Coronary Heart Disease

Guidance for implementing the preventive aspects

of the National Service Framework

 The Health Development Agency

The Health Development Agency (HDA) is a special health authority with a remit
to improve the health of people in England and in particular, to reduce
inequalities in health. It achieves this by:

• Working with key statutory and non-statutory organisations at national,

regional and local level

• Finding out what works and maintaining this evidence base

• Turning the evidence into action by building up the skills and capacity of
those working to improve the public’s health

• Advising on the setting of standards for public health planning and

practice.
Contents

iii
INTRODUCTION

Methods used to develop the guidance 1

Focusing on coronary risk factors 3

PREVENTION OF CHD THROUGH

PROMOTING HEALTHIER LIFESTYLES 5

Chapter 1: REDUCING SMOKING PREVALENCE 7

1.1 Introduction 7
1.1.1 The National Service Framework
for coronary heart disease 7
1.1.2 Benefits of smoking cessation for CHD 8
1.1.3 Trends in smoking 8
1.2 Objectives of interventions to reduce smoking 9
1.3 Features of effective interventions 9
1.4 Components of a local strategy 10
1.4.1 Develop smoking cessation services 10
1.4.2 Reduce smoking in public places
including workplaces 12
1.4.3 Support national media campaigns 13
1.4.4 Use media advocacy 13
1.4.5 Monitor the voluntary advertising ban 14
1.4.6 Reduce sales of cigarettes to children
under 16 years old 14
1.4.7 Encourage the introduction of smoking
policies in schools 14
1.5 Reducing inequity 15
1.5.1 Black and minority ethnic groups 15
1.6 Tables of suggested activities to support
local action
Intervention, Evidence, Outcome, Who could be involved?,
Skills and resources, Points to consider, Further information 17
1.7 References 21

Contents
 Chapter 2: IMPROVING DIET AND NUTRITION 25

2.1 Introduction 25
2.2 Objectives of nutritional interventions 25
2.2.1 Professional knowledge and expertise 26
2.3 Features of effective interventions 27
2.4 Components of a local strategy 27
2.4.1 Schools 27
2.4.2 Local/community projects 28
2.4.3 Workplace 28
2.4.4. Healthcare 29
2.5 Reducing inequity 29
iv
2.5.1 Black and minority ethnic groups 30
2.5.2 Children 30
2.6 Tables of suggested activities to support local action
Intervention, Evidence, Outcome,
Who could be involved?, Skills and resources,
Points to consider, Further information 31
2.7 References 40

Chapter 3: INCREASING PHYSICAL ACTIVITY 43

3.1 Introduction 43
3.2 Objectives of physical activity interventions 43
3.3 Features of effective interventions 44
3.4 Components of a local strategy 44
3.4.1 Healthcare interventions 44
3.4.2 Exercise referral schemes 44
3.4.3 Workplaces 44
3.4.4 Mass media 45
3.4.5 Schools 45
3.4.6 Older people 45
3.4.7. Physically active transport 46
3.5 Reducing inequity 46
3.6 Useful sources of information about community
based programmes 47
3.7 Tables of suggested activities to support local action
Intervention, Evidence, Outcome,
Who could be involved?, Skills and resources,
Points to consider, Further information 48
3.8 References 54

Coronary heart disease: guidance for implementing the preventive aspects of the NSF
Chapter 4: REDUCING OVERWEIGHT AND OBESITY 57

4.1 Introduction 57
4.2 Objectives of weight management 58
4.2.1 Definitions of ‘lifestyle’ weight management
interventions 58
4.3 Features of effective interventions 59
4.3.1 Skills 60
4.4 Reducing inequity 60
4.5 Further information 61
4.6 Tables of suggested activities to support
local action
v
Intervention, Evidence, Outcome,
Who could be involved?, Skills and resources,
Points to consider, Further information 63
4.7 References 68

STRATEGY DEVELOPMENT 71

Chapter 5: DEVELOPING A LOCAL STRATEGY 73

5.1 Establishing a local CHD implementation team 73

5.1.1 Milestones and goals 73
5.2 Developing local delivery plans 73
5.3 Building effective partnerships 74
5.3.1 New freedoms to promote and support
joint working 74
5.3.2 Making the partnership effective 75
5.4 Involving local communities 75
5.4.1 Consulting local communities 76
5.4.2 Developing capacity 77
5.4.3 Engaging ‘excluded’ groups 77
5.5 Health needs assessment 77
5.6 Community profiling 77
5.7 Equity profiling 78
5.7.1 Audit of current provision 78
5.7.2 Personal and professional development audit 78
5.8 Monitoring progress 79
5.8.1 Developing local targets 80
5.8.2 Monitoring frameworks 82
5.9 Illustrative monitoring frameworks
5.10 Further sources of information 87
5.11 References 90

Appendix 91
Contributors 91

Glossary 93

Contents
Foreword by the Secretary of State for Health

i
Coronary heart disease is the biggest killer of men and women in this country. More than 111,000 people die from
this condition, and about 300,000 have heart attacks every year. The national service framework for coronary heart
disease (NSF CHD), which the government published in March 2000, is our blueprint for tackling this chronic disease.
This document is a key component of that blueprint.

The framework and The NHS plan describe a range of strategies to diagnose, treat and care for people who suffer
from heart disease, and also how to prevent it occurring in the first place. The health service must give people who
want to make changes to their lifestyles, the support and advice that they need. Effective interventions at an early
stage will not only reduce the immediate risks, but also slow down the progression of the disease, identify the early
symptoms and limit the incidence of death and long term incapacity.

This document explains how this is possible at local level. It provides evidence-based examples of effective interventions
for dealing with all the primary risk factors for heart disease – smoking, poor nutrition, physical inactivity, overweight
and obesity. It is, in effect, an early warning system for tackling heart disease.

I am confident that the document will help to transform prevention services throughout the NHS.

Alan Milburn
Secretary of State for Health
Introduction
The prevention of coronary heart disease (CHD) is a
government priority. The white paper Saving lives: our
healthier nation [Department of Health (DH) 1999] set a
target of reducing the death rate from heart disease,
stroke and related conditions by 40% in those aged
under 75 years by the year 2010. CHD is common,
frequently fatal and largely preventable. The burden of
heart disease is higher, and has fallen less in the UK than
many other countries. It is the leading cause of death,
killing over 110,000 people in England in 1998,
including more than 41,000 under the age of
75 years (DH 2000a).
The recently published NHS plan reinforces CHD
as a clinical priority and focuses on preventive
aspects of the disease. The Plan emphasises the
importance of the NHS role of working in
partnership with others to address health
inequalities (DH 2000b). The plan highlights the
importance of the NSF CHD which, for the first time,
sets out national quality standards for preventive
and clinical services.
The HDA, at the request of the DH, has developed this
guidance. It is intended to assist local implementation
teams [health authorities (HAs), primary care groups
(PCGs) and primary care trusts (PCTs), local authorities
(LAs) and other local stakeholders] in developing their
approaches to addressing the preventive aspects of the
NSF CHD. It therefore relates to Standards 1, 2, 3, 4
and 12 (see Box on the next page). The guidance
should be read in conjunction with the NSF CHD
main report (DH 2000c), Chapter 1 of the NSF (DH
2000a) and relevant sections of Chapter 2
(DH 2000d) and Chapter 12 (DH 2000e). The HDA’s
Health update: coronary heart disease and stroke
provides useful information on trends and risk
factors (HDA 2000).
1
The guidance covers strategy development and
interventions to promote CHD-related healthier
lifestyles (smoking, nutrition, physical activity and
weight management). In the strategy section,
approaches that should underpin all health
improvement work are covered briefly and further
information is signposted where available. In the
sections on risk factors, key objectives are presented
that will contribute to CHD prevention together with
an overview of effective approaches that will promote
healthier lifestyles. In addition to CHD, the risk factors
and the strategies listed in this resource will also
have a significant impact on other initiatives in public
health, such as The cancer plan, the forthcoming
NSF for older people and the NSF on diabetes.
A range of interventions to be developed locally is
suggested, involving a range of players in a variety
of settings, which could link with other local initiatives.
This work is evolving and represents the first stage of
support for those working on preventive aspects of
the NSF CHD at a local level (see box on next page).
The HDA welcomes comment on this document
and suggestions on how to improve the guidance.
Please contact Karen Ford (karen.ford@hda-online.org.uk)
or Hilary Whent (hilary.whent@hda-online.org.uk)
at the HDA.
Methods used to develop the guidance
A range of research and expert opinion has been drawn
upon in preparing this report. Systematic reviews and
literature reviews have been scanned, and literature
searches and consultation with expert informants have
been carried out. Some 65 critical readers were sent a
first draft of this document and amendments were made
in the light of their comments.
Introduction
 Preventive aspects of the National Service Framework

Reducing heart disease in the population

Standard 1
The NHS and partner agencies should develop, implement and monitor policies that reduce the prevalence of
coronary risk factors in the population, and reduce inequalities in risks of developing heart disease.

Standard 2
The NHS and partner agencies should contribute to a reduction in the prevalence of smoking in the general population.

2
Milestones: pages 20–21 of NSF CHD (DH 2000c)

Prevention of coronary heart disease in high risk patients in primary care

Standard 3
GPs and primary care teams should identify all people with established cardiovascular disease and offer them
comprehensive advice and appropriate treatment to reduce their risks.

Standard 4
GPs and primary care teams should identify all people at significant risk of cardiovascular disease but who have not
yet developed symptoms and offer them appropriate advice and treatment to reduce their risks.

Milestones: pages 25–26 of NSF CHD (DH 2000c)

Cardiac rehabilitation

Standard 12
NHS trusts should put in place agreed protocols/systems of care so that, prior to leaving hospital, people admitted to
hospital suffering from coronary heart disease have been invited to participate in a multidisciplinary programme of
secondary prevention and cardiac rehabilitation. The aim of the programme will be to reduce their risk of
subsequent cardiac problems and to promote their return to a full and normal life.

Milestones: pages 54–55 of NSF CHD (DH 2000c)

The HDA takes a broad approach to evidence, valuing a public health, it identifies the complex
range of research methods, which contribute to the interaction of causes of poor health, and
multidisciplinary nature of health improvement work. recommends action right across government to
Implications from the research evidence have been drawn reduce social inequalities in health (DH 1999). The
out and recommendations for local action are made. government’s strategy is informed by the evidence
Gaps in the evidence base have been highlighted. from the Independent Inquiry into Inequalities in
Health, chaired by Sir Donald Acheson (Acheson
1998). This recommended that a broad front
A broad front approach: upstream and approach be taken to tackle the underlying,
downstream root causes of inequalities in health. The
inquiry reported that policies to improve
The government recognises the socio-economic health are needed both ‘upstream’ and
influences on population health. In its strategy to improve ‘downstream’.

Coronary heart disease: guidance for implementing the preventive aspects of the NSF
 ‘For instance, a policy which reduces inequalities in
income and improves the income of the less well
off, and one which provides pre-school education
for all four year olds are examples of “upstream”
policies which are likely to have a wide range of
consequences, including benefits to health. Policies
such as providing nicotine replacement therapy on
prescription, or making better facilities for taking
physical exercise, are “downstream” interventions
which have a narrower range of benefits’ (Acheson
1998).
This guidance document fully endorses this approach
to improving health.
Where evidence is available on the impact of
upstream policies, it is reported. However, for the
most part, there is greater evidence of the impact of
downstream policies. There are more reported studies
of interventions aimed at individuals (lifestyle and
health related behaviours) than there are of
policies that seek to influence the broader
determinants of CHD.
This preponderance of research aimed at assessing
the effectiveness of downstream policies should not be
seen as evidence that downstream policies are more
effective than upstream policies. It simply reflects the
fact that downstream policies tend to be more amenable
to research efforts that seek to assess the effectiveness
of interventions.
Focusing on coronary risk factors
‘... by April 2001 all NHS bodies, working closely
with local authorities will have agreed and be
contributing to the delivery of local programmes
of effective policies on:
a) reducing smoking
b) promoting healthy eating
c) increasing physical activity
d) reducing overweight and obesity’
(DH 2000c, page 57; DH 2000a, page 18)
The NSF CHD focuses on three main lifestyle behaviours
that are associated with risk of CHD: smoking,
physical activity and diet. It also focuses on obesity,
which is associated with both these last two factors,
and is also independently associated with some
increase in CHD risk. In addition, there is now strong
evidence that a moderate intake of alcohol reduces
the risk of CHD, but an excessive alcohol intake
increases the risk.
Quantifying the impact of risk factors
on CHD
It is hard to give figures for the proportion of CHD that
could be prevented if lack of physical activity, poor diet
(high fat, low fruit and vegetables) and smoking were
successfully eliminated. This is because many people with
3
heart disease have multiple risk factors, and it is hard to
disentangle the separate effects. The American Public
Health Association did make an attempt at such an
estimate (Smith and Pratt 1993) and the results are
shown in the box below. A similar modelling exercise in
the UK would be expected to produce slightly different
findings because more of the UK population are smokers,
while fewer are obese. However, the information is useful
in giving some indication of the relative importance of
these risk factors in terms of the potential for making an
impact on CHD rates.
Proportion of CHD attributable to various
modifiable risk factors in the USA
Risk factor Best estimate Range
% %
Cholesterol >200 mg/dl 43 39–47
Physical inactivity 35 23–46
Cigarette smoking 22 17–25
Obesity 17 7–32
Source: Smith and Pratt (1993)
In the following sections, information is presented about
effective interventions, which aim to bring about change
in these risk factors. Implications are drawn from the
evidence and suggestions are made for local action at a
number of levels, involving a range of players and linking
to other local initiatives. Further information sources are
also signposted.
The gaps have been identified in the evidence base.
There is an urgent need for more and better designed
evaluations of interventions aiming to improve health and
well being and the dissemination of results. Evaluation is
Introduction
 a planned set of activities, which helps people to see
how work is progressing and whether or not it is
effective. It should be seen as an integral part of projects
and programmes. Evaluation requires relevant skills and
it is worth considering making links with local researchers
(within the NHS, LAs and academic institutions). There
are many approaches to evaluation and sources of support
are listed on p89.
References
4
Acheson, D., 1998. Independent inquiry into inequalities in health.
London: The Stationery Office.
DH, 1999. Saving lives: our healthier nation. London: The Stationery Office.
DH, 2000a. National service framework for coronary heart disease:
Chapter 1. Reducing heart disease in the population. London: DH.
Coronary heart disease: guidance for implementing the preventive aspects of the NSF
DH, 2000b. The NHS plan. A plan for investment. A plan for reform.
London: The Stationery Office.
DH, 2000c. National service framework for coronary heart disease: main
report. London: DH.
DH, 2000d. National service framework for coronary heart disease,
Chapter 2. Preventing coronary heart disease in high risk patients.
London: DH.
DH, 2000e. National service framework for coronary heart disease:
Chapter 12. Cardiac rehabilitation. London: DH.
HDA, 2000. Health update: coronary heart disease and stroke.
London: HDA.
Smith, C. and Pratt, M., 1993. Cardiovascular disease. In: R. Brownson,
P. Remington and J. Davis, eds. Chronic disease epidemiology and
control. Washington: American Public Health Association.
Chapter 1
Reducing smoking prevalence
1.1 Introduction
Smoking is the cause of one out of every seven deaths
from heart disease (nearly one in four deaths among men
and one in 10 among women). Nine in 10 deaths from
lung cancer among men and nearly three in four among
women are estimated to have been caused by smoking –
84% of all lung cancer deaths. Among those aged under
65 years, two in five deaths from stroke were caused by
smoking. Smoking is also linked to many other serious
conditions, including asthma and other respiratory
illnesses, cataracts, peripheral vascular disease,
periodontal disease and brittle bone disease (Callum
1998). Treating the illnesses and diseases caused by
smoking is estimated to cost the NHS up to £1.7 billion
every year (Raw et al. 1998).
Passive smoking – breathing in other people’s tobacco
smoke – is also a major cause of mortality and morbidity.
It contributes to death from heart disease and a range of
other health problems (Royal College of Physicians 1992).
In December 1998, the Government’s first-ever white
paper on tobacco, Smoking kills, set three targets, for
adults smoking, smoking during pregnancy and children
smoking (DH 1998a).
• To reduce adult smoking in all social classes so that
the overall rate falls from 28% to 24% or less by
2010, with a fall to 26% by the year 2005. In terms of
today’s population, this would mean 1.5 million fewer
smokers in England.
• To reduce the percentage of women who smoke
during pregnancy from 23% to 15% by the year 2010,
with a fall to 18% by the year 2005. This will mean
approximately 55,000 fewer women in England who
smoke during pregnancy.
7
• To reduce smoking among children from 13% to
9% or less by the year 2010, with a fall to 11%
by the year 2005. This will mean approximately
110,000 fewer children smoking in England by
the year 2010.
The cancer plan published in September 2000
introduces new national and local targets to
address inequalities in smoking rates between
socio-economic groups. At a national level the
target is:
• To reduce smoking rates among manual groups from
32% in 1998 to 26% by 2010 (DH 2000a).
1.1.1 The National Service Framework
for coronary heart disease
The NSF CHD (DH 2000b) states that ‘by October
2000 HAs, LAs, PCGs/PCTs and NHS trusts will have
set up, or have firm plans in place [for a range of NHS
smoking cessation services which will enable national
and regional targets for the numbers of smokers
quitting to be met]. By April 2001, HAs, LAs, PCGs/PCTs
and NHS trusts will have agreed and be contributing to
the delivery of the local programme of effective policies
on reducing smoking; as an employer, have implemented
a policy on smoking and be able to refer clients/service
users to specialist smoking cessation services, including
clinics …’
The immediate priorities for implementing the smoking
cessation area of the NSF CHD are:
• By April 2001, health authorities will introduce
specialist smoking cessation clinics, helping 150,000
people
Reducing smoking prevalence
 • Delivering the early milestones set out in Chapter 1 of
NSF CHD: Reducing heart disease in the population
(DH 2000b).
The requirements of smoking cessation are
detailed in Appendix A, Chapter 1 of NSF CHD: Reducing
heart disease in the population (DH 2000b).
1.1.2 Benefits of smoking cessation for CHD
The costs and benefits of smoking cessation are well
8
established (Raw et al. 1998).
• Reductions in smoking prevalence are guaranteed
to bring population health gains (Raw et al. 1998;
US Department of Health and Human Services 1990).
• Smoking cessation reduces the risk of dying from
smoking related diseases.
Smokers have about twice the risk of dying from
CHD compared with lifetime non-smokers. This
excess risk is reduced by about half among ex-
smokers after only one year of abstinence and
declines gradually thereafter. After 15 years of
abstinence, the risk of CHD is similar to that of
people who have never smoked (Tang et al. 1992).
Smoking cessation is particularly important in the
secondary prevention of CHD. In smokers with
existing CHD, the risk of premature CHD mortality
can be reduced by 50% or more on giving up (US
Department of Health and Human Services 1990).
• Reductions in smoking prevalence will produce sizeable
reductions in common hospitalised events and costs
(Naidoo et al. 1999).
• The cost savings that can be made through moderate
success in smoking cessation programmes are
significant and cumulative (Naidoo et al. 1999).
1.1.3 Trends in smoking
Adults
The prevalence of smoking in the UK over the past 20
years or so has fallen. In 1998, 27% of adults aged
16 years and over smoked cigarettes compared with 40%
Coronary heart disease: guidance for implementing the preventive aspects of the NSF
in 1978. However, most of this decline occurred in the
1970s and 1980s. In the 1990s, the decline in smoking
prevalence among adults levelled off (DH 2000c).
The prevalence of smoking is higher among people in
manual than non-manual social classes (32% compared
with 21% in 1998). The widening of this gap over the
past 20 years reflects a steeper decline in smoking
prevalence among non-manual classes compared with
manual classes (DH 2000c).
The social class differentials in smoking are reflected in
the social gradients of deaths caused by smoking. The
percentage of deaths from ischaemic heart disease
caused by smoking ranges from 39% for men aged
35–64 years in social classes I–II to 49% of those in
classes IV–V. For women aged 35–64 years the figures
range between 35% for classes I–II to 46% for
classes IV–V (Callum 1998).
Pregnant women
The proportion of women who smoke during pregnancy
has fluctuated over the past eight years (Owen et al. 1998;
Owen and Penn 1999). In 1999 nearly a third of women
(30%) smoked during pregnancy compared with 27% in
1992. Among young pregnant women (aged 16–24 years)
from social groups C2DE (similar to manual and unemployed
classes), the percentage is even higher, with 51% smoking
during pregnancy in 1999 (Owen and Penn 1999).
Teenagers
In 1999, an estimated 9% of children aged 11–15 years
smoked cigarettes (DH 2000c). This figure has varied
considerably over time, showing a low of 8% in 1988
and a high of 13% in 1996 (DH 2000b). As the majority
of smokers take up the habit in their teens, any increases
in the rates of young smokers will eventually feed
through into adult smoking rates.
Black and minority ethnic groups
Cigarette smoking among minority ethnic groups is
generally less than among the UK population as a whole
(28%1). However, a more detailed examination reveals
important differences between and within groups. The
smoking rate among Bangladeshi men is very high (49%).
1Differences between the HEA (1999a) and DH (2000c) surveys in
timing and methodology most likely account for the 1% difference in
the estimates of the percentage of adults who smoke.
This same group of men also has high rates of chewing
tobacco products. Smoking rates are even higher among
middle-aged and older Bangladeshi men (54% and 70%
for men aged between 30–49 and 50–74 years,
respectively). Smoking rates among African-Caribbean
men and women resemble, and sometimes exceed, the
rates for the UK population as a whole. Smoking rates
among African-Caribbean women are higher for younger
women [Health Education Authority (HEA) 1999a].
Poverty and smoking
Traditional measures of social class tend to underplay the
extent to which smoking has become concentrated in the
poorest sections of society. Recent studies have shown
that smoking levels have remained virtually unchanged
among those in the poorest groups, and among lone
mothers smoking levels have risen (Marsh and McKay
1994; Dorsett and Marsh 1998; Jarvis 1998). In a detailed
study, lone parents living in rented accommodation and
relying on social security benefits were found to have
smoking levels in excess of 75% (Dorsett and Marsh 1998).
1.2 Objectives of interventions to reduce
smoking
The importance of a comprehensive approach has long
been recognised (WHO 1979). As well as approaches
aimed at the individual, there has been a recognition of
the need for policy and legislative measures and social
and environmental initiatives as essential components of
any strategy to reduce tobacco use (WHO 1998). Ideally,
each component of such a comprehensive strategy would
encompass the following objectives:
• Promote quitting (not cutting down) among adults and
young people
• Reduce exposure to environmental tobacco smoke
• Create a social environment that is supportive of
non-smoking and cessation.
In the context of reducing smoking among adults, a
secondary objective could include strategies to prevent
the uptake of smoking among young people. However,
it is important to note that there is little evidence that
teenage strategies, especially in the absence of adult
strategies, have any impact on the uptake of smoking
among children (Reid 1996; Hill 1999).
Local strategies to reduce smoking prevalence should
reflect the policies and population groups set out in the
white paper on tobacco Smoking kills (DH 1998a), The
NHS plan (DH 2000d, Chapter 13), NSF CHD (DH 2000b)
and The cancer plan (DH 2000a).
Local strategies should also include an alliance of NHS,
local government, education and commercial interests,
as well as voluntary agencies, to help reduce smoking
and to provide information on smoking by using local
media, creating local activities and promoting debate to
generate interest. Some areas of the country already
9
have smoking alliances. These cover about 60% of the
population of England and are supported by the DH.
1.3 Features of effective interventions
A comprehensive approach – combining community wide
approaches with economic and regulatory measures –
was identified by the US Surgeon General as the
strategy most likely to have the greatest long-term,
population impact (US Department of Health and
Human Services 2000). Educational and clinical
approaches were considered to be of greater
importance in helping individuals resist or abandon
the use of tobacco.
Community wide approaches typically involve a range
of agencies including health services, voluntary agencies,
the media (paid and unpaid), as well as government and
local authorities (see 5.3, Building effective partnerships,
p74). Together, they undertake a range of activities such
as direct smoking cessation, helplines, training and
resources for health professionals, development of
policies to reduce smoking in public places, media
campaigns and advocacy, reducing sales to minors and
work in schools. Overall, community interventions seek to
influence both individual behaviour and the environmental,
social and cultural conditions that affect tobacco use
(Lantz et al. 2000).
The impact of a comprehensive approach is difficult to
evaluate, especially given the potential for individual
components to work synergistically to produce
combined effects (Chapman 1993; US Department of
Health and Human Services 2000). For example, the
effectiveness of school based programmes appears to
be enhanced when they are included in broad based
community interventions (Lantz et al. 2000). Nevertheless,
Reducing smoking prevalence
 studies that have sought to measure the effects of a
comprehensive approach have yielded encouraging
results (US Department of Health and Human Services
2000; Lantz et al. 2000; Sowden and Arblaster, 2000a,b;
Wakefield and Chaloupka 2000).
It is accepted that population-wide approaches should aim
to reduce both adult and teenage smoking. But where should
the emphasis lie? Experts agree that teenage smoking rates
are unlikely to decline in the absence of a fall in adult rates.
The view that smoking among adults should therefore be
tackled ahead of teenagers was discussed by Hill (1999)
10
in a recent article. His argument is fivefold:
• First, reducing smoking among adults will lead to a
quicker and bigger reduction of tobacco related
harm, because there is a higher level of smoking
related mortality and morbidity among adults than
teenagers
• Second, reducing smoking among adults will provide
protection to the unborn and recently born against
exposure to direct and indirect tobacco smoke
• Third, quitting by adults (especially by parents) reduces
the likelihood of children taking up smoking
• Fourth, while there are clear ethical reasons for
educating children about what is the largest
preventable cause of death, beyond this, the methods
of delivering interventions are fraught with practical
problems and the evidence of effectiveness of
interventions aimed at young people is poor
• Finally, the fact that the tobacco industry itself
supports antismoking campaigns targeted at teenagers
should be taken as a warning signal: ‘Even Phillip
Morris was confident that [antismoking] youth
campaigns could do them little damage’ (Hill 1999).
1.4 Components of a local strategy
1.4.1 Develop smoking cessation services
• The health improvement programme (HImP) should
emphasise the importance of an integrated service
including primary care advice, specialist smoking cessation
clinics, one-to-one cessation advice [Health Service Circular
(HSC) 1998, 1999; Action on Smoking and Health
Coronary heart disease: guidance for implementing the preventive aspects of the NSF
(ASH) 2000a,b]. The requirements for smoking cessation
are detailed in Appendix A, Chapter 1 of NSF CHD:
Reducing heart disease in the population (DH 2000b).
• Build upon and develop these guidelines for local
cessation services.
• Provide special services for pregnant women.
The NHS plan (DH 2000d) states that ’the specialist
smoking cessation services will focus on heavily
dependent smokers needing intensive support, and on
pregnant smokers as part of antenatal care. Primary care
groups will take the lead in commissioning – and where
appropriate providing – these services’. In support of the
smoking cessation treatments bupropion is now available
on prescription and The NHS plan recommends that
nicotine replacement therapy (NRT) should also be made
available on prescription. These services followed
evidence based guidelines for smoking cessation
published in December 1998 (Raw et al. 1998). These
guidelines have been updated and will be available in
December 2000. The Committee on Safety of Medicines
will consider whether NRT can be made available for
general sale. An evaluation of the first year of the
development of the national cessation services has
recently been published (Adams et al. 2000).
At a meeting of smoking cessation experts held in July
2000, it was agreed that the smoking cessation services
should offer support to all people who request it. The
focus on particular groups could be achieved through
recruitment to the services – for example by engaging
midwives or promoting the services at antenatal classes
(ASH 2000a,b; http://www.ash.org.uk/?cessation). The
meeting, with representation from the DH, identified a
model approach to smoking cessation services in primary
care, which also sought to provide clarification on the role
of intermediate cessation services. Discrepancies in the
guidelines concerning intermediate services had caused
confusion in some health action zones (HAZs) (Adams et
al. 2000). Both intermediate services and specialist clinics
have been subsumed in the model by the term ‘qualifying
specialist services’ for which a minimum standard of
service to the smoker has been set and for which the
centrally provided smoking cessation budget may be used.
The model of the service is set out in Figure 1 on facing
page. For full details and further guidance see:
http://www.ash.org.uk/?cessation

