved in the programme, it was difficult to change eating habits within

families. Industry has also carried out consumer research to look at changes in the sales of breakfast

food, and changes in consumer profiles. The effect of the breakfasts in schools programme on weight-

related outcomes has not been measured.

The NZNF thought that nutrition in schools could be improved by all schools having a written,

enforced food policy, and by involving the food industry as partners in helping to improve the quality

and portion sizes of food supplied to school canteens. The NZNF also felt that there was a need for

PHOs to be up skilled in imparting nutrition information. Efforts have been made in the past to add a

PA component to the breakfast campaign, in the form of WSB, but the food industry have been

unwilling to sponsor this initiative. The effectiveness of the breakfast programme is impaired by

principals and teachers lacking the confidence/knowledge to teach nutrition, or having uninformed

ideas about nutrition that are difficult to change.

The NZNF suggested that ARPHS and MoH could work alongside the food industry to produce healthy

nutrition policies for the industry, put healthy nutrition messages in Supermarkets, and produce healthy

food messages.

Nutrition Education in Schools and Home EconomicsThe NZ schools’ ‘Health and Physical Education Curriculum’ (HPEC) (273) is compulsory up to and

including Year 10, and also provides the basis for senior students’ studies in Home Economics (HE)

after Year 10. The curriculum replaced past syllabuses in health, physical education, and home

economics. The HPEC covers a wide range of health-related issues, with food and nutrition and

physical activity being key areas of learning relevant to obesity prevention, although obesity prevention

is not directly targeted as an achievement objective. Most nutrition education in schools is taught in

HE, which is usually introduced between Years 6 and 8. There are some related papers such as Food

Technology and Hospitality, however these emphasise food production processes and food hygiene/

safety, respectively, rather than nutrition. In HE years 11 to 13 there is some leeway given regarding

the specifics of what is taught provided that a minimum of 24 credits are obtained from certain defined

achievement and unit standards (274, 275) to satisfy NCEA (National Certificate of Educational

Achievement) requirements. Only three of the achievement standards are likely to encompass learning

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in the area of obesity prevention, one is taught in Year 12 (AS90243: determine and address a

nutritional concern for a targeted group), and two in Year 13 (AS90531: explore a current nutritional

health issue in NZ; AS90532: examine the nutrient content of food to meet individual needs).

However, none of these standards are specific enough to ensure that obesity prevention is taught.

Schools’ Setting: PA Interventions

Jump Rope for HeartJump Rope for Heart (JRFH) is a nationwide, primary school based programme that promotes physical

fitness through a range of curriculum-based skipping skills and activities, and has been operating in NZ

schools for more than 18 years. At the end of the 10-week JRFH course, fundraising days are held to

recover the programme’s running costs and raise funds to assist NHF research projects. JRFH formed

a partnership with Pump water in 2003, with the aim of augmenting the programme to reach more

children, and providing extra incentives for children to participate in JRFH (276). More recently,

training workshops for teachers have been funded, in collaboration with the Todd Foundation, that aim

to increase teachers’ understanding, knowledge and confidence in the programme, and its links to the

Health and Physical Education Curriculum (277). The programme is to be evaluated in 2004, although

weight-related outcomes are not being considered. It costs $400,000-500,000 per annum nationally,

and is largely funded by Pump water (owned by Coca Cola). There are two Auckland-based JRFH

field officers who promote the programme and fundraise in Auckland schools.

More Kids, More Active, More OftenMore Kids More Active More Often (MK) is a two year physical activity pilot programme being run by

Harbour Sport from 2003-2004. This programme is part of a joint venture between SPARC and the

Ministry of Education (MoE) involving four schools in each of four areas: urban and rural Canterbury,

Counties Manukau, and North Harbour. SPARC is funding physical activity coordinators from sports

trusts in each area to provide PA programmes outside curriculum time, within schools and their

communities, with the aim of ensuring that students have more opportunities to become more active,

more often. SPARC funding is contingent upon schools having healthy tuck-shop food. The MoE is

funding a Southern and Northern physical education and health advisor to guide teachers’ professional

development within the Health and Physical Education curriculum. Counties Manukau Sport has one

physical activity coordinator (PAC). Harbour Sport also has one PAC who has set up five programmes

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for the four North Harbour schools: the sports leaders’ programme, a WSB, the before school jump

jam, police bike education, and the community health promotion committee.

The sports leaders’ programme is currently operating one lunchtime per week at St Mary’s and

Coatesville Schools, and involves senior children being trained (by the PAC and teachers) to organise

and run physical activities for junior students while being supervised by the on duty teacher. Both

schools have noted an increase in activity levels in Year 1 and 2 students, especially girls, an increase

in leadership ability in older students, and a decrease in playground trouble (278). Two WSB routes

have been started at Stanmore Bay School through collaboration between the Rodney District Council

Road Safety Coordinator and the Auckland Regional Council (ARC) WSB Coordinator. The Before

School Jump Jam is exercise to music choreographed by Brett Fairweather and involves two 20 minute

sessions taken by a teacher twice a week. The aim is to have parents or a local leisure centre running it

by the end of the year. The Police Bike Education programme aims to encourage bicycle use via a bike

safety workshop covering rules, skills, and bike maintenance, and is run by a police education officer.

The MK programme will be evaluated using PA-related outcomes rather than weight-related outcomes.

The Community Health Promotions Committee consists of the PAC from Harbour Sport, the school

principal and teacher representative, a WDHB board representative, HPS, and a parent representative,

and aims to create future sustainable links between schools and their communities in the delivery of PA

programmes. Future links with other programmes having similar goals (e.g. NHF’s JRFH and SFP,

ARC WSB, HPS etc) are planned, in concert with the WDHB’s Wellbeing schools project, described

above. Identified gaps or problems include the following: a need for nutrition education to be linked

with PA programmes, a need for primary school specialist physical education teachers, and a need for

more research investigating how best to increase children’s activity. Harbour Sport also suggested that

ARPHS could have a role in providing an overall view of existing PA/nutrition programmes and

strategies in the Auckland region to Regional Sports Trusts.

Pre-Schools’ Setting: Multi-component Interventions

Healthy Heart AwardThe Healthy Heart Award (HHA) is a national programme run by the NHF for early childhood centres

that encourages and rewards early childhood teachers for promoting healthy food and physical activity

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to the under fives and their families. Centres need to satisfy seven criteria in order to receive a healthy

heart award:

� Provision of healthy food which involves either sending in guidelines for parents about

lunchbox contents or sending in a copy of the menu if the centre has a food service.

� A written nutrition policy.

� A written PA policy.

� Parent/whanau education.

� Professional development.

� PA linked to the Early Childhood Curriculum (279), including documenting the daily PA

available to children.

� Curriculum linked nutrition activities including documenting the weekly healthy food

activities available to children.

Centres are provided with a HHA pack containing a manual, wall poster and other resources. The

outcomes sought relate to fulfilment of the seven criteria listed above, rather than any weight-related

outcomes.

A pilot evaluation of the HHA was completed in 2002 (280). Early childhood centres in Wellington

who received the HHA pack and an opportunity for staff to attend workshops, were compared with

non-intervention early childhood centres, and both groups were surveyed both before and after the six

month intervention period. Intervention centres were more likely to have nutrition (p<0.0001) and PA

(p<0.0001) policies, lunchbox guidelines (p=0.015), and food menus that cycled between different

healthy choices on a periodic basis (p=0.052). Intervention centres were also more likely to involve

parents in education sessions (p=0.005) and the children were more likely to have a piece of fruit or

vegetable (p=0.0008) and less likely to have salty pre-packaged snack food (p=0.034) in their

lunchboxes. The intervention teachers showed increases in nutrition and PA knowledge scores

(p=0.029).

The annual cost of the HHA and the SFP is $700,000, with the HHA programme also sharing the two

FTE health promotion coordinators in Auckland with the SFP. Gaps in service provision exist in

Maori-only speaking early childhood centres, the Kohanga Reo, who will only adopt exclusively Maori

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resources, and with a lack of ‘on the ground’ nutrition support for the programme as the NHF

coordinators work at a more strategic level.

Pre-Schools’ Setting: Nutrition Interventions

ADHB ServicesADHB provides some nutrition services to pre-schools via ARPHS and the Community Child Health

and Disability Service. ARPHS provides some nutrition workshops for early childhood staff, advocacy

for more specific nutrition standards for Long-Day care centres, and in 2004 produced a practical food

and nutrition manual for preschools (281). Gaps in services identified by ARPHS could be addressed

by: an increased number of regional workshops for childcare staff, an advisory service for childcare

centre staff that could include menu appraisals, and an advisory service for parents’ groups.

ARPHS has also collaborated with the ARC Botanic Gardens to help South Auckland communities

create vegetable and fruit gardens in Pacific early childhood centres (282). The gardening programme

began in September 2001, involving Samoan, Tongan, Niuean, Tokelauan, and Cook Island

communities. The programme consists of educational workshops with pre-school centres,

demonstrations, and an evaluation of the gardens with a prize-giving ceremony. The gardens have

proven a practical way of increasing nutritious food choices and providing regular PA. Produce from

the gardens has become part of the children’s lunchtime diets and is also circulated to the communities;

gardens have also become a useful focus for educational activities such as literacy, numeracy and the

sciences.

The Community Child and Disability Service has contracts to deliver Well Child services, health

promotion using the HPS concept in preschools, promotional events such as the Well Child week

which has a nutrition theme this year, and the refugee contract to assist refugees in accessing health

services (see ‘Primary Care’ setting, below). Well Child services, provided by public health nurses,

target high needs families from lower socioeconomic groups with problems requiring social support,

maternal mental health services, help with domestic violence etc, all of which have an impact on

childhood nutrition. Well Child services also promote breastfeeding for a minimum of nine months,

provide good childhood nutrition advice for pre-schoolers, and monitor height, weight and risk factors

for diabetes. Gaps in service provision exist as a result of targeting high-need families only and, in

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addition, most problems with overweight begin at the time monitoring stops i.e. around school age.

Ongoing monitoring could occur at strategic times.

Public health promotion with pre-schools follows the HPS framework that encourages centres to

identify and prioritise their health needs. Two preschools to date have identified nutrition as a priority,

and they have received nutrition education, developed their own vegetable garden, and utilised

resources from NHF, Sanitarium, and 5+ A Day to provide demonstrations of healthy meals. However,

gaps in this service exist as the health promotion team only target high needs pre-schools, and

nutrition/PA interventions are only introduced if these problems are identified as a priority area.

In addition, the ADHB early childhood health team are currently looking at developing a Food With

Attitude (FWA) resource for pre-schools (see below). This is a treatment rather than a prevention

resource for overweight and obese children that involves one-on-one interaction between child, family,

and nutrition educator, with PA input from Sport Auckland. Children are referred via their GPs, school

nurses etc. There are also plans to work with the MoE to develop the Early Childhood Curriculum to

reinforce nutrition, PA and other messages.

Family Setting: Multi-component Interventions

‘Food With Attitude’ and ‘Young and Active’FWA is an evidence-based, overweight and obesity treatment programme for 5-12 year-olds that has

been developed and run over the past five years by ADHB’s Community Child Health and Disability

Service. While this is not an obesity prevention programme per se, its family focus may have positive

effects on other family members in preventing or reducing weight gain, although to date the weight of

other family members has not been recorded. FWA involves a multidisciplinary team (Public Health

Nurse, Dietitian, Maori/Pacific Community Health workers, and a Medical Officer) who educate and

provide long-term support for the children and their families using a ‘stages of change model’ and

appropriate cultural assistance. Although it is acknowledged that attempting to change individual

behaviour to prevent weight gain is generally ineffective, the literature of psychological and behaviour

change models suggests that a multifaceted approach based on ‘stages of change’, and with good social

support, is more effective than one-off educational sessions (283).

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Children are referred to FWA by GPs/specialists, teachers, school pubic health nurses, family or self-

referral. FWA is a year-long programme that involves monthly visits to the child at school or the home

following an initial visit to the child and his family by a Public Health nurse and Dietitian. The family

sign a contract to give their child lots of encouragement and help with healthy living, eating, and

exercise. In addition, written information and advice are given, goals are reviewed and set monthly, a

food diary is completed, and participants weight and height are measured at baseline followed by three-

monthly. Success is measured by changes in behaviour, self-esteem, improvement in health risk,

achievement of individual goals set according to stage of change (e.g. activity levels, TV watching,

cooking methods, frequency of takeaways etc), and “growing into their weight”. After 12 months, a

certificate of completion is awarded.

The FWA programme was evaluated in 2003 using questionnaires and data gathered from existing

medical records, for 22 children and 22 family members (284). However, the small sample size and

incomplete medical record data made it impossible to conclude causal relationships between FWA and

measured changes, although improvements in shortness of breath, sports participation, and confidence

levels may be occurring. Although Public Health Nurses reported that 40.9% of children had reduced

their BMI, analysis of all medical records (n=39) for children enrolled in FWA showed that 28.2% of

children had increased their BMI, 25.6% decreased, and 35.9% had only one record of BMI. Public

Health Nurses also reported an increase in children’s self-confidence (54.5%) and PA (72.7%), and an

improved diet (68.2%), although changes to BMI did not relate to any of these measures. However, a

relationship was found between family members who had increased their PA and made positive dietary

changes, and a decrease in their children’s BMI. This supports the view that whole-family

participation is a key to programme effectiveness.

Identified gaps/problems with the programme included the following, and were identified in the

latest evaluation:

� Poor medical record keeping for BMI as well as other physical indicators i.e. blood pressure,

pulse rate, blood tests, snoring, sleep apnoea, shortness of breath on exertion, muscular pain,

and flexibility.

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� FWA needs the flexibility to devote the time to families that is needed for them to develop and

maintain a significant level of commitment to FWA. Family commitment is perceived as

being central to the programme’s effectiveness.

� FWA providers need more time to devote to their role within FWA that is not eroded by the

other roles required of them, with a particular need for more Dietitian and Maori/Pacific-

appropriate input.

As a conjunct to FWA, Sport Auckland has been funded by SPARC to work with FWA children and

their families to develop appropriate exercise activities (Young & Active programme). However, not

all children are identified as being ready to participate in Young & Active (YAA), and some do not

have increasing PA as an individual goal. Those with PA goals are referred on to YAA via a green

prescription and the family are subsequently visited in their home by the activity advisor, assessed, and

started on an individual PA programme. YAA also hold weekly group activity sessions for the children

and their families. During the first month children receive three home visits followed by monthly

individual visits, and then bimonthly visits after six months with a total of one year on the programme.

The activity advisor monitors children’s level of activity, level of sedentary behaviour, participation in

community activity, cardiovascular fitness, strength, flexibility, and child/family attendance and

involvement/application to goal setting.

Identified gaps/problems with the programme/services included the following:

� YAA has not evaluated any of the data collected due to lack of resources for evaluation, and

suggested that it should be evaluated in combination with FWA.

� There is no committed funding of salaries for YAA workers.

� Sport Auckland sees a need to extend the YAA programme to overweight/obese children who

are not on the FWA programme, and to children who are not overweight or obese.

� Harbour Sport have developed a PA manual (Action Kids) (285) to fit with the Health and

Physical Education curriculum, but because there are no physical education specialists in

primary schools, have delivered the programme to three schools themselves.

� Parents/caregivers often need more support from YAA, FWA, and from community sports and

PA groups to help them to take responsibility for family PA and nutrition.

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� There is a need to work with local/regional councils and involve communities in initiating

environmental changes that support PA.

In addition, FWA suggested that ARPHS could keep track of existing PA/nutrition programmes,

strategies, and research in the Auckland region.

Kids in ActionKids in Action (KIA) is a family-based childhood obesity treatment programme that started in February

2003. It targets children and youth, especially Pacific people, who are clinically obese and hence are at

high risk of diabetes and other chronic illnesses. Currently, there are no other childhood obesity

treatment services in the CMDHB area (286). This programme was included because, like FWA, its

family-based setting could possibly have a role in preventing other family members from becoming

overweight/obese. Referrals are received from schools and primary/secondary care providers. The

programme involves a paediatrician from Kidz First, a nurse and dietitian from South Seas Health

Care, and exercise instructors who work with the children and their families. The programme involves:

� paediatrician assessments,

� dietary assessments and nutritional advice,

� a weekly exercise session, home visits from a nurse or other community health worker,

� family group conferences to develop strategies for families to create healthy environments and

continue PA and healthy lifestyle upon exit from the programme,

� health promotion resources and information for families and children including nutrition

information, PA messages, and

� links to other support services.