Figure 1. Configuration of smoking cessation support services.
Model of the service to the smoker
Each smoker contacting the NHS should be offered a
package of both pharmaceutical aids and behavioural
support that meets their particular needs and circumstances.
Given restrictions on who can prescribe drugs, and
limitations on the extent to which those who may
prescribe are able to offer support, it will not always be
possible to provide a ‘one-stop shop’. The aim must be to
make access to drugs and support as straightforward as
possible. The elements of the support package include:
• Influences on smokers’ motivations to quit, including
advice from primary care professionals, national
campaigns, No Smoking Day and manufacturers’
advertising
• Brief opportunistic interventions by the GP and other
primary care professionals
• Prescribing pharmacotherapies: NRT and bupropion
(Zyban)
11
• Behavioural support. This will need to be tailored to
match the circumstances of the smoker, but the range
of options includes:
Referral to a ‘qualifying’ specialist service – these
would qualify for funding from the smoking
cessation budgets if they offered a certain
minimum service standard
Discussion of other support options (eg telephone,
self-help) that the smoker could consider, if he/she
chose not to attend a qualifying specialist service.
Reducing smoking during pregnancy
For pregnant women, pregnancy specific materials are
more cost effective than less specific, cheaper, standard
information because of their greater effectiveness (Buck
and Godfrey 1994). The intensity of the intervention also
affects outcome. While there is some evidence of the
effectiveness of advice when literature is coupled with
follow up, more intensive interventions (eg a structured
Reducing smoking prevalence
 cessation course based on self-help booklets) provide
stronger evidence (Raw et al. 1998). Public education
campaigns may be effective in shifting pregnant women’s
attitudes and behaviour (Campion et al. 1994). The
difficulties of advising outright cessation in pregnancy has
led some health professionals to suggest cutting down as
an alternative. However, there is little evidence to show
that cutting down is of any health benefit (Raw et al.
1998). Thus quitting as opposed to cutting down needs
to be emphasised.
Many women who do stop smoking in pregnancy go
12
back to smoking after the birth of the baby. In one
American study over half (56%) of women who stopped
during pregnancy were smoking within one month of the
birth (Secker-Walker et al. 1995). Relapse prevention
interventions with pregnant women and women who
have recently given birth are needed.
• All those responsible for providing antenatal care
should ensure that relapse prevention is included as
a component in the smoking cessation service.
The lower rate of cessation associated with mothers
from lower socio-economic groups, led the Scientific
Advisory Group on Inequalities to conclude that
‘interventions that target the individual behaviour
alone may not be sufficient ... broader policies to
combat inequality are also required’
(Acheson 1998).
Further information on smoking and pregnancy can be
obtained in the following reports:
• Smoking and pregnancy: a survey of knowledge,
attitudes and behaviour 1992–1999 (Owen and Penn
1999)
• Smoking and pregnancy: guidance for purchasers and
providers (HEA 1994a)
• Helping pregnant smokers quit: training for health
professionals (HEA 1994b)
• Smoking and pregnancy: developing a
communications strategy for cessation (Owen
and Bolling 1996)
• Smoking and pregnancy: a growing problem (HEA
1996a).
Coronary heart disease: guidance for implementing the preventive aspects of the NSF
Mechanisms for delivering cessation services for young
people are outlined in the document Smoking cessation
in young people: should we do more to help young
people quit? (HDA 2000a).
1.4.2 Reduce smoking in public places
including workplaces
Restricting smoking is important not only for limiting the
public’s exposure to toxins in sidestream smoke, but also
for broader policy reasons. First, it puts smoking in a
broader context than one of personal choice and personal
risk and legitimises it as a social problem; second, it may
be the source of litigation against employers or businesses;
and third, the spread of smoking restrictions reduces the
opportunities to smoke and thus reduces consumption
(Borland et al. 1991; Brenner and Mielck 1992; Marcus et
al. 1992; Wakefield et al. 1992; Jeffery et al. 1994;
Glasgow et al. 1997; Brauer and Mannetje 1998).
The Health and Safety Executive (HSE) has been
examining current practice on restricting smoking at work
with a view to issuing an Approved Code of Practice (ACoP).
There are potential legal liabilities for employers who do
not address passive smoking in the workplace. Employees
have recourse to civil law, contract and employment law
and the general provisions of the Health and Safety at
Work Act (1974). The ACoP will clarify the legal position
for both employers and employees, and enable LA
environmental health officers (EHOs) to intervene.
Local plans should include objectives to:
• Ensure that all local hospitals have smoking policies
(DH 1998a; HEA 1999b), and that these are fully
implemented
• Implement policies to restrict smoking in public places
[Scientific Committee on Tobacco and Health (SCOTH)
1998]
• Encourage restaurants, bars and other leisure facilities
to provide smoke free areas.
Many employers now find an advantage in smoking
restrictions through savings on sickness absences,
increased productivity, lower insurance and cleaning
costs. The checklist in Box 1.1 will help managers of
workplaces to develop an effective strategy on smoking.

Box 1.1 Management checklist for a
smoking policy
• Review current situation.
• Assess need, capacity to change.
• Make sure you consult with everyone.
• Seek feedback, not permission.
• Decide on the policy details.
• Decide on a total or partial ban.
• Decide what restrictions to impose if a total ban
is not possible.
• Communicate final decisions clearly to all staff.
• Label smoking and smoke-free areas.
• Monitor and review the policy.
Source: HEA (1999c)
Further information
For examples of case studies of effective practice within
the NHS see Tobacco control policies within the NHS:
case studies of effective practice (HDA 2000b). For further
information on developing, reviewing and amending
tobacco control policies, see Been there, done that: revisiting
tobacco control policies in the NHS (HEA 1999b). Sample
policies and consultation questionnaires can be found in
Smoking policy for the workplace: an update (HEA 1999c)
and Towards tobacco-free environments: guidelines for
local authorities (HEA 1999d). Also see the ASH website:
http://www.ash.org.uk
1.4.3 Support national media campaigns
Mass media campaigns can influence smoking behaviour
(DH 1998a; Lantz et al. 2000; Sowden and Arblaster
2000a,b) and may be especially appropriate for reaching
those who are less educated (Mackaskill et al. 1992) and
those in poor communities (Jenkins et al. 1997). Message
content and the intensity and duration over which the
messages are delivered appear to be important factors in
determining the impact of mass media campaigns (Grey
et al. 2000; Lantz et al. 2000).
Media campaigns should focus predominantly on adults,
since the majority of cigarettes (>95%) are consumed by
adults and adult smokers are a major factor influencing
the uptake of smoking by minors.
Local media may be used to raise the profile of national
campaigns (No Smoking Day). For ideas in planning local
media campaigns see:
http://www.no-smoking-day.org.uk/campaign.htm
Tel: 020 7916 8070.
• Local plans should include links to the network of local
smoking control alliances in England.
1.4.4 Use media advocacy
13
There is some evidence that the use of media advocacy
(see Box 1.2) may affect tobacco consumption (Buck and
Godfrey 1994), but its major role is in social marketing.
This involves shaping the media agenda, prompting policy
changes and influencing the social norms around
smoking (Reid et al. 1992). Media advocacy techniques
Box 1.2 Checklist for setting up local
media advocacy work
First think about the following points:
• What you hope to achieve
• Who your campaign is aimed at
• How much you think it will cost
• How it will be supported by local activity and
action
• How you plan to evaluate it (have you achieved
what you hoped?).
Create a media plan:
• What stories or angles will attract the media?
• What information is needed for a newsworthy
press release?
• Draw up a media list – names and contact
numbers of relevant journalists
• Find out the deadlines for media you are
targeting
• Find out how media contacts want you to
communicate with them (press release, direct
contact)
• Decide who will act as spokespersons
• Coordinate media schedules with partners who
may also be using the media
• If the campaign is a long one, create a media
calendar to ensure a constant supply of news
items.
Reducing smoking prevalence
 may be especially effective with poor communities
(Jernigan and Wright 1993) since low income groups,
including smokers, are high consumers of TV.
For further guidance on media advocacy and factors that
influence its effectiveness, see An investigation into the
potential of media advocacy as a health promotion
strategy (HDA in press).
14
1.4.5 Monitor the voluntary advertising ban
Indirect marketing of cigarette brands is the growing and
preferred marketing strategy of the tobacco industry,
perhaps in response to threats of advertising restrictions.
Until legislation is introduced, the existing ‘voluntary
agreements’ on tobacco promotion should continue to
be monitored locally, not so much because these
restrictions have been found to be effective in preventing
uptake of smoking, but because infringement of the
rules offers opportunities for media advocacy. Those
provisions include, for example, banning advertising on
billboards near schools and promotions in magazines for
young people.
People working locally should be vigilant in monitoring any
new marketing strategies, for example, using events at
discos, student functions and the Internet to promote brands.
1.4.6 Reduce sales of cigarettes to children
under 16 years old
Combining regular test purchasing with a high profile
media approach has been found to be successful in
reducing the incidents of reported sales of cigarettes to
people under 16 years of age. Overall, the evidence of
effectiveness of sales restrictions suggests that vigorous
local enforcement of the law forbidding sale of tobacco
to under-16s can reduce sales (Stead and Lancaster
2000). This strategy has also been shown to have a
small delaying effect on the uptake of smoking among
children. There is little evidence, however, to suggest that
it has any effect on the uptake of smoking among
children. Considerable resources are required, both in
terms of trading standards officers’ and court time.
The existing law is not being applied effectively (DH
1998a). The Local Government Association and Local
Authorities Co-ordinating Body on Food and Trading are
Coronary heart disease: guidance for implementing the preventive aspects of the NSF
Box 1.3 Enforcement protocol
• Local authorities should publish a clear statement
on underage tobacco sales.
• Ensure that all shops and vending machines
display notices stating the law.
• Use test purchases to assess local compliance by
retailers. Gather information about premises
likely to be breaching the law.
• Use media advocacy to raise the profile locally.
• Educate to increase compliance.
• Detail enforcement action taken, prosecutions
and fines, to act as a deterrent.
developing a new enforcement protocol to address this.
Features of the protocol are listed in Box 1.3.
Proof-of-age card schemes have been developed, but the
government recommends that a single system be agreed. The
vending machine trade association, the National Association
of Cigarette Machine Operators, has produced a new,
stricter code for its members to clarify siting arrangements
and monitoring for vending machines (DH 1998a).
1.4.7 Encourage the introduction of
smoking policies in schools
A formal, well publicised school policy on smoking
reinforces non-smoking as the norm in society, supports
health messages in the curriculum and may have
positive effects on smoking levels among pupils, staff
and all adult users of the premises (see Box 1.4).
Additional potential benefits include reduced
absenteeism, reduced costs and elimination of the
harmful effects of passive smoking.
• Provide support to schools to introduce no smoking
policies.
The National Curriculum Science Order recommends that
teaching the harmful effects of tobacco, alcohol and
other drugs should begin at Key Stage 2 (age 7–11
years). The Office of Fair Standards and Training in
Education (OFSTED) 1999 report Drug education in
schools and the Department for Education and
Employment (DfEE 1998) report Protecting young people:
good practice in drug education in schools and the youth

Box 1.4 Checklist for a school’s
smoking policy
• Put the development of a smoking policy on the
agenda.
• Review the current situation.
• Identify staff with sufficient skill and seniority to
take responsibility for developing a new policy if
necessary.
• Form a working party involving key people from
the school and community, if appropriate.
• Establish a rationale for the policy.
• Identify educational, health and economic
reasons for introducing a policy or improving
existing conditions.
• Draft the policy.
• Evaluate the draft policy by consulting with all
relevant parties, identify potential constraints and
problems.
• Inform everyone about the policy before it is
implemented.
• Allow sufficient time for implementation of the
new policy – three to six months is considered a
reasonable time between initiating and
implementing the policy.
• Monitor the operation of the new policy.
service recommend teaching young people from the age
of five years upwards about the risks and consequences
of tobacco, alcohol and drug use, together with teaching
the life skills needed to resist the pressure to misuse these
substances. Teaching should clearly cover issues relevant
to the child’s age and experience. This frequently entails
tackling smoking and alcohol-related issues first, as these
are the substances that young people will generally be
exposed to first.
1.5 Reducing inequity
With little or no decline in the lowest income groups,
smoking has become concentrated in Britain’s poorest
households. For example, among lone parents on benefits
and living in council housing, more than three-quarters
smoke (Dorsett and Marsh 1998). Moreover, recent
research suggests that nicotine dependence is higher in
people experiencing disadvantage (Jarvis and Wardle
1999). In keeping with these findings, the Independent
Inquiry into Inequalities in Health recommended a short-
term strategy to reduce nicotine dependence, which is
likely to be stronger in disadvantaged smokers, through
the provision of free NRT. A complementary, longer-term
strategy aims at removing the cultural and environmental
barriers that disadvantaged people face. Community
based interventions, brief advice from a GP and
specialised smoking clinics are also recommended as
effective settings in which to provide NRT (Acheson 1998).
Attempts to set up community based projects to promote
smoking cessation have met with mixed success. In a
15
report of initiatives set up in low income communities in
Scotland, the authors concluded that:
‘small grant funding for time limited projects can
promote work on smoking amongst women living
or working in low income communities. Although
reducing smoking was a long term goal for the
majority of the initiatives most did not perceive
themselves as a cessation group. As a result they
did not measure success by the numbers quitting.
Changes in individual smoking behaviours were
noted and these ranged from extending the
period of smoke free time, to restricting smoking
to a specific room or location and trying nicotine
replacement therapy’ (ASH Scotland and HEBS 1999).
Examples of other community based projects funded
through small grants schemes can be found in
Empowering smokers to quit: success principles for
community stop-smoking projects (HEA 1996b).
The use of mass media, especially TV, may be
particularly appropriate for reaching less educated and/or
disadvantaged smokers. This reflects the tendency for the
less educated to receive information from TV more often
than those who are more educated (Buck and Godfrey
1994). Indeed, research has shown that mass media
antismoking campaigns can have a significant impact on
low income and low educational groups (Macaskill et al.
1992; Jenkins et al. 1997).
1.5.1 Black and minority ethnic groups
Little has been published on the impact of smoking
cessation interventions in reducing tobacco use among
black and minority ethnic groups in England. However,
studies from the USA suggest that they can be effective
Reducing smoking prevalence
 (Botvin et al. 1992; Elder et al. 1993; Lillington et al.
1995; Elder et al. 1996). In the absence of UK studies,
patterns of tobacco use (HEA 1999a) and research into
the role of tobacco within and between black and
minority ethnic groups (Maltby et al. 2000) can provide
some pointers for the way forward. Examples of these are
highlighted below (HEA 1999a; Maltby et al. 2000).
• The high rates of tobacco chewing, especially
among Bangladeshis, suggests that this practice
should be included in interventions aimed at reducing
tobacco use.
16
• Sensitivity to gender issues is vital.
• Literature should be multi-lingual and in a style that is
culturally familiar (eg use of vignettes to highlight
health risks associated with tobacco use).
• Information campaigns should be developed to redress
misperceptions about tobacco use (eg belief that
tobacco use can relieve indigestion; belief that healthy
practice in other areas such as diet and exercise will
offset the detrimental effects of smoking).
• Ethnic differences in attitudes and beliefs about
cigarette smoking should be incorporated into smoking
cessation interventions.
Thus, to be successful, a tobacco cessation campaign
must take account of the culture, tradition and
religion of the particular target group. In so doing it
Coronary heart disease: guidance for implementing the preventive aspects of the NSF
will need to involve community groups, religious groups,
smoking cessation coordinators, local tobacco alliances,
primary health care (PHC) teams, culturally relevant local
and national media as well as key individuals within
different ethnic groups.
In response to ethnic health inequalities, the government
has announced that £1,000,000 will be made available
to help reduce the high rates of smoking among certain
ethnic groups.
Further information on black and minority
ethnic groups
DH, 1996. Directory of ethnic minority initiatives, G60/008 3934 1P 5K
May 96 (23). London: DH.
Gervais, M. and Jovchelovitch, S., 1998. The health beliefs of the
Chinese community in England: a qualitative research study.
London: HEA.
HEA, 1999. Black and minority ethnic groups and tobacco use in
England: a practical resource for health professionals. London: HEA.
HEA, 2000. Black and minority ethnic groups in England: the second
health and lifestyles survey. London: HEA.
McKeigue, P. and Sevak, L. 1994. Coronary heart disease in South
Asian communities. London: HEA.
Sproston, K., Pitson, L., Whitfield, G. and Walker E., 1999. Health
and Lifestyles of the Chinese population in England. London: HEA.
 Table 1.6 Suggested activities to support local action
Intervention Evidence Outcome Who could be Skills and resources Points to consider Further information
involved?

Smoking cessation Effectiveness and cost effectiveness
are well established (Fiore et al.
1996; Raw et al. 1998). Updated
guidelines (Dec 2000).
Depends on the particular
intervention under
consideration (see below).
Health professionals, Smoking cessation skills,
LAs, specialist carbon monoxide monitor,
smoking cessation leaflets. Although training
coordinators, schemes are available
voluntary sector, nationally, accredited courses
HAZs, local smoking should be established.
alliance. Demonstrate cultural
sensitivity.
Major component of
government strategy to
reduce smoking in England.
HSC (1999) has set out
guidelines on monitoring for
the new services.
The availability and
accessibility of services should (Adams et al. 2000). ASH
take account of cultural
differences.
HSC (1998, 1999), DH
(1998a), Acheson (1998).
Cochrane Library website:
http://www.update-
software.com/clibhome/
clib.htm
Evaluation of year one of
national cessation strategy
(2000a).

Nicotine Doubles chance of success of Can double the effectiveness PHC, pharmacists, Smoking cessation skills, Currently, some are available See above.
replacement smokers wishing to stop (Fiore et al. of an intervention, be it brief health promotion access to NRT products. on prescription as well as
therapy 1996; Raw et al. 1998). advice from a GP or intensive specialists. being available over the
support through a specialist counter (OTC). Nasal spray is
clinic or will-power alone. OTC and 2 mg gum is also
available on the general sales
list (GSL).

Bupropion (Zyban) Just launched in the UK. An GPs and those Smoking cessation skills. Prescription only.
effective pharmacotherapy (Hurt et approved for
al. 1997; Jorenby et al. 1999), it will prescribing through
be available on prescription. the Patient Group
Directive,
PHC, pharmacists,
health promotion
specialists.