Children set goals for themselves (e.g. to walk to school and maintain their weight) and achievements

are acknowledged with prizegivings. Clinical records are maintained including BMI. In 2003, an

internal evaluation of data showed that 70% of 71 children had lost or maintained their weight, while

42% had lost weight. Twenty-five percent of children in KIA had medical comorbidities.

Problems identified with the programme included the following:

� Lack of resources require that effort be focused on motivated children and families as less

motivated people require excessive resources for little or no positive outcome.

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� When the programme is stopped during school holidays the children always gain weight

suggesting that more time with families is required to develop exercise and healthy eating

practices that have the flexibility to continue at all times.

� The paediatrician seeing KIA children received no funding for her role.

� There is a need to develop PA sessions that are suitable for the very obese children.

� Public health measures need to be oriented towards the family with more research required to

see how families actually live and how this impacts on lifestyle. For example, 30% of the

children are from single families with many adolescents eating irregularly and most not eating

breakfast (12) due to a lack of time or food in the house or because they feel sick and not

hungry. Many eat pies on the way to school and also have energy-dense, low nutrient foods

for lunch such as sausage rolls and soft drinks (Dr Teuila Percival, personal communication).

Recently, KIA received funding from CMDHB to provide services to 70 children per year, at a total

annual cost of $130,000.

It was suggested that ARPHS could have a role in holding small group seminars on nutrition, reading

and understanding food nutrition labels, and how to select and prepare low-cost, nutritious food.

Primary Care Setting: Multi-component Interventions

Primary Health Organizations (PHOs)Health promotion is a key component of the Primary Health Care Strategy (287) and all PHOs are

required to develop and implement health promotion plans, although differences in PHO size cause

great variability in resources, public health skills, and technical advice available to individual PHOs.

An initiative is currently underway between ARPHS and the Auckland DHBs which aims to link PHOs

with key stakeholders in school health programmes, and other health settings, to promote the

development of PHO health promotion plans. A meeting was held in January 2004 at CMDHB which

looked at how PHOs in the Auckland region might develop health promotion plans for schools. At this

meeting, secondary schools were identified as being desperate for health services partly because they

have no dedicated funding for school nurses, the exception being the AIMHI schools mentioned above,

which have MoH funding for a school nurse. Another current problem was the separation of health

promotion from the school health curriculum, which could be addressed by PHOs and other school

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health providers by working with Team Solutions to integrate health promotion into the school Health

and Physical Education Curriculum.

PHOs also felt constrained from approaching schools with health promotion programmes due to a lack

of knowledge of what programmes are currently in place in schools, or available to schools, and

uncertainty regarding how best to approach schools. PHO’s also thought that the MoH/DHBs should

perform a needs’ assessment of schools to find out what programmes schools required, the cost, people

and other resources needed etc. PHOs did not think it appropriate to conduct this exercise individually

due to a lack of funding confidence and not wanting to get into a ‘one PHO per school’ situation. In

summary, PHOs did not want to provide health promotion programmes to schools unless they were

properly costed, coordinated, and sustainable.

Secondary schools were felt to be too individualistic to embrace the HPS directive, instead preferring

the more consultative approach operating in AIMHI schools, and it was suggested that PHOs might

therefore find AIMHI schools an appropriate starting-point for designing and implementing HP plans.

To date, no PHO health promotion plans, let alone plans in the arena of childhood obesity prevention,

have been made in collaboration with schools. The following is a list of PHOs in the Auckland region

and plans/programmes that they have in the arena of childhood obesity prevention.

ADHB

Auckland PHO Ltd

No obesity prevention projects.

AuckPac PHO

No obesity prevention programmes targeting children. AuckPac is collaborating with HealthStar

Pacific and Procare to increase AuckPac members access to their PA programmes (e.g. Procare’s green

prescription project and Health Star’s PA programmes), although these programmes mainly target

adults.

Primary Health Network for Auckland

� Modified Green Prescription Project: the ProCare Network for Auckland is planning to extend

the Green Prescription Programme whereby GPs recommend PA to high needs patients who

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are then supported by workforce from the regional sports trusts. Procare plans to develop this

idea further so that healthcare professionals can prescribe exercise to high need patients

knowing that suitable and accessible programmes will be available (288). A pilot programme

is currently running in Glen Innes, and similar multi-faceted community-wide campaigns have

proven to be effective in getting people to be more physically active (289). The programme is

aimed at adults, with modification and delivery to children and youth being considered for the

future. The primary aim of the programme is to increase PA, with obesity prevention and

weight reduction listed as secondary aims. Secondary outcome measures will include monthly

BMI and waist-hip ratio, and bi-monthly blood pressure. There are current proposals to

introduce the modified green prescription project into the Mt Roskill, Manurewa, and Clendon

areas (288, 290).

Tamaki Healthcare

No obesity prevention programmes established currently.

Tikapa Moana PHO

Tikapo Moana PHO was only recently established on Waiheke Island (April, 2004), and has no health

promotion programmes established.

Tongan Health Society

No known childhood obesity prevention programmes.

CMDHB

East Health

East Health delivers well-child checks, supports the NHF’s school food programme, children’s WSB,

and collaborates with schools to improve PA through the health and physical education curriculum.

Mangere Community Health Trust

The Mangere Community Health Trust focuses on smoking cessation and has no childhood obesity

prevention programmes.

People’s Health Trust

People’s Health Trust is a small PHO that only deals with childhood obesity treatment on an individual

basis through children attending GP practices. Perceived barriers to healthy weight include: parental

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denial of obesity as a problem (PHO population consists of Maori 45%, Iraqi 35%, and European

20%), and a general lack of school PA programmes for children who don’t do competitive sport.

Primary Health Network for Manukau

See Primary Health Network (Procare) for Auckland above.

TaPasefika

TaPasifika is a PHO targeted at Pacific people and consists of three clinical providers throughout

Auckland (South Seas Health Care, Pasifika Healthcare, and Health Pacifica Ltd) and one health

promotion provider, Health Star Pacific. There are currently three programmes for children that may

have a role in obesity prevention, as below:

� KIA Programme: KIA is discussed above under ‘family setting’. As mentioned, it is run by

South Seas Health Care.

� School breakfast programme: Health Pacifica is involved in providing sponsored breakfasts to

some high-needs schools.

� Pre-school programmes: TaPasifika is involved in delivery of the well-child programme to

Pacific pre-schools. Pacifika Healthcare is also involved in advocacy for pre-school nutrition

policies, a pre-school dance to music programme four nights a week for 3 to 5 year-olds, and

also runs a gardening programme with pre-schools where children get to look after their own

plant. This is being extended to show parents how to cook and prepare garden produce, using

the Pacific Fair this year as a medium to demonstrate produce preparation.

Barriers to good nutrition identified by TaPasifika staff included:

� The traditional Pacific view that weight is a sign of wealth and therefore desirable.

� Parents lack of knowledge of NZ produce and how to prepare and store it.

� Parents lack of understanding of the link between food and the physical/ mental health of

the body.

� Key school staff (Principal, nurse etc) often failing to appreciate the importance of

establishing a healthy school environment.

Te Kupenga o Hoturoa

Currently, has smoking related health promotion plans only.

Total Healthcare Otara

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Total Healthcare Otara has no childhood obesity prevention programmes, although it is currently

piloting a PA programme (the Getting Started Programme) run from the Otara Leisure Centre that

targets the adult population and includes nutrition and healthy lifestyle education. The PHO organises

a well child party during well child week with participation from various providers including leisure

and PA programme providers and public health nutritionists, and has future plans to support the DPT’s

‘Adolescent obesity & diabetes prevention programme’.

WDHB

Coast to Coast

No known childhood obesity prevention programmes.

HealthWEST

No specific childhood obesity prevention programmes.

� GPs from the PHO support the Push-Play campaign every year. This is a SPARC-led

campaign promoting the message of 30 minutes of moderate-intensity PA on most days of the

week (291).

� A youth clinic once a week and several school-based health clinics are currently in operation

and occasionally deal with overweight or obese children.

� HealthWEST has contracted a dietitian for GP referrals who offers a service similar to FWA.

However, there is no funded FWA programme available in WDHB, and therefore children’s

families must pay for public health nurse and dietitian visits. Other barriers to good nutrition

and achieving a healthy weight that have been noted by the HealthWEST dietitian include:

poor participation by parent(s) who work or are solo, inadequate parenting skills resulting in

poorly disciplined children, children given regular access to money for food, dysfunctional

families, and overweight/obese parents. These problems highlight the need for a

multidisciplinary team in the treatment and prevention of obesity, namely, a paediatrician,

dietitian, physical education teacher, public health nurse (to visit children in schools so that

parental availability does not become a limiting factor), and a psychologist (to help with

parenting skills and dysfunctional families).

North Harbour

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� Social Workers in Schools Programme: North Harbour proposes that social workers be placed

in five schools on the North Shore (4 x primary, 1x intermediate) to address children’s health

issues in concert with other local health providers. The programme plans to begin in July

2004.

� Child/Rangitahi Health: this programme aims to link in with the social workers programme,

with social workers identifying health issues of importance to children, such as oral health and

obesity, and offering parents information about available services. There are plans to develop

a nutrition programme using the FWA framework that overweight/obese children could be

referred to by utilising the dietitian services currently offered by North Harbour PHO. As

with FWA, outcome measures will include change in BMI, and also changes in social

behaviour. The combined cost of the social workers, dietitian and FWA programmes is

estimated at approximately $200,000.

� Move for Health “Hikoi mo te Oranga”: this is a PA programme that runs one day a week at

the Birkenhead Leisure Centre, but is aimed at all community members with no particular

focus on children or youth.

Procare Network North

See Primary Health Network (Procare) for Auckland above.

Waiora Healthcare Trust

Waitakere Union Health Centre and Wai Health make up the Waiora Health Care Trust PHO with an

enrolled population of around 10, 409 people. It provides free well-child checks but no specific obesity

prevention programmes for children (see ‘Te Whanau O Waipereura Trust’ below).

The Centre for Youth HealthThe Centre for Youth Health (CFYH) was established in 1996 by South Auckland Health and

supported by the University of Auckland. It aims to promote the well being and healthy development

of young people in the context of their family/whanau and wider environment by the provision of the

following services:

� Clinical services for youth with chronic, complex health issues. Obesity prevention/treatment

is usually dealt with in the context of the prevention/treatment of other health problems such

as diabetes mellitus, polycystic ovarian syndrome, and asthma etc.

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� Assistance to other youth health providers. Evidence-based advice on how best to develop

effective school- or family-based services for young people is provided in the form of

workshops, seminars, or individual consultation. Advice covers issues such as service access,

workforce structure, an understanding of the health promotion/ risk reduction philosophies

underlying best-practice, how clinical personnel can best work effectively with youth etc.

� Education and training opportunities for tertiary students in youth health or related services.

� The Kidz First Resource and Information Service provides child and youth health information

to planners, purchasers, providers, communities, young people and their families.

� Research on a range of relevant adolescent health studies in collaboration with other

researchers.

� Advocacy for policy, planning and legislation that addresses the healthy development and well

being of youth.

Although none of the above services include any specific childhood obesity prevention programmes,

many of these services are important in reducing childhood obesity. For example, assistance to health

providers is valuable for providers setting up obesity prevention services for youth; advocacy for policy

is important for population-based obesity prevention in children, for example, policy regarding the

school food and PA environment, and the advertisement of obesogenic foods to children; and research

on youth behaviours provides a vital foundation for effectively addressing youth issues. For example,

the Youth2000 survey provides a comprehensive population-based study of youth health problems,

concerns, and risk factors, including patterns of PA and attitudes to body weight (18).

Children and Young People’s Diabetes Prevention and Management Project (CYPDPMP)The planning for this ADHB project began in 2003 from a joint partnership between Starship Child

Health Services, Community Child Health and Disablity Services, Tamaki Health PHO, and Pacific

Health, and originated from two separate proposals: ‘Management of Childhood Obesity’ submitted by

Child Health and Disability Services, and ‘Diabetes Outreach Services’ submitted by Starship

Children’s Health. These proposals recognised that increasing obesity, reduced healthy lifestyles, and a

lack of service coordination are leading to an inability to respond effectively to increasing diabetes,

with a need to change focus to partnership and prevention management to meet the increasing

childhood diabetes demands on services (292). The incidence of diabetes in Auckland’s children and

young people is increasing rapidly with the annual incidence of Type I diabetes increasing by 10%, as

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it has done for the last ten years, and the annual incidence of Type 2 diabetes growing by 25% annually

(292). Over the next two years the number of children (<16 years of age) in Auckland with diabetes

will increase from approximately 380 children to >500 children, with greatest increases in Maori,

Pacific, and Asian children (292). Key drivers for this increase are increasing obesity in children and

young people and reduced healthy lifestyles especially nutrition.

The CYPDPMP aims to provide a management model for diabetes and obesity prevention and care for

children and young people within a community framework using a population-based approach. One of

the project’s four main objectives is to strengthen and develop agencies including NGOs (Non-

Governmental Organisations) and PHOs locally with the capacity to undertake obesity prevention and

management activities as outlined in the MoH’s Healthy-Eating-Healthy Action implementation plan

(293). The project has three distinct, interlinking components, one of which involves promoting

healthy lifestyles through the following interventions:

� Creating a database of current educational and health promotion materials on nutrition,

obesity, and diabetes established and maintained, and made available to GPs.

� Training of primary care providers in the use of health promotion materials.

� Training of health workers, school teachers, and community leaders in diabetes and obesity

prevention and management.

� Collaboration with/mobilisation of agencies such as PHOs, community groups, schools, ACC

(Auckland City Council), Sports Auckland, and the private sector, to work in obesity

prevention and management. Currently, there are plans to collaborate with NHF, FWA, HPS,

AIMHI schools, well child providers, HealthWEST PHO, and ARPHS (Wendy Cook,

personal communication).

� Establishment of an 0800 line for obesity prevention and management.

� Supporting community-based research programmes in the Auckland region.

� Supporting priority groups that promote healthy community environments for obesity

prevention and management.

Specific outcome measures have not yet been stated, although results from the FWA programme will

continue to be monitored, and hospital admission /length of stay data will be available for children with

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diabetes and obesity-related diseases. Strategies for monitoring obesity per se have not yet been

specified, except as mentioned above for the FWA programme. The project will be evaluated at

inception (April 2004, April 2005), implementation (April 2006), and then six monthly to the Project

Steering Committee and annually to ADHB standards. After 20-22 months an external review by an

overseas expert (Paediatric Endocrinologist) will evaluate the performance of the diabetes and obesity

prevention and management project. Currently, the cost of the project is approximately $700,000

annually.

Maori Provider Setting: Multi-component Interventions

Te Hotu Manawa MaoriTe Hotu Manawa Maori (THMM) is national health promotion organisation with the aim of reducing

the likelihood of cardiovascular disease and death amongst Maori. It has three priority areas, two

concerned with smoking and one with improving Maori health and well being through better nutrition

and regular PA. Interventions related to THMM’s four nutrition and PA objectives are as follows:

� Increasing the knowledge and health promotion skills of Maori community workers with a

Train-the-trainer course. This is a 15-day course that is run three times a year in different

parts of NZ. Currently, this workshop is being provided by Te Whanau O Waipareira Trust in

the Auckland region (see below). An annual two-day hui is held for those who have

completed the course that provides updates on new resources, programmes, research and

information in nutrition and PA.

� Developing and disseminating nutrition and PA education resources including posters,

pamphlets, booklets (such as their recipe booklet) (294), and newsletters (295). THMM is

also developing and adapting the NHF’s Healthy Heart Award for Maori. In addition, there is

a need for adapting the SFP for Kura Kaupapa, of which there are 50 throughout the country.

� Facilitating networking opportunities and disseminating information through the THMM

website (296), hui, and responses to individual requests.

� Performing an advisory and advocacy role, by advising on research projects, resource

development, and proposals on issues affecting Maori, and advocating for Maori nutrition and

PA issues at national level with the Obesity Action Coalition (OAC).

THMM’s Train-the-trainer course was evaluated externally four years ago by the Maori Unit at

Auckland University, although the course has changed considerably since that time.

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Hapai Te Hauora Tapui LtdHapai Te Hauora Tapui Ltd (HTHT) is the MoH-funded, Auckland, Maori public health organisation

that is involved in funding and overseeing the coordination, planning and workforce development of its

four subregional providers. Each provider takes responsibility for leading in one area of public health.

Of the four providers, Te Whanau O Waipareira Trust takes the lead role in PA and nutrition with

Tuakau Homebuilders and Raukora having lesser roles. The public health issues addressed by each

provider were determined by a combination of existing provider skills and community-identified

priority issues. HTHT also provides support to HPS coordinators by providing advice on how best to

work with the Maori community, using the Maori Ora Mauri Ora community development model

(297). This model was initially developed in 2000 by HTHT as a mental health resource and is based

on Maori Tikanga, Maori imagery to promote positive hauora concepts, and inclusion of the tangible

and intangible worlds.

Gaps in service and barriers to healthy nutrition and exercise identified by HTHT include the

following:

� There is a need to increase the workforce skill base particularly in the area of good nutrition.

� There is a need for providers to work within a wider range of settings e.g. schools, families,

and food retailers.

� Healthy food is perceived to be more expensive.

� Environmental change, not gyms, is the answer for Maori e.g. cycle lanes, paths, pedestrian

crossings and other features of urban design that encourage PA.

Te Whanau O Waipareira TrustWai Health, the health branch of Te Whanau O Waipareira Trust based in Henderson, is one of the

largest providers of health services to Maori in New Zealand. These services include clinical, public

health, and child care services (298). Child care services provide regular well child checks to kohanga

reo, kura kaupapa and whakekura, and a child health service for tamariki aged 1 month to 5 years that

includes home visiting, milestone checks and regular visits, education etc. Child care services also

provide a Parents As First Teachers programme that involves visits from a personal educator, for

families with 0-3 year-old children, who encourages parents to stimulate their child and encourage

positive learning outcomes from birth. This could include advice about nutrition.

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Public health services offer the ‘Kai and Nutrition’ training certificate, based on the Train-the-trainer

course delivered by THMM, which is an AUT accredited course offered to people working in hauora

from local marae, kohanga reo, churches, sports groups, kai mahi and health promoters, but includes

anyone keen to learn about nutrition. In addition, Waipareira are organising the annual national

nutrition hui 2004 for course graduates and kai mahi who work in nutrition and PA. Wai Health also

offer healthy nutrition displays and promotions to community groups such as kura kaupapa, kohanga

reo, churches, and young mothers groups. In the PA arena, daily PA programmes are offered,

including touch running, netball, and the youth transition programme aimed at youth. The youth

transition programme targets 12-18 year-olds and includes rap, break-dancing, and tagging/bombing

(mural painting). Children and youth with weight problems are linked with Wai Health’s nutritionist or

dietitian (visits from AUT once a week) and given healthy lifestyle and kai advice.

Wai Health also offers a free clinical service to children <18 years and operates a weekly mobile clinic

to schools, kohanga reo, kura kaupapa, and caravan park locations in West Auckland. Waipareira Trust

also runs a bilingual Te Rito early childhood centre with a focus on health.

Gaps in, and barriers to, services identified include the following:

� A greater need to reach and educate parents and families about healthy lifestyles.

� Conflicting health messages given by the health community are causing confusion, with a

need for greater collaboration and alignment within the health community.

� There is a need for all-Maori resources for children within the exclusively Maori education

system (Kohanga Reo etc.).

Tuakau HomebuildersTuakau Homebuilders (TH) is preparing to deliver a PA and nutrition programme to children and in

June aims to start a nutrition programme for overweight/obese children. Preparations have included

sending two members of TH to the Train-the-trainer course being run by Waipareira Trust, and

introducing a PA programme for their own overweight workforce to avoid the irony/hypocrisy of

having weight-loss messages being delivered by a significantly overweight workforce. Details of

funding and specific outcome measures were not available.

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Raukura Hauora O TainuiRaukura Hauora (RH) in South Auckland provides a smoking cessation programme targeted at young

Maori mothers, PA programmes, and more recently, a rangitahi (youth) nutrition programme.

Currently, RH’s smoking cessation programme does not incorporate nutrition advice to help mothers

replacing smoking with food to maintain a healthy lifestyle. PA programmes are aimed at all ages,

with the waka ama programme particularly targeting children and youth. There are plans to incorporate

nutrition advice into this programme although to date there have been no dietitians or nutritionists

employed to provide this service. At present, the rangitahi nutrition programme targets intermediate

and secondary school children and consists of a one hour education session.

Gaps/problems identified with providing PA and nutrition services to children are as follows:

� No nutritionist or dietitian available to provide advice to young Maori mothers ceasing

smoking, to complement the waka ama programme, or to extend the rangitahi nutrition

programme.

� Links between health providers in the areas of PA and nutrition are needed to provide a

coordinated and comprehensive service.

Aotearoa Maori Netball Oranga Healthy Lifestyle Trust Inc.Aotearoa Maori Netball (AMN) began as the Maori Women’s Welfare League in 1987 and was

registered as a Constituted Charitable Trust in 1996. AMN uses netball for Maori women and girls as a

vehicle to promote awareness of issues such as healthy nutrition, weight control, regular moderate

exercise, and smoking cessation, using the overall Maori concept of Oranga (total well being). The

Healthy Lifestyles Programme is delivered through annual national netball tournaments in one of the

eleven regions in NZ, netball training live-ins that include the presentation of nutrition and PA

information, occasional health promotion workshops/hui, blood pressure and diabetes screening clinics

at tournaments, and the promotion of healthy nutrition at tournaments and team practices. Public

health funding is provided by the MoH. This programme was evaluated in 2002 as part of an

evaluation of the MoH’s nutrition and PA contracts in the northern region (299). Gaps in services

included a lack of good nutritional information, including information on fad diets, presented in a

culturally appropriate way, and funding for netball training camps. Perceived barriers to good nutrition

included the affordability of fruit and vegetables, the relative convenience of fast foods, and poor

budgeting skills in low-income families.

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Pacific People Provider Setting: Multi-component Interventions

Pacific Islands HeartbeatPacific Islands Heartbeat (PIH) is the division of NHF devoted to the health of Pacific people. PIH

provide the following services:

� A Train-the-trainer certificate in Pacific nutrition through AUT that runs twice a year.

� The Healthy Heart Award programme for Pacific early childhood centres.

� Nutrition pamphlets in a range of Pacific languages, nutrition videos, and newsletters (300).

� A fat kit visually demonstrating the fat content in popular Pacific foods used during

educational sessions.

� Advocacy, media commentary.

� The Heartbeat Pacific Lifestyle Project was piloted in 2000 and aimed to encourage and

empower the Pacific church community to promote and practise healthy lifestyles.

Specifically, it aimed to reduce cardiovascular disease, diabetes and high blood pressure

among Pacific people. The pilot programme involved training members of two Samoan

churches in Auckland in healthy nutrition, PA, and lifestyle. Churches then signed up to

deliver a PA session once a week and 10 group sessions a year on nutrition, PA, and smoking

cessation. An evaluation of the programme pilot, based on data from very few families from

each of the churches, showed that some changes in behaviour were reported with families

eating fewer takeaways, less fat, smaller portions, more fruit and vegetables etc, with these

changes extending to church-catered functions involving food (301). Families also reported

doing more exercise. Baseline BMI measurements revealed that >70% of participants were

obese and >20% overweight in one church, while >60% were obese and >30% overweight in

the second church. These measurements did not improve, in the small sample evaluated, over

time. The evaluation concluded that the church programme was appropriate for the Samoan

church setting and that it had a positive impact on various aspects of family lifestyle although

this was not reflected in the small amount of BMI data evaluated. The main problems

identified included difficulty sustaining commitment among church programme leaders, and

variable skills and resources between churches.

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A more comprehensive study of adult BMI change over one year, compared the two pilot

church participants (n=365) with participants from a non-intervention control church (n=106)

(302). Baseline BMI for the intervention and control churches was (mean+/-s.e.) 34.8+/-0.4

and 34.3+/-0.9 kg/m2, respectively. The intervention churches lost an average of 0.4+/-0.3 kg

compared to a 1.3+/-0.6 kg weight gain in the control church (p=0.039, adjusted for

confounders). The number of people who were vigorously active increased by 10% in the

intervention churches compared to a 5% decline in the control church (p=0.007). Nutrition

education had little apparent impact on knowledge or behaviour.

Other studies have revealed that there is an excess prevalence of obesity amongst church

communities (303-305), and that church-based weight-loss interventions are effective (305-

307). There is no literature showing how church-based interventions affect children’s BMI,

although this will be researched as part of the Pacific Obesity Prevention in Communities

Study, described above.

Other gaps identified in obesity prevention services included: lack of a comprehensive list of providers

of childhood nutrition/PA programmes, and lack of consistent nutrition advice from health providers

although all advice should fit with the NZ Food Nutrition Guidelines (254). Barriers identified to good

childhood nutrition and PA included: poor Pacific parental involvement in their children’s nutrition and

PA, partly due to the demands of work and a lack of involvement in the school community due to

cultural and language barriers. There is also a lack of available and financially accessible resources for

PA, for example free swimming pools. It was suggested that ARPHS could have a role in providing

nutrition education, advice, and resources; advocating for change at a policy level (for example, by

advocating for nationwide healthy school food policies); and providing links and coordination between

childhood nutrition/PA services.

Moto’otua LtdMoto’otua Ltd is based in Otara and provides PA programmes to Pacific people. Currently they have

no PA programmes aimed at children, although they are proposing to run a programme for morbidly

obese adult Pacific people and Maori through Bruster’s recreation centre.

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Community Setting: Physical Activity InterventionsIn this section, community services discussed include activities and programmes provided by councils,

regional sports trusts, ARPHS, and advocacy groups.

Councils in Auckland:

Councils in Auckland provide a variety of facilities and services that promote PA in the whole

community. Auckland councils provide a number of recreational facilities such as swimming pools,

recreational centres, and YMCAs. Facilities also offer a number of children’s PA programmes through

CLM (Community Leisure Management) for preschoolers and primary-school age children including

swimming, gym, holiday programmes, the Fit Kidz after-school gym programme for children aged 5-

12 years of age, and the OSCAR (Out of School Care & Recreation) after-school programmes (308).

Walking Schools Buses is a nation-wide programme aimed at school children that is supported by most

Auckland councils and is discussed below. Programmes supplied by MCC and Waitakere City Council

(WCC) are also discussed in more detail below.

MCCMCC helps provide services to the eleven HPS in Manukau City including support for the following:

an annual mini Olympics, school garden projects, student health team training in nutrition and how to

hold meetings etc, the NHF’s SFP, and teacher training in the NHF’s JRFH, with plans to provide some

physical education resources to schools (309, 310). In addition, as part of its role in the WHO ‘Healthy

Cities’ project (311), MCC coordinates a Food in Schools (FIS) programme, and has developed a

collaborative plan of action to reduce child poverty (312). The FIS programme provides healthy

lunches and breakfasts to 40 schools (1355 children), including Kohanga Reo and early education

centres, in Manukau. Resources and funding are provided by MCC and several sponsors, including

members of the food industry.

Tomorrow’s Manukau, MCC’s strategy for the future of Manukau City from 2001-2010, lists

improving health (including a CMDHB strategy to improve child health and reduce the level of obesity,

and an objective to support groups delivering healthy lifestyles and active transport) and fitness (by

promoting programmes that encourage more PA) as goals for obtaining a healthy and economically

secure population (313) and has subsequently produced a health policy and action plan to support these

goals (314). This is particularly important for the Counties Manukau population given that the

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proportion of physically active boys and girls in this region (62% and 55% respectively) is less than for

boys and girls throughout NZ (73% and 64% respectively) (315).

WCCWCC has made a concerted effort to provide services, programmes, and activities more suited to

children and youth in recognition of the fact that 33% of Waitakere City’s population is under 20 years

of age. WCC’s secondary schools youth council is seen as a practicable means of involving young

people in decision making by allowing a two-way exchange for student concerns and council issues

affecting youth (316). This has contributed to the formation of strong youth targeted programmes such

as the following (317):

� Time Out – cheerleading, indoor sports, graffiti art etc for 12-18 year-olds.

� Street Sports – sports and activities for 11-18 year-olds.

� Raise up ‘n’ Represent – provides a safe socialising environment for encouraging and

supporting personal growth, physical fitness, leadership skills, and self-respect. Includes

basketball, hip hop, break dancing, phat, and skate-ramping for 13-18 year-olds.

� Youth Fitness – at the Massey Leisure Centre for ≥14 year-olds.

� Ranui Youth Group – PA programmes.

� McLauren Park Youth Group – discos, sport days, leadership training etc.

� YMCA Basketball League.

Walking School Buses (WSB)In March 2000, ‘Zippy’s Walking Bus’ was launched at Gladstone School, becoming the first of its

kind in the Auckland area (318). Its success prompted Infrastructure Auckland to review the

programme. They concluded that it helped reduced city traffic congestion and subsequently made

$1500 grants available through Road Safe Auckland for schools that adopted the system and

maintained the WSB for a year. The WSB concept is promoted by Road Safety Coordinators at most

of Auckland’s councils who encourage local schools to become involved, and in September 2002, the

Auckland Regional Council (ARC) created a new role for a WSB Coordinator to organise and oversee

the region’s efforts.

The WSB involves groups of children walking to and from school under adult supervision (usually two

parents with one acting as a front driver and one a back conductor) along a set route complete with

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stops that allow children to embark and disembark. A recent survey has shown that 40% of children in

Auckland are driven to school (319), with a world-wide trend for declining levels of childhood activity;

in NZ, 32% of school students aged 5-17 years are now inactive (315). However, parents see the

health-promoting potential of walking (320, 321) as being more than offset by road safety concerns,

perceived ‘stranger danger’ (322), and difficulty coordinating children’s walking between home and

school with their own complex travel routines and ‘journey to work’ (323). Nevertheless, studies have

shown that city streets become safer for walkers the more people walk (324), walking alleviates

vehicular congestion (especially in the vicinity of schools), and enables children to accrue health

benefits (325). Research has also shown that children prefer walking (326-328).

North Shore City Council (NSCC) have appointed a council-funded school travel plan coordinator to

develop solutions to transport issues in collaboration with schools, parents, and pupils, that will reduce

school-related car journeys and increase local road safety through a combined package of practical and

educational actions (329). The aim is to encourage children to travel to and from school safely by

walking including WSB, cycling, or public transport. This initiative has been branded the ‘TravelWise

to School’ project and began in February 2002 (330). Currently, NSCC is developing travel plans with

22 primary schools, three of which have been completed and are available on the NSCC website

(Bayswater, Brown’s Bay, and Vauxhall primary schools) (331, 332). As at April 2004, NSCC had 43

WSB routes involving 18 primary schools and 442 children, and this has led to a daily reduction of 158

cars at schools (333).

In addition, AUT worked with some NSCC schools on a case-control study to measure the effect of

WSB on activity level using pedometers. No difference was found in the number of pedometer steps

between children using the WSB and those not. However, only small numbers surveyed and many of

the children who joined WSB were already walking to school. It was observed that children living 3km

or more away accumulated significantly more steps than others, indicating that children walking ≥3km

to school can accumulate significantly more daily PA than children who do not walk this distance to

school (Dr Grant Schofield, personal communication). However, this study was not able to show that

more school children were walking to school as a result of the WSB intervention.

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Three Auckland evaluations of the WSB scheme have been carried out (334-336). The first was

performed 15 months after the establishment of the first WSB at Galdstone School, mentioned above,

and showed multiple benefits to children, parents, and the community at large, including the finding

that 19.5 car trips per day were being saved as a result of the WSB (334). The second was

commissioned in late 2002 by the ARC to obtain a snapshot survey of WSB in Auckland (335), and the

third built on this research with the aim of surveying all schools in Auckland operating WSB to

determine: numbers of children involved, number of car journeys saved, benefits and challenges, and

sustainability (336). Findings as at Nov/Dec 2003 showed that 53 schools in Auckland have WSBs

with 1738 children estimated to walk on WSBs per day. The majority of WSB coordinators reported a

reduction in traffic congestion (1046 car trips saved per day) with two thirds reporting neighbourhood

improvements. The previously observed gradient in favour of higher decile school communities

remained, with proportionately low numbers of WSBs in Manukau City (Figure 6).

Figure 6: Walking School Buses - schools by decile and TLA (Territorial Local Authority) (336).

0

5

10

15

20

25

AucklandCity

WaitakereCity

ManukauCity

NorthShore City

RodneyDistrict

Num

ber o

f WSB High SES (deciles

8-10)Average SES(deciles 4-7)Low SES (deciles1-3)

The main gaps/barriers identified to WSB services included: sustainability of parental input, poor

uptake in lower decile schools where overweight and obesity prevalence is greatest, and differing levels

of commitment to WSBs throughout the TLAs in Auckland. MCC is working to revamp its WSB

service as currently it has only one in operation which was thought to be due to a lack of parental

support and a lack of confidence in being able to walk safely to school in the neighbourhood.