Reducing smoking prevalence

17

Intervention Evidence
Brief advice in NHS Fiore et al. 1996; Raw et al. 1998;
and primary care updated guidelines (December
2000).
Intensive support Fiore et al. 1996; Raw et al. 1998;
(eg smokers’ clinics) updated guidelines (Dec 2000).
Cessation advice Fiore et al. 1996; Raw et al. 1998;
and support for updated guidelines (Dec 2000).
Coronary heart disease: guidance for implementing the preventive aspects of the NSF
hospital patients
Cessation advice Raw et al. 1998; Fiore et al. 1996;
and support for updated guidelines (Dec 2000).
pregnant smokers
Telephone Evidence base for effectiveness is
helplines growing and Thorax guidelines
indicate that they may provide an
effective service (Raw et al. 1998).
A meta-analysis reports a significant
effect (Fiore et al. 1996).
Outcome
Very brief advice (three
minutes) can result in a 2%
increase in number of
smokers abstinent for six
months or longer compared
with no advice. Brief advice
(10 minutes) can result in a
3% increase. Adding NRT to
brief advice can result in a
6% increase.
Compared with no
intervention intensive support
can result in an 8% increase
in the number of smokers
abstinent for six months or
longer.
Result in a 5% increase in the
number of smokers abstinent
for six months or longer.
Result in a 7% increase in the
number of smokers abstinent
for six months or longer.
Quit rate of 15.6% (adjusted)
reported in England with
mass media campaign (Owen
2000).
18
Who could be Skills and resources Points to consider Further information
involved?
PHC team, link with Smoking cessation skills. As above.
other support
services if
appropriate
[eg healthy living
centres (HLCs),
hospital staff,
doctors, nurses,
midwives].
See above. Smoking cessation skills. Reach lower than that for As above. The Maudsley
brief advice, but associated smokers’ clinic is an example
with a higher success rate; of good practice highlighted
resource intensive; ease of in the tobacco white paper
access (eg convenience, safe (DH 1998a).
location, timing) and cost
(if any) are important
considerations.
Smoking cessation skills.
Smoking cessation skills.
Providers of (national Smoking cessation skills, Mass reach, easy and Lichtenstein et al. (1996),
and local) helplines, trained staff required. convenient for smoker. NHS Direct Helpline
workplace, public Guidelines are available for 0800 169 0169,
places, NHS, those wanting to set up local Quit (Charity)
community groups, helplines. Alternatively, 020 7388 5775,
cessation services. activities and literature could Quitline 0800 002200.
be undertaken to raise public
awareness of and use of
existing helplines. Can be
used to promote other
cessation support services in
locality.
 Intervention Evidence
Other treatments Insufficient evidence of effectiveness Likely impact uncertain.
for hypnotherapy and acupuncture,
etc. (Abbot et al. 2000; White et al.
2000).
Reduce smoking in Associated with reduced
public and work consumption, possible reductions in
places prevalence in the longer term
(Brenner and Mielck 1992; Buck
and Godfrey 1994; Reid 1996).
Mass media Can enhance natural quit rate and
campaigns may reduce relapse (Reid 1996;
McVey and Stapleton in press); may
also reduce uptake of smoking in
young people (Sowden and
Arblaster 2000a).
Reducing smoking prevalence
Outcome
A US study of employees
reported a reduction of 5%
in smoking prevalence and
10% in consumption after
the introduction of workplace
bans. Other benefits include
recognition of non-smoking
as norm, protection of non-
smokers, increased public
awareness and acceptance of
health risks. May encourage
adolescents not to start.
Quit range 0–5% for adult
interventions (Reid 1996),
direct influence on climate of
public opinion.
Who could be Skills and resources Points to consider Further information
involved?
Private sector, links Smokers should be given British Hypnotherapy
with other smoking information about other Association (BHA), 1
cessation providers. treatments to enable them to Wythburn Place, London
In view of lack of make an informed choice W1H 5WL Tel: 0207 723
evidence base, without discouraging 4443, email:
consider contacting attempts to stop. Level of firebird@agonet.co.uk
recognised training likely to vary from
professional none to sufficient to justify British Society of
associations for membership of a professional Hypnotherapists (BSH), 37
trained individuals. body (Raw et al. 1998). Orbain Road, London SW6
7JZ Tel: 020 7385 1166
Association of General
Practitioners of Natural
Medicine (AGPNM), 38 Nigel
House, Portpool Lane,
London EC1N 7UR
Tel: 020 7405 2781.
Institute of Complementary
Medicine (ICM), PO Box 194,
London SE16 1QZ
Tel: 020 7237 5165.
British Hospitality Charter agreed between DH (1998a), HEA (1999c,d).
Association, The government and licensed The National HSE (NHSE) is
Restaurant hospitality trade. The HSE is developing a toolkit to help
Association, British producing a new ACoP on with the implementation of
Institute of smoking in the workplace, its policies.
Innkeeping, Brewers which will provide practical
and Licensed advice on how to comply
Retailers Association, with the law.
Association of
Licensed Multiple
Retailers, employers
and employees, NHS.
National and local Costly; requires minimal level High reach; works well with DH smoking policy team,
media, community of exposure and development other interventions such as DH communications team,
settings and of new messages to avoid tax increases; can support review of use of mass media
campaigns in England
activities, workplaces consumer burn-out. local cessation services; focus
available from HDA (Grey et
and public places. should be on adults. al. 2000). Cochrane Library
website http://www.update-
software.com/clibhome/clib
19

Intervention Evidence
Media advocacy Effectiveness lower than more
and No Smoking intensive interventions but highly
Day cost-effective because the reach is
much greater (Reid et al., 1992;
Buck and Godfrey 1994).
Advertising ban Possible effect on adult
consumption and teenage
prevalence (Reid et al. 1992;
Sowden and Arblaster, 2000a).
Coronary heart disease: guidance for implementing the preventive aspects of the NSF
Reduce illegal sales Local activity can reduce sales. This Local activity can reduce
may have a small delaying effect on sales; useful for media
children’s uptake of smoking.
Smoking policies in Impact on uptake of smoking
schools uncertain.
Outcome
One year net quit rates
estimated 0.3–0.5% (Reid et
al., 1992; Buck and Godfrey
1994); influence on public
opinion; provides basis for
other initiatives; may
contribute to impact of mass
media campaign;
extends debate about
smoking.
Impact of monitoring local
infringement of voluntary
agreement not known, but
does offer opportunities for
media advocacy.
advocacy; may have a small
delaying effect on children’s
uptake.
Implementation varies so that
outcome is unclear; reinforces
non-smoking as the norm;
other potential benefits
include reduced absenteeism,
reduced costs and elimination
of passive smoking.
20
Who could be Skills and resources Points to consider Further information
involved?
NHS, local Cheaper than paid Relies on good links with http://www.no-smoking-
government, advertising but substantial other agencies (eg voluntary day.org.uk/campaign.htm
commercial interests, resources required for sector, local government, Example of good practice:
voluntary agencies. generating stories; hospitality trade) to create Roy Castle Good Air Awards
good contacts with local local activities.
media and the leisure and
hospitality trade. Training in
media advocacy needed.
Government, health Local activity could include DH (1992). Issued with DH
promotion specialists, monitoring infringements to circular EL (92) 71.
tobacco advocates voluntary agreements (eg
and others can advertising on billboards near
monitor existing schools, promotions in
voluntary magazines aimed at young
agreements. people).
Magistrates, retailers, Requires substantial Existing law states that it is National Association of
local trading resources. illegal to sell tobacco Cigarette Machine Operators
standards officers, products to under 16s, but has produced a code for
schools, parents, enforcement is problematic. members. Local Government
local government Possibly adds to perception Association (LGA) and Local
association, LAs, that smoking is a forbidden Authorities Coordinating
National Association fruit (Kay Scott Associates Body on Food and Trading
of Cigarette Machine 2000). have produced an LA
Operators. enforcement protocol.
School teachers, Supports health messages in HEA (1993, 1999e).
governors, heads, the national curriculum.
parents, pupils, local
community (for
policies that involve
non-smoking in
school premises for
community activities).
1.7 References
Abbot, N.C., Stead, L.F., White, A.R., Barnes, J. and Ernst, E., 2000.
Hypnotherapy for smoking cessation, Cochrane Review. In: Cochrane
Library, Issue 3. Oxford: Update Software.
Acheson, D., 1998. Independent inquiry into inequalities in health
report. London: The Stationery Office.
Adams, C., Bauld, L. and Judge, K., 2000. Baccy to front. Health Service
Journal, 110 (5713), 28–31.
ASH, 2000a. Smoking cessation in primary care: how to spend NHS money
much more effectively. London: ASH. (http://www.ash.org.uk/?cessation)
ASH, 2000b. Smoking cessation services: Implementing the NHS
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Reducing smoking prevalence
Chapter 2
Improving diet and nutrition
2.1 Introduction
Diet plays a fundamental role in the development of
CHD. The type and amount of fat and its relationship to
blood cholesterol levels have been recognised for some
time as being particularly influential. Salt intake has been
implicated in relation to blood pressure and, more recently,
an increased intake of fruit and vegetables has been
identified as an important factor in reducing the
rates of both heart disease and some cancers (DH 1994,
1998). The promotion of healthy eating is important in
reducing the risk not only of CHD but also of other
chronic conditions, such as obesity and diet related
cancers.
Effective strategies to promote healthy eating are generally
those that work at several levels. It is important to identify
the barriers to dietary change in the local population and
then select interventions to address them (see Box 2.1).
Box 2.1 Identification of barriers to healthy eating and interventions to address them:
an example
Barrier
• Belief that the family is already eating enough fruit
and vegetables
• Dislike of taste of vegetables and lack of confidence
in cooking and preparing them; fear of waste and
of rejection by the family
• Difficulty in finding affordable, good quality fruit
and vegetables locally
25
2.2 Objectives of nutritional interventions
Diet is one of the key modifiable risk factors in the
prevention of CHD. The government’s Committee
on the Medical Aspects of Food and Nutrition Policy
(COMA; DH 1994) recommended a reduction in fat
(particularly saturated fat), a reduction in salt and an
increase in complex carbohydrates. In addition, fruit
and vegetable consumption should be increased by at
least 50% (to at least five portions per day). The
recommendations are summarised in nutrition
briefing papers produced by the HEA (1992, 1996).
Also, it has been estimated that around one-third
of all cancers might be influenced by diet. In 1998,
COMA reviewed the evidence on diet and cancer in the
UK (DH 1998). The working group recommendations
were consistent with other dietary recommendations
made for the prevention of obesity, diabetes and
cardiovascular disease.
Intervention
• Information about five portions a day and portion
sizes
• Set up cooking skills clubs and tasting sessions, or
develop cooking sessions as part of the activities of
existing groups (eg women’s groups, youth groups)
• Set up community owned retailing and food
cooperatives to introduce affordable supplies
Improving diet and nutrition
 In promoting a healthy balanced diet to reduce the risk of
cardiovascular disease and diet related cancers in the
population, interventions should focus on the following:
• Reducing the amount of fat, and in particular, the
amount of saturated fat
It has been estimated that a 10% reduction in
saturated fat intake within the UK population would
be associated with a reduction in CHD mortality of
between 20% and 30% (Marmot 1994). Therefore, to
help achieve a healthy diet, people should be
encouraged to use reduced fat spreads and dairy
26
products in place of full fat versions, to replace oils and
fats high in saturates with those high in
monounsaturates, to reduce the amount of fat used in
cooking, to trim fat from meat and to reduce the
amount of products such as biscuits, pastries, cakes,
and crisps in the diet.
• Increasing the amount of fruit and vegetables
eaten to at least five portions each day
Apart from being rich sources of carbohydrate, dietary
fibre, antioxidants and other bioactive factors, fruit and
vegetables are also rich sources of potassium, which is
associated with lower blood pressure and a lower risk
of stroke (Joshipura et al. 1999). For many people, this
will mean almost doubling their intake. It will mean
having fruit and vegetables at most meals, and as
snacks between meals. Access to affordable, good
quality supplies of fruit and vegetables must be
ensured and skills and confidence to prepare and cook
fruit and vegetables should be developed [National
Heart Forum (NHF) 1997].
• Increasing the intake of fibre rich, starchy foods,
such as bread, potatoes, pasta and rice, by half as
much again
Make these foods the main part of most meals, and
replace fattier snacks.
• Reducing the average salt intake by around a
third
There is now a consensus that dietary sodium is a
factor in the development of high blood pressure
(DH 1994). People should be encouraged to gradually
reduce the salt they add to food, both in cooking and
at the table. Also, people should be more aware of
low-salt alternatives to processed foods if available and
should recognise the salt content of processed foods
by reading food labels.
Coronary heart disease: guidance for implementing the preventive aspects of the NSF
• Increasing the amount of fish eaten to at least
two portions each week, one of which should be
an oily fish
Encourage people to eat fish more often: this may
mean working with communities to develop their
cooking skills and confidence to cook fish.
A useful tool to support health promoters in promoting a
balanced diet is The balance of good health [HEA, DH and
Ministry of Agriculture, Fisheries and Foods (MAFF) 1994].
It shows what proportion of the diet should come from
the different food groups and could provide a consistent
and easily understood message about a balanced diet1.
The balance of good health has also been modified for
use with black and minority ethnic groups. The British
Dietetic Association and Sainsburys have developed an
African-Caribbean version and the British Nutrition
Foundation has produced a model suitable for use with
the Chinese community. Dietitians at Wandsworth
Community Health Trust, with support from Spillers
Milling, formed a healthy alliance and produced a version
suitable for use with South Asian groups.
2.2.1 Professional knowledge and expertise
Identifying the barriers and developing an integrated
programme of complementary activities will require the
input of staff with a range of skills. While most areas
have access to a community dietitian, it is quite common
for clinical duties to interfere with the dietitian’s ability to
spend time in the community. In planning the resources
needed to implement the strategy, it may be worth
considering ring fencing a block of dietitian time to
devote to community work. Public health nutritionists can
provide the expertise to develop and implement a public
health nutrition strategy and to work on other nutrition
issues at a population level. In recent years, the Nutrition
Society has introduced a registration system for public
health nutritionists (RPH Nutr). In addition, the Nutrition
Society has recently developed an associate registration
1The balance of good health does not apply to children under two years
of age, who need a diet that is higher in fat and lower in fibre rich,
starchy foods, to children aged between two and five years (a gradual
transition towards a diet consistent with The balance of good health is
needed here) or to people with special dietary requirements or those
under medical supervision.
scheme for newly qualified public health nutrition
professionals who have not yet accumulated the
three years’ experience required for full registration
as a public health nutritionist. The Register of
Public Health Nutritionists can be found on
http://www.nutsoc.org.uk/RPHNutr.html or contact Jackie
Landman at the Nutrition Society (020 7602 0228) for
further information on the associate scheme.
Local people are an important addition to this skill base.
Research suggests that the efficiency and effectiveness of
community based interventions can be improved by using
local people to complement the work of health
professionals. McGlone et al. (1999) suggested that ‘if
local food projects are to work, then they must genuinely
involve local people’. Services provided by local people
are often considered more appropriate and more
accessible for the health needs of the community. Such
services foster self-reliance, community participation and
can help overcome barriers. They also allow access to
groups that are typically hard to reach and can be
particularly beneficial for black and minority ethnic
groups. These benefits are two way, as local people have
the opportunity to develop their own skills. Exploratory
work with this peer education approach (Hodgson et al.
1995; Kennedy et al. 1999) showed that it was possible
to achieve both significant increases in nutrition
knowledge and potentially beneficial changes in the
dietary practices of low income families. The best
approach appears to be one in which guided ‘hands on’
food preparation/cooking sessions allow the participants
to acquire knowledge and skills. However, it was noted
that this approach was resource intensive, particularly in
professional staff time, and there is little evidence of
effectiveness in terms of dietary change. This approach
may result in potential health, social and economic
benefits and therefore warrants further study.
2.3 Features of effective interventions
A meta-analysis of randomised controlled trials shows
that dietary interventions can be effective in reducing
CHD risk factors (Brunner et al. 1997). A systematic review
of the effectiveness of interventions to promote healthy
eating found that characteristics of a successful
intervention had the following features (Roe et al. 1997):
• It focused on diet alone, or diet plus physical activity
rather than tackled a range of risk factors
• Clear goals were set, based on theories of behavioural
change, rather than relying on the provision of
information alone
• There was personal contact with individuals or small
groups sustained over time
• Participants received personalised feedback on any
changes in their behaviour and risk factors
• Changes in the local environment were promoted, for
example in shops and catering outlets to help people
27
choose a healthy diet.
Providing information alone is not a solution. Improving
people’s knowledge about diet does not necessarily
lead to behaviour change. Improvements in knowledge
should be accompanied by the development of skills
and provide the opportunity to put the knowledge into
practice. For example, there is little point in
encouraging people to eat more fish, in particular oily
fish, if access to these foods is not available, and if
people lack the skills and confidence to prepare and
cook fish. Integrated programmes of activity could be
more effective if they first identify the barriers to
dietary change, and then provide the information, skills
and opportunities to put the suggestion into practice
(NHF 1999).
2.4 Components of a local strategy
2.4.1 Schools
A meta-analysis of 12 intervention studies to promote
heart-healthy eating behaviour in schools concluded that
they can have a significant effect (McArthur 1998).
Two reviews have identified the following features of an
effective school intervention (Contento 1995; Roe et al.
1997):
• Nutrition education interventions are more likely to be
effective when they employ educational strategies that
are directly relevant to a particular behaviour (eg diet
or physical activity) and are derived from appropriate
theory and research
• Interventions need adequate time and intensity
to be effective
Improving diet and nutrition
 • Family involvement enhances the effectiveness
of programmes for younger children
• Incorporation of a self-evaluation or self-assessment
and feedback is effective in interventions for
older children
• Effective nutrition education includes consideration of
the whole school environment and community
• Interventions in the larger community can enhance
school nutrition education
28
• The most effective interventions focus on diet alone or
diet and physical activity.
2.4.2 Local/community projects
This section includes a range of interventions from
small-scale local projects to well funded community
interventions. Little rigorous evaluation of the
effectiveness of the small scale projects has been
carried out.
Roe et al. (1997) concluded that intensive, smaller scale
projects generally resulted in positive changes in diet and
blood cholesterol, at least in the short term. However,
many large community-wide studies failed to show a
similar effect because they were conducted in the 1980s,
a time when awareness of CHD risk factors had increased
in the population. Therefore, in one study, the reduction
in blood cholesterol observed in the intervention
communities was also found in the comparison
community. In addition, there was a diversity of other
informational and educational interventions; therefore,
the investigators were unable to attribute any change to
their specific intervention.
Effective community interventions appear to:
• Focus on diet or diet plus physical activity
• Use a theoretical model
• Use diverse multiple interventions at individual, group,
community and environmental level
• Include small-group interventions (Contento 1995; Roe
et al. 1997).
Coronary heart disease: guidance for implementing the preventive aspects of the NSF
McGlone et al. (1999) identified the characteristics of
projects that appear to have been ‘successful’ using a
range of criteria:
• Flexibility needed by agencies to respond to the needs
of particular communities
• Access to secure, and ongoing, funds
• Professionals work in partnership with a community
• Projects need to involve local people, and ensure equal
respect
• Evaluation should not be confined to narrow clinical and
behavioural measures. Include food purchasing patterns,
structural changes and social outcomes, for example
• Strike a balance between partnerships and local
ownership
• Local and national networks should enable sharing of
experiences
• Training for professionals and members of the
community to acquire skills for a new way of working
• Government policies that do not deter volunteers (eg
social welfare benefits)
• Provide incentives for local projects and small
businesses, such as tax relief
• Allow time for community projects to develop, on the
basis that there is no ‘quick fix’ and that local policy
should support realistic time frames for community
food projects.
However, to date, there has been no systematic
evaluation of the effectiveness of local projects.
2.4.3 Workplace
Three out of four good-quality interventions showed
positive effects of nutrition workplace interventions, with
decreases in blood cholesterol of between 2.5% and
10% (Roe et al. 1997). An HEA review of the
effectiveness of health promotion interventions in the
workplace (Peersman et al. 1998) identified four studies
on healthy eating with adequate methodologies. Three
showed positive effects on fat, fruit and vegetable intake,
intention to change the diet and self-efficacy.
Characteristics of an effective workplace intervention
include:
• Visible and enthusiastic support and involvement from
management
• Involvement by employees at all levels in the planning
and implementation phases
• A focus on definable and modifiable risk factors rather
than multiple risk factor interventions
• Screening and/or individual counselling
• Changes to the composition of best selling foods
provided in canteens and vending machines
• Tailoring to the characteristics and needs of the
employees
• Use of local resources in organisation and
implementation of the intervention
• Combine population based policy initiatives with
intensive individual and group oriented interventions
• Built-in sustainability.
2.4.4 Healthcare
In a meta-analysis by Brunner et al. (1997), the study
participants were well motivated. Most studies were
conducted in either a healthcare or an institutional
setting. Interventions included dietary advice to reduce
fat or sodium and to increase fibre. The authors
estimated that, if changes in dietary behaviour were
sustained, they could lead to a reduction in the incidence
of CHD by 14% and the incidence of stroke by 9%.
A meta-analysis by Yu-Poth (1999) reported a 10%
reduction in plasma total cholesterol with a low intensity
intervention, and a 13% reduction with the high intensity
intervention. Tang et al. (1998) reported reductions in blood
cholesterol following individual dietary advice to modify fat
intake: 8.5% at three months and 5.5% at 12 months.
Another systematic review (Roe et al. 1997) included
interventions in the primary healthcare setting. Four
‘good quality’ studies were identified in the past
10 years. Modest and sustained effects on both blood
cholesterol and dietary fat intake were achieved for
dietary interventions only, or for multifactorial
interventions.
Characteristics of an effective healthcare intervention
include:
• Small group or one to one counselling sessions
29
• Targeting higher risk groups, which is also more cost-
effective (Van der Weidjen 1998; Wood et al. 1998)
• Family counselling and education for those at increased
risk
• Tailoring to the personal characteristics of individuals
• Educational and behavioural frameworks which are
client centred
• Staff training and development (topic based
knowledge and counselling skills)
• Low intensity interventions, such as mailed, computer
generated, personalised, nutrition education material
for well-motivated groups (Roe et al. 1997).
2.5 Reducing inequity
There are inequalities in diet between those on
higher and lower incomes (Acheson 1998). The
most striking difference is that people in lower
socio-economic groups tend to eat less fruit and
vegetables. The 1997 National Food Survey
(MAFF 1998) found that consumption of fruit and
vegetables by those in the upper socio-economic
groups was a third higher than that of those in lower
groups. This social class difference has also been
reported in children (Gregory et al. 2000). Studies
have shown that people on a low income can
describe a healthy diet as well as those on higher
incomes (Lobstein 1997). Food poverty, affordability
and access to a healthy and varied diet have been
identified as possible barriers (Lobstein 1997;
DH 1996).
Improving diet and nutrition
 The Acheson report (Acheson 1998) recommended
further development of policies that will ensure adequate
retail provision of food to those who are disadvantaged.
A report by Policy Action Team (PAT) 13 (1999)
confirmed that accessing affordable, good quality fruit
and vegetables within some local areas might be difficult.
However, access should not be seen purely in terms of
physical proximity, and other kinds of access need to be
considered, for example, financial access, knowledge and
information (HEA 1998a). In areas where a large proportion
of the population is unemployed, on low income or in
receipt of benefits, interventions to improve people’s
30
access to a healthier diet are likely to be a key priority.
2.5.1 Black and minority ethnic groups
Improving the health of minority ethnic groups is also a
priority in the government’s drive to reduce social
exclusion and inequalities in health. Further impetus was
provided by Acheson (1998), who recommended that the
needs of black and minority ethnic groups be considered
specifically. The HEA (2000) found that among black and
minority ethnic groups, understanding of healthy eating
messages varied widely across groups and knowledge of
foods high in complex carbohydrates, fibre, fat and
saturated fat was often poor across all ethnic groups.
There is, therefore, a need to raise awareness of the links
between diet and CHD among these groups and to
promote culturally relevant messages.
2.5.2 Children
Early childhood experiences strongly influence dietary
preference and good eating habits. While they may not
have an immediate effect on the rates of CHD, strategies
to promote healthy eating among children will benefit in
the longer term. They will help to address the concerns
Coronary heart disease: guidance for implementing the preventive aspects of the NSF
raised by the recent National Diet and Nutrition Surveys,
of children aged 11⁄ 2 to 41⁄ 2 years (Gregory et al. 1995)
and 4 to 18 years (Gregory et al. 2000). Acheson (1998)
concluded that ‘pre-school education or day care may be
especially effective in improving the achievement and
health of the most disadvantaged children’. A recent
review by Tedstone et al. (1998) of the effectiveness of
interventions to promote healthy eating in pre-school
children aged 1–5 years found that pre-school and day
care centres were likely to be appropriate settings for
interventions, and that parental involvement may
enhance the effectiveness of interventions and
should be facilitated. In more detail, the review
reported that:
• Traditional, video or computer-based teaching
methods were successful at increasing nutrition
knowledge and the effectiveness was enhanced by the
inclusion of parents
• Behavioural modification techniques using repeated
exposure to initially novel foods were successful in
increasing willingness to consume the foods only if
tasting was facilitated as part of the exposure
• The use of reward to encourage consumption of foods
was not successful once the reward had been removed
• One to one diet counselling that was ‘needs focused’
was successful at bringing about improvements in UK
mothers.
Acknowledgement
Information in Table 2.6 concerning some of the
local community interventions was drawn in part from
Making Links – a toolkit for local food projects (Sustain
2000).
 Table 2.6 Suggested activities to support local action
Intervention Evidence Outcome Who could be Skills and resources Points to consider Further information
involved?

Nutritional Roe et al. (1997) identified two
standards for good quality studies relevant to
school lunches school meals. Ellison et al. (1989,
1990) showed that passive
From April 2001,
manipulation of fat content reduced
new legislation will
saturated fat intake by 2% with a
require school
similar increase in polyunsaturated
lunches to meet
fat intake. Whitaker et al. (1994)
minimum nutritional
showed a 3% increase in low fat
standards.
choices when promoted.
Compliance with legal
requirement; gives a sound
basis to a whole school
approach; will contribute to
achieving the National
Healthy Schools Standard
(NHSS); clear guidance and
framework for monitoring
will be provided; will ensure
good nutritional standards for
free meals.
Local education Support for caterers from Pricing of healthier choices – Department for Education
authority (LEA), direct community dietitian or public and caterers’ perceptions of and the Environment (DfEE)
service organisation; health nutritionist in training the higher production costs; http://www.nutritional.stand
contract caterers and in healthier catering practices introducing a school food ards@dfee.gov.uk
in-house dietitians; and in monitoring compliance policy to support adoption of
National Standards for
Local Authority with the standards. the standards; opportunity to
School Lunches, England.
Caterers’ Association review snack provisions at
Regulations 2000. Statutory
(LACA): http://www. same time, as well as
Instrument number 1777.
laca.co.uk breakfast clubs and vending
The Stationery Office. £1.50.
machines.
Schools Nutrition
Eating well at school: dietary
Action Group (SNAG) Meeting and monitoring
guidance for school meal
initiative can help standards will be a legal
providers (1997). DfEE
schools in developing requirement.
Publications, PO Box 5050,
a school food policy. Annesley, Nottingham,
Local healthy schools NG15 0DJ. Tel: 0845
programme. 602260. Free of charge.
Child Poverty Action School Meals Assessment
Group: Pack (SMAP; computer
http://www.cpag.org. package assessing the
uk nutritional quality of
secondary school meals)
produced by the NHF.
SMAP, PO Box 7, London
W5 2GQ. £45.00, cheques
payable to BSS.
School food policy guide
produced by SNAG.
Contact Joe Harvey, Health
Education Trust (tel/fax:
01789 773915).
Nutrition guidelines for
school meals (1992) available
from The Caroline Walker
Trust, 22 Kindersley Way,
Abbots Langley, Herts, WD5
0DQ. Cost £10 including
postage and packing (p&p).
What are today’s children
eating? The Gardner Merchant
School Meals Survey 2000.
Gardner Merchant
(tel: 01793 512112).

Improving diet and nutrition

31
 32
Intervention Evidence Outcome Who could be Skills and resources Points to consider Further information
involved?

Future of food in schools

report (1998). Available free
of charge from Penny Rolfe,
Chartwells, Icknield House,
40 West Street, Dunstable,
Beds LU6 1TA.
McMahon, W. and Marsh,
T., 1999. Filling the gap.
Child Poverty Action Group.
Cost £5.00,
http://www.cpag.org.uk or
94 White Lion Street,
London W1 9PF. Tel: 020
7837 7979. Their website
also contains briefing papers
on school meals and healthy
eating and school meals in
Scotland.

Coronary heart disease: guidance for implementing the preventive aspects of the NSF
National healthy Evaluation of pilot sites (Rivers et al. Addresses a range of risk Local healthy schools Local programme Schools agree priorities with National Healthy School
school standard 2000) found conflict between factors for CHD as part of programme coordinators will welcome coordinators of local healthy Standard guidance.
(NHSS) healthy eating criteria and school whole school approach. Has coordinators based in the involvement of school programmes. Healthy DfEE (1999). Available free
Criteria for healthy meals contracts. New legal a formalised support LEAs or HAs. community dietitians, public eating may not be the first from DfEE Publications, PO
eating, to inform minimum standards for school network. Could be used to health nutritionists, health priority. Box 5050, Annesley,
implementation of lunches should overcome this. formalise and secure funding promotion specialists, in This is an opportunity to Nottingham NG15 0DJ.
whole school for any school based meeting the standard.
Not yet evaluated nationally. become involved in the The ‘Your healthy school’
approach. initiatives. Allows a flexible strategic planning to meet
approach to meeting section of
the healthy eating standard. http://www.wiredforhealth.
standard criteria.
NHSS support materials will Legal requirements for school gov.uk
facilitate strategic lunches will increase the Food – a fact of life: range
connections and help identify priority for healthy eating. of teaching resource
local partners as well as All LEAs have now signed up material for primary and
provide case study examples to achieve the NHSS. secondary schools (British
of good practice. Nutrition Foundation).
Contact 020 7404 6504 or
http://www.nutrition.org.uk
 Intervention Evidence Outcome
Breakfast and after 34 breakfast clubs; breakfast club Offer broader benefits
school clubs evaluations currently under way. (eg pre- and after-school
care).
Government has
recently funded 230 Opportunity to encourage the teachers, school
school breakfast intake of fruit on cereal, as
clubs as part of its juice or after school as
drive to tackle snacks. May also help to
inequalities in health. address low intakes of iron
and other micronutrients
(Gregory et al. 2000).
HEA Young People and
Health Survey (1999) revealed http://www.breakfast
that almost one in five (18%) -clubs.co.uk/
young people aged 11–16
years never (or hardly ever)
had breakfast before school
(males 13%, females 23%).
Improving diet and nutrition
Who could be Skills and resources Points to consider Further information
involved?
LEA Direct Service Paid staff to prepare food Could form part of a whole Breakfast Clubs. A how
Organisations; school and supervise children; school approach to improving to…guide. Kellogg’s New
caterers; head venue, facilities and diet. Policy Institute and
equipment for the safe and
Breakfasts and snacks offered Kellogg’s. Available from
governors and PTAs; hygienic preparation and http://www.breakfast-
need to reflect The balance
regional and local storage of food; activities/
of good health (HEA, DH and club.co.uk
coordinators of the resources to occupy the Street, C. and Kenway, P.,
MAFF 1994) (eg wholegrain
healthy schools children; research support to 1998. Fit for school – how
cereals with semiskimmed
programmes; schools evaluate success of breakfast clubs meet health
milk and fruit).
nutrition action programme. education and childcare
Free EU intervention stocks of
groups (SNAGs); needs. New Policy Institute.
Kellogg’s fruit could be useful. Fruit is
Cost £12.50.
available to schools but this
must be in addition to normal Donovan, N. and Street, C.,
supplies and not used as part 1999. Food for thought –
Local healthy schools breakfast clubs and their
of school canteen meals.
programme. challenges. New Policy
Currently, government is
Institute. Cost £7.50.
funding breakfast clubs in
areas of deprivation, Reports available from:
including HAZs, education New Policy Institute, 109
action zones (EAZs) and Sure Coopergate House, 16
Start areas, to help tackle Brune Street, London E1 7NJ
health inequalities. (tel: 020 7721 8421).
Scottish Community Diet
Project, c/o Scottish
Consumer Council, Royal
Exchange House, 100 Queen
Street, Glasgow G1 3DN
(tel 0141 226 5261).
Email
scdp@scotconsumer.org.uk
Website:
http://www.dietproject.co.uk
Information on EU
intervention stocks of fruit
from the Intervention
Board’s fruit and vegetable
withdrawal section
(tel: 0118 953 1694). An
information sheet for schools
is available (form HOR 18).
School food policy guide
produced by SNAG.
Contact Joe Harvey, Health
Education Trust (tel/fax:
01789 773915).
33
 34
Intervention Evidence Outcome Who could be Skills and resources Points to consider Further information
involved?

Cooking skills Lang et al. 1999 showed a general Clubs can stimulate interest DfEE’s Cooking for Access to school kitchens or Clubs take place out of http://www.wiredforhealth.
clubs dearth of cooking skills in the and confidence to develop Kids; RSA and community kitchens school hours or in holidays gov.uk
Cooking and food population and that schools are a cooking skills out of the Waitrose Focus on equipped for the safe and and for most children this is a
Cooking for Kids project
preparation skills key setting for learning such skills.school setting; Cooking for Food; LEAs; head hygienic preparation and one day experience. manual. Available free from
compulsory within Kids reports opportunities to teachers, parents and storage of food; teaching
Focus on Food is being evaluated by Not a replacement for regular Joe Monks at the
National Curriculum the University of Reading, results reinforce nutrition and food school governors, staff/school meals staff teaching of cooking skills; Department of Health tel
Food Technology hygiene lesson taught in school caterers, willing to participate out of
due 2001. can be a useful part of a 020 7972 2000.
(Key Stage 1 and 2, class, a head start in Year 7 teachers of food hours; parents or volunteers whole school approach; for
Cooking for Kids reported a range food technology; getting to technology; local to assist with supervision; Focus on Foods campaign:
optional at Key Stage some children this may be
of benefits at end of first year, know new school/teacher in chefs restaurateurs ingredients and equipment; http://www.waitrose.com/
3 and 4).
social as well as educational one of very few opportunities focusonfood/
advance; opportunity to build and shops who may funding sources (eg
National Initiatives on (Waldon 1999, unpublished report). interest and enthusiasm for to cook. Tel: 01422 383191.
be willing to Education Extra; The
cooking skills include cooking skills. help/donate Foundation for After School
Cooking for Kids ingredients. Clubs).
(DfEE) for Years 6
and 7 and Focus on Local healthy schools
Food cooking skills programme.
bus, Retail Services
Association (RSA)
and Waitrose.

Healthy tuck shops, Food Standards Agency has funded Part of a ‘whole school’ Local growers, A dedicated person to New National Plan for the British Dietetic Association

Coronary heart disease: guidance for implementing the preventive aspects of the NSF
break times and three studies promoting fruit and approach to healthy eating; markets, manage ordering and NHS has announced a Give Me 5 Pack
vending vegetables in schools reinforces the taught greengrocers, food preparation of National School Fruit Scheme http://www.bda.uk.com/
(Anderson et al., University of curriculum on healthy eating cooperatives and fruit/vegetables; facilities for where every child in nursery Tel: 0121 633 9555.
Food and drinks
Dundee; Barker et al., University of and oral health; complements supermarkets; LEAs; the safe and hygienic and aged four to six years in
available at break Information on EU
Sheffield; Moore et al., University of the new nutritional standards school caterers, local storage, washing and infant schools will be entitled
times are an intervention stocks of fruit
Bristol). for school lunches; provides and regional NHSS preparation of fruit and to a free piece of fruit every
important part of a (see Breakfast and after
ideal opportunity to increase programme vegetables; for tuck school day (see Breakfast and
whole school school clubs).
fruit and vegetable intakes coordinators; head shops/vending machines, after school clubs).
approach to healthy
and promote snacks safe for teachers and school someone to manage the School food policy guide
eating and are an National Diet and Nutrition
teeth. governors; SNAGs; money; a pricing policy produced by SNAG.
ideal opportunity to Survey of young people
community where fruit is purchased; Contact Joe Harvey, Health
increase children’s (Gregory et al. 2000) showed
development stock rotation and Education Trust
fruit and vegetable low intakes of fruit and
workers. temperature in vending (tel/fax: 01789 773915).
intakes. vegetables and high intakes
machines. of confectionery and soft
drinks.
Fruit and vegetable intakes
are lowest in households on
low income and receiving
benefits.
 Intervention Evidence Outcome Who could be Skills and resources Points to consider Further information
involved?

Cook and eat Caraher et al. (1999) suggested that Sustain (2000) reported that Sessions could be run Venue, facilities and Could be used to encourage Food and low income (FLI)
Sessions redesigned cooking and food such projects could increase in groups such as equipment for the safe and intakes of fruit and database
classes changed diets of young nutritional knowledge and women’s groups, hygienic preparation and vegetables by providing (http://www.hea.org.uk),
Mainly local
people and their families. improve skills as long as the youth clubs; church, storage of food; funding; opportunity to taste new our healthier nation in
initiatives, some
based originally on A general lack of cooking skills in approach was relevant to temples or religious ingredients; a project leader varieties. May provide a way practice (OHNiP), HAZnet.
the former Get the population was found and participants’ cultural and settings; local with practical food in to working with certain South Asian cooking club in
cooking! confidence to cook varied with age socio-economic catering colleges, preparation skills, food audiences (eg South Asian Luton HAZ is a Beacon Site
programme. and gender (Lang et al. 1999). circumstances. and home economics hygiene and nutritional women) as a socially and can be visited at: http://
teachers; LACA; local knowledge; link workers/ acceptable activity.
Increased self confidence and Evaluations also report wider www.nhsbeacons.org.uk/
retailers or gardening peer educators, particularly
esteem found in Get Cooking in health benefits such as Saffron Food and Health
and allotment for work with minority ethnic
Wales (Caraher and Lang 1995). reducing social isolation, and Project:
schemes for produce groups or young people;
building self confidence. http://www.crsp.ac.uk
Saffron Food and Health Project and ingredients; budget management skills.
(Dobson et al. 2000) suggests that May provide a forum in health visitors. Get cooking and get
the aim of community food projects which to discuss other health shopping pack from Sustain,
must be to get people interested issues. £14 (tel: 020 7837 1228).
and improve confidence and basic OK! Let’s cook, Healthy
cooking skills. Norfolk 2000, £2
(tel: 01603 487 990).
No dosh good nosh from
Nightsafe, Blackburn, £1
(tel: 0125 4587687).

Community cafes Not well documented; an evaluation Can help people access LA, EHO and trading Venue, facilities and Cafes reliant on external FLI database; OHNiP;
of a community café in southeast affordable meals; may reduce standards; funding equipment for the safe and funding, and so sustainability HAZnet.
Run on a local and
England (Kaduskar et al. 1999) social isolation; could be available hygienic preparation of may be an issue; involving
‘not for profit’ basis, Just for starters from the
could not determine whether the empowerment of project from regeneration foods; a project leader with the community in
often part of a wider Health Education Board for
cafe was successful in its aim of workers and development of related initiatives food preparation and book development seems to lead
community centre Scotland (tel: 0131 536
providing cheap, good quality food. their skills base; may provide (eg New Deal for keeping skills; training in to greater sustainability;
offering other 5500) ‘starting up’ advice
point of access to other Communities and food preparation and food should be run as a proper
services; aim to and recipes.
health and social services. Single Regeneration hygiene for volunteers and business, complying with
provide affordable
Budget); links with paid staff. environmental health (EH) Community Catering
(not necessarily
local supermarkets, and trading standards; local Initiatives conference report
healthy) meals in a
retailers, community circumstances important: and ‘how to’ information,
sociable atmosphere,
owned retailing (food particularly good for people from Community Health UK,
to reduce social
cooperatives) and who are homeless, lack £7.50 + £1.75 (p&p)
isolation.
growing schemes; cooking facilities or are (tel: 01225 462 680).
local catering colleges, elderly/single on low income. Heartbeat Award caterers’
LACA (investigate peer guide (see ‘Catering
education of local awards’).
volunteers); job
centres for caterers
seeking work.

Improving diet and nutrition

35
 36
Intervention Evidence Outcome Who could be Skills and resources Points to consider Further information
involved?

Community owned Evaluations in Bolton and in Tower Likely to be broader than LA EHO and trading Venue, including hygienic Food cooperatives are legal Start your own food co-op
retailing (food Hamlets and Stepney (Price and increasing the availability of standards; funding storage space and transport; entities and have to run on a video Bolton co-op, £15 (tel:
cooperatives) Sephton 1995; Ostasiewicz 1997) fruit and vegetables alone could be available equipment such as till, scales, membership basis. Fees for 01204 360094/360095).
Locally organised showed increased availability of fruit (eg providing a social from regeneration- float; start up costs and fuel membership can help with
Food for thought report and
initiatives that can and vegetables. It allowed people to meeting place in the local related initiatives costs; staff, including drivers start up costs.
video. Wolverhampton Food
improve accessibility try new foods at affordable prices; community); empowerment (eg New Deal for and a bookkeeper. Commitment of the staff is Co-ops Umbrella Group Ltd,
to foods such as fruit increased the confidence, self of local community and skills Communities and essential to ensure survival. £1 (tel: 01902 304 851).
and vegetables in esteem and developed new skills in development in those Single Regeneration Payment for their time may
those running the cooperative. running it; Bolton Food Budget); suppliers The co-op start up pack
areas that lack local help.
cooperative developed spin- such as local CWS. Available free (tel:
affordable supplies.
offs, supplying fruit wholesalers, farmers’ There is a need to comply 0161 827 5349).
In some areas it is tuckshops in schools and markets or with trading standards and
CWS small grants
difficult to access delivery to the elderly. The community allotment EH regulations, and to supply
Community Dividend
affordable good Tower Hamlets cooperative and growing culturally appropriate foods.
Scheme
quality fruit and has subsequently developed a schemes. Food cooperatives are not (tel: 0161 827 5950).
vegetables (PAT 13 local farmers’ market. Increase buying viewed as a long-term
1999). FLI database, OHNiP,
power by linking solution but can be used
HAZnet.
with other local food alongside other regeneration
initiatives to improve access. Sandwell Beacon site
cooperatives.
http://www.nhsbeacons.org.
The NHS Plan states that the
uk/
government will work with

Coronary heart disease: guidance for implementing the preventive aspects of the NSF
industry to increase provision
of fruit and vegetables and
where necessary to establish
local food cooperatives.

Community Bradford ‘Gardening for Health’ May increase physical activity, Local Agenda 21 Start up costs; land, Getting access to land and FLI database.
growing schemes project, run with Bangladeshi reduce social isolation, and (LA 21) coordinators; equipment, storage, water setting up an agreement for
Sustain publications:
women. Participants reported build confidence. LA leisure or supply, seeds; project leaders its use over a suitable period
May vary from city Growing food in cities (£10);
eating more fruit and vegetables, environmental with experience in gardening/ of time; possible
farms to allotments Participants in the Bradford City harvest (£30 full report,
services; local horticulture who will need to contamination of land in
or schemes set up on being more active, losing weight Project initially grew familiar summary £5);
and feeling more confident to go horticultural colleges. be paid; a bookkeeper; if some areas; sharing out
wasteland; can Asian vegetables but then tel: 020 7837 1228.
out alone (Hussain and Robinson Funding could be working with black and produce between participants
increase supplies of grew and started to eat
minority ethnic groups may and/ or selling it on to food Federation of City Farms and
affordable vegetables 2000). British vegetable varieties available from
need a link worker. cooperatives, farmers’ Community Gardens, Starter
and fruit locally; can which are cheaper; also regeneration related
markets, community cafes; pack (tel 0117 923 1800).
be linked to food developed marketable initiatives (eg New
Deal for Communities may be useful in areas of
cooperatives; gardening skills.
and Single regeneration where access to
sometimes set up
Regeneration Budget). affordable fruit and
with an
vegetables are poor.
environmental rather National Society of
than health agenda. Allotment and Leisure May help meet priorities of
Gardeners Ltd LA 21.
(tel: 01536 266576).
 Intervention Evidence Outcome Who could be Skills and resources Points to consider Further information
involved?

Farmers’ markets Farmers’ markets offer good value Improved access to affordable LA and trading Staff (paid or voluntary) to Needs help and support from The National Association of
for money; provide an opportunity fruit and vegetables; retail standards; any local liaise with local council, LA; need to encourage Farmers’ Markets has a list
Markets that allow
to buy fresh, local produce; give outlet for community growers’ growers and consumers; growers to participate; needs of farmers’ markets
farmers and growers
local people a sense of well being growing schemes; associations; suitable venue in proximity to publicity; an accessible venue (tel: 01225 787914)
to sell directly to
and belonging; provide a social environmental benefits in LA 21 coordinator; area of need; access to not requiring costly public http://www.farmersmarkets.
consumers, thereby
meeting place; and also play a role that produce is not National Association growers willing to participate transport; ensure bona fide net
reducing the price.
in revitalising the local rural transported great distances; of Farmers’ Markets within the locality. growers only participate; may
‘Eco-logic’ publications on
They are often set up economy (Bur et al. 1999; Bullock increased social capital. (tel: 01225 787914); improve access to retail
farmers’ markets
as environmental 2000). Soil Association local services and increase supply
(tel: 01225 484472).
initiatives and require food links of affordable fruit and
produce to be grown department vegetables; may affect trade The Soil Association provides
within a certain (tel: 0117 914 2426). in local small shops. training on setting up and
radius of the market. running a farmers’ market:
Meets priorities of LA 21.
Some focus on (tel: 0117 914 2426).
organic produce.

Community shops Community shops are a recent Improved access to foods LA, EH department Project leaders with retail ‘Not for profit’, therefore How to make your
and similar schemes innovation, which have not yet such as fruit and vegetables; and trading experience and/or book dependent on grants or community shop succeed.
useful in rural areas where standards; Village keeping skills; driver and subsidies; membership fees Community Enterprise Ltd
Set up in response to been evaluated.
public transport is poor; shop Retail Services transport to travel to can help start up costs: must (tel: 0131 475 2345).
closure of local shops
staff can develop marketable Association (VIRSA; wholesalers; funding from comply with trading
on housing estates or Village shops and post
skills and gain work tel: 01305 259 383); grants or subsidies; suitable standards, EH regulations; in
in rural areas; may be offices: a guide to
experience; can be part of funding could be premises with storage some areas more appropriate
run on a ‘not for deployment of village
neighbourhood renewal available from facilities and equipment in to take people to shops
profit’ basis, usually investment to rescue, sustain
initiatives. regeneration-related the locality, which complies rather than shops to people
by volunteers. and revive. VIRSA, £15 (tel:
initiatives (eg New with EH and health and (PAT 13 1999); could help
01305 259 383).
Deal for safety regulations. improve access to fruit and
Communities and vegetables; may contribute to If the village shop closes …
Single Regeneration neighbourhood renewal a handbook on community
Budget). strategies. shops. Oxford Rural
Community Council, £3.50
Community Owned (tel: 01865 883488).
Retailing: training
and support in
setting up
neighbourhood
shops
(tel: 01435 883005)
http://www.communi
t.retailing.co.uk

Improving diet and nutrition

37
 38
Intervention Evidence Outcome Who could be Skills and resources Points to consider Further information
involved?