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Regional Sports TrustsThere are 17 regional sports trusts (RST) funded by SPARC that deliver sports-based programmes and

promote healthy active lifestyles throughout NZ. Amongst their numerous activities, RST also

promote SPARC’s Push-Play campaign that encourages 30 minutes a day of moderate intensity PA to

all New Zealanders. The Push Play campaign was evaluated in 2003 and results showed that the

campaign had achieved significant increases in message recognition and intent to become more active,

but no impact on adult PA levels (337). In general, media campaigns and promotions can have a

significant impact on awareness, attitudes, knowledge, and intention to change (338), but do not change

behaviours unless the message is highly specific and achievable e.g. a campaign aimed at changing

people from high to low-fat milk use (339). In addition, RST provide PA programmes to support the

green prescription (this is mostly aimed at adults but there are plans to extend the programme to target

children), provide links with other community centres and services, and sometimes work with schools

to provide specific PA programmes (such as the MK programme provided to Stanmore Bay School by

Harbour Sport). Programmes specifically aimed at children and youth are discussed below although

some have already been discussed above e.g. the MK programme run by Harbour Sport with North

Harbour Schools, and the ‘Young & Active’ programme run in conjunction with FWA by Sport

Auckland. In addition, Sport Auckland have compiled a school lesson-plan manual of physical

activities called the ‘Action Kids’ programme that has been designed for use with the Health and

Physical Education school curriculum for primary children (285).

Fitt KidzSport Waitakere and Bruce McLaren Intermediate School recently developed the Fitt Kidz health and

fitness programme for school children and their families due to concern over increases in overweight

and Type 2 diabetes in school children and the community. Interventions include the following:

� A school health council consisting of a local GP, school children, the deputy principal, the

district nurse associated with the school, and the school counsellor. The council promotes a

different project each term e.g. nutrition, sun smart awareness etc.

� PA coordinators (hired AUT students) to take lunch-time activities, with the choices changing

every term, for example, hip-hop, cheer-leading, bowls (attracts few children but a large

proportion of the obese school population), line-dancing, swimming (requires a bus trip), ten-

pin bowling, extreme trampolining etc.

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� The tuck shop has been enrolled in the SFP and has obtained a bronze award thus far, with the

tuck shop and school undertaking not to advertise unhealthy foods.

� Parents walking group/ evening exercise classes – these have attracted poor response rates.

Community Setting: Nutrition Interventions

ARPHS Community ServicesARPHS Nutrition Service has a role in promoting healthy food choices in the Auckland region to

support healthy lifestyles. Initiatives include providing nutrition information to churches, preschools,

schools, marae, and other community groups, for example, by demonstrating healthy cooking methods,

providing food budgeting and labelling information, developing preschool gardening projects (see

Pacific preschool garden project above), and via the Mangere Healthy Kai (MHK) project. The MHK

project began in September 2003 as a collaboration between ARPHS, NHF, four local community

health providers, and 12 retailers in the Mangere town centre, with the aim of encouraging retailers to

provide healthy kai choices. Several nutrition promotion activities have been conducted at the

Mangere shopping centre with contributions from stakeholders, including healthy eating messages,

nutrition quizzes, cooking demonstrations, and PA classes. In addition, retailers whose wares fulfil

certain healthy nutrition criteria are awarded a Mangere Healthy Kai banner to display in their retail

outlets. MHK was internally evaluated in April 2004 by shopper surveys and by measuring the change

in food sold by retailers (340). Comparisons were made with a baseline survey conducted in

September 2003 prior to the programme launch. The percentage of Mangere Town Centre (MTC)

shoppers that ate a healthy kai choice for their last meal/snack at MTC increased from 32% in

September 2003 to 57% in April 2004 amongst those aware of MHK. Approximately half of those

surveyed were aware of the MHK programme. Changes amongst MHK retailers were more difficult to

measure, however, positive changes included more fish being grilled than fried, and more sandwiches

and fewer pies were being sold.

Public Health DietitiansPublic health dietitians (PHDs) perform health promotion activities related to good nutrition and are

essential for training other health workers and disseminating well-informed, consistent, healthy

nutrition messages to the general public and various community groups such as school tuckshop

owners, pre-schools, and refugee/migrant groups. They also have a role in liaising with and providing

advice to the MoH. ADHB has two full-time and one part-time dietitians (2.3 FTE, services described

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above) at ARPHS, and four part-time dietitians (2.6 FTE) working for CCHDS. The CCHDS dietitians

spend approximately 20% of their time on health promotion which includes work with well child,

FWA, HPS, and pre-schools. ARPHS is also in the process of employing two more

dietitians/nutritionists with a public health community role: one will take a lead role in promoting

healthy ‘ready to eat’ food choices in suburban shopping centres, and the other will have a role in

providing nutrition expertise to health promotion programmes in the school setting e.g. HPS nutrition

programmes. NHF employs nutritionists and a Pacific dietitian. CMDHB have one PHD who is also

engaged in clinical work, and are currently considering a project to train the trainers in Primary Care

around nutrition for the prevention of obesity. In addition, the Diabetes Projects Trust employs a PHD

part-time and TaPasifika has a Pacific PHD.

Gaps in services identified include a lack of PHDs in WDHB and CMDHB and a lack of PHDs for

input into programmes such as NEW and HPS. Until 1996, community dietitians were funded to do

health promotion work but since then health promotion money has gone to the public health service,

although the CCHDS community dietitians have continued to be funded in their health promotion role.

This has led to the fragmentation of PHD services throughout the region, and the current need for a

more directed and coordinated approach.

Advocacy GroupsThere are a number of obesity prevention advocacy groups in NZ including FOE (Fight the Obesity

Epidemic), OAC (Obesity Action Coalition), and ANA (Agencies for Nutrition Action). FOE is a

voluntary organization that was founded in 2001 at a meeting of the International Diabetes Federation

and WHO in Kuala Lumpur. FOE advocates for policy changes to stop the rise of obesity and Type 2

diabetes in children. Its initial aims are to improve children’s nutrition through legislation, regulation,

taxation, and education by:

� Banning or severely restricting TV food advertising directed at children.

� Restricting all TV advertising of foods that are high in saturated fat and sugar.

� Removing soft-drink vending machines from schools.

� Introducing healthy food in school canteens.

To this end, FOE has undertaken several initiatives, including writing a report on legislative measures

in place or proposed in other countries to reduce obesity (discussed in detail under

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‘macroenvironments’ above) (341), helping in the preparation of a private members’ bill to restrict fast-

food advertising aimed at children, sending requests to schools for the removal of soft-drink vending

machines and inappropriate food from school canteens etc (342).

The OAC was formed in 2003 to provide a strong and united voice that can be heard at a political level,

and to provide a forum from which to inform members about planned advocacy so that organisations

can support and strengthen each other’s activities (343). The coalition members include the Cancer

Society, NHF, Public Health Association, NZNF, Diabetes NZ, the NZ Dietetic Association, and the

Health Sponsorship Council, plus other interested community groups. OAC aims to advocate for

government policy, regulation, and legislation that will help reduce obesity rates by changing the

environment from one where high energy food is available everywhere and there are limited

opportunities for exercise, to an environment that supports people in making healthy choices.

Examples of issues to be tackled include: sports’ sponsorship by the fast food industry, fat tax,

advertising to vulnerable groups, warning labels on high energy foods, and regulating foods available

in schools. Currently, OAC has been advised by the MoH that it is not able to lobby politicians using

MoH funding. However, as the bulk of funding for OAC comes from the MoH there is minimal

independent funding available for lobbying (344).

ANA is an incorporated society that was established in 1992 with six founding members: NHF,

THMM, National Diabetes Forum, NZ Dietetic Association, and the NZNF. More recently, the PI

Food and Nutrition Action Group and the NZ Recreation Association have joined, while SPARC and

the MoH are observer members of ANA. ANA aims to work cooperatively to support healthy weight

in New Zealanders through PA and good nutrition. Main approaches include the promotion of

consistent nutrition/PA messages, cooperation within the nutrition and PA sector through annual

forums, regular newsletters, and their website, and advocacy for a comprehensive environmental

approach to prevent obesity and support healthy eating and PA (345). In 2001 ANA produced the

document ‘Healthy Weight New Zealand’ to highlight the overweight/obesity issue and provide

strategies for intervention (56), and in 2002 ANA supported the establishment of the OAC to advocate

for government policy, regulations and legislation. In addition, ANA is funded by the MOH to keep a

national inventory of providers, programmes (346), and relevant research (347) which are available on

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their website. However, the provider/programme listing is not comprehensive for the Auckland region

and lacks detail regarding the programmes provided.

Refugee and Migrant Health SettingARPHS provides free comprehensive health screening to refugees arriving in Auckland. The

Community Child Health and Disability Service of the ADHB provide some ongoing community care,

as mentioned previously, such as the well child programme for under fives. ARPHS also provides

some nutrition education sessions targeted at refugee families, and there is currently a refugee nutrition

programme underway for Somalian families that is run in collaboration with the Community Child

Health and Disability Service. In addition to nutrition education, this programme includes a PA

component. Sport and PA is particularly important to refugee communities as it can produce benefits

such as increased self-esteem, and provide avenues for social connectedness and a sense of belonging.

To this end, ARPHS, Procare, Sport Auckland, and Roskill Aquasport, have recently formed a

collaboration to launch a Muslim women’s swimming group that will allow Muslim women to gain

swimming instruction and PA once a week.

Data from the 1998-99 Hillary Commission, SPARC survey showed that men and women from other

ethnic groups are least likely to be active compared to Maori, European, and Pacific people (348).

There is also evidence of poor nutrition amongst the refugee community. An Auckland study

published in 1998 showed that children from refugee and migrant backgrounds were at risk of rickets

from Vitamin D deficiency (349). Poor oral health has also been observed in children from refugee

backgrounds living in NZ, and is a reflection of high sugar intake, particularly from soft drinks (350).

A survey of NZ refugee communities in NZ has shown that they are adopting NZ dietary patterns that

are high in fat and low in fruits and vegetables (351), and overseas studies have linked this process of

dietary acculturation with an increased disease risk in refugee and migrant populations, most

particularly for obesity, Type 2 diabetes, and cardiovascular disease (352).

Numerous barriers to PA and healthy nutrition were identified including the following:

� Poor knowledge of NZ fruit and vegetables and how to recognise, prepare, and store them,

combined with a traditional diet very low in vegetables.

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� The combination of dark skin and clothing preventing much sun exposure leading to Vitamin

D deficiency and problems such as fatigue and bone pain in adults and rickets in children.

� Compensation for poor diets in refugee camps often leads to over-consumption of energy-

dense and sugary foods.

� Hot drinks are consumed with significant amounts of added sugar.

� Cultural taboos such as those preventing Muslim women from exposing their body to men

during PA.

� Financial and language barriers.

� Mental trauma due to the refugee experience and prior persecution.

Gaps in services include:

� Lack of a nutrition team dedicated to refugee and migrant nutrition.

� Lack of funds for developing targeted interventions.

� Lack of research characterising the health status of refugee and migrant populations.

� Lack of information offering dietary advice e.g. targeted at the Muslim halal diet, despite there

being 35,000 Muslims in Auckland.

� Lack of a well child resource targeted at refugees.

Asian Health SettingRecently, ARPHS compiled a report on Asian public health needs for the Auckland region, which

included a stocktake of the services available to the Asian population (353). There are 146,103 Asians

in Auckland, representing 12.5% of the Auckland population. Twenty percent of the Asian population

in Auckland is aged between 0 to 14 years and another 20% aged between 15 and 24 years, with

diabetes being one of the six top potentially avoidable causes of death due to lifestyle changes affecting

diet and PA leading to obesity and hyperlipidaemia (354). Overseas studies have shown that

compliance with ‘Western’ dietary advice is poor, probably due to language and cultural barriers (355).

However, no childhood obesity prevention programmes targeted at Asian youth were identified.

Multiple gaps in services were identified including the following:

� Lack of an Asian nutrition programme at ARPHS.

� Lack of an Asian branch of the NHF.

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� HealthWest has a population that is 11% Asian, but recently dissolved its only health

promotion coordinator position.

Barriers identified to good nutrition and PA in the Asian community included:

� Changes in lifestyle and type of food eaten in NZ compared with Asian countries. This

includes an increase in car ownership with transportation by car rather than by

walking/cycling.

� Both parents often work and are not available to take children to recreational venues. In

addition, there are often no extended family available to help out.

It was also suggested that ARPHS could have a role in providing a half-time person for refugee,

migrant, and Asian nutrition. In addition, ARPHS could provide a budget for community trainers to

work alongside organisations such as Plunket and PHOs to coordinate and maintain community and

personal care programmes

The Food Industry SettingNo trials of macroenvironmental interventions aimed at preventing childhood obesity and involving the

food industry have been implemented, although taxation, reducing TV advertising to children, and

federal control of the school food environment are interventions in place in some countries. The effect

of food nutritional labelling on the prevalence of overweight and obesity has not been studied. In NZ,

the National Heart Foundation’s ‘Pick the Tick’ programme aimed to encourage a healthy food supply

by allowing industry to use the tick logo for foods meeting criteria for healthy levels of fat, added

sugar, sodium, fibre, and calcium (Soya milk only). However, subsequent evaluation has shown that

while the food industry has responded by reducing salt content in frequently eaten foods (356), the

public were confused by the significance of the logo (357). It is not known if ‘Pick the Tick’ has

impacted on BMI, chronic disease, the dietary quality of the population, or whether it influences the

food choices of one demographic more than another. Similarly, national media campaigns, such as ‘5

+ a day’ that aims to increase consumption of fresh fruit and vegetables, and the healthy food pyramid

that aims to illustrate recommended dietary guidelines, have lacked obesity prevention goals or

outcome measures (358, 359). Research on nutrition labelling in the USA has shown an association

between label readers and female gender (360), higher educational attainment (361), greater nutrition

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knowledge (362), and a reduction in percentage of energy in the diet obtained from fat (361, 363). This

suggests that nutrition labelling of food needs to be accompanied by strategies that influence the food

choices of less educated and lower socioeconomic groups (362).

The food industry’s primary aim is to make money and to continue to grow in a competitive

environment. The strategies used to encourage growth often harm the health of the consumer and

include the following: the use of cheap saturated fats and sugars in fast foods, snack foods, and

processed foods to reduce price, improve palatability, and hence encourage consumption (121, 122,

125); increasing portion sizes that also encourage people to over-consume (125-128); increasing the

variety of fat- and sugar- laden snack foods as variety also encourages over-consumption (129), for

example, the variety of Oreo cookies grew from 6 to 27 in the 1990s in the USA (Professor Marion

Nestle, personal communication); increasing the availability of food e.g. via vending machines

encourages consumption (364); advertising of energy-dense foods to children (170); lobbying and

threats to influence the wording of dietary guidelines, for example the food industry successfully

lobbied to have the following recommendation removed from the draft WHO strategy on ‘diet,

nutrition and the prevention of chronic diseases’ (156), fearing that it would impact adversely on the

soft- and fruit- drink industry: no more than 10% of daily calories should be consumed in the form of

sugars (365, 366), etc.

Nevertheless, there may be a place for the food industry in helping to prevent obesity in the population.

How the food industry might be engaged in health promotion is an issue that ARPHS and other health-

promoting organisations are currently grappling with, for example, should ARPHS allow McDonalds to

display its Mangere Healthy Kai banner because it now provides the ‘Salads Plus’ menu when the rest

of its menu is cheaper, tastier, more filling and energy-dense, and available in larger portion sizes?

NHF’s ‘Pick the Tick’ programme, discussed above, involves the NHF endorsing certain food products

in exchange for payment from the food industry. This faces the NHF with a potential conflict of

interest when it is vital that any health-promoting organisation is seen to be able to maintain integrity

for its primary aim of ensuring that the population’s health benefits. It may also be misleading to

endorse ‘products’ instead of nutrition and lifestyle, as no food or food product can singly promote

health. In addition, as mentioned above, there is no evidence that Pick the Tick has done anything for

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the population’s health apart from lowering the salt content of endorsed food products (356), although

the Auckland University’s Clinical Trials Unit is currently working on a trial to examine the impact of

Pick the Tick on some potential health outcomes (Dr Jo Wall, personal communication).