Transport to shops Case study
schemes
Hackney Community transport
Can be run on a local developed to increase access to
basis or by linking local activities for disabled and
with supermarket elderly people. ‘Plusbuses’ now run
chains or local every 30 minutes on a fixed route
retailers. which links up the local hospital,
day centres, schools, shops and
other transport interchanges.
Access to mainstream shops
and services (PAT 13 1999).
Overcome difficulties
experienced by people in
carrying heavy fruit and
vegetables from shops.
Local supermarkets Drivers, vehicles and funding
and local chamber of to support running costs;
commerce or trade. insurance and compliance
with safety regulations.
Areas that need to be linked,
frequency of services; linking
with local retailers bus
schemes.
Schemes may be very useful
in increasing access to
affordable supplies of fruit
and vegetables.
Community Transport
Association (tel: 0161 367
8780).
Ferguslie Park Access to
Shopping project report
(tel: 0141 887 9650).

Supermarket tours Increase in self reported ‘healthy’ May be useful as part of a Supermarkets, Dietitian/public health Useful with groups with a Retailers’ own materials
purchases and behaviour compared wider programme of healthy nutritionists based in nutritionist; good relationship particular focus (eg diabetics); based on The balance of
Usually led by a
with controls, one month after eating supermarket initiatives, head office; local with local supermarket and useful to base the tour on good health (HEA, DH and
dietitian or
two-hour tour, but study was of but most need to be press; groups with ability to identify and use PR The balance of good health MAFF 1994) could be used
nutritionist with small
poor quality (Silzer et al. 1994). coordinated nationally rather particular interest opportunities. (HEA, DH and MAFF 1994); as a resource.
groups of consumers.
than locally. (eg diabetics, opportunity to make links
May focus on
mothers of young with local retailers.
interpreting food Roe et al. (1997) found four
children).
labels and health good quality supermarket
claims and on studies: three point of
selecting foods and purchase labelling, one video
discussing healthier feedback which showed

Coronary heart disease: guidance for implementing the preventive aspects of the NSF
preparation methods. increases in sales of
promoted products while the
Sometimes used with
study was running.
groups with a
particular area of
interest (eg diabetes).

Catering awards One of six schemes evaluated by Better relationships between Caterers, catering EH, dietetics and health To maximise impact may be Heartbeat Award Starter pack;
HEA in 1998 showed significantly caterers and EH department; trainers, employers, promotion expertise on best concentrated in venues A caterer’s guide to the
For example,
good public relations (PR) for occupational health smoking policies; partnership where the same people eat Heartbeat Award (packs 5);
Heartbeat Award is a greater use of healthier catering
caterers, a commitment to nurses; health working skills; evaluation every day (eg workplaces, Heartbeat Award flyers (packs
nationally recognised practices in award holding premises
customer care and to food promotion specialists skills; time for processing prisons); needs to have both 50).
but locally run award (Paterson et al., in preparation).
hygiene training; difficult to with an interest in annual renewals in addition dietetic and EHO input, Heartbeat award certificates
made to caterers A quarter of Heartbeat Award
demonstrate the effect of the evaluation. to new applications; funding requires a good working and window stickers (packs
who adopt healthier premises reported increases in sales
scheme on the overall diet of to support scheme; PR relationship between the two 10 each).
practices, have good of some healthier items but sales of
consumers. support. departments; could help to
standards of food less healthy choices tended to A guide to evaluating the
hygiene and offer remain the same (Holdsworth et al. support HImPs as requires joint
Heartbeat Award. (HEA
nonsmoking seating. 1999). working between LA and HA
1998).
Usually run by LA trusts. Evaluation is vital, as
Greater provision of some healthier funders may seek evidence of The Heartbeat Award: Making
EHOs in partnership foods, healthier options and greater benefits before committing the most of the media (HEA
with dietitians and commitment to healthy eating resources to continue the 1996).
health promotion (Warm et al. 1997). scheme. This will also help to
specialists. All HEA publications available
build evidence base nationally. from Marston Book Services
(tel: 01235 465565).
 Intervention Evidence
Adoption of Positive effect on food choices for
healthier catering the duration of interventions
practices in modifying recipes or highlighted
workplace catering healthier choices in variety of
and highlighting settings; no good quality studies in
‘healthier‘ choices a workplace setting (Roe et al.
1997); increase in sales of low fat
meals in the workplace when
highlighted with symbols on menus
and posters (Levin 1996).
Making small changes to best
selling dishes can be effective in
promoting healthier choices, and
presentation is important.
Promoting menu items is successful
where parallel choices are on offer
(HEA 1998b).
Promoting healthy Pre-school and day care centres
eating in pre- were likely to be appropriate
schools, such as settings for interventions (Tedstone
family centres run et al. 1998b).
by social services or
private day
nurseries
Improving diet and nutrition
Outcome
Around an eighth of energy,
fat, and saturated fat in the
diet is from the food eaten
away from home.
Workplace caterers may
prepare a significant
proportion of meals for
regular customers and so
have an important influence
on the overall diet.
Increase child carers, children
and parents’ nutritional
knowledge; improve main
meal provision and between
meal snacks and drinks.
Who could be Skills and resources Points to consider Further information
involved?
Caterers, service Some training of caterers and Workplace offers a major Tipping the balance video
staff, catering service staff; basic research opportunity to gain access to, and workshop notes, HEA;
managers, chef skills to carry out needs and communicate with, a A caterer’s guide to the
trainers; workplace assessment among large proportion of the adult Heartbeat Award, HEA; Dine
management, human customers. population; acknowledged by out eat well, leaflet, DH;
resources, government as a useful The national catering
occupational health; setting for general health initiative: promoting
contract caterers promotion. healthier choices, HEA;
dietitians/in house Framework for action.
Covert changes to the menu
chef trainers; Health at work in the NHS,
overall have potential to
community dietitians, benefit all customers, HEA.
Public Health promoting healthier options These publications are
Nutritionists, only benefits customers that available free from Marston
workplace health choose them. Book Services
promotion specialists. (tel: 01235 465565).
Should extend to vending
and snack provision and to
hospitality catering.
May help caterer qualify for
an HBA.
Health promotion Community dental staff and A comprehensive healthy Website:
specialists; LA early community dietitians can eating policy should include http://www.surestart.gov.uk/
years adviser; provide specialist knowledge all meals, should consider home.cfm on Sure Start
voluntary sector and local data (eg on oral children with special includes a comprehensive
(eg Pre-School health of under fives). requirements and should contact list for under 5s
Learning Alliance, foster good eating skills and agencies and web links.
National table manners.
Caroline Walker Trust
Childminding A more limited policy may (1998). Eating well for
Association); local not cover between meal under-5s in child care.
Sure Start snacks. Practical and nutritional
programmes working guidelines. 22 Kindersley
in partnership with Way, Abbots Langley,
parents. Hertfordshire, WD5 0DQ.
Cost £12.95 (including p&p).
Watt, R., ed., 1999. Oral
health promotion: a guide to
effective working in pre-
school settings. London:
HEA. Available free from
Marston Book Services
(tel: 01235 465565).
39
 2.7 References
Acheson, D., 1998. Independent inquiry into inequalities in health
report. London: The Stationery Office.
Brunner, E., White, I., Thorogood, M., Bristow, A., Curle, D. and
Marmot, M., 1997. Can dietary interventions change diet and
cardiovascular risk factors? A meta-analysis of randomised control
trials. American Journal of Public Health, 87 (9), 1415–1422.
Bullock, S., 2000. The economic benefits of farmers’ markets. London:
Friends of the Earth.
40
Bur, A.M., Jewell, T. and Rayner, K., 1999. Sussex Farmers’ Market: an
evaluation of three pilot markets in Lewes. Lewes: Common Cause.
Caraher, M. and Lang, T., 1995. Evaluating cooking skills classes: a
report to Health Promotion Wales. Cardiff: Health Promotion Wales.
Caraher, M. and Lang, T., 1999. Can’t cook, won’t cook: a review of
cooking skills and their relevance to health promotion. International
Journal of Health Promotion and Education, 37 (3), 89–100.
Contento, I., 1995. The effectiveness of nutrition education and
implications for nutrition education policy. Journal of Nutrition
Education, 27, 279–418.
DH, 1994. Nutritional aspects of cardiovascular disease: report of the
cardiovascular review group of the Committee on Medical Aspects of
Food Policy. London: The Stationery Office.
DH, 1996. Low income, food, nutrition and health: report from the
Nutrition Task Force. London: DH.
DH, 1998. Nutritional aspects of the development of cancer: report of
the working group on diet and cancer of the Committee on Medical
Aspects of Food and Nutrition Policy. London: The Stationery Office.
Dobson, B., Kellard, K. and Talbot, D., 2000. A recipe for success? An
evaluation of a community food project. Loughborough: Centre for
Research in Social Policy, Loughborough University.
Ellison, R.C., Capper, A.L., Goldberg, R.J., Witschi, J.C. and Stare, F.J., 1989.
The environment component changing school food service to promote
cardiovascular health. Health Education Quarterly, 16, 285–297.
Ellison, R.C., Goldberg, R.J., Witschi, J.C., Capper, A.L., Puleo, E.M. and
Stare, F.J., 1990. Use of fat modified food products to change dietary
fat intake of young people. American Journal of Public Health, 80,
1374–1376.
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Gregory, J.R., Collins, D.L., Davies, P.S.W., Hughes, J.M. and Clarke,
P.C., 1995. National diet and nutrition survey: children aged 11⁄2 to 41⁄2
years. Vol. 1, Report of the diet and nutrition survey. London: The
Stationery Office..
Gregory, J., Lowe, S., Bates, C. J., Prentice, A., Jackson, L. V., Smithers,
G., Wenlock, R. and Farron, M., 2000. National diet and nutrition
survey: young people aged 4 to 18 years. Vol. 1, Report of the diet
and nutrition survey. London: The Stationery Office.
HEA, 1992. Scientific basis of nutrition education: a synopsis of
dietary reference values. London: HEA.
HEA, 1996. Nutritional aspects of cardiovascular disease. London: HEA.
HEA, 1998a. Deprived neighbourhoods and access to retail services:
a report on work undertaken by the Health Education Authority on
behalf of the Department of Health and the Social Exclusion Unit
(unpublished). London: HEA.
HEA, 1998b. The national catering initiative: promoting healthier
choices. London: HEA.
HEA, 1999. Young people and health: health behaviour in school-aged
children. A report of the 1997 findings. London: HEA.
HEA, 2000. Black and minority ethnic groups in England: the second
health and lifestyles survey. London: HEA.
HEA, DH and MAFF, 1994. The balance of good health.
London: HEA.
Hodgson, P., Wyles, D., Kennedy-Haynes, L. and Hunt, C., 1995. Friends
with food: the development of a nutrition education programme for
low income groups, 1990–1994. Huddersfield: Huddersfield Health
Promotion Unit.
Holdsworth, M., Haslam, C. and Raymond, N.T., 1999. An assessment
of compliance with nutrition criteria and food purchasing trends in
Heartbeat Award premises. Journal of Human Nutrition and Dietetics,
12, 327–335.
Hussain, H. and Robinson, J., 2000. Gardening for health:
evaluation. Bradford: Heartsmart and Bradford Community
Environment Project.
Joshipura, K.J., Ascherio, A., Manson, J.E. and Stampfer, M.J., 1999.
Fruit and vegetable intake in relation to risk of ischemic stroke.
Journal of the American Medical Association, 282,
1233–1239.
Kaduskar, S., Boaz, A., Dowler, E., Meyrick, J. and Rayner, M., 1999.
Evaluating the work of a community café in a town in the South
East of England: reflections on methods, process and results. Health
Education Journal, 58, 341–354.
Kennedy, L. A., Ubido, J., Elhassan, S., Price, A. and Sephton, J., 1999.
Dietetic helpers in the community: the Bolton Community Nutrition
Assistants Project. Journal of Human Nutrition and Dietetics, 12,
501–512.
Lang, T., Caraher, M., Dixon, P. and Carr-Hill, R., 1999. Cooking skills
and health. London: HEA.
Levin, S., 1996. Pilot study of a cafeteria program relying primarily
on symbols to promote healthy choices. Journal of Nutrition
Education, 28 (5), 282–285.
Lobstein, T., 1997. If they don’t eat a healthy diet, it’s their own
fault! Myths about food and low income. London: National Food
Alliance.
Lowe, F., 2000. The psychological determinants of children’s food
preferences. Bangor: University of Wales (in press).
Marmot, M., 1994. The cholesterol papers. British Medical Journal,
308, 351–352.
McArthur, D., 1998. Heart-healthy eating behaviors of children
following a school based intervention: a meta-analysis. Issues in
Comprehensive Pediatric Nursing, 21, 35–48.
McGlone, P., Dobson, B., Dowler, E. and Nelson, M., 1999. Food
projects and how they work. London: Joseph Rowntree Foundation.
MAFF, 1998. National food survey 1997, annual report on food
expenditure, consumption and nutrient intakes. London:
The Stationery Office.
NHF, 1997. At least five a day – strategies to increase fruit and
vegetable consumption. London: The Stationery Office/NHF.
NHF, 1999. Looking to the future: making CHD an epidemic
of the past. London: The Stationery Office.
Ostasiewicz, L., 1997. Evaluation of Tower Hamlets food co-ops.
London: Tower Hamlets Food Co-op.
Paterson, K., Poulter, J., Swann, C. and Peploe, K., 2000. The
effecitveness of the Heartbeat Award in England: a review. London
(in preparation).
PAT 13, 1999. Improving shopping access for people living in deprived
neighbourhoods. London: Social Exclusion Unit.
Peersman, G., Harden, A. and Oliver, S., 1998. Effectiveness of health
promotion interventions in the workplace: a review. London: HEA.
Price, S. and Sephton, J., 1995. Evaluation of Bolton’s food co-ops.
Bolton: Community Healthcare.
Rivers, K., Aggleton, P., Chase, E., Downie, A., Mulvihill, C., Sinkler, P.,
Tyrer, P. and Warwick, I., 2000. Setting the standard: research linked to
the development of the national healthy school standard (NHSS).
41
London: DH and DfEE.
Roe, L., Hunt, P., Bradshaw, H. and Rayner, M., 1997. Health promotion
interventions to promote healthy eating in the general population: a
review. London: HEA.
Silzer, J.S., Sheeska, J., Tomasik, H.H. and Woolcot, D.M., 1994. An
evaluation of ‘Supermarket Safari’ nutrition education tours. Journal of
the Canadian Dietetic Association, 55, 179–183.
Sustain, 2000. Making links – a toolkit for local food projects. 2nd ed.
London: Sustain: the alliance for better food and farming.
Tang, J.L., Armitage, J.M., Lancaster, T., Silagy, C.A., Fowler, G.H. and
Neil, H.A.W., 1998. Systematic review of dietary intervention trials to
lower blood total cholesterol in free-living subjects. British Medical
Journal, 316, 1213–1220.
Tedstone, A.E., Aviles, M. Shetty, P. and Daniels, L.A., 1998.
Effectiveness of interventions to promote healthy eating in pre-school
children aged 1–5 years: a review. London: HEA.
Van der Weijden, T., 1998. Economic evaluation of cholesterol related
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Epidemiology and Community Health, 52, 586–594.
Warm, D.L, Rushmere, A.E, Margetts, B.M, Kerridge, L. and
Speller, V.M., 1997. The Heartbeat Award Scheme: an evaluation
of catering practices. Journal of Human Nutrition and Dietetics, 10,
171–179.
Whitaker, R.C., Wright, J.A., Koepsell, T.D., Finch, A.J. and Psaty, B.M.,
1994. Randomized intervention to increase children’s selection of
low-fat foods in school lunches. Journal of Paediatrics, 125,
535–540.
Wood, D., Durrington, P., Poulter, N., McInnes, G., Rees, A. and Wray,
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Improving diet and nutrition
 Association, British Hypertension Society and British Yu-Poth, S, 1999. Effects of the National Cholesterol Education
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Heart, 80 (suppl 2). Nutrition, 69, 632–646.

42

Coronary heart disease: guidance for implementing the preventive aspects of the NSF
Chapter 3
Increasing physical activity

3.1 Introduction Since there is a high rate of inactivity in the population, 43

the majority of the population could benefit from

There is international consensus that a physically
active lifestyle is important for health and has great
potential health gain (WHO/Federation of Sports
Medicine 1995; US Department of Health and Human
Services 1996).
Physical activity has been shown to have the following
benefits:
• Regular physical activity or cardiorespiratory fitness
decreases the risk of cardiovascular disease mortality in
general and of CHD mortality in particular
• The level of decreased risk of CHD attributable to
regular physical activity is similar to that of other
lifestyle factors, such as not smoking
• Regular physical activity prevents or delays the
development of high blood pressure, and exercise
reduces blood pressure in people with hypertension
• Physical activity is also important in controlling
diabetes, regulating weight and reducing the risks of
osteoporosis and colon cancer.
increasing their activity. The attributable risk from
inactivity for CHD is considerable. It has been estimated
that in the US, 35% of CHD deaths could be attributed
to inactivity (Powell and Blair 1994). Physical activity is an
important element in controlling overweight and obesity
(discussed in more detail in Chapter 4).
3.2 Objectives of physical activity
interventions
The current guideline is to achieve 30 minutes of moderate
intensity activity (such as brisk walking, heavy gardening
and heavy housework) on at least five days of the week
(DH 1996). Walking and cycling are frequently cited as
examples of how to achieve this recommendation
(WHO/Federation of Sports Medicine 1995; US
Department of Health and Human Services 1996).
The overall prevalence of physical activity is low (see Box
3.1). Data from the 1998 Health Survey for England (Joint
Surveys Unit 1999) showed that 37% of men and 25%
of women met the current guidelines for activity (30
minutes of activity per day on at least five days of the

Box 3.1 Proportion of men and women in England meeting physical activity
guidelines by age, 1998

Age (years) 16–24 25–34 35–44 45–54 55–64 65–74 75+ All ages

Men 58 48 43 36 32 17 7 37
Women 32 31 32 30 21 12 4 25

Source: Joint Surveys Unit (1999)

Increasing physical activity

 week). These levels drop with age. Participation is lower
among many black and minority ethnic groups.
An important step in the effective promotion of
physical activity is developing strategies that
encourage partnerships between a variety of
professionals and community groups. Reviews of
effective policy development emphasise the
importance of a strong evidence base, ownership by a
range of stakeholders, community involvement, needs
analysis and evaluation (HEA 1995; NHF 1995; Foster
2000). For more data on the effectiveness of physical
44
activity strategies, see Table 4.7 in Chapter 4: Reducing
overweight and obesity.
3.3 Features of effective interventions
A review of randomised controlled trials of physical
activity promotion found some evidence that physical
activity can be increased and maintained for up to two
years. Interventions that encourage walking and do not
require attendance at a facility appear most likely to lead
to sustainable increases in physical activity (Hillsdon et al.
1999). Others have found that promoting lifestyle
physical activity (eg walking) leads to similar changes in
behaviour and CHD risk factors as does promoting
structured, facility-based, interventions (Dunn et al. 1999).
Hillsdon et al. (1999) also reported that brisk walking has
the greatest potential for meeting current physical activity
recommendations. Regular brisk walking can lead to the
majority of health benefits associated with physical
activity (Morris and Hardman 1997).
Interventions aimed at modifying the environment, such
as signs posted to increase stair climbing (Brownell et al.
1980; Blamey et al. 1995), have proved effective also
over the short term.
3.4 Components of a local strategy
3.4.1 Healthcare interventions
Interventions in healthcare settings can increase physical
activity for both primary and secondary prevention
(Simons-Morton et al. 1998). Long-term effects are more
likely with continuing intervention and multiple
intervention components such as supervised exercise,
Coronary heart disease: guidance for implementing the preventive aspects of the NSF
provision of equipment and behavioural approaches
(Simons-Morton et al. 1998).
Mixed results have been obtained on the effectiveness of
primary care based interventions, but these have been
shown to be moderately effective. A recent study did not
find evidence of longer-term maintenance of increased
levels of physical activity (Harland et al. 1999). A benefit
of primary care based intervention is that it can reach a
wide range of the population (Harland et al. 1999).
3.4.2 Exercise referral schemes
These involve primary care staff (usually practice nurses or
GPs) referring patients to leisure centres for advice and
assistance in increasing physical activity. Although there is
a lack of rigorous evaluation of these programmes, there
is some evidence of short-term increases in the level of
activity. However, there is no evidence of a sustained
long-term behaviour change. Data from case studies suggest
an impact on a range of parameters in a variety of people.
The effectiveness of the schemes may be improved when:
• Staff are trained in behaviour change strategies
• Quality supervision is achieved by adequate
practitioner–patient ratios
• Liaison between health and leisure service personnel is
established and maintained
• Community based networks offer support beyond the
referral period, incorporating sustained, active living
(Riddoch et al. 1998).
Some practitioners have expressed concerns about the
amount of time and resources required to set up and run
high quality referral schemes that address the needs of
only a small section of the population. Targeting of
appropriate referrals will be an important task where
schemes are adopted.
3.4.3 Workplaces
Workplaces provide an organisational structure for
coordination of health programmes. However, existing
research, although not conclusive, shows that it can lead
to increases in physical activity (Shephard 1990; Bovell
1992; Dishman et al. 1998). A booklet is available
with ideas for introducing workplace physical activity,
giving examples of three case studies (Elder 1996).
Some interventions to promote active commuting using
written materials have shown increases in physical
activity levels (Mutrie et al. 1999; see also section 3.4.7:
Physically active transport).
3.4.4 Mass media
In mass media interventions, the number of contacts
and tailored interventions was important for
increasing effectiveness but there was little impact
on long-term physical activity behaviour (Marcus et al.
1998).
3.4.5 Schools
Physical activity programmes in schools have been
associated with a number of positive changes. Most
interventions are developed as a result of collaboration
between schools and external advisory and support
services, in the context of local healthy schools
programmes (HEA 1998a). Reviews of activity
promotion in schools (Shephard et al. 1980;
Simons-Morton et al. 1988; Pieron et al. 1996; Harris
1997; Sallis et al. 1990, 1993) have
concluded that:
• Appropriately designed, delivered and supported
physical activity curriculum can enhance current levels of
physical activity and can improve physical skill
development
• Young people benefit from access to suitable
and accessible facilities and opportunities for physical
activity
• Interventions are likely to be more effective
when young people are involved in planning
programmes.
A qualitative exploration of the views of young people
(aged 11–15 years) shows clear gender differences, with
young women less likely to engage in active pursuits. A
flexible and differentiated approach to physical activity
promotion may be required to meet the needs and
preferences of this group (Mulvihill et al. 2000).
Features of well-designed schemes [Department of
Environment, Transport and the Regions (DETR) 1999]
include:
• Quality of teacher skills, knowledge and experience
enhanced through professional education and training
programmes
• Differentiation in the design of interventions according
to young people’s developmental and other needs
• A range of enjoyable, health enhancing physical
45
activities
• A whole school approach to the promotion of physical
activity, including
– a physical and health education curriculum
– extracurricular activities
– links with the local community
– safe transport routes to schools
• The involvement and support of the local community
• Provision of appropriate activities to meet the religious
and cultural needs of people from minority ethnic groups
• A mechanism to demonstrate how a school will
measure increases in the levels of participation in
regular physical activity.
3.4.6 Older people
Physical activity promotion for older people (HEA 1995;
Walters et al. 1999) should:
• Provide opportunities for affordable, accessible
physical activity (particularly for those least likely to
take part)
• Address psycho-social needs and combine fun and
socialising with physical activity
• Involve older people in the planning, implementation
and evaluation of programmes
• Address the specific needs of different groups
• Address the political, social and economic barriers that
discourage older people from participating
Increasing physical activity
 • Ensure that the outdoor environment is safe and
pleasant for taking exercise.
Addressing the environmental and planning aspects that
promote or deter physical activity is important in meeting
the needs of older people. This includes factors that make
older people feel unsafe, either from other people or
hostile environments (Walters et al. 1999).
A WHO (1996) consensus statement is available on levels
of physical activity to improve health in older adults.
46
3.4.7 Physically active transport
Transport offers potential for health enhancing physical
activity. Cycling and walking can be of suitable intensity,
and trips such as commuting or travel to school are
regular, frequent and often of a suitable length (71% of
journeys are less than five miles, and 45% less than two)
(DETR 1996). Mutrie et al. (1999) found significant
increases in walking to work when written interactive
promotional material was used, but no increases in cycle
commuting. Evidence suggests that promoting workplace
based cycling requires attention to environmental factors,
both in the workplace (eg cycle parking and showers) and
to the road environment (eg safety). Walking and cycling
to work have been shown to lead to improved health
outcomes (Vuori and Oja 1999).
3.5 Reducing inequity
Deprived groups are twice as likely to be sedentary as the
most affluent groups (Gordon et al. 1999). A higher
proportion of men in lower social classes participate in
moderate or vigorous activity, but this is mainly due to
occupational physical activity. The trend does not apply to
women. However, a higher proportion of men and
Coronary heart disease: guidance for implementing the preventive aspects of the NSF
women in non-manual occupations participate in sports
and leisure activities compared with those in manual
occupations.
The characteristics of good practice in work on physical
activity and inequalities (HEA 1999a) include:
• Proactive outreach work
• A multidisciplinary approach
• Involving the targeted communities
• Developing new partnerships with professionals who
have good access to ‘hard to reach’ groups.
Barriers to participation in physical activity among black
and minority ethnic groups tend to be similar to many of
those in other groups, including lack of time and concerns
about body shape. Additional barriers include racism,
cultural inappropriateness (eg lack of single sex provision),
the importance of family responsibilities and language
issues (HEA 1997a). More single sex exercise facilities may
encourage uptake among Asian women (HEA 2000).
Participation in physical activity tends to be low among
people with disabilities. A key issue is for people with
disabilities to participate in activities that they enjoy,
perceive as supportive in maintaining activities of daily
living and are activities which can be incorporated easily
into routine life. Activities must be:
• Appropriate from a social, environmental and
physiological perspective
• Planned in close cooperation with the target group
• Involve specialist advice where appropriate
(HEA 1997b).
3.6 Useful sources of information about community based programmes

The European Heart Network has produced a report Physical activity and http://www.ehnheart.org/pdf/act
cardiovascular disease prevention in the European Union. It summarises the ivity.pdf
evidence on the relationship between physical activity and cardiovascular
health and provides recommendations to encourage a more active
environment.

Europe on the move! is an information network of the European http://www.europe-on-the-

programme for the Promotion of Health-Enhancing Physical Activity (HEPA). move.nl/europe/start.html
There are many links on their website to European local initiatives with
contact details. A guide for promoting walking in the community has been 47

produced by the Finnish Rheumatism Association and links are available via
this site.

Promotion of transport, walking and cycling in Europe: strategy directions is http://www.europe-on-the-

a web accessible document that includes useful and practical information move.nl/europe/start.html
on promoting transport walking and cycling. It suggests strategies, defines
targets, and provides advice on funding, advocacy and lobbying, monitoring
and evaluation. It can be accessed at the Europe on the Move site.

Looking to the future: making CHD an epidemic of the past (NHF 1999)
reviews successes and failures of health policy in reducing high rates of
CHD.

Moving on: international perspectives on promoting physical activity is a

report from a symposium in 1994 designed to support the Physical Activity
Task Force in its role of developing a national strategy for promoting
physical activity in England (Killoran et al. 1995).

A community approach to behavioural change in the promotion of physical activity, http://www.cdc.gov/nccdphp/dn

published by the Center for Disease Control and Prevention (CDC), is aimed pa/pahand.htm
at all those interested in a community-wide strategy (central and local
government, transport, health and community planners, exercise specialists
and health professionals, community groups, businesses, schools, colleges and
universities).

The CDC in the USA has a report entitled Physical activity and health which http://www.cdc.gov/nccdphp/sgr
covers the promotion of physical activity in our daily lives. /summary.htm

The CDC has also published a set of guidelines on the promotion of physical http://www.cdc.gov/nccdphp/das
activity in children and adolescents, with guidance on the benefits and h/physact.htm
consequences of physical activity.

For helpful advice on active school travel projects the School Travel Advisory www.local-
Group (STAG) report gives extensive recommendations for the development transport.detr.gov.uk/schooltravel
of active travel patterns in the school setting. These have been endorsed by
DH, DETR and the DfEE.

Increasing physical activity


Table 3.7 Suggested activities to support local action
Primary care
Intervention Evidence
Individual patient Some evidence for short-term
risk assessment and effectiveness but no evidence of
advice sustainability (Bull and Jamrozik
1998; Marcus et al. 1998; Eakin et
al. 2000).
Counselling for Frequent professional contact is
behaviour change associated with adherence (Hillsdon
Coronary heart disease: guidance for implementing the preventive aspects of the NSF
et al. 1999). Long-term effects are
more likely with continuing
interventions and behavioural
approaches (Simons-Morton et al.
1998).
Physical activity Small but possibly meaningful
referral improvements achieved (Riddoch et
al. 1998); no evidence of long-term
impact.
Outcome
Identification of levels of
activity, interventions based
on predicted risk.
Sustained behaviour change
in target group, possible
reduction in risk factors
(eg hypertension) in target
group.
Effective partnership between GP, PHC staff, leisure
health and leisure services,
identification and referral of HLC staff.
appropriate patients,
sustained behaviour changes.
Who could be Skills and resources
involved?
PHC staff. Assessment protocols,
tailored advice, responsive to
client’s needs, knowledge of
health impact of physical
activity on health.
PHC staff, Motivational interviewing,
physiotherapists, good knowledge about
leisure professionals. physical activity and local
facilities.
Collaboration with leisure
service personnel, services trained staff,
community networks to
support post-referral; costly,
resource intensive.
48
Points to consider Further information
NSF CHD requirement to Coats et al. (1995).
‘identify all people at
significant risk of
cardiovascular disease … and
offer them appropriate advice
and treatment to reduce their
risks’ (Standard 4);
knowledge of local facilities
useful; knowledge of
messages about physical
activity may be low among
PHC staff; focus on active
living likely to be appropriate
for many people.
Availability and time of PHC Harland et al. (1999);
staff; most effective in those Hillsdon et al. (1999).
actively contemplating
increasing levels of physical
activity.
Effectiveness improved when: Riddoch et al. (1998).
staff are trained in behaviour
change strategies, and quality
supervision is achieved by
adequate patient/practitioner
ratios; opportunities for
targeting groups with clinical
conditions putting them at
risk.
 Transport
Intervention Evidence Outcome Who could be Skills and resources Points to consider Further information
involved?

Promotion of active Walking is a key intervention to Reduced danger to LAs, education Cross sectional financing Production of a local HEA (1998c, 1999b,c);
transport promote active lifestyles (Morris and pedestrians/cyclists by services; business; through HImPs possible; skills transport plan (LTP) is a DETR (1999, 2000). Free
This includes walking Hardman 1997). Environmental encouraging greater active nongovernmental – joint working, target setting requirement for LAs; copies of the latter (School
to school changes are important to facilitate transport; modal shift organisations (NGOs); and planning. promotion of cycling and travel strategies and plans. A
(eg Walking buses) its uptake. Areas that promote the towards these transport local road safety walking is encouraged, as is best practice guide for local
and walking/cycling needs of cyclists and pedestrians choices. officers; police; joint working with HAs, HImP authorities) are available, tel:
to work. have above average use of these LA 21. coordinators and others. 0870 1226236 (quoting:
modes (eg York transport policy: Schemes addressing danger
99ASCS 0240A).
House of Commons 1996). from vehicles (eg 20 mph WHO (1998); website:
zones) have shown dramatic www.who.dk/environment/
accident reduction outcomes pamphlets
(61% drop in pedestrian
casualties and a 67% drop in
child pedestrian and cyclists
casualties; Webster and
Mackie 1996).

Increasing physical activity

49
 50
Schools
Intervention Evidence Outcome Who could be Skills and resources Points to consider Further information
involved?

NHSS, ‘whole Positive outcomes have been
school’ approach reported following implementation
of physical activity programmes in
schools.
Suggests all pupils experience
two hours of physical activity
a week; encourages staff,
pupils, parents/carers and
other adults to become
involved in promoting
physical activity.
Staff, pupils, local In-service training of teachers. Physical activity participation
education authority may enhance academic
(LEA), healthy schools performance and encourage
network, leisure lifelong physical activity;
services, transport provides positive
department, NGOs environmental impact (eg
(eg Sustrans). reduced car travel); helps
fulfil National Curriculum
requirements for science and
physical education as well as
contributes to the national
framework for personal,
social and health education
(PSHE).
The NHSS identifies criteria
on physical activity to inform
good practice and the
implementation of a ‘whole
school’ approach (NHSS
2000).
NHSS support material on
physical activity for primary
and secondary schools;
NHSS physical activity, DH
and DfEE (2000). London:
HDA.
British Heart Foundation
(BHF) (2000).
http://www.wiredforhealth.
gov.uk/

Coronary heart disease: guidance for implementing the preventive aspects of the NSF
School travel plans Case studies have shown increases Improved environment for Staff, pupils, parents, May involve physical changes School travel plans are The STAG report is available
[including Safer in cycling, walking and bus use cycling and walking; changes local transport to road layout or school supported by Integrated at: http://www.local-
Routes to School (eg Walking buses) (DETR 2000a). in use of motorised travel to planners, NGOs environment; provision of Transport White Paper (DETR transport.detr.gov.uk/school
(SRTS)] school; reduced road danger. (Sustrans), school safe cycle parks. 1998); can be incorporated travel/index.htm#1998-
1999report
governors. into a local transport plan;
links to local environmental DETR School Travel Plan Best
concerns (Community Practice Guide:
Strategy, LA21). http://www.local-
transport.detr.gov.uk/schoolt
ravel/bpgla/index.htm
School Travel Strategies and
Plans Case Studies Report
can be accessed at:
http://www.local-
transport.detr.gov.uk/school
travel/bpgla/casestudies/index
.htm In this guide, details are
provided for urban and rural
schools.
Sustrans SRTS can be
accessed at:
http://www.sustrans.org.uk/
f_srs.htm
 Workplace interventions
Intervention Evidence
’Green‘ transport Schemes to promote walking to
plans (GTPs) work can be effective (Walk in to developed transport plans;
work out, Mutrie et al. 1999);
changes in travel modes when GTPs
have been implemented.
Stair use promotion Promotion of stair use was effective Stair use to become the
in Glasgow, using posters (Blamey
et al. 1995).
Increasing physical activity
Outcome
Percentage of employers with
changes in workplace travel.
norm; increased prominence
of stairs in building design
compared to lifts/escalators;
increased use of stairs.
Who could be Skills and resources Points to consider Further information
involved?
Staff, unions, local Provide safe parking for NSF CHD milestone: ‘By April Transport 2000 (1998).
transport planners, bicycles and showers. 2002 every local health
DETR advice for government
local public transport community will … have
departments: ‘green
providers. developed “green” transport
transport guide’
plans’ (milestone 3).
http://www.environment.
Promotion of GTPs need not detr.gov.uk/greening/fleet/
be confined to health service gcont.htm
sites. Workplace cycling
DETR (1999, 2000b). Free
promotion in particular
copies of the latter (School
requires environmental
travel strategies and plans. A
changes (in the workplace
best practice guide for local
and on the road).
authorities) are available, tel:
0870 1226236 (quoting:
99ASCS 0240A).
WHO (1998); website:
www.who.dk/environment/
pamphlets
Staff, unions, Cheap intervention;
employers, architects. objectives allied with
environmental concerns
(reduction in use of
electricity).
51
 52
Leisure activities
Intervention Evidence Outcome Who could be Skills and resources Points to consider Further information
involved?

Promoting use of Access and cost are important Identification of groups not Leisure services, Audit and evaluation skills, Cultural and language issues HEA (1997a,b, 1998b,
facilities determinants for many groups. participating in local professionals/ translation, knowledge of may be important. ‘Sporty’ 1999a).
These include leisure Involving ‘hard to reach’ groups is provision; increased community leaders local facilities; community connotations of leisure and The Confederation of Indian
and sports centres, likely to increase uptake and participation by ‘hard to involved with ’hard development skills; separate exercise centres can be off Organisations runs an
community centres, appropriateness of projects. reach’ groups; involvement in to reach‘ groups, changing areas; provision of putting. HLC funding is exercise project to increase
and local community design and running of PHC, community appropriate facilities. available. Projects need to be levels of walking in the
interventions for projects by representatives groups, HLCs. additional to statutory Asian community in
minority groups. from specific local groups, provision and involve Leicester (contact Sandeep
such as older people, black communities in development Rohit, tel: 0116 225 9299,
and minority ethnic groups, and management. for details).
young people, people with
disabilities.

Coronary heart disease: guidance for implementing the preventive aspects of the NSF
 Community strategies/LA 21/neighbourhood renewal
Intervention Evidence
Health walks and Uncertainty about who participates
other non-facility and impacts on other physically
based physical active behaviours; 11% of the
activity Sonning Common population; three
times more women than men
(Bartlett 1998); some evidence of a
shift from car journeys to
walking/cycling.
Integration of local Environment important for informal
plans physical activity (eg walking, active
play) but frequently not formally
evaluated.
Increasing physical activity
Outcome
Local health walks,
partnerships with
transport/environment
services; raised profile of
physical activity; addresses
some safety issues.
Development of effective
intersectoral partnerships;
provision of safe,
appropriately built design for
active, high quality lifestyles.
Who could be Skills and resources Points to consider
involved?
PHC staff, Maps and/or marked routes, Participants tend to be older
environment, trained leaders. and from higher socio-
planning and economic groups. Consider
transport community gardening
professionals, leisure schemes or gardening on
services, LA 21. prescription.
Communities, local Skills in developing LAs will have requirement to
planners, architects, partnerships across sectors. produce community
developers, business, strategies and many have
Regional LA21 plans. Neighbourhood
Development renewal consultation was
Agencies (RDAs), published recently. Supports
government offices, several sustainable
police. development aims. Personal
safety is frequently an
important concern restricting
use of open space and needs
to be addressed. Lottery
funding (£125m) is available
for ‘Green and sustainable
communities’.
53
Further information
Bartlett, H., 1998. Walking
the way to health. BHF/
Consumers Association (CA).
Sonning Common Health
Walk programme an
example (Bartlett 1998).
New Opportunities Fund
(NOF) website:
http://www.nof.org.uk/env/
temp.cfm?content=envi_1
Community strategy
consultation website:
http://www.local-
regions.detr.gov.uk/consult/
lgbill99/pcsdraft/index.htm
DETR (1999, 2000b). Free
copies of the latter (School
travel strategies and plans. A
best practice guide for local
authorities) are available, tel:
0870 1226236 (quoting:
99ASCS 0240A).
WHO (1998); website:
http://www.who.dk/environ
ment/pamphlets
 3.8 References
Bartlett, H., Ashley, A. and Howells, K., 1998. Evaluation of the
Sonning Common health walks scheme. Oxford: Brookes University.
BHF, 2000. Active school resource pack. London: BHF.
Blamey, A., Mutrie, N. and Aitchison, T., 1995. Health promotion
by encouraging use of stairs. British Medical Journal, 311, 289–290.
Bovell, V., 1992. The economic benefits of health promotion in the
workplace. London: HEA.
54
Brownell, K.D., Stunkard, A.J. and Albaum, J.M., 1980. Evaluation and
modification of exercise patterns in the natural environment. American
Journal of Psychiatry, 137, 1540–1545.
Bull, F.C. and Jamrozik, K., 1998. Advice on exercise from a family
physician can help sedentary patients to become active. American
Journal of Preventive Medicine, 152, 85–94.
Coats, A., McGee, H. and Stokes. H., eds., 1995. British Association of
Cardiac Rehabilitation guidelines for cardiac rehabilitation.
Oxford: Blackwell Science.
DETR, 1996. Vulnerable road users, Transport Committee, third report.
London: The Stationery Office.
DETR, 1998. A new deal for transport: better for everyone. London:
DETR.
DETR, 1999. School travel: strategies and plans: a best practice guide
for local authorities. London: DETR.
DETR, 2000a. School travel strategies and plans: case study reports.
London: DETR.
DETR, 2000b. Encouraging walking: advice to local authorities.
London: DETR.
DH, 1996. Strategy statement on physical activity. London: DH.
Dishman, R.K., Oldenburg, B., O’Neal, H. and Shephard R.J., 1998.
Worksite physical activity interventions. American Journal of Preventive
Medicine, 15, 344–361.
Dunn, A., Marcus, B., Kampert, J., Garcia, M., Kohl, H. and Blair, S.
1999. Comparison of lifestyle and structured interventions to promote
physical activity and cardiorespiratory fitness: a randomised trial. Journal
of the American Medical Association, 281, 327–34.
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Eakin, E.G., Glasgow, R.E. and Riley, K.M., 2000. Review of primary
care-based physical activity intervention effectiveness and implications
for practice and future research. Journal of Family Practice, 49 (2), 158–168.
Elder, P., 1996. Promoting physical activity in NHS workplaces. London:
NHS Executive and HEA.
Foster, C., 2000. Guidelines for health-enhancing physical activity
promotion programmes. Oxford: BHF Health Promotion Research Group.
Gordon, D., Shaw, M., Dorling, D. and Smith, G.D., eds., 1999.
Inequalities in health: the evidence presented to the independent inquiry
into inequalities in health, chaired by Sir Donald Acheson. Bristol: The
Policy Press.
Harland, J., White, M., Drinkwater, C., Chin, D., Farr, L. and Howel, D.,
1999. The Newcastle exercise project: a randomised controlled trial of
methods to promote physical activity in primary care. British Medical
Journal, 319, 828–832.
Harris, J., 1997. Physical education: a picture of health? The
implementation of health related exercise in the national curriculum in
secondary schools in England and Wales, doctoral dissertation.
Loughborough: Loughborough University.
HEA, 1995. Promoting physical activity: guidance for commissioners,
purchasers and providers. London: HEA.
HEA, 1997a. Physical activity ‘from our point of view’: qualitative
research among South Asian and black communities.
London: HEA.
HEA, 1997b. Guidelines: promoting physical activity with people
with disabilities. London: HEA
HEA, 1998a. Young and active? Young people and health enhancing
physical activity: evidence and implications. London: HEA.
HEA, 1998b. Guidelines: promoting physical activity with older people.
London: HEA.
HEA, 1998c. Transport and health: a briefing for health professionals
and local authorities. London: HEA
HEA, 1999a. Physical activity and inequality: a briefing paper.
London: HEA.
HEA, 1999b. Making THE links: integrating sustainable transport, health
and environment policies: a guide for local authorities and health
authorities. London: HEA.
HEA, 1999c. Active transport: a guide to the development of local
initiatives to promote cycling and walking. London: HEA.
HEA, 2000. Health and lifestyle survey. London: HEA.
Hillsdon, M., Thorogood, M. and Foster, C., 1999. A systematic review
of strategies to promote physical activity. In: D. MacAuley, ed. Benefits
and hazards of exercise, Vol. 1. London: British Medical Journal
Publications, 25–46.
House of Commons, 1996. Risk reduction for vulnerable road users,
Transport Committee, third report. London: The Stationery Office.
Joint Surveys Unit, 1999. Health survey for England, 1998.
London: The Stationery Office.
Killoran, A., Fentem, P. and Caspersen, C., eds., 1995. Moving on:
international perspectives on promoting physical activity. London: HEA.
Marcus, B.H., Owen, N., Forsyth, L.H., Cavill, N.A. and Fridinger, F.,
1998. Interventions to promote physical activity using mass media,
print media and information technology. American Journal of
Preventive Medicine, 15, 362–378.
Morris, J. N. and Hardman, A. E., 1997. Walking to health. Sports
Medicine, 23, 306–332.
Mulvihill, C., Rivers, K. and Aggleton, P., 2000. Views of young
people towards physical activity: determinants and barriers to
involvement. Health Education, 100, 190–199.
Mutrie, N., Blamey, A. and Whitelaw, A., 1999. A randomised
controlled trial of a cognitive behavioural intervention aimed at
increasing active commuting in a workplace setting. Edinburgh:
Chief Scientist’s Office of the Scottish Executive.
NHF, 1995. Physical activity: an agenda for action. London: NHF.
NHF, 1999. Looking to the future: making CHD an epidemic of the past.
London: The Stationery Office.
NHSS, 2000. National Healthy Schools Standard: physical activity. London: HDA.
Pieron, M., Cloes, M., Delfosse, C. and Ledent, M., 1996. An
investigation of the effects of daily physical education in kindergarten
and elementary schools. European Physical Education Review, 2, 116–132.
Powell, K.E. and Blair, S.N., 1994. The public health burdens of
sedentary living habits: theoretical but realistic estimates. Medicine and
Science in Sports and Exercise, 26, 851–856.
Riddoch, C., Puig-Ribera, A. and Cooper, A., 1998. Effectiveness of
physical activity promotion schemes in primary care: a review.
London: HEA.
Sallis, J.F., Hovell, M.F., Hofstetter, C.R., Elder, J.P., Hackley, M.,
Casperson, C.J. and Powell, K.E., 1990. Distance between homes and
exercise facilities related to frequency of exercise among San Diego
residents. Public Health Reports, 105, 179–185
Sallis, J.F., Nader, P.R., Broyules, S.L., Berry, C.C., Elder, J.P., McKenzie,
T.L. and Nelson, J.A., 1993. Correlates of physical activity at home in
Mexican-American and Anglo-American pre-school children. Health
55
Psychology, 12, 390–398.
Shephard, R.J., Jequier, J.-C., Lavallee, H., La Barre, R. and Rajic, M.,
1980. Habitual physical activity: effects of sex, milieu, season and
required activity. Journal of Sports Medicine, 20, 55–66.
Shephard, R.J., 1990. Costs and benefits of an exercising versus a
non-exercising society. In: C. Bouchard, R.J. Shephard, T. Stephens,
J.R. Sutton and B.D. McPherson, eds. Exercise, fitness and health.
Champaign, IL: Human Kinetics, 1990, 49–60.
Simons-Morton, D.G., Calfas, K.J., Oldenburg, B. and Burton, N., 1998.
Effects of interventions in health care settings on physical activity or
cardiorespiratory fitness. American Journal of Preventive Medicine,
15, 413–430.
Transport 2000, 1998. Healthy transport toolkit. London: Transport 2000.
US Department of Health and Human Services, 1996. Physical activity
and health: a report of the Surgeon General. Atlanta: US Department of
Health and Human Services, Centers for Disease Control and Prevention.
Vuori, P. and Oja, P., 1999. The health potential of physical
activity through transport by walking and cycling: a scientific review
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Copenhagen: WHO.
Walters, R., Cattan, C., Speller, V. and Stuckelberger, A., 1999. Proven
strategies to improve older people’s health: a Eurolink Age report for
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Webster, D.C. and Mackie, A.M., 1996. TRL report 215: review of traffic
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 WHO, 1996. Guideline series for healthy ageing: No. 1. The Heidelberg WHO, 1998. Walking and cycling in the city, LAs, health and
Guidelines for promoting physical activity among older persons. environment briefing pamphlet series no. 35. Copenhagen: WHO
Geneva: WHO. Regional Office for Europe.