In April 2004, members of the food industry involved in a coalition of food industry groups chaired by

the ANZA (Association of NZ Advertisers Inc) became signatories to the ‘Food Industry Accord’

(367). This is a collaborative document involving representatives of major groups within the food

industry and its associated business partners that aim to help reduce obesity, improve nutrition, and

increase exercise. Accord members have agreed to develop relationships with the nutrition and PA

industries, develop strategies to support the promotion of healthy eating with priority given to ensuring

appropriate messages to children, promote industry-specific initiatives consistent with the MoH’s

Health Eating-Healthy Action (HEHA) Plan, and develop a communication strategy for implementing

the Accord objectives. CMDHB has begun negotiations with local members of the Food Industry

Accord to enlist their help with obesity prevention as part of CMDHB’s diabetes prevention plan

(Meeting with the food industry and CMDHB, 23.08.04). The Food Industry Accord are funding the

development of a nutrition and PA health promotion series featuring the unbranded character ‘Willie

Munchright’ which will screen during children’s TV time but will cut into programme rather than

advertising time. At this stage the food industry in Auckland are not considering limiting the

advertising of food and drink to children.

While the food industry is, not surprisingly, more devoted to healthy profit than healthy nutrition, there

may be a place for industry to promote health by funding PA campaigns, sports, and PA programmes,

ideally without using industry logos/advertisements to show sponsorship. Nestle is a foundation

sponsor of the Millenium Institute of Sport and Health and together they have produced a number of

resources: ‘Be Healthy Be Active’ advice on PA, and nutrition, diet, and recipe information (368-371).

Coca Cola has a campaign entitled ‘activity balance choice’ that promotes activity while heavily

advertising its beverages under the ‘choice’ part of its campaign (372). It has also formed a partnership

with the National Association of OSCAR with which it formed the ‘Go Kids’ PA programme for

children after-school (373-375). Sarah Ulmer has partnered with McDonalds to promote their ‘Eat

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Smart Be Active’ campaign which promotes McDonalds at the same time as promoting activity. In

Sarah’s words (376):

Earlier this year I approached them with an idea of how we could work together – to teach

people about the importance of exercise and a balanced diet, how McDonalds fits in with

that…

As an athlete I watch my diet carefully. I eat a range of foods, including burgers…

Watties has partnered with Plunket to produce a series of information pamphlets on baby’s and young

children’s nutrition which contain the Watties and Plunket logos. While many of the PA and nutrition

programmes produced by industry claim to aim at promoting healthy weight, none have been evaluated

for weight-related outcomes, although effects on consumer consumption, company profit, and

consumer satisfaction are regularly evaluated.

Policy SettingThe WHO has recently released its global strategy on diet, physical activity and health, listing as one of

its four main goals that “…policies and action plans are developed to improve diet and increase

physical activity that are sustainable, comprehensive and actively engage all sectors, including civil

society, the private sector and the media” (377). It continues on to discuss policies that could protect

public health, for example, preventing inappropriate food advertising to children, establishing healthy

school policies and programmes, and appropriately pricing and taxing unhealthy foods. In NZ, key

Ministry of Health documents have identified overweight and obesity prevention as a priority area for

action (12, 39, 57, 61, 378, 379), although currently in NZ there are no legislative interventions that

aim to control or reverse the obesity epidemic. Of note, the recently released HEHA Implementation

Plan 2004-2010 for NZ, aims to adopt policy to improve PA and nutrition in schools, and to develop

‘policy options’ for the advertising of foods to children (293). Following release of the HEHA Plan, a

memorandum of understanding was jointly signed by the MoE, MoH, and SPARC, that aims to

improve student’s wellbeing by working with other government agencies, schools, and their

communities to implement an effective annual programme of activities in schools, particularly

targeting nutrition, PA, and obesity (380).

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A report prepared for Fight the Obesity Epidemic (FOE, NZ) and Diabetes NZ Inc, summarises key

legislative measures in place overseas that could be used as a basis for legislative measures in NZ

(341):

� Restrictions on the sale of certain foods and drinks in schools: the USA has strong federal

regulation of food and drink sold in school cafeterias during lunch, and has recently begun

targeting food and drink sold at other times and places, with the federal government and many

states introducing bills to limit the sale of unhealthy foods. California now has legislation in place

that limits the sale of unhealthy foods in schools. In NZ, guidelines for vending machines in

schools are apparently being developed in conjunction with the Ministry of Education (381). In

addition, the Education Minister aims to make extra funds available to schools that have

appropriate measures in place to combat child obesity e.g. to schools selling only healthy foods

and not soft drinks and sweets (382). A recent NZ study of food sold in school canteens found that

the food environment was not conducive to healthy food choices for NZ school children (383).

The ratio of ‘less healthy’ to ‘more healthy’ main choices was 5.6:1, for snacks 9.3:1, and for

drinks 1.4:1. ‘Less healthy’ choices dominated food sales by more than 2:1 with pies being the top

selling item.

� Restrictions on TV advertising to children: there is a wealth of proposed and completed legislation

restricting advertising to children in general, and some useful examples of restrictions targeting

unhealthy foods. Many states such as Sweden, Norway, Belgium, Denmark, and the Canadian

province of Quebec prohibit advertising during children’s programmes, and many more have strict

regulations. The UK and Ireland have both considered Private Member’s bills that seek to

specifically prohibit the TV advertising of unhealthy food and drink during children’s

programmes. In fact, since the report by the Commons Health Select Committee (1), the UK

Labour party has announced that it will ban companies from targeting children with advertisements

for a range of unhealthy foods including burgers, crisps, fizzy drinks and sweets (384).

� Taxes on certain foods and drinks to fund health promotion: taxation at the state level in the USA

provides an excellent example of the revenue-gathering potential of small taxes on soft drink and

snack foods for spending on public health. However, a small tax may not reduce the consumption

of unhealthy foods, although it may be more politically feasible than a steep tax. USA surveys

found that 45% of adults would support such a tax if revenue was spent on health education – this

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was prior to the current media furore over the obesity epidemic. There is also some evidence, at a

microenvironmental level, that food pricing affects food choices. For example, a study involving

12 secondary schools and 12 work sites showed that price reductions of 10%, 25%, and 50% on

low-fat snacks in vending machines increased the percentage of low-fat snack sales by 9%, 39%,

and 93%, respectively (385). Two studies have shown that lower pricing is just as effective in

promoting sales of healthy foods such as fresh fruit and vegetables as it is for sales of energy-dense

vending machine snacks (385, 386).

It has been cogently argued that macroenvironmental and global strategies are needed to control the

food industry, similar to those used against the tobacco industry (387). Lessons from the tobacco

epidemic have shown that policy/legislative changes often have the greatest impact on reducing

prevalence. For example, in NZ, where we are considered to have the most comprehensive tobacco

control programme in the world, tobacco consumption decreased more rapidly than in any other

country with adult prevalence reducing by one quarter (from 32% to 24%) between 1981 and 1996

(388). Most of this success was attributed to legislation and tax increases; the tax increase of 50 cents

in 1991 increased the price of a 20-pack of cigarettes by 17% and decreased sales by 15% over the next

12 months. Similarly, a 13% increase in price in 1998 decreased consumption by 13% (388). Tax

rates were increased in line with consumer prices and increases were linked with other methods of

tobacco control such as advertising the health message behind tax increases and increasing people’s

access to effective cessation treatments and services (389). The Smoke Free Environments (SFE) Act

1990 and its subsequent amendments have also been effective in establishing smoke-free environments

and have had a role in reducing disease from second-hand smoking and the social acceptability of

smoking (390).

Transportation and Town Planning SettingEvidence shows that New Zealand children are spending less and less time in transportation-related

physical activities such as walking or cycling to school. The 1997/98 NZ Household Travel Survey

revealed that twice as many car trips were being made to schools than in the 1989/90 survey (391). In

Auckland, where residential intensification is reducing the safety and accessibility of outdoor spaces,

and urban planning is focusing on reducing commuting times by proposing the construction of new

motorways and prioritised lanes for vehicular buses (336), precipitous declines in rates of walking have

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been observed. This was illustrated in a survey which found that more than one-third of Auckland

children spend less than five minutes walking per day (392). In fact, a 1996 survey showed that 40%

of all Auckland children were being driven to and from school (319). While there have been no large-

scale interventions to improve urban design in Auckland in favour of increasing children’s physical

activity (393), the recent introduction of the Local Government Act 2002 requires that community

plans reflect the community’s social, environmental, and other aspirations, and that such aspirations are

determined through proper community consultation (394). Therefore, the Act provides a means

whereby the urban environment could be changed in response to society’s increasing need for living

environments that stimulate physical activity.

An American study has shown that transit-oriented neighbourhoods generated 120% more pedestrian

and bicycle trips than automobile-oriented neighbourhoods. Transit-oriented neighbourhoods had

gridded street patterns with four-way intersections that were initially built around a streetcar or railroad

line, while automobile-oriented neighbourhoods often had random street patterns designed without

regard for transit lines (395). Other studies have shown that residents from communities with higher

density, greater connectivity, and more land use mix report higher rates of walking/cycling for

utilitarian purposes than low-density, poorly connected, and single land use neighbourhoods (2, 396-

398). The USA Department of Transportation is implementing ways to increase walking and cycling

for transportation, and has calculated that up to 50% of the population could commute by bicycle as

that proportion lives within five miles of work/school (399).

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RecommendationsThe following list of recommended strategies for action is based on the above review of causes for

childhood obesity, interventions for obesity prevention, gaps identified by providers in existing

Auckland services, and the role for ARPHS suggested by other providers in childhood PA and

nutrition. Recommendations are split into those appropriate at a national or local (Auckland region)

level, and are further divided according to the part of the epidemiological triad that each strategy

addresses and the category or setting for each recommendation. Current evidence suggests that, as a

population, we are not undereating sufficiently to compensate for being underactive in our modern

society where overabundance of food, few opportunities to be physically active, and a physiology

geared to avoiding starvation rather than caloric excess, regularly overwhelms our capacity for

regulating appetite and energy balance (400). This situation, along with lessons from other epidemics,

suggests that all three parts of the epidemiological triad must be addressed (environment, vector, and

host), and that environmental strategies are often the most powerful and sustainable (194).

In agreement with many authors in the field of obesity prevention (1, 75, 240, 377, 400-405), these

recommendations acknowledge the need for policy-driven structural changes in the environmental

determinants of eating and PA patterns to address the underlying factors that predispose to and

perpetuate obesity. The argument underlying environmental solutions is that lifestyles are determined

more by the environment within which choices are made than by individual will. Such strategies are

termed ‘passive’ as they do not require individual behaviour change and may be more successful than

those requiring active decision-making (406) as they do not require health to be the basis of decision

making and also help reshape community norms (407).

Such strategies must be combined with vector-based strategies that increase the availability of low-

energy, high-nutrient foods while reducing the availability of high-energy snacks and drinks. Host-

based strategies that enable the development of lifeskills and individual competence to influence

factors determining health are also needed, particularly as the environment is unlikely to return to one

in which cognitive control of body weight is not required.

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National Strategies for Action

HostRESEARCH

� More research is needed to examine how individual behaviours that lead to energy excess are

affected by environmental factors, for example, how the amount of TV viewing is associated

with the safety of Auckland neighbourhoods; how the consumption of soft drinks relates to

soft drink vending machines in schools; how levels of PA correlate with factors such as the

proximity, density, attractiveness, or safety of recreation facilities or spaces; how a child’s

family food environment influences eating behaviours etc. This includes NZ research to

determine what behaviours are associated with low socioeconomic status and poorer PA and

nutrition outcomes.

� As mentioned previously, the scientific literature on childhood obesity interventions is

currently lacking in its ability to guide strategies and actions. Research barriers to be

overcome include: conducting trials of sufficient size and duration, using best methodology

including good measures of diet and PA, and identifying appropriate BMI cut offs for defining

overweight and obesity in non-European populations especially Maori, Pacific, and Asian

(this includes identifying Asians as a separate ethnic group in NZ research and presenting

separate results for this group). However, in the words of John Catford, given the seriousness

of the trends in childhood obesity, we must also “guard against nihilists and procrastinators

who require top-level evidence from randomized controlled trials before action is taken”

(408).

MEDIA

� Mass media campaigns, such as the Push Play campaign and 5+ A Day, to promote PA and

healthy nutrition. For example, campaigns could promote cycling and walking as means of

transportation, and promote water as the daily drink of choice etc. There is also a need to raise

awareness that obesity and overweight is a growing problem that has many undesirable health

and economic consequences, as people must become concerned enough to support social

changes that address the problem.

SCHOOLS

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� The schools’ role in PA and nutrition/lifestyle education needs to be reassessed and

strengthened. A concerted campaign is required to educate schools and pre-schools

concerning the importance of PA and nutrition especially in relation to childhood obesity. As

the child obesity statistics given above have shown, the time has come for schools and the

MoE to give nutrition education, PA, and the role of the school environment in encouraging

healthy eating and PA, the same priority as its scholastic functions.

� A curriculum-based approach is needed to influence eating patterns, reduce soft drink

consumption, reduce sedentary behaviours (especially TV viewing), promote PA, and provide

daily PA. School-based education could be delivered using a multimedia or multi-strategy

approach, as is currently being used by the DPT in delivering monthly education sessions to

Southern Cross High School as part of its adolescent obesity and diabetes prevention

programme.

� Schools should provide all school children with regular PA classes, preferably five days a

week, with the aim of getting all children active as well as catering for those who like sporting

activities. To this end, all schools, including primary schools, need dedicated PE specialists

who could also help coordinate externally-provided PA programmes.

� Pedometers could be issued to children at school as part of the PE curriculum with teaching

around their use, desired targets, and ways of increasing activity. Pedometer information

could also be used to monitor the level of PA in our nation’s children and evaluate various

interventions to increase PA.

FAMILY

� Promote healthy home-cooked meals and nutritious low-fat snacks that appeal to children

including raw fruits and vegetables.

� Address the decline in level of cooking skills in families, perhaps through the introduction of

compulsory healthy cooking classes to schools.

� Promote parental regulation of the amount of TV viewing and other sedentary activities such

as computer, play-station and video activities per day.

� Motivate parents to get active and encourage PA in their children.

� Promote family-friendly work policies such as flexible working hours that would allow

parents to participate in activities such as after-school sports coaching, have time after work to

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prepare home-cooked meals of high nutritional value and appropriate energy density, or walk

home with young children after school etc.

COMMUNITY/ PRIMARY CARE

� Continue to inform and support women of child-bearing age in healthy nutrition, weight

control, and not smoking, to help prevent obesity and other chronic health problems

developing in themselves and their offspring.

� Continue to educate, encourage, and support women to breastfeed infants up until at least six

months of age.

� Continue to inform and support preschool children and their parents regarding healthy weight,

nutrition and PA. For example, through healthy pre-school nutrition policies such as are

advocated by the NHF’s Healthy Heart Award and using the Well Child checks to monitor

growth, BMI, nutrition, and PA. In order to be effective, Well Child checks must also be

structured to target particularly at-risk groups such as Maori, Pacific, Asian, Refugee, and

Migrant groups.

� Health workers should encourage healthy foods and drinks, appropriate portion sizes, PA and

other positive actions in children rather than dietary restriction. Although, to date, the long-

term effectiveness of medical interventions has been low (409, 410), ARPHS is currently

planning a study to examine the effect of computer-generated nutrition messages tailored to

individual stage of change on various health indicators including BMI, and this may prove to

be a more effective means of improving adult and family nutrition (Kate Sladden, personal

communication).

EnvironmentPOLICY

� National policy is required to prevent the marketing of fast foods and soft drinks to children,

especially on TV during children’s viewing hours and in pre-schools and schools. Similarly,

marketing of low-energy, high-nutrient foods could be encouraged.

� National policy should ensure that food labelling listing energy, fat, sugar, and other content,

is accurate and ultimately of benefit to the consumer in enabling healthy food choices to be

made, especially the most at-risk consumer groups. To this end, research on labels such as the

Tick logo for Pick the Tick is needed to determine if consumers’ health has benefited and to

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identify the demographic characteristics of consumers. In addition, energy-density criteria are

needed to limit the Tick logo to products with lower energy density.

� Appropriate pricing +/- a fat tax on energy-dense foods of low nutritional value would be of

value if it achieved the aim of reducing consumption in at-risk groups and was not used

primarily as a means of obtaining money for health-promotion. As with tobacco tax, food

taxation should increase in line with consumer prices and be accompanied by campaigns to

advertise the health message behind tax increases, increased access to nutritious food of low

energy density, and opportunities for PA. In addition, as noted by Swinburn and Egger, 2002,

it would also be important to include public health nutrition consequences into the decision-

making process for current fiscal food policies (194).

� An intersectoral, national policy on obesity control could be developed. To this end, a method

is needed for measuring the health impact of current and proposed policies across all sectors as

a result of their effects on food supply/consumption and PA (411). This could require health

professionals with skills across sectors: urban planning, transportation, education, finance, and

acumen in the areas of legislation and regulatory policy.

� The health sector should lead the way by introducing nutrition policies, healthy food, and PA

options into its workplaces. For example, remove McDonald’s outlets and vending machines

containing non-diet soft drinks and energy-dense snacks from hospitals.

RESEARCH

� Government needs to support policy with appropriate surveillance of dietary habits, patterns

of PA, BMI and associated morbidity and mortality, and applied research and evaluation of

different policies and interventions. To this end, it would be useful if future surveys such as

the National Children’s Nutrition Survey (12) and SPARC’s Physical Activity Survey (348)

were conducted, and that outcomes were also examined by school, locality, method of

transportation to school, and other markers useful for evaluating the effect of policy in

different settings. It may also be possible to combine the collection of children’s nutrition and

PA facts in one regional or national survey.

� SPARC’s survey identifying barriers to PA in adults (412) should be repeated for children and

youth.

SCHOOLS

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� Serious thought needs to be given to the siting of schools and surrounding food retailers. It is

not appropriate that dairies and fast-foods are readily available (unavoidable in the case of

schools such as Southern Cross where the school’s main entrance has a zebra crossing that

discharges crossing children directly into one of the local dairies) to children during breaks or

immediately before and after school. Future zoning and planning could regulate the location,

density, or hours of junk-food outlets around schools.

� Active transportation to and from school must be encouraged in all schools with the

establishment of WSB and other innovations, for example, safe cycleways and walkways; the

school bus route could terminate a kilometre or so from school in a safe area with children

forming a WSB to complete the journey to school etc.

COMMUNITY

� There is an urgent need for urban design to reflect the growing need for children and adults to

engage in active transportation, i.e. walking, cycling, or taking public transport (which often

involves regular short walking journeys) to common destinations such as schools, shops, and

the workplace. To this end, a working relationship between the health sector and local/

regional councils and the transportation sector must be established. Initiatives could include:

safe cycle- and walk-ways that go somewhere useful, creating mixed-use neighbourhoods

integrating residential and commercial real estate that make active transportation more likely,

slowing or banning traffic from some areas; modifying building design to encourage the use of

stairways, providing safe parking at a distance from public venues such as schools and

shopping centres, protecting open recreational spaces, providing more drinking fountains in

public buildings and outdoor areas, providing formal recreation facilities such as sports

grounds or recreation centres etc. Changes in urban design could ideally be combined with

mass-marketing of active-transport options in order to influence long-term behaviours.

Marketing proved successful in a pilot study in Perth where a 14% reduction in car travel was

observed and associated with increased walking, cycling and use of public transport (413).

FOOD INDUSTRY

� The health sector needs to firmly establish what it can realistically achieve by working with

the food industry, and to determine how an ethical relationship can be maintained without

compromising its primary health goals.

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VectorPOLICY

� National policy is needed to prevent soft drink vending machines in any of our schools and

pre-schools (including school-based marae and Maori-speaking schools), or at least to limit

vending machines to those providing diet soft drinks, water, and possibly milk products.

� National policy is needed to ensure that all snack-vending machines are prohibited in schools

or at least provide low-energy, high-nutrient snacks such as fresh fruit, salads, wholemeal

sandwiches, and salad rolls.

� National policy is needed to ensure that all food sold in school tuck shops or provided in early

childhood centres is consistent with the National Nutrition Guidelines. Nutritious menus

could be developed in concert with the NHF’s SFP.

SCHOOLS

� Water fountains should be readily accessible throughout schools, kept clean and hygienic, and

provide water that is pleasant-tasting.

� In school tuck shops, the healthiest choices should also be the cheapest.

� Nutritious food policies must be supported by preventing children from leaving school

grounds for food during breaks.

FOOD INDUSTRY

� Work with restaurants, fast-food outlets and food retailers is needed to improve the content of

foods and reduce their energy density through changes in food processing and food

preparation e.g. changing to unsaturated rather than saturated fats for deep-frying of fast

foods, and using low-calorie cooking methods such as stir fry, steaming and

baking/microwaving.

� Involve the food industry in helping to reduce the energy density, improve the nutritional

quality, and reduce the portion sizes of food supplied to school tuck shops.

Local Strategies for ActionThe strategies mentioned above are obviously also important for the Auckland region but have not been

repeated below.

HostSCHOOLS

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� There is a need for more obesity prevention information to be available for school children

such as the video and diabetes prevention comic produced by DPT.

� School-based BMI checks could continue after Well Child checks finish at age five, by public

health nurses in schools. Overweight children could be identified early on and referred to

FWA, Young and Active, or some other school or community based programme. This would

require extending the capacity of these services; in fact Sport Auckland have already identified

a need to extend the YAA programme to include overweight and obese children who are not

on the FWA programme and children who are not overweight or obese.

FAMILIES

� The barriers to consumption of fresh, frozen or canned produce identified by Maori, Pacific

and migrant/refugee providers, 5+ A Day (261), and the recent Cancer Society survey (262),

included: perceived cost, the planning ahead required, knowledge of proper storage of

produce, lack of knowledge regarding available fruits and vegetables or the methods of

preparation, lack of time to prepare home-cooked meals, children preparing meals without

adequate knowledge of produce preparation etc. Survey findings should be used to help plan

public health measures aimed at improving nutrition by promoting fresh, frozen, and canned

produce, and removing real and perceived barriers to access.

� Families need help with identifying healthy foods and choosing wisely within the available

choices e.g. choosing the Salads Plus menu for lunch at McDonalds instead of a burger

combo. Media campaigns and providing comprehensible point-of-sale nutrition information

could help families make healthy choices. However, a nutrition message may need to be

presented in various ways before it is widely accepted. For example, media messages about

the fat content of fries and burgers may have no impact until the same message is associated

with, for example, a family member dying of a heart attack while eating a hamburger at a fast-

food outlet. This may be because eating burgers is usually associated with happy times with

friends and family, and that experience needs to be challenged before the implications of

burgers and fries are accepted. More research is needed to determine what drives food

choices.

� A large need for enhancing parenting skills in families was identified. Family-based

programmes such as FWA, YAA and KIA require extra resources to provide more family

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support to enable caregivers to provide children with an environment that supports healthy

weight and lifestyle.

COMMUNITIES

� There is a need for non-dietitian nutrition educators to provide simple and consistent

messages. However, educators themselves must have a much deeper knowledge of the subject

that is based on scientific fact and not obscured by cultural beliefs and traditions that

encourage obesity. In addition, many of our current providers in childhood nutrition are obese

and this gives children mixed messages. Would we expect our children to be educated against

smoking by an educator who smokes? Therefore, it seems desirable that standards of

knowledge and behaviour are set for educators, and that workplaces fully support educators to

obtain these standards by providing education, professional development, healthy workplaces,

and support for healthy lifestyles such as subsidised or free gym memberships. These

standards should also be taught as an integral part of all regional train-the-trainer courses.

Some Maori providers (RH and AMN) identified a particular need to provide their workforce

with more nutrition knowledge.

PRIMARY CARE

� None of the PHOs have childhood obesity prevention programmes, including TaPasifika

which provides the dietitian service for the childhood obesity treatment programme, KIA.

PHOs who have identified childhood obesity prevention as a priority area could liaise with the

PHO Plans Coordinator based at ARPHS and the ARPHS nutrition service to obtain

information about existing or planned obesity prevention programmes and to link with PHOs

having similar goals.

ARPHS

� There is a need for ARPHS to take a more proactive role in coordinating HPS in the Auckland

region in order to address the problems mentioned previously. HPS Facilitators should

maintain their links with HPS and keep up-to-date lists of HPS, their health goals, the

programmes running in each school, and the PA/ nutrition (and other) programmes available

locally that HPS can access if required. The Regional Coordinator should keep this

information updated for the whole region. Furthermore the Coordinator could take a proactive

role in the professional development of Facilitators, work with them on important regional

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health issues, such as obesity prevention, to coordinate strategies for action across the region,

and help ensure that programmes have clear objectives with measured outcomes and

evaluation if appropriate. Work is also required to determine the specific health needs of

Maori schools and Asian pupils and provide appropriate programmes. Facilitators must work

to establish sustainable relationships between HPS and programme providers by ensuring that

programmes meet the school’s specific goals and that sustainable funding is available.

� ARPHS could have input into improving pre-school nutrition by holding more regional

nutrition workshops for childcare staff, and providing advice on pre-school menus.

� A need has been identified for the ARPHS nutrition workforce to include a public health

dietitian or nutritionist to work with the Asian, refugee, and migrant community.

� There is a need for one or more public health dietitians in the Waitemata and Counties

Manukau regions to provide nutritional advice and support to programme providers such as

HPS, NEW, PHOs, pre-schools, schools, community groups and the general public. FWA

dietitians require more time for their role in FWA and more Maori and Pacific input.

PROGRAMME EVALUATION/ RESEARCH

� Due to the extreme lack of both international, national, and local research regarding the

efficacy of childhood obesity prevention interventions, where possible children’s programmes

aimed at increasing PA or improving nutrition should have obesity prevention as an additional

primary goal, with weight-related measures (BMI, waist circumference, or skin fold thickness)

included as an outcome. Even programmes that do measure weight, i.e. FWA, Well Child,

KIA, and the PIH pilot, have significant data problems, with the possible exception of KIA.

FWA has a large amount of data missing or unrecorded, Well Child weight data has not been

evaluated or published, and the PIH pilot evaluation involved very small numbers of family

members, while one subsequent evaluation of BMI was for adults only. Data collection and

recording needs to be identified as a specific programme goal supported by education and

monitoring of collected data. Collection of weight data (and also possibly diet and

PA/pedometer data) seems particularly appropriate for the larger school-based programmes,

for example, HPS where obesity prevention is an identified goal, the adolescent obesity &

diabetes prevention programme, and possibly schools running the SFP. ADHB’s Diabetes

Project and PHOs offering programmes to children in future could also be well-placed to

97

collect data. Some of the programmes run by RST with schools and the community, such as

Fitt Kidz and MK, could consider collection of weight-related data in addition to PA/

pedometer information.

� Programme evaluation must be built into the cost of programmes and include baseline

measurements and ongoing process and outcome evaluation. The University’s School of

Population Health, AUT’s Department of Sport and Recreation, ARPHS Nutrition Service,

ADHB’s Children and Young People’s Diabetes Prevention and Management Project, or

private evaluators could provide some advice regarding the structure and evaluation of PA and

nutrition programmes. The YAA programme has PA data that remains unevaluated due to

lack of resources (funding and expertise). In future, YAA data could be evaluated with FWA

data.

� Programmes that aim to increase PA need better measures of PA such as could be obtained

with the use of sealed pedometers or accelerometers. Similarly, dietary measurements should

be taken over a minimum of three days including one weekend day.

� There is a need for programmes targeted at individuals to be based on best models of

behavioural change. Some work is being done in this area by ARPHS for adults (using

computer-generated nutrition messages based on the stages of change model), and by Massey

University’s Department of Commerce who are planning to look at the association between

the success of obesity prevention programmes and the model of behavioural change on which

programmes are based (Jacinta Hawkins, personal communication).

� More local public health measures need to be directed towards lower socioeconomic status

families, with more research needed to determine how families are actually living and how

this impacts on lifestyle. For example, 30% of the children attending KIA are from single

families; a large proportion eat pies on the way to school for breakfast and buy energy-dense

foods such as sausage rolls and soft drinks for lunch (Dr Teuila Percival, personal

communication).

EnvironmentMore nutrition/ PA programmes in the Auckland region should incorporate non-host (i.e.

environmental or vector based) interventions to help prevent childhood obesity, such as those described

above under ‘national recommendations’. Currently, such interventions are limited to: healthy tuck

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shop/nutrition policies in some schools and pre-schools (that have proven to be extremely difficult to

maintain over time), removal of soft drink vending machines from some AIMHI schools, school travel

plans such as TravelWise, food in schools and the breakfast in schools campaign, school and pre-

school gardening projects, MHK, advocacy for policy and planning changes, and advocacy for fat

taxes, food labelling, restricting TV food advertising to children and environmental change supporting

PA.

SCHOOLS

� WSB and other forms of active transport need to be established and supported, particularly in

the lower socioeconomic areas of Auckland. Research is needed to identify factors important

to increasing their success in these areas.

� Many of the problems experienced locally by schools, such as teachers lacking the knowledge,

confidence and time to teach nutrition or take PE classes; difficulty enforcing healthy food

policies; lack of coordination between externally-provided programmes with programmes

remaining separate from the school Health and Physical Education Curriculum; the absence of

‘obesity prevention’ from the school curriculum etc, could be resolved if there were

intersectorial recognition of: (1) the importance of PA and good nutrition in schools, (2) the

need for national school policy regulating: tuck shop food, soft drink and snack vending

machines, daily PA coordinated and led by trained PE teachers, and the PA and nutrition

opportunities in the wider school environment. To this end, as mentioned above, a concerted

campaign is required to educate the Health and Education Sector and local schools/pre-schools

about the importance of PA and nutrition especially in relation to childhood obesity.

COMMUNITIES

� Schools and communities need to lobby and work with councils to help plan and initiate the

environmental changes, described above, that support PA and healthy nutrition.

� NHF could take a lead role in formulating school tuck shop food policy at a local or regional

level.

ARPHS

� ARPHS, as the regional provider of public health services, could have a role in initially

defining the relationship between Auckland health providers and the food industry, and

subsequently working with industry on nutrition policy, product labelling with health

99

promotion messages, and promoting nutrition messages and healthy choices in supermarkets

and food retail outlets.

� ARPHS could take a lead role in providing regional workshops educating tuck shop retailers

in nutrition education. This could initially be done in schools enrolled in the NHF’s SFP and

in HPS, and extended to all other schools in time. ARPHS could also have a role in

advocating for environmental-level policy such as regional or nationwide healthy school food

policy.

MINISTRY OF HEALTH

� There is a lack of awareness amongst providers of children’s PA and nutrition programmes

available in the Auckland region. MOH and SPARC make efforts to coordinate the strategies

that they fund and keep lists of providers. In addition, ANA is funded by the MOH to keep a

national inventory of providers, programmes, and relevant research. However, there is a need

to maintain more comprehensive, detailed and up-to-date lists of providers and programmes,

increase provider awareness of, and access to, relevant programmes and providers, and further

help providers build collaborative relationships in the area of childhood obesity prevention,

nutrition, and PA.

100

�

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Appendices

Appendix 1: Auckland component of the Pacific Obesity Prevention in Communities (OPIC)study for children in Years 9 to 12.

SUMMARY OF AUCKLAND COMPONENT

1.1 Specific design features-South Auckland

1.1.1 Background:

A multi-sectoral intervention study is planned in Mangere, South Auckland, focused mainly

around schools, but also involving Pacific Island churches and other local community settings.

The intervention area was chosen because it has a large Pacific population and it is a

reasonably localised area, which is bounded by water on three sides. This study meets all the

concerns raised by a recent review of interventions for preventing obesity in children (191). It

has an adequate sample size to detect achievable changes in BMI, an intensive intervention

planned for a period of 30 months, and it is multi-faceted through the involvement of schools,

parents and churches.

1.1.2 Design-School interventions:

Sample: The intervention group will comprise year 9-12 students (first 4 years of high school)

from 4 co-educational high schools from the Mangere region who will be invited to participate

in .the survey. The control group will come from four control schools in other parts of South

Auckland. Within each group, there are 2 schools with SES decile I rating and 2 with SES

decile 2 rating. We have met with principals at the intervention schools, who all support the

study. Other parts of Auckland with a significant Pacific community geographically distant to

Mangere, such as West Auckland, are not suitable as the control area because their schools all

have higher SES decile ratings (range of 3-6) and a lower proportion of Pacific pupils.