56

Coronary heart disease: guidance for implementing the preventive aspects of the NSF
Chapter 4
Reducing overweight and obesity
4.1 Introduction
The prevalence of overweight and obesity has increased
in the United Kingdom in recent decades (see Box 4.1).
The incidence of CHD is highest in obese men and
women, especially in those under 50 years old. There is a
graded, increased risk of cardiovascular and total
mortality in people with a body mass index (BMI) over 25
kg/m2 (Nutrition and Physical Activity Task Forces 1995).
Approximately 75% of non-insulin dependent diabetic
patients are overweight (Jung 1997). In women, a weight
gain of about 10 kg can lead to a threefold increased risk
of developing diabetes (Jung 1997). Women with a BMI
over 35kg/m2 (compared with a BMI of 22 kg/m2) have a
93 times higher risk of diabetes and men have a 42-fold
increased risk (Jung,1997).
Obesity in childhood is on the increase and predicts
adolescent obesity and adult obesity (Parsons et al. 1999).
Adolescent obesity is associated with an increased risk of
adult mortality and morbidity (Epstein 1995). Children are
more likely to be obese if they have an obese parent.
Box 4.1 Prevalence of overweight and obesity
Overweight (BMI 25–29.9 kg/m2)
Obese (BMI >30kg/m2)
Overweight or obese aged 16–24 years
Overweight or obese aged 55–64 years
Over last 10 years, increase in obesity
25% of women in unskilled occupation are obese compared with 14% of women in professional jobs.
Source: Petersen et al. (1999)
57
There are critical periods in the life course where weight
gain is more likely. In women these are between the ages
of 15 and 19 years, after marriage, pregnancy, the
menopause and retirement. In men the categories are
between ages 35 and 40 years, after marriage and after
retirement.
Although the causes of obesity are varied, energy intake
exceeds energy expenditure for weight gain to occur.
Major weight gain tends not to occur over the short-term,
and an energy imbalance of only 1–2% per day can lead
to the trend towards overweight and obesity seen in the
UK over the years. Daily energy consumption has
decreased by approximately 20% since 1970, but
obesity has increased over this period of time (Prentice
and Jebb 1995). The number of hours spent watching
TV has increased since the 1960s and a more
automated lifestyle (domestic appliances, use of a
motor car) eliminates the amount of physical activity
incorporated into daily life. The population is more
sedentary with the result that the amount of energy
expended has reduced. The prevalence of obesity is
Men % Women %
45% 33%
17% 20%
27% 28%
74% 69%
Increase by 50% Increase by 42%
Reducing overweight and obesity
 increasing, despite decreasing energy intake (Barlow and • To support weight maintenance in young children and
Dietz 1998). weight loss in children and adults

Losing weight is in itself beneficial to reducing CHD risk • To encourage weight maintenance and prevent
but increased cardiorespiratory fitness should also be increases of weight in individuals who have
encouraged. Normal weight men with low cardiorespiratory successfully reduced their body weight.
fitness have a greater risk of cardiovascular disease
mortality than overweight or obese men who do not The US National Heart, Lung and Blood Institute
have low cardiorespiratory fitness (Wei et al. 1999). See (1998) guidelines have suggested that weight loss
box 4.2. programmes should aim initially to reduce body weight
by 10% from baseline, at a rate of one or two pounds
(approximately 0.5–1 kg) a week, for six months. The
58
Box 4.2 Health benefits of weight Scottish Intercollegiate Guidelines Network (SIGN 1996)
reduction recommend a period of 12 weeks of weight loss followed
by 12 weeks of weight stabilisation in order for energy
A 10 kg reduction in body weight can lead to the expenditure to readjust.
following health benefits:
US guidelines for the evaluation and treatment of
Mortality >20% fall in total mortality obesity in children (Barlow and Dietz 1998) recommend
>30% fall in diabetes related deaths that children with a BMI greater than or equal to the
>40% fall in obesity-related cancer 85th percentile with complications of obesity or with a
deaths BMI greater than or equal to the 95th percentile, with or
without complications, should undergo evaluation and
Hypertension Approximately 10 mmHg systolic possible treatment.
and diastolic blood pressure
Determinants of weight and weight gain are
Lipids 10% total cholesterol reduction multifactorial (Sherwood et al. 2000). The Pound of
15% low density lipoprotein Prevention study concluded that exercise, fat intake
cholesterol reduction and total energy intake all contribute to successful long-
30% triglycerides reduction term control of body weight (Sherwood et al. 2000).
7% increase in high density Energy consumption must be reduced. High calorie/low
lipoprotein cholesterol volume foods should be avoided and replaced with an
increase in complex carbohydrates (such as whole grain
Diabetes Fall of 50% in fasting glucose foods) and an increase in fruit and vegetables. A
reduced fat intake is also an important element of a
Source: Jung (1997) balanced healthy diet. See the sections on promoting
healthy eating (Chapter 2), and increasing physical
4.2 Objectives of weight management activity (Chapter 3) in this document for further details
on the effectiveness of interventions for those
Prevention, identification and treatment of obesity, and risk factors.
sustainability of weight loss after the intervention are all
important in a weight management strategy.
4.2.1 Definitions of ‘lifestyle’ weight
Specifically: management interventions

• To prevent an increase in prevalence of obesity in Behavioural therapy

children and adults Cognitive behaviour modification and behavioural
skills training to modify eating and physical activity
• To promote a reduction of obesity in children and habits to prevent weight regain are often used with
adults dietary therapy.

Coronary heart disease: guidance for implementing the preventive aspects of the NSF
Family therapy
Behavioural therapy sessions involve all members of the
family rather than individual counselling of the affected
member (to be used in the prevention of obesity in
children specifically).
Dietary therapy
Two main types of dietary therapy are a low calorie diet
(800–1500 kcal daily), and a very low calorie diet (less
than 800 kcal of energy daily), which usually consists of a
protein-enriched liquid.
Exercise therapy
The primary goal is to move sedentary people into an
active category (even if it is moderate levels of intensity)
and to move moderate level individuals into more
vigorous levels. Accumulation of daily physical activity
should be the key if 30 minutes at least five times a week
seems unobtainable. (See Chapter 3 on Increasing
physical activity for further information.)
4.3 Features of effective interventions
A number of themes are emerging on what strategies are
the most effective in preventing obesity. These are: to
reduce sedentary behaviour in obese children; to use diet,
physical activity and behavioural strategies for adults, in
combination where possible; and to use maintenance
strategies such as continued therapist contact. A gradual,
incremental stepwise approach seems to have the most
beneficial long-term effect. Evidence for the effectiveness
of obesity prevention and treatment is inconclusive
(Harvey et al. 2000).
Where possible, the intended target group or geographic
area should be consulted to establish what strategies are
most appropriate and it is important to monitor the impact.
Accurate recording of baseline data at the local level and
the establishment of clear objectives can aid this. It is
impossible to measure the impact of an intervention where
the aims and objectives are too vague and multi-faceted.
The overwhelming evidence is that overweight and obese
people should be encouraged to integrate changes to
their lifestyle over a longer period of time to maintain the
benefit of initial weight loss (Tremblay et al. 1999). A
combination of decreased food intake and increased
physical activity is more likely to lead to sustained weight
loss (Sherwood et al. 2000).
• A combination of diet and physical activity (in
conjunction with behavioural counselling) is probably
more effective in sustaining weight loss than diet or
exercise alone in adults. The type of activity does not
seem important.
• Family therapy is more effective than conventional
diet and exercise in preventing weight gain in
children (but not necessarily in treatment of obesity).
Family therapy is essential in treatment with younger
children.
59
• Small, sustainable modifications in diet, exercise and
communication are more effective than restrictive
strategies. With small steps, the family/individual can
accommodate the required lifestyle modifications.
• Maintenance of weight loss interventions (self-help
peer groups, relapse prevention strategies and
continued therapist contact by phone and mail) may
require longer-term contact to promote sustainability
of weight loss.
Further information is available from Glenny et al. (1997),
NHS Centre for Reviews and Dissemination (1997) and
Edmunds and Waters (2000). More detail can be found in
Table 4.7 at the end of this chapter.
Modest, regular bouts of physical activity can lead to
benefits. The type of exercise is not important and short
bouts of walking can cumulatively be of much benefit.
Walking a mile a day for a year is equivalent in energy to
that stored in 3 kg of adipose tissue (DH 1994). Habitual
physical activity can also help keep weight off after
weight loss has been achieved, and can reduce the
threat of the post-weight-loss seesaw effect (DH 1994).
Generally, it is agreed that the cumulative effect of
physical activity can benefit weight loss (DH 1994)
although this view has been questioned by some
(Sherwood et al. 2000).
Very low calorie diets are not advisable in children
(Epstein 1995) and they are not effective. In terms of
increasing children’s physical activity, a more active
daily lifestyle should be encouraged rather than
structured aerobic exercise schedules (Epstein 1995).
It appears to be more effective to promote less
sedentary lifestyles (with less opportunity to eat
excessively while watching TV, for example) than
simply attempt to increase activity.
Reducing overweight and obesity
 Potential barriers to effective obesity management may
include lack of access to appropriate support services,
lack of motivation by professionals due to negative
perceptions of overweight and obese people or the
efficacy of treatments (Harvey et al. 2000). There is still
very little information about how clinical practice in a
primary care setting or the organisation of care in this
area might be improved (Harvey et al. 2000). A
workbook has been published by the former HEA
to guide health professionals in their weight
management strategies (Cowburn and Foster 1998).
It provides self-learning advice in counselling
60
approaches.
4.3.1 Skills
A local assessment of the provision of weight
management services will be necessary. The PCGs
will be carrying out a mapping/profiling exercise. If
obesity management services are not considered, an
equity profile (see p78) should be part of the local
assessment. Groups at greater risk of obesity and
related CHD illness should be identified and targeted.
A local mapping exercise can help achieve this goal
(population structure by age, ethnicity, employment
and housing status as well as identification of food
suppliers, access to parks/leisure facilities and
specialist centres).
There will be a need for training of the professionals
who will be delivering the services (primary care,
specialist exercise and nutrition staff). This will
involve providing information about what options and
services are available as well as equipping them with
the skills to identify, treat and manage ‘at risk’
overweight or obese people.
Coronary heart disease: guidance for implementing the preventive aspects of the NSF
4.4 Reducing inequity
There are socioeconomic and ethnic differences in the
prevalence of obesity. There is a higher level of obesity in
the more deprived groups (Gordon et al. 1999). This
should be considered when planning obesity prevention
and treatment interventions. Studies have shown that
weight loss and prevention of weight regain are less
effective in lower income groups (Jeffery and French
1997; Hardeman et al. 2000).
Epidemiological evidence suggests that there are a
number of groups who are most at risk of gaining
weight, and subsequently of suffering from co-morbidity
associated with obesity. These groups are:
• South Asians
• African-Caribbeans
• Those living in socially deprived areas
• Smokers planning to stop (need to liaise with
smoking cessation planners)
• People with disabilities.
Identification of individuals or groups who are at
risk of associated obesity co-morbidities must be an
essential element of a strategy to reduce the increased
prevalence of overweight or obesity. Consideration must
be given to disabled people who may suffer a range of
additional barriers to managing their weight and
participating in weight loss programmes. There is no
evidence to suggest effective interventions in this area,
but training in identifying and prescribing appropriate
strategies must be considered.
4.5 Further information

There is an obesity toolkit available from the Faculty of Public Health Tel: 020 7935 0243;
Medicine, Tackling obesity: a toolbox for local partnership action. A number email: enquiries@fphm.org.uk
of interventions are listed by setting (community, home, school and
workplace). It is divided into prevention, and weight management in the
treatment of obesity (Davis et al. 2000). A copy was sent out to all directors
of public health and all health promotion units.

A comprehensive overview of obesity will shortly be available on the web as http://hcna.radcliffe-online.com

part of the Health Care Needs Assessment Series. It covers the epidemiological
data, services available and the effectiveness of interventions of the
61
prevention and treatment of obesity in adults and children.

A directory of projects of weight management compiled by the DH is available

in each regional office. Three main themes emerged: that weight loss is
rarely maintained, that multicomponent programmes are more successful
and that regular follow up is important (Hughes and Martin 1999) .

The US National Institute of Health’s Clinical guidelines on the identification, http://www.nhlbi.nih.gov/guideli

evaluation, and treatment of overweight and obesity in adults (National nes/obesity/ob_gdlns.htm
Heart, Lung, and Blood Institute 1998) is available on the web. Useful http://www.nhlbi.nih.gov/guideli
information for healthcare professionals working in obesity treatment and nes/obesity/ob_home.htm
prevention can be located on their website.

The appendices in the Clinical guidelines on the identification, evaluation, http://www.nhlbi.nih.gov/guideli

and treatment of overweight and obesity in adults list a number of useful nes/obesity/practgde.htm
strategies to help treat obesity. Examples of weight goal records, food
substitution ideas and food preparation leaflets, guide to behavioural
change strategies and exercise programmes for gradual build up of
activity/fitness are included. Consideration should be given to making this
available to health professionals.

An initiative Shape up America, designed for doctors, nurses, dietitians and http://www.shapeup.org/professi
other health professionals, has produced guidance on treating obesity. It onal/index.html
includes ideas for weight gain prevention and weight loss. The appendices
may be a useful practical toolkit for suggested approaches and include
suggestions for walking (including safety considerations and food diaries).

The US CDC has a report entitled Physical activity and health, which covers http://www.cdc.gov/nccdphp/sgr
the promotion of physical activity in our daily lives (US Department of Health /summary.htm
and Human Services 1996).

CDC has published a set of guidelines on the promotion of physical activity Physical activity:
in children and adolescents, with guidance on the benefits and http://www.cdc.gov/nccdphp/das
consequences of physical activity. There is a separate set of guidelines for h/physact.htm
the promotion of healthy eating in schools. Nutrition:
http://www.cdc.gov/nccdphp/das
h/nutraag.htm

Reducing overweight and obesity

 Further information (continued)

A community approach to behavioural change in the promotion of physical Community physical activity
activity, published by the CDC, is aimed at all those interested in a community- approach:
wide strategy (central and local government, transport, health and community http://www.cdc.gov/nccdphp/dn
planners, exercise specialists and health professionals, community groups, pa/pahand.htm
businesses, schools, colleges and universities).

The International Obesity Task Force (IOTF) has a web site with many links http://www.iotf.org/
to obesity related sites.

WHO report Obesity: preventing and managing the global epidemic (1999). The executive summary can be
62
viewed in the publications
section at http://www.iotf.org/

There are two Cochrane reviews in progress on the prevention and Campbell et al. (2000a,b).
treatment of obesity in childhood.

Coronary heart disease: guidance for implementing the preventive aspects of the NSF
 Table 4.6 Suggested activities to support local action
Community
Intervention Evidence Outcome Who could be Skills and resources Points to consider Further information
involved?

Individual weight Individual strategies may be most Increase in accessible and HAs, education Awareness of the Mass media has limited
management effective alongside wider safe settings for the sector, local complexities in the aetiology short-term impact on physical
integrated with environmental interventions (Jeffery promotion of physical activity; environment of obesity and an activity participation but may
population 1995; Nestle and Jacobson 2000). greater access to affordable planners. understanding of the have an impact in
interventions and healthy food options. multifactorial approach to encouraging a climate of
reducing obesity. change (Cavill1998).

Small but steady Weight loss about 1–2 lb/week for Weight reduction by about Primary care team, Skill in encouraging patients There is cumulative benefit in
change in diet and a period of six months. In the 10% of baseline weight; dietitians, who may become frequent, but short spells of
activity longer term, weight loss can be prevention of relapse to behavioural disillusioned with slow loss. physical activity.
maintained. Women who did some previous weight level. therapists.
form of moderate exercise on a
regular basis gained weight more
slowly than those who were less
active (Sherwood et al. 2000).

Combine diet, A combination of interventions is Improved links between Nutrition and Regular meetings between Frequent ongoing contact is
physical activity most effective (Clinical Evidence leisure facilities, caterers, LAs physical activity different sectors will be suggested to help maintain
and behavioural 2000). Evidence suggests that and HAs. experts. required. Identify lead person the benefits.
therapy effects are short term. or organisation.

Reducing overweight and obesity

63
 64
Schools
Intervention Evidence Outcome Who could be Skills and resources Points to consider Further information
involved?

Secondary About a 10% mean reduction in Prevent increases in weight in School nurses, Access to gyms and playing Need longer-term data to see More information on young
prevention in overweight was reported (Story already overweight children. teachers, counsellors, fields. Children can eat up to whether weight loss can be people’s attitudes to diet,
schools 1999). Younger (pre-adolescent) local healthy schools two meals per day in schools; sustained. Potential harmful health and exercise can be
Use ‘whole school’ interventions were more successful. programme. families are not to incur the effects (stigmatisation, eating found at:
approach (Goran et This result was based on a short- cost (Goran et al. 1999). disorders, labelling) may http://www.ex.ac.uk/~dregis/
al. 1999; Story term follow up (mostly less than six result. Potential framework Pubs/yp98.html
1999). months). for PSHE. A summary of the side
effects of treatment in
children can be found in
(Epstein et al. 1998).

Primary prevention Approach shown to be effective Prevent becoming overweight LAs, food sector, Provide a culturally A systematic review on
in schools (Story 1999). or obese. leisure facilities appropriate intervention; health promotion in schools
Use ‘whole school’ managers, teachers, include classroom health is available (Lister-Sharp
approach. school based education classes; potential et al. 1999). It can also be
counsellors, youth framework for PSHE. accessed on the Web:
workers/youth clubs, http://hta.nhsweb.nhs.uk
parents, local healthy
schools programme.

Coronary heart disease: guidance for implementing the preventive aspects of the NSF
Supportive and Qualitative interviews of US children Build self-confidence and self Teachers, school Will require trained youth Be aware of adverse
respectful approach (Story 1999); increased adherence if esteem. based counsellors, counsellors/dietitians. psychological impact.
approached in a sensitive manner. parents, local healthy
schools programme.
 Children
Intervention Evidence Outcome Who could be Skills and resources Points to consider Further information
involved?

The ‘Stoplight Diet’ Younger children achieved better Weight loss; modification of School based health Leaflets on diets. Ensure the child has Epstein, L.H. and Squires,
for treatment of weight loss, and maintenance of eating and exercise carers (dietitians and adequate nutrition for S.S., 1998. The Stoplight
pre-adolescent loss (Epstein et al. 1998). behaviours. school nurses), PE growth. Monitor Diet for children. Boston,
children teachers, family. psychological impact on MA: Little, Brown and Co.
children.
It has ‘red’ foods for
best avoided, ‘amber’
for foods that can be
eaten in moderation
and ‘green’ for plentiful.
Regular daily Integrating regular activity into daily Regular physical activity in School, physical Education for parents and Safety issues with local urban BHF leaflets for parents: Get
activity in children; life is more effective than structured daily life becomes the norm. education (PE) children will be required. planners and recreational kids on the go:
combine diet and aerobic exercise. The effect was teachers, exercise division to ensure safe play https://www.bhf.org.uk/publ
exercise maintained at a two year follow up specialists, family, areas. ications/uploaded_pdfs/activ
(Epstein et al. 1998). local parks and echildren.pdf
recreation areas;
local healthy schools
programme.

Encourage less Trial of reducing TV watching
sedentary leisure resulted in decreased adiposity
time (Robinson 1999). Trial of a reward
system for decreasing sedentary
behaviour showed a reduction in
percentage overweight (Epstein et
al. 1995).
Increased activity and less
‘snacking’ time.
Parents, teachers, Teachers to explain how to Long-term outcome not yet
youth workers, local be selective in choice of TV known.
healthy schools watching; leaflets to parents
programme. about recording child’s
activities; TV monitoring
boxes could be considered.

Family group Prevented progression to severe
sessions with obesity in adolescence in 10- and
dietary advice, and 11-year-olds (Flodmark et al. 1993), members.
regular visits to GP but no difference at one-year follow
up.
A trial with a 10-year follow up
showed that involvement of parent
and child was most effective
(Epstein et al. 1998). Inclusion of
mastery element (taking control of
own behaviours) and use of
rewards were found to be more
effective in reducing weight in
children.
Encourage changes in
habitual lifestyle by all family
Counselling services, One study shows that if the
dietitians, PCGs, child and parent are
school nurses. counselled separately, better
weight loss is achieved. Both
are involved in the process,
but are seen apart.
Self-monitoring and goal
setting praise are suggested.
Gradual behavioural therapy
over a longer period of time
had a better long-term effect
than intense sessions (Epstein
et al. 1998).

Reducing overweight and obesity

65
 66
Primary care level
Intervention Evidence Outcome Who could be Skills and resources Points to consider Further information
involved?

Individualised Group sessions appeared more Appropriately tailored Primary care teams, Link with local community Assessing readiness to A framework has been
advice and risk effective (Hughes and Martin 1999). interventions for particular GPs, community groups working with ethnic change is important when developed that runs through
assessment Sustained weight loss in primary groups lead to better dietitians, community minorities; language skills, recommending a weight the stages of promoting
Provide regular care settings is uncommon (Hughes compliance and effective (ethnic group) link recognition of cultural and reduction programme (Dietz exercise for weight
follow up contact. and Martin 1999). outcomes; can be used for workers, health religious requirements; see 1999). Identify barriers management from assessing
higher risk groups such as visitors. Improving diet and nutrition (access to affordable, readiness to change to the
ethnic minority or disabled (Chapter 2) for interventions. nutritious food, child care process of change and
groups. arrangements, opening hours interventions (Biddle and Fox
of facilities). 1998).

Exercise as integral Moderate (short-term) effects of Increased activity as part of PCGs, practice Training for primary care A motivated coordinator and
part of primary care based counselling and everyday living; better nurses, leisure facility teams about the role of supportive team may improve
intervention interventions tailored to particular balance of energy intake and personnel; some physical activity; see outcomes.
Encourage friends needs with written materials had a expenditure. health visitors have Increasing physical activity Patients should be given
and family to stronger effect (Eakin et al. 2000). this role. (Chapter 3). choice of activity (including
accompany home based) (Hillsdon 1998).
participant (maybe a Exercise referral schemes can
buddy scheme where identify suitable candidates

Coronary heart disease: guidance for implementing the preventive aspects of the NSF
participants can link and establish the
up with another responsibilities within a
member of the programme between the
group). parties (Hughes and Martin
1999), but recruitment and
adherence may be fairly low
and not reach those with
most to gain (Hillsdon 1998)

Energy-restricted Randomised controlled trial (RCT) Dietitians, practice Training for health See Improving diet and
diet (1,000–2,000 showed greater weight loss in the nurses. professionals (see Improving nutrition (Chapter 2).
kcal/day) rather energy restricted diet, at 18 month diet and nutrition,
than fat restricted follow up (Clinical Evidence 2000). Chapter 2).
diet (22–26 g/day)

Specialist weight A weekly clinic (with a health Maintenance of weight loss PCG, health visitor, Room in the practice; training
loss clinic within a visitor) achieved weight loss even at through regular follow up. community dietitian. for a health visitor (which
GP practice a one-year follow up; 33% could be shared between
achieved a 10% weight reduction practices in the area).
and 6% maintained this loss at one
year (Sleath 1999).
 Maintenance of weight loss
Intervention Evidence Outcome Who could be Skills and resources Points to consider Further information
involved?

Frequent contact Systematic review showed that any Reduce weight gain. GP, practice nurse or Resources to follow up over Self-help peer groups, self-
over long term type of frequent contact led to less weight specialist. longer time period required management techniques and
weight gain (Clinical Evidence (staff/phone calls/letter); family or spousal involvement
2000). Interventions should last for frequent or long-term follow may all be of some help
least six months and incorporate up may require extra practice (Clinical Evidence 2000).
continuing contact to prevent resources.
weight regain (National Heart, Lung
and Blood Institute 1998). Face to
face contact (house visits) were
shown to be effective in reducing
weight regain in one RCT (more so
than phone or letter contact)
(Clinical Evidence 2000).

Provision of home Improved weight loss achieved with Cumulative daily activity can Physical activity Supervised sessions require Approach can encourage
exercise equipment provision of exercise equipment for be of benefit in a weight advisor, counselling extra resources. Liaison with sedentary people to become
Also supervised the home combined with advice on control programme and can services. leisure facilities or local more active. Smaller bouts of
exercise sessions with continuous exercise (versus improve adherence (Jacicic suppliers may make it easier activity may appear more
simple behavioural intermittent) (Clinical Evidence et al. 1995). to provide home based attainable. Aim to
therapy (SBT) at one 2000). Supervised exercise sessions equipment (consider a accumulate about 30 minutes
year compared with (three times a week for 12 weeks) renting scheme?). of activity per day (National
SBT and simple plus SBT was more effective in Heart, Lung and Blood
exercise (Clinical weight loss at one year, but another Institute 1998).
Evidence 2000). found that supervised walks or a
personal trainer resulted in less
weight loss than SBT alone (Clinical
Evidence 2000).

Commercial weight Evidence that better weight loss is Improve psychological well- Motivated class leader may Evaluation tools for
loss programmes achieved in group settings (Davis being. Make the process of be important. commercial weight loss
et al. 2000). losing weight more programmes are needed
enjoyable. (Conley 1998).

Reducing overweight and obesity

67
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Campbell, K., Summerbell, C., O'Meara, S. and Waters, E., 2000b.
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Reducing overweight and obesity
Chapter 5
Developing a local strategy
5.1 Establishing a local CHD
implementation team
As outlined in the NSF CHD, every HA should
make contact with all local NHS organisations,
LAs and other partner agencies to establish an
implementation team. This will work on behalf of the
local health community with members representing
relevant stakeholders, including users and carers (DH
2000a, Chapter 3.7, p63). Partnership working,
both for strategy development and implementation
will be crucial to success.
5.1.1 Milestones and goals
Organisational and health promotion milestones
and goals are set out on pp57–60 of the NSF CHD main
report (DH 2000a). These include responsibilities
for NHS organisations and LAs as employers (smoking
policy, ‘green transport’ policies, and employee-friendly
policies) and responsibilities for implementing the
preventive aspects of the NSF. In particular, by
April 2001 all NHS bodies, working closely with LAs,
will have agreed and be contributing to the delivery
of local programmes of effective policies (DH 2000a, p57;
DH 2000b, p18) on:
• Reducing smoking
• Promoting healthy eating
• Increasing physical activity
• Reducing overweight and obesity.
73
5.2 Developing local delivery plans
The local implementation team is responsible for
producing a local delivery plan for implementing the NSF
CHD. Local delivery plans should be in place and agreed
by all the relevant players by October 2000 (DH 2000a,
Chapter 3.38, p70).
The key elements of NSF CHD delivery are:
• Identifying service developments – what needs to
be done differently?
• Identifying organisational and systems
developments – how will the service developments
be delivered?
• Professional and personal development – what skills
are needed and who needs them? (DH 2000a, pp
64–65).
The NSF CHD should be delivered within the
context of the overall HImP and the National Priorities
Guidance. The plan should be consistent with the
development plan for clinical governance and be
reflected within the service and financial frameworks.
The plans should also link and be consistent with primary
care investment plans (DH 2000c), and the emerging LA
community strategies. Teams should identify other local
strategies and plans to which the delivery plan should be
linked and map the contribution that they currently make
to CHD prevention.
Developing a local strategy
 It will be important to consider local plans in the context 5.3 Building effective partnerships
of regional health strategies. Box 5.1 identifies local
initiatives which are relevant to CHD prevention. Local implementation of the NSF CHD is intended
to be partnership based. There are three broad
objectives for local partnerships to
Box 5.1 Local plans and initiatives prevent CHD:
linking to CHD prevention
• improving the coordination and integration of
All areas should include: policies (eg integration of the CHD prevention
• HlmP strategy with relevant health and other
• Primary care investment plans policies such as health at work and healthy
• Community strategy schools policies; environmental, regeneration
74
• LA 21/sustainable development/environment and leisure policies)
strategy
• LTP. • developing innovative and high quality services
by bringing together the contributions and
Those areas covered by the following (eg): expertise of all partners
• HAZ
• Healthy cities/health for all • increasing and maximising the financial and
• HLCs other resources available for local services by
• School health plans developing joint ventures between statutory
• Sports and leisure strategies organisations, the voluntary sector and the
• Anti-poverty strategies private sector (such as healthy living
• Existing health topic strategies centre approaches, health at work
• Secondary prevention strategies (including initiatives).
coronary rehabilitation services, open access
chest pain clinics) The development of effective policies and
• Regeneration initiatives and plans (eg New Deal interventions to prevent CHD requires the
for Communities). involvement of the NHS, LAs, voluntary
organisations, businesses and the local community
in the strategic reshaping of service provision. In
In order to develop their local implementation plans, many areas this will mean building on alliances
teams need to develop partnerships, involve their local and partnerships, which already exist. Existing local
communities and assess local needs. The planning process partnerships should be reviewed. They may be able
follows a number of key stages as outlined in Figure 1. to take on this responsibility, or new partnerships
may need to be formed to deliver the NSF
locally.

5.3.1 New freedoms to promote and

support joint working

New powers to enable HAs and LAs to work

Figure 1. Suggested framework for local plans.
together more effectively came into force on
1 April 2000 (DH 2000d). Pooled budgets,
integrated provision and lead commissioning
are operational flexibilities, which enable
services to be developed according to need,
irrespective of the boundaries between
organisations.

Coronary heart disease: guidance for implementing the preventive aspects of the NSF
5.3.2 Making the partnership effective
Box 5.2 Who could be involved in the
Effective partnership working should include (Geddes CHD prevention partnership?
1998; Plamping et al. 2000; Watson et al. 2000):
From the NHS:
• Leadership and vision – the management and • Community Health NHS Trusts
development of a shared realistic vision for the • Community nurses, health visitors and midwives
partnership’s work through the creation of common • Hospitals and staff
goals • GPs (Local Medical Committee and/or GP Forum)
• HAs
• Involvement and commitment – the commitment of • Health promotion
local players and particularly the involvement of • Nutrition and dietetic services
75
communities as equal partners. Senior level • Occupational health
commitment and involvement from NHS, LAs and • Physiotherapy
other partner organisations • PCGs/PCTs
• Public health
• Resources – the contribution and shared utilisation of • Smoking cessation services
information, financial, human and technical resources. • Ambulance trusts
LAs and HAs should report the proportion of their • NHS Direct
budgets to be given to health promotion, including • Community pharmacists
heart health promotion (DH 2000b, p15). From LAs:
• Community development
Box 5.2 provides examples of a range of people and • Education
organisations who could be involved in different aspects • Environmental health
of CHD prevention. • Highways
• Housing
• Leisure
5.4 Involving local communities • LA 21
• Regeneration and planning
A community development approach enables • Social care services
communities to make their own decisions about how to • Schools
achieve better health for themselves, their families and • Transport, roads and highways
the wider community. Professionals are required to act as • Youth and community services
facilitators, rather than imposing an agenda on the From the voluntary sector:
community. Community development projects do not • Local voluntary organisations with a remit for CHD
usually have a focus on disease prevention; however, prevention or which address relevant CHD risk factors
many address at least one of the lifestyle risk factors for • Local voluntary organisations who have links with
CHD and/or its broader social determinants. local target groups (eg groups who work with
older people, black and minority ethnic groups)
The NSF requires that there is at least one community From the local community:
development project with a focus on CHD in one of the • Schools and colleges
most deprived communities in every LA area. Health • Groups which work with relevant local target groups
visitors will be a vital resource in securing successful From private sector:
community development (DH 2000a, p19). HLCs, which • Food retailers and local businesses
are funded through the NOF, can provide a focus for • Medium to large size local employers (for health
community development initiatives at work policies)
(http://www.nof.org.uk). • Private sector leisure providers
• Restaurateurs, caterers and other local food outlets
Consulting and involving communities is a key part of • Private transport companies
government policy which service providers are required

Developing a local strategy

 to implement and is a key part of many local initiatives
(eg NHSE 1998, 1999; DETR 2000). Involving local
communities in developing strategies and action plans
improves the quality and effectiveness of programmes
(Nichols 1999).
Local communities should be actively involved in CHD
partnerships at every stage to include strategy development,
action planning, delivery and review and evaluation.
Local people are able to provide insights into the nature
of health and social issues and the appropriateness and
76
acceptability of policies and strategies (Rogers et al.
1997). Actively involving local communities in needs
assessment research processes, ensuring their
representation within planning and management
arrangements and providing training and resources for
volunteers and local networks are key factors for success
in initiatives to improve health and well being (Gillies 1998).
5.4.1 Consulting local communities
The Audit Commission (1999) has identified principles of
good practice in this area. Consultation should:
• Be related to a decision that the organisations intend
to take
• Have clear objectives
• Be competently carried out
• Be inclusive
• Be used in practice.
Effective consultation is not easy to achieve. It needs to
be carefully planned, effectively carried out and
thoughtfully used. Communities contain many different
Box 5.3 Level of involvement
Less involvement
One off polls Regular surveys of views
(eg referendum, public (eg panel survey)
opinion survey)
Source: Audit Commission (1999)
Coronary heart disease: guidance for implementing the preventive aspects of the NSF
interests and interest groups and it is important to try to
establish whom a representative is representing, and to
whom in the community the representative is accountable.
Findings from community consultations have to be
balanced with other factors such as other stakeholder
priorities, available resources and statutory requirements.
There are many different consultation methods, each
with their own advantages and disadvantages. These
include: meetings, surveys, focus groups, user groups,
citizens’ juries, citizens’ panels, neighbourhood fora,
youth councils, community visioning/mapping exercises,
and participatory appraisal and participatory action
research. A broad spectrum of approaches should be
used and selection of those which are relevant to the
purpose of the consultation, and suitable for those who
are being consulted, is recommended.
Public participation and consultation occurs at different
levels, and the degree of control local people experience
relates to the level of involvement (see Box 5.3).
When planning community consultation it is
important to:
• Identify information from consultation that has already
taken place through existing initiatives such as LA 21
• Work with other partners to agree a joint approach
to consultation and to agree the most appropriate
methods (this will avoid consultation overload, and
make the best use of available resources)
• Present the exercise realistically to avoid raising
unrealistic expectations
• Plan feedback to the participants.
High involvement
One off deliberative Ongoing consultation
exercises groups
(eg citizens’ jury, (eg neighbourhood
community visioning forum)
events)
Once the consultation is completed consider who else
would find the results useful in planning and delivering
their services, and disseminate the findings accordingly.
5.4.2 Developing capacity
To support effective community development and
involvement, consideration needs to be given to capacity
building on three levels (Russell and Killoran 1999):
• Individual development
• Capacity building within local groups (eg through
training, support workers, skills development,
administrative resources)
• Developing the local community infrastructure.
Capacity building enables individuals in communities
to develop knowledge, skills and self-efficacy that may
help them to continue to be involved with prevention
initiatives and to sustain programmes and activities
within the community.
5.4.3 Engaging ‘excluded’ groups
As a first step it is vital that the implementation team
has a clear picture of those who take part. A
participation profile may include:
• Demographic analysis (age, ethnicity, gender, disability)
• Geographical breakdown (town, ward, enumeration
district)
• Economic background (employment status, occupation).
Comparing this with the profile of the whole population
will enable the identification of those who are not yet
involved, and allow efforts to be targeted to include
them. A first step is to ascertain whether there are any
specific reasons preventing participation, and to address
them. Reasons may include:
• Language barriers
• Time
• Lack of awareness of the consultation or project
• A feeling that ‘it isn’t for us’.
Implementation teams need to know the composition
of their communities and have targets and strategies to
ensure they are included in the process. Capacity
building will be particularly important with groups
who are less likely to be involved. A traditionally
‘excluded’ group may be an appropriate focus for
a community development project.
5.5 Health needs assessment
Assessing local need, and profiling the local
77
community is the first step towards developing a
local delivery plan. Different areas will be at different
stages. As part of the HImP and Director of Public
Health’s Annual Report, many places will have well
developed local needs assessment for CHD and
community profiles will already have been undertaken.
In other places more work will need to be done. Local
Public Health and Health Promotion experts provide
an important resource for local implementation
groups.
This guidance concentrates on prevention activities
only, but consideration should be given to needs
assessment as part of planning the delivery of
other parts of the NSF CHD. Needs assessment is
intended to inform local plans: to look at unmet
need for services and to provide information that
will allow services to be tailored to local populations.
Successful local strategies to address CHD risk will
take a broad approach to needs assessment,
involving a wide range of partners and ensuring
community involvement.
5.6 Community profiling
A community profile describes the local area in
terms of local populations (eg ethnicity, age,
gender) and characteristics of the local
environment (eg employers and employment;
parks and open spaces; housing and estates)
of importance in planning local CHD prevention
strategies.
Assessing health needs of the local population involves:
• Defining the different ’segments‘ or target groups
within their local population
Developing a local strategy
 • Describing these different groups according to their
needs and preferences using a variety of data.
Target groups can be distinguished in two ways:
• Geographical groups bound together by locality
• Social groups bound together by some other attribute,
such as age, gender, ethnic origin, health status or
socio-economic status (and combinations of these).
Consultation with local communities will identify
78
factors that local people consider are important,
which should be included in the profile.
A well developed community profile would include
local data (qualitative and quantitative) on the burden
of CHD disease, and on risk factors (smoking
prevalence, physical activity, diet, and weight);
perceptions of health, service and facility provision
and use, socio-economic information. Examples of
data items to include are presented on p82
on local indicators. Where local data do not exist, risk
profiles may be derived from national data sets (by
applying risk profiles based on the total population to a
locality). Consideration should be given to collecting
missing local data, relevant to the local action plan.
Sources of local data can be found in Box 5.4. As part of
the development plan, identify gaps in current data which
need to be filled to enable better targeting and
monitoring of local implementation.
Box 5.4 Local sources of data
• The annual reports of the Director of Public
Health
• HlmPs and other local plans and profiles
(eg poverty profile)
• LA data sets
• Socio-economic data derived from the census
• Neighbourhood statistics
• Regional data sets (eg health and lifestyle
surveys)
• Public health observatories
• Local surveys (eg by LAs, HAs and local colleges
or universities)
Coronary heart disease: guidance for implementing the preventive aspects of the NSF
5.7 Equity profiling
The incidence of CHD is not uniformly distributed
among the population. CHD risk is stratified by sex,
age, social class, ethnic origin, and region of residence.
The NSF highlights the importance of developing a
local equity profile, with equity targets. Directors of
public health are charged with producing the profile.
The equity profile is intended to identify inequalities in
heart health and in access to preventive and treatment
services. It will concentrate on the needs of individuals
and groups, especially those for whom special
consideration is warranted (poorer people, children,
pregnant women, women of childbearing age,
minority ethnic groups, other vulnerable groups). The
equity profile should identify the inequalities which
exist locally in terms of CHD mortality and morbidity.
The equity targets are local targets to reduce these
inequalities. As part of the prevention strategy equity
profiling should cover smoking, nutrition, physical
activity and weight management, with associated
targets.
5.7.1 Audit of current provision
Local needs assessment requires a comprehensive
audit of activity relevant to the four areas for
prevention (smoking, physical activity, nutrition and
overweight and obesity). An example for physical
activity is presented in Box 5.5. This type of audit will
allow the identification of gaps and in conjunction
with the equity profile, will identify unmet need for
interventions.
5.7.2 Personal and professional
development audit
A local skills audit is an important aspect of needs
assessment. There will be a need for appropriate
personal and professional development for a wide
range of people. This will include not just health
professionals, but other professional groups
involved in planning and delivering services
(eg LA officers, teachers, social workers, youth
leaders, voluntary sector staff) and members of
the public involved in needs assessment and
in delivering community-based
programmes.
 Box 5.5 Audit of local provision of services and facilities for physical activity

Group/locality

How many? Where? How accessible to group?

Facilities
Swimming pools
Sports facilities
Health clubs
School facilities
79
Community facilities

Conducive environments
Cycle routes/tracks
Walks
Parks/playing fields
Other open spaces

Active local groups

Sports clubs
Sports promotion units
Primary care
Health promotion
Local resources

Workplace facilities
NHS
LA
Local business

Source: HEA (1995)

5.8 Monitoring progress
Monitoring is a review of progress towards goals.
To do this it is important to set targets and related
indicators. Targets are an expression of the goals of the
programme and indicators track movement towards or
away from them. The NSF CHD identifies priorities
and uses milestones, which set out the time by which
the recommendations should be implemented. These
milestones should be used to set local targets and be
reflected in HImPs and other local plans.
The broad performance indicators for CHD fit within the
areas of the national Performance Assessment Framework
(PAF) and are designed to track progress. The PAF is
summarised in the main NSF document (DH 2000a, p74).
There will be additional performance indicators for
CHD and these are also set out in the main NSF CHD
(DH 2000a, pp81–82). Chapter 1 of the NSF CHD
includes a framework for the preventive aspects of the
programme, and highlights data items that should be
collected locally (DH 2000b, p16). A technical
supplement to follow the white paper Saving lives: our
healthier nation (DH 1999) is currently being drafted and
will set out the scientific basis for target setting and
the indicators available for the assessment of progress at
both national and local level. See further sources of
information on p88.

Developing a local strategy

 5.8.1 Developing local targets
A target is usually expressed numerically (quantitative).
Targets should be feasible in the timeframe and be
revised according to changes in the policy environment.
They should be measurable – that is, it must be possible
to measure them and to collect the required data items.
There is a national target for reducing the death rate
from CHD: stroke and related diseases in people under
75 years should be reduced by at least two-fifths by
2010 (DH 1999). The NSF CHD emphasises the need for
intervention with other sections of the population such
80
as children and pregnant women that will have an
impact on CHD long after the 2010 deadline.
Local targets can be based on national targets for CHD
risk factors, modified to take into account the population
profile. They can be set in terms of long-term disease risk,
risk factors or be focused on areas or groups at particular
risk. Local targets need to take into account past trends
and performance. Baseline measures for the target in question
need to be collected (although initially, national data can
be adapted while local data are collected). An example,
focusing on physical activity, is presented in Box 5.6.
Equity targets
The government intends to set national targets for
reducing inequalities in health (DH 2000c). However, as
discussed above, local plans should include an equity

Box 5.6 Example of local targets for physical activity

Local targets for physical Description Example

activity

Long-term disease or health Mortality and morbidity A reduction in CHD mortality rates by 32%
status by 2010

Risk factor Relating to physical activity An increase in the proportion of the

population taking the recommended
amount of physical activity* to 45% by 2003
(from 37% of men and 25% of women)

Process/Intermediate Policy An increase in the number of employers

with more than 100 employees with a
workplace physical activity policy by 20%
by 2003

Groups or areas at particular A decrease in the proportion of

risk Bangladeshi people who are sedentary
(from 52% men and 56% of women to
30% by 2005)

Access and delivery An increase in young women from X

locality accessing leisure services from 10%
to 20% by 2004

*The recommendation is that adults build into their daily routine half an hour of moderate intensity physical activity.

Note: For each target baseline values should be established. If data exist the trend over time should be looked at to
help set achievable targets. Sources of data for measuring progress should be identified, and plans made to collect missing
data items.

Coronary heart disease: guidance for implementing the preventive aspects of the NSF
profile and equity targets. Equity targets should address
the wider determinants of health and specify the need for
levelling up (Kendall 1998). Those setting equity targets
should be aware that differential targets may be required
to take account of differential causes and effects in
different population groups. Improving the potential for
health amongst the most vulnerable could mean a
reduction in services for other sections of the population.
Objectives
Objectives are the methods used to achieve the targets
and are usually expressed in the form of desired changes.
For example, if the aim were to increase access to leisure
provision, objectives could include: to set up a special bus
service to take people to facilities; to make facilities
available more cheaply to certain groups; and to increase
opening hours.
Indicators
Indicators measure the movement towards or away from
objectives. They are used to assess progress against
baselines and for comparative purposes. A small number
of indicators will be collated nationally as part of the NSF
CHD, but local implementation teams will need to assess
performance using a wider range of appropriate local
indicators.
Indicators can be based on the input, process, output and
outcome (Ziglio 1996).
Input measures of resources and action
Process also known as formative or intermediate
indicators. These relate to the implementation
of the actions defined in the delivery plan.
Output also known as impact indicators. These
measure the immediate impact of the work on
its target group.
Outcome also known as summative indicators. These
focus on the end product and look at the
extent to which the objectives have been
achieved. It is a measure of the long-term
goal, such as the improvement in health status.
The NSF CHD notes that most local indicators will relate
to inputs and processes where it will be important to
assess the level of progress, and where data can be
analysed at a local level. Output indicators can also be
defined and assessed locally. Outcome measures, on the
whole, can be assessed only regionally and nationally,
where the numbers will be large enough to show trends
over time (DH 2000a, p77).
All performance indicators should relate to evidence-
based changes towards the achievement of the
desired outcomes. Not all will be quantifiable.
Indicators can be quantitative or qualitative or a
combination of the two.
• Quantitative indicators can use standardised
81
measuring instruments to collect data systematically
over time. The size of the effect can be measured and
compared over time with baselines (Hawe et al. 1990).
A list of local sources of data is presented on p78.
A CD-ROM resource, Health and lifestyles guide to
sources (HEA 1997) is available, which provides an
overview of quantitative health and lifestyle surveys of
sound methodological design available at a national
level. It presents details of these surveys, indicating
information that could be usefully collected at a local
level and used to support policy development and
planning.
• Qualitative indicators assess non-quantifiable aspects
of the intervention that contributed to its impact.
These indicators are generally assessed through
questionnaires, observational studies, interview studies,
focus groups and other forms of community
consultation. Qualitative indicators can be a series of
criteria that need to be fulfilled in order for the
intervention or programme to be deemed a success
or failure.
See boxes 5.7 and 5.8 on p82.
Challenges in setting indicators in public health
• Limited data and resources (can lead to availability
driving the indicator rather than the other
way around)
• Setting robust indicators for non-quantifiable outputs
• Need to define short-, medium- and long-term goals