Interventions: During 2004 discussions will be held with schools to implement a range of

school interventions, starting in Term 2 of 2005 after baseline measurements are taken in

Term I. We have met with community groups involved with school-based interventions, and

we will incorporate their activities into the program: Manukau City Council (Health

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Promoting Schools); Manukau District Health Board (Healthy Schools Project); Counties

Manukau Sport (Sports Mark Quality Assurance Programme); and '5 Plus a Day' (school fruit

donation programme). These organizations have agreed to focus their school-activities in the

intervention schools. Gaps for implementing some interventions have been identified (eg.

sporting equipment, payment for after-school sporting co-ordinators, provision of water

fountains, subsidies for fruit purchased from school canteens) and have been budgeted into

this application. A new curriculum package, specifically aimed at obesity prevention, will be

developed for Years 9-11 (first 3 years of high school). This will be an intensive course,

running for the 3 years, and will include a component on decreasing TV viewing. Resources

for this are budgeted.

Input & Outcome Measures: Main measurements in intervention and control schools will be

at baseline (term I, 2005), 12 months (term I, 2006), and 30 months (term 3, 2007) and will

include: I) Audits of the school environment, using the ANGELO framework; 2) Individual

student diet and physical activity (including hours of watching TV) by the food frequency

questionnaire and activity questions used in the NZ national children's nutrition survey. A

general questionnaire will also collect information on demography (parents' occupation),

ethnicity, name of church and frequency of attendance during the intervention period; 3)

Individual student outcomes - weight and height (shoes removed and in light clothing, to

calculate the primary outcome of BMI), abdominal circumference (for fat distribution), bio-

impedance to measure body fat using an IMP 5 analyser, and blood pressure (in duplicate

using an electronic Omron digital blood pressure monitor). Socio-cultural, economic and

quality of life measurements will also be taken. All students (Pacific and non-Pacific) in Years

9-12 will be surveyed at each time point, so some will only contribute 12 or 18 months of

follow up data. With an estimated 80% response rate and a 30% drop out rate at follow up, the

effective sample size is expected to be approximately 1500.

1.1.3 Design -Church interventions:

Sample: There are 26 churches in Mangere, nearly all with Pacific Island congregations.

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Interventions: The diet and activity program developed for Pacific churches by National Heart

Foundation's Pacific Islands Heartbeat Programme will be promoted to all Pacific churches in

the study region and run by Pacific Heartbeat. It involves a range of health activities (eg.

cooking classes, aerobics sessions) that are supported by individual churches with signed

agreements for completion.

Input & Outcome Measures: Since the individual measurements will be done in the school

setting, our evaluation measures will only be at the church level. The input measures will

focus on assessing the level of church-based activities that might affect the target age group

during the 30-month follow-up period. This information will be used to develop a score of

church exposure to interventions to rank students. Qualitative data (key informant interviews)

will assess the changes that occur at a church level towards a supportive environment for

healthy eating and physical activity .

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Appendix 2: Key informant structured questionnaire.

Key Informant Structured Questionnaire

1. Name:

2. Organization:

3. Work role:

4. What child obesity prevention services do you offer?

� Programme/intervention provided:

� Target group (ages, settings):

� Locality of service:

� What, if any, evaluations have been done on your obesity preventionprogramme(s)?

� What resources does your obesity prevention programme require (cost,people, time, materials)?

� What, if any, gaps have you identified in the service delivery of thisprogramme?

5. What gaps have you identified in wider Auckland’s child obesity preventionservices:

6. What services or role do you think ARPHS could offer?

7. What research or surveys have you carried out on obesity prevention?

8. What other child obesity prevention services do you know of?

� Service:

� Contact details:

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Appendix 3: List of Auckland providers interviewed (ordered by organisation).

Name Organisation Work Role InterviewFirst SurnamePaula Dudley 5 Plus-A-Day General Manager InterviewUtulei Antipas ADHB PHO Funding InterviewWendy Cook ADHB Project Manager: Children and young peoples diabetes

prevention and management projectInterview

Leane Els ADHB - Community Child & Family Services Public Health Nurse InterviewVikki Ham ADHB - Community Child Health & Disability Service Health Promoting Schools Facilitator InterviewGrace Hinder ADHB - Community Child Health & Disability Service Team leader child and youth health InterviewFiona Smith ADHB - Community Child Health & Disability Service Community Dietitian - Food with Attitude InterviewPenny Wilson ADHB - Community Child Health & Disability Service Team Manager early childhood health InterviewWayne Cutfield ADHB - Starship Hospital Diabetes Specialist. Co-Leader: Children and young peoples

diabetes prevention and management projectPhone interview

Trix Bradley Aotearoa Maori Netball Oranga Healthy Lifestyle Trust National health coordinator InterviewJune Mariu Aotearoa Maori Netball Oranga Healthy Lifestyle Trust National coordinator InterviewEvelyn Taumaunu Aotearoa Maori Netball Oranga Healthy Lifestyle Trust Assistant national coordinator InterviewRangimarie Bassett ARPHS Health promoting schools coordinator InterviewJanet Chen ARPHS Asian public health coordinator InterviewChris Cook ARPHS Dietitian: Mangere Healthy Kai and community health

promotionInterview

Cheryl Hamilton ARPHS Manager, Special Projects. Coordinator of PHO plans inAuckland

Interview/Follow-up

Annette Mortensen ARPHS Refugee and migrant health coordinator InterviewKasalanaita Puniani ARPHS Nutrition and health promotion advisor. PI pre-school

gardening projectsInterview

Megan Tunks ARPHS Maori services development InterviewVivian Cheung Asian Network/ Centre for Asian & Migrant Health AUT Chairperson/ Researcher InterviewErica Laws Auckland City Council Leisure Manager Phone interviewSue Kendell Auckland Regional Council Walking School Buses Coordinator Phone interviewKaryn Ne'emia AuckPAC Project Management InterviewSusie Tameifuna AuckPAC Practice Nurse InterviewElaine Rush AUT Body Composition & Metabolism Research Centre InterviewGrant Schofield AUT Senior lecturer (sport & recreation) InterviewCarolyn Watts Cancer Society Ex-dietician. Fruit/vege campaign (Wgtn) InterviewSimon Denny Centre for Youth Health Youth2000 report NZDA Conference 2003 InterviewPeter Watson Centre for Youth Health Manager. Clinics for Type 2 diabetics Phone interviewJohn Newman Centre for Youth Health (WDHB) Paediatrician (Futures West clinics) Phone interviewPat Flanagan CMDHB Professional Leader & Dietitian CMDHB InterviewArun Gangakhedkar CMDHB Paediatric Fellow Interview/ Follow-upAndrew Lindsay CMDHB PHO contracts CMDHB InterviewAlison Vogel CMDHB Paediatrician CMDHB InterviewJude Woolston CMDHB Projects co-ordinator: Healthy schools InterviewAlison Sykora Coca Cola Activity/Balance/Choice campaign InterviewCathy Newman Counties Manukau Sports Foundation Team Leader Sport DevelopmentLance Watene Counties Manukau Sports Foundation Active living team leader Email responseHelen Gibbs Diabetes Projects Trust (Sth Ak) Dietitian InterviewKaren Pickering Diabetes Projects Trust (Sth Ak) Manager InterviewJudy Rowden Diabetes Projects Trust (Sth Ak) Nurse. Adolescence project co-ordinator. Lifestyles. InterviewKate Smallman Diabetes Projects Trust (Sth Ak) Lifestyle Nurse Co-ordinator InterviewRobyn Toomath FOE (Fight the Obesity Epidemic) Spokesperson (Endocrinologist-Wgtn) Email responseRobin White FOE (Fight the Obesity Epidemic) Editor of FOE Email responseKatherine Clarke Hapai Te Hauora Tapui Ltd Chief Executive Officer InterviewRiki Burgess Harbour Sport Physical Acitivity Co-ordinator InterviewSarah Dunning Harbour Sport CEO InterviewEdwin Puni Health Star Pacific PI health (preschool, school, radio programmes) InterviewAlan Greenslade HealthWest PHO CEO Phone interviewTrish Lawther HealthWest PHO Project Manager Westkids. InterviewColleen Stewart HealthWest PHO Dietitian Phone interviewTeuila Percival Kids First Paediatrician (obesity clinic) InterviewJane Harding Liggins Institute Barker's hypothesis Email responseGillian Rushton Lynfield College Teacher (Food and Nutrition) InterviewYvonne Townsend Lynfield College Faculty Manager/Teacher in Home Economics InterviewShelley Edwards Manukau City Council Health promoting schools manager InterviewTony Kake Manukau City Council Manager of community advocacy and funding Phone interviewSam Noon Manukau City Council Community leisure planner Phone interviewHeather Smith Manukau City Council Food in schools programmeSue Zimmerman Manukau City Council Planner for health and wellbeing Phone interviewPauline Ashfield-Watt Massey University (Albany) Lecturer (Nutrition). Evaluation of 5+ a day. MailJacinta Hawkins Massey University (Albany) PhD in childhood obesity prevention programmes InterviewElizabeth Stewart Massey University (Albany) Evaluation for 5+ a day with Dr Ashfield. InterviewPhillipa Bennetts McCauley High School School nurse (AIM HI school) Phone interviewBeverley O'Laughlin McCauley High School School nurse (AIM HI school) Phone interviewShayne Nahu Ministry of Health (Penrose) Portfolio Manager: Public Health Directorate InterviewBarbara Lusk Ministry of Health (Penrose) Portfolio Manager: nutrition & physical activity contracts InterviewMegan Grant Ministry of Health (Wellington) Implementing HEHA plan InterviewMoananu Okesene Mot'otua Ltd PI programmes Phone interviewAnna Lindross National Heart Foundation School settings manager InterviewCarol Murray North Shore City Council Road safety co-ordinator Phone interviewBernadette Walsh North Shore City Council CEO Phone InterviewBronwen Hannay NZ Nutrition Foundation Breakfast in schools campaign InterviewCelia Murphy Obesity Action Coalition (Wellington) Coalition Director Email response

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Henga Amosa Pacific Islands Heartbeat Programme Church settings InterviewMaria Cassidy Pacific Islands Heartbeat Programme Nutritionist InterviewMafi Funaki-Tahifote Pacific Islands Heartbeat Programme Dietitian InterviewEstelle Meuller Pasifika Health Care CEO InterviewAnnette Schwalger-Miller Pasifika Health Care PI preschools InterviewSiobhan Matich People's Health Trust Manager Phone interviewJenny Tanner PHO (Health West) Health promotion in schools coordinator ResignedNicola Young Procare Health Promoter MailSue Grant Public Health Nurse, Pukekohe Health promoting schools facilitator Phone interviewElaine Preston Raukora Hauora o Tainui Executive Manager of Whanau & Community Health InterviewJackie Dawson Rodney City Council Road safety coordinator Phone interviewKarlynne Barry Southern Cross High School Health Centre Manager InterviewDebbie Edwards SPARC Auckland regional sport and recreation strategy InterviewLisa Logan Sport Auckland Green prescription manager, Auckland InterviewSimon Peterson Sport Auckland Chief executive InterviewRachelle Hobbs Sport Waitakere Programme co-ordinator (Fitt Kidz Programme) Kay LindleyKay Lindley Sport Waitakere Active living manager InterviewAumea Herman Tau Pacifica Health promoter/ public health registrar InterviewSoana Muimuiheata Tau Pacifica Community health promoting Dietitian InterviewLaurie Wharemate Te Hotu Manawa Maori Nutrition & physical activity manager InterviewJulia Peters Tikapa Moana PHO Health PromoterTe Ata Teau Tuakau Homebuilders CEO Phone interviewRobert Scragg University of Auckland Lead researcher: the Pacific Obesity Prevention in

Communities ProjectInterview

Lynne Eagle University of Massey (Albany) Associate professor in marketing. Department of Commerce InterviewRocky Tahuri Waipareira Trust Team Leader - public health arm InterviewHelen Anderson Waitakere City Council Leisure projects leader InterviewJoanne Evans WDHB Health promotion Phone interviewMaria Kekus WDHB Public health nurse Phone interviewHope Munro WDHB Health Promoting Schools Co-ordinator Waitakere InterviewRobyn Whittaker WDHB Childhood obesity prevention InterviewSue Wilson WDHB Public Health Nurse Phone interviewRobyn Rummins WDHB - Community Child & Family Services Health Promoting Schools Co-ordinator North Shore Interview

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Appendix 4: List of programmes in Auckland having a role, or potential role, in childhood obesity prevention.

Programme/Organisation

Target Group(ages/ settings)

Interventions Locality Evaluation/ Measured Outcomes

Setting: SchoolsAdolescent obesity &diabetes preventionprogramme.Diabetes Projects Trust& NEW working party.

13-14 year-olds(form 3=Year 9).High Schools.

*Roadshow to explain the interventions, including a healthyeating/ PA video.*Workshops one morning a month on aspects of healthylifestyle.*Lunch-time physical activity classes 3x a week.*Healthy tuck shop contract; removal of coca cola fromvending machines etc.*Student health council.

AIMHI Schools inManukau. Currentlyestablished in twoAIMHI schools:Southern Cross Collegeand McAuley HighSchool.

None. Plans to evaluate the roadshow video andinterventions. Completed pilot survey (Year 9assessment) of all AIMHI schoolchildren. SouthernCross have also evaluated children's attitudes to theYear 9 assessment.

Health PromotingSchools.Ministry of Health/Ministry of Education.

5-12 year-olds(Year 1 to Year 8).Primary Schools.

Various PA and nutrition services in schools whereincreasing activity and improving nutrition have beenidentified as priority areas. For example, healthy tuckshoppolicy, augmented nutrition education given as part of theschool curriculum, the NHF School Food Programme,WSB, lunchtime PA organised by Sports' Trusts such asthe 'Young and Active' programme run by Sport Aucklandin conjunction with FWA etc.

Primary schoolsthroughout the Aucklandregion. Nationwideproject.

Evaluations have been done on WSB, FWA, and theNHF School Food Programme. FWA is the onlyprogramme measuring and evaluating BMIoutcomes. Young and Active also measures BMIoutcomes but results have not been reported orevaluated. Broader evaluations of the HPSprogramme have been done, but the overall effect onweight has not been assessed.

The School FoodProgramme.National HeartFoundation.

Primary andsecondary schools.

*Providing food choices consistent with the Food andNutrition Guidelines by ensuring that an appropriate schoolfood and nutrition policy is implemented.*Promoting/marketing healthy foods to students, staff,parents and caregivers.*Nutrition education in the classroom using units developedfrom the ‘Health and Physical Education’ school curriculum.*Promoting nutrition to the wider school community

Nationwide. Outcome evaluations were conducted in 1992, 1999,and 2004 (in progress). No weight-related outcomesreported. Outcomes evaluated were changes in theschool food environment.

The Pacific ObesityPrevention inCommunities Study.The University ofAuckland and DeakinUniversity, Australia.

Years 9 to 12children (13-16years-old).Secondary Schools.

RCT with multi-component interventions. Interventions willinvolve nutrition/PA education, environmental changes, andincreased PA.

Mangere SecondarySchools (x8) andMangere churchesmainly PI (x26).

*Weight-related measures: BMI, abdominalcircumference, and bio-impedance to measure bodyfat.*Individual measures of diet and PA.*Audits of the school environment.*The level of church-based activities that might affectthe target age group will be assessed and used todevelop a score of church exposure to interventionsto rank students.

5+ A Day. United Fresh NZ Inc.

Mainly preschooland primary schoolchildren.

*Fruit and vegetable nutrition education packages suppliedto teachers of 5+ A Day schools and preschools.*Trial of fruit to schools programme in 10 year-old South

Nationwide in interestedprimary and preschools.Also part of some Food

Evaluations have been conducted: Baselineevalution in 1995. Outcome evalution in 1999 ofknowledge of nutrition, and fruit consumption.

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Auckland schoolchildren. Technology courses atsecondary schools.

Consumer survey 2001 of fruit consumption. Twoevaluations in progress assessing consumerknowledge and consumption. No weight-relatedoutcomes.

Breakfast in SchoolsCampaign.NZNF.

Mainly primaryschool children andsome preschoolchildren.

*Nutritious school breakfasts.*Teachers' resource packs containing educational material.

Nationwide to primaryand intermediateschools.

Evaluation conducted in 2002 which showed that70% of participants always ate breakfast, 12%sometimes, and 18% never. 71% reported changesin their eating habits including having breakfast andchoosing cereals in place of left-over dinner. Noweight-related outcomes measured.

Nutrition Education inSchools and HomeEconomics.Ministry for Education.

All school children. *Health and physical education curriculum: food andnutrition, physical activity.*Home economics curriculum.

Nationwide in schools. No weight-related outcomes.

Jump Rope for Heart.National HeartFoundation.

Primary schoolchildren.

*School curriculum-based skipping skills and activities.*JRFH promotional activities such as "Jump Rope AllStars" visits.*JRFH workshops to educate teachers about theprogramme and how it links with the schools' Health andPhysical Education Curriculum.

Nationwide to primaryschools.

Evaluation to be conducted in 2004. No weight-related outcomes.

More Kids More ActiveMore Often.Harbour Sport andNorth Harbour Schools.

School children. *Sport Leaders Programme.*WSB.*Before School Jump Jam.*Police Bike Education.*Community Health Promotion Committee.

North Harbour Schools. Programme is a 2-year pilot yet to be completed/evaluated. No weight-related outcomes.

Setting: Pre-SchoolsHealthy Heart Award. NHF.

Under five years-old. HHA pack aiming to achieve the following seven criteria:*Provision of healthy food which involves either sending inguidelines for parents about lunchbox contents or sendingin a copy of the menu if the centre has a food service.*A written nutrition policy.*A written PA policy.*Parent/whanau education.*Professional development.*PA linked to the Early Childhood Curriculum (283),including documenting the daily PA available to children.*Curriculum linked nutrition activities including documentingthe weekly healthy food activities available to children.

Nationwide to preschoolcenters.

Pilot evaluation:Intervention centres were more likely to havenutrition (p<0.0001) and PA (p<0.0001) policies,lunchbox guidelines (p=0.015), food menus thatcycled between different healthy choices on aperiodic basis (p=0.052), parents in educationsessions (p=0.005), children were more likely to havea piece of fruit or vegetable (p=0.0008) and lesslikely to have salty pre-packaged snack food(p=0.034) in their lunchboxes. The interventionteachers showed increases in nutrition and PAknowledge scores (p=0.029). No weight-relatedoutcomes.

ADHB Services.ARPHS and CommunityChild Health andDisability Services.

Under five years-old. ARPHS:*Nutrition workshops for early childhood staff.*Nutrition standards advocacy for Long-Day childcarecentres.*Food and nutrition manual for pre-schools.

Auckland earlychildhood centres.

No formal evaluations. Body weight is recorded byWell Child services.

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*Gardening project for PI pre-schools.Community Child Health & Disability Service:*Well Child services.*Health promotion using the HPS framework in pre-schools.*FWA resource for pre-schools.*Promotional events e.g. Well Child week.*Work with the MoE to develop the Early ChildhoodCurriculum.

Setting: FamilyFood With Attitiude. Community Child Health& Disability Service(ADHB).

5-12 year-olds andtheir families. One-year programme.

*Individual goal-setting, nutrition education, and on-goingassessments using a 'stages of change' model andengaging family support.

ADHB area. Evaluated in 2003. Small n and incomplete medicalrecord data made it impossible to conclude causalrelationships between FWA and measured changesin BMI, although improvements in shortness ofbreath, sports participation, and confidence levelsmay be occurring. Analysis of all medical records(n=39) for children enrolled in FWA showed that28.2% of children had increased their BMI, 25.6%decreased, and 35.9% had only one record of BMI.Children's BMI decreased where family membershad increased their PA and made positive dietarychanges.

Young & Active.Sport Auckland.

FWA participantsreferred to YAA via agreen prescription.One-yearprogramme.

*Individual goal-setting, PA education, and assessmentsengaging family support.*Weekly group PA sessions held by Sport Auckland.

ADHB area. Not evaluated.

Kids in Action. South Seas Health CareLtd.

School-age childrenand their families.Special focus onPacific people.

*Paediatrician assessments*Dietary assessments and nutritional advice.*Weekly exercise session, home visits from a nurse orother community health worker.*Family group conferences to develop strategies forfamilies to create healthy environments and continue PAand healthy lifestyle upon exit from the programme*Health promotion resources and information for familiesand children including nutrition information, PA messages.*Links to other support services.*Individual goal-setting.*Prizegivings.

CMDHB area. 2003 evaluation: 70% maintained or lost weight; 42%lost weight.

Setting: Primary Health CareModified GreenPrescription Project.ProCare PHO.

Adults (�18 yearsold) currently. Plansto extend and modifythe programme to

*Procare patients that are overweight/obese etc are given agreen prescription which prescribes participation in PAprogrammes that are provided by the regional sports trusts.

Current plans includethe Procare populationin Mt Roskill, Manurewa,and Clendon areas.

The proposed evaluation will measure the primaryoutcome of change in PA, and the secondaryoutcome of change in BMI. Secondary outcomemeasures will include monthly BMI and waist-hip

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target youth andchildren.

ratio, and bi-monthly blood pressure.

Support for variousexisting programmes. East Health PHO.

Preschool andschool-age children.

*Well-child checks.*Supports the NHF’s school food programme, children’sWSB, and collaborates with schools to improve PA throughthe health and physical education curriculum.

East Health PHOpopulation in theCMDHB area.

See above.

Various programmes.TaPasifika PHO.

Pre-school andprimary schoolchildren.

*KIA programme run by South Seas Health Care.*School breakfast programme supported by HealthPacifica.*Pre-school programmes:TaPasifika - well-child programme to Pacific pre-schools.Pacifika Healthcare - advocacy for pre-school nutritionpolicies, a pre-school dance to music programme fournights a week for 3 to 5 year-olds and a gardeningprogramme with pre-schools. This is being extended toshow parents how to cook and prepare garden produce.

TaPasifika PHOpopulation throughoutthe South (South SeasHealth Care, HealthPacifica Ltd) and West(Pasifika Healthcare)Auckland region.

See above for KIA. No evaluation of the otherprogrammes. Only KIA measures weight-relatedoutcomes.

HealthWEST PHO. Children of all ages. *Provide annual support for the Push-Play campaign.*A dietitian is contracted by HealthWEST for GP referrals -offers a service based on the nutrition component of FWAbut not funded by HealthWEST so patients must pay.

HealthWEST PHOpopulation in WestAuckland.

No evaluation of dietitian service, although change inBMI measured.

Move for Health “Hikoimo te Oranga”, andChild/Rangitahi Healthprogramme.North Harbour PHO.

Move for Health: allages (adults andchildren).Child Health: primaryand intermediateaged children.

*Move for Health: PA programme one day a week at theBirkenhead Leisure Centre, aimed at all communitymembers.*Child Health: social workers identify health issues ofimportance to children, such as obesity, and offer parentsinformation about available services. Plan to develop anutrition programme using the FWA framework so thatoverweight/ obese children could be referred to the dietitianservices currently offered by North Harbour PHO.

North Harbour PHOpopulation in NorthAuckland.

There are plans to evaluate the Child Healthprogramme. Outcome measures will include changein BMI, and also changes in social behaviour.

The Centre for YouthHealth.

Focus on adolescentyouth.

*Clinical services for youth with chronic, complex healthissues.*Assistance to other youth health providers.*Education and training opportunities for tertiary students inyouth health.*Kidz First Resource and Information Service.*Research on a range of relevant adolescent healthstudies.*Advocacy for policy, planning and legislation thataddresses the healthy development and well being ofyouth.

South Auckland. No evaluation of BMI outcomes for overweight orobese youth attending the clinical service.

Children and YoungPeople’s DiabetesPrevention andManagement Project.

Children and youth. *Database of educational and health promotion materialson nutrition, obesity, and diabetes established andmaintained.*Training of primary care providers in the use of health

Auckland region. Evaluation planned at inception (April 2004, April2005), implementation (April 2006), and then sixmonthly to the Project Steering Committee andannually to ADHB standards. After 20-22 months an

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ADHB. promotion materials.*Training of health workers, school teachers, andcommunity leaders in diabetes and obesity prevention andmanagement.*Collaboration with/mobilisation of agencies such as PHOs,community groups, schools, ACC (Auckland City Council),Sports Auckland, and the private sector, to work in obesityprevention and management.*Establishment of an 0800 line for obesity prevention andmanagement.*Supporting community-based research programmes in theAuckland region.*Supporting priority groups that promote healthycommunity environments for obesity prevention andmanagement.

external review by an overseas expert is planned.Specific outcome measures have not yet beenstated, although results from the FWA programmewill continue to be monitored, and hospital admission/length of stay data will be available for children withdiabetes and obesity-related diseases.

Setting: Maori ProvidersTe Hotu Manawa Maori. Children, youth and

adults.*Developing and adapting the NHF’s Healthy Heart Awardfor Maori pre-school children.*Nutrition and PA education resources including posters,pamphlets, booklets (such as their recipe booklet aimed atMaori youth), and newsletters.*Advisory and advocacy role.

Nationwide. No details for evaluation of the Maori Healthy HeartAward developed yet.

Wai HealthProgrammes.Te Whanau OWaipareira Trust.

All ages. *Child care services: well child checks to kohanga reo, kurakaupapa and whakekura, a child health service for tamarikiaged 1 month to 5 years, and a Parents As First Teachersprogramme that involves visits from a personal educator,for families with 0-3 year-old children.*Public health services: ‘Kai and Nutrition’ trainingcertificate, annual national nutrition hui 2004, healthynutrition displays and promotions to community groupssuch as kura kaupapa, kohanga reo, churches, and youngmothers groups, daily PA programmes, the youth transitionprogramme targeting 12-18 year-olds which includes rap,break-dancing, and tagging/bombing (mural painting).*A nutritionist and dietitian (visits from AUT once a week)are available for healthy lifestyle and kai advice.*Free clinical service to children <18 years, a weeklymobile clinic to schools, kohanga reo, kura kaupapa, andcaravan park locations in West Auckland.*Te Rito early childhood centre with a focus on health.

West Auckland. None known.

Raukura Hauora. All ages. *PA programmes.*Waka ama programme particularly targeting children andyouth.*Rangitahi nutrition programme targeting intermediate and

South Auckland. Not known.

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secondary school children.Aotearoa Maori NetballOranga HealthyLifestyle Trust Inc.

Maori women andyouth.

*Annual national netball tournaments. *Netball training live-ins that include the presentation of nutrition and PAinformation.*Occasional health promotion workshops/hui.*Blood pressure and diabetes screening clinics attournaments, and the promotion of healthy nutrition attournaments and team practices

Nationwide. Evaluated in 2002 as part of an evaluation of theMoH’s nutrition and PA contracts in the northernregion. No weight-related outcomes.

Setting: Pacific People ProvidersPacific IslandsHeartbeat.

All ages. *A Train-the-trainer course in Pacific nutrition.*The Healthy Heart Award programme for Pacific earlychildhood centres.*Nutrition pamphlets in a range of Pacific languages,nutrition videos, and newsletters.*A fat kit used during educational sessions.*Advocacy, media commentary.*The Heartbeat Pacific Lifestyle Project (HPLP) forSamoan church communities.

Nationwide. Evaluation of results for HPLP 2001: baseline BMIfor the intervention and control churches was(mean+/-s.e.) 34.8+/-0.4 and 34.3+/-0.9 kg/m2,respectively. Intervention churches lost 0.4+/-0.3 kg;control churches gained 1.3+/-0.6 kg (p=0.039,adjusted for confounders).

Setting: Community ProvidersFood in Schools. Manukau City Council.

Pre-school andschool-agedchildren.

*Healthy lunches and breakfasts are supplied to 40 schoolsincluding Kohanga Reo and early education centres.

Manukau. None. No weight-related outcomes monitored.

Health PromotingSchools.Manukau City Council.

Primary schoolchildren.

*Annual mini Olympics.*School garden projects.*Training for student health teams in nutrition, meetingskills etc.*Support for NHF SFP, JRFH.

Manukau. See HPS, above.

Various programmes. Waitakere City Council.

Intermediate andsecondary school-aged children.

*Time Out – cheerleading, indoor sports, graffiti art etc for12-18 year-olds.*Street Sports – sports and activities for 11-18 year-olds.*Raise up ‘n’ Represent – provides a safe socialisingenvironment for encouraging and supporting personalgrowth, physical fitness, leadership skills, and self-respect.Includes basketball, hip hop, break dancing, phat, andskate-ramping for 13-18 year-olds.*Youth Fitness – at the Massey Leisure Centre for ≥14year-olds.*Ranui Youth Group – PA programmes.*McLauren Park Youth Group – discos, sport days,leadership training etc.*YMCA Basketball League.

Waitakere. No weight-related outcomes measured.

Walking School Buses. Auckland TLAs andARC.

Primary schoolchildren.

*Children walk to and from school under adult supervision(usually two parents with one acting as a front driver andone a back conductor) along a set route complete with

Nationwide in the maincities.

*Evaluated in 1991, late 2002, and late 2003.*Findings as at Nov/Dec 2003: 53 schools inAuckland have WSBs with 1738 children walking on

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stops that allow children to embark and disembark. WSBs per day; 1046 car trips saved per day; twothirds report neighbourhood improvements; gradientin favour of higher decile school communities withproportionately low numbers of WSBs in ManukauCity.

Fitt Kidz. Sport Waitakere andBruce McLarenIntermediate School.

Intermediate schoolchildren.

*A school health council promoting a different project eachterm e.g. nutrition, sun smart awareness etc.*PA coordinators (hired AUT students) to take lunch-timePA.*Tuck shop enrolled in the SFP. Tuck shop and schoolhave undertaken not to advertise unhealthy foods.*Parents walking group/ evening exercise classes.

Bruce McLarenIntermediate School.

None. No weight-related outcomes monitored.

Various communityservices. ARPHS.

All ages. *Nutrition information to schools and pre-schools.*Pacific pre-school garden project.*Mangere Healthy Kai project.*Community dietitian to encourage healthy food choices insuburban shopping centres.

Auckland region. *Mangere Healthy Kai evaluation April 2004:percentage of shoppers who ate a healthy kai choicefor their last meal/snack at MTC increased from 32%in September 2003 to 57% in April 2004 amongstthose aware of MHK. Approximately half of thosesurveyed were aware of the MHK programme.Changes amongst MHK retailers included more fishbeing grilled than fried, and more sandwiches andfewer pies being sold.*No weight-related outcomes monitored.

Public Health Dietitians. All ages. *Health promotion activities around good nutrition.*Training other dietitians.*Education/advice to community groups.*Advice to MoH.

Auckland region exceptWaitemata.

Evaluations of programmes PHD are involved in hasoften been done e.g. FWA, PIH, MHK etc (seeabove).

Advocacy Groups. FOE, OAC, ANA.

All ages with a focuson children.

*Advocacy for macroenvironmental changes throughlegislation, regulation, and taxation. For example:*Banning or severely restricting TV food advertisingdirected at children.*Restricting all TV advertising of foods that are high insaturated fat and sugar.*Removing soft-drink vending machines from schools.*Introducing healthy food in school canteens.*Fat tax.*Warning labels on high-energy foods.*Promotion of consistent nutriton/PA messages.*Promotion of environmental changes that support PA.

National. NA.

Setting: Refugee and Migrant HealthRefugee and MigrantHealth. ARPHS/ CCHDS.

All ages. *CCHD: well child programme for under-fives.*ARPHS: targeted nutrition education sessions.*CCHD/ARPHS: Somalian refugee nutrition/PAprogramme.

Auckland region. None. No weight-related outcomes measured.

Setting: Food Industry

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Various programmes -most in partnership withhealth-promotingorganisations.

All ages. *Mangere Healthy Kai.*McDonalds 'Salads Plus' menu.*Pick the Tick.*Watties nutrition pamphlets advising on babys' and youngchildren's nutrition.*PA resources: Nestle 'Be Healthy Be Active'; Coca-Cola'activity, balance, choice' and OSCAR PA programme;McDonalds 'Eat Smart Be Active'.

Auckland region andnational.

None.

Setting: PolicyVarious. All ages. *WHO Global Strategy on Diet, PA, and Health:

Prevent inappropriate food advertising to children.Healthy school policies and programmes.Appropriate pricing/taxation unhealthy foods.*Healthy Eating-Healthy Action Implementation Plan:Policy to improve PA and nutrition in schools.Develop ‘policy options’ for food advertising to children.*MoE/MoH:Developing guidelines for vending machines.Extra MoE funds to schools with measures in place tocombat child obesity.*Legislative measures proposed by FOE/Diabetes NZ:

Restrictions on sale of certain foods/drinks inschools.Restrictions on TV advertising to children.Taxes on unhealthy foods and drinks to fundhealth promotion.

National andInternational.

None.

Setting: Transportation and Town PlanningVarious. All ages. *Local Government Act 2002:

Community plans must reflect community’s environmental,social needs etc.*Transit-oriented neighbourhoods.*USA Department of Transportation:Interventions to increase transportation by walking andcycling.

National andInternational.

None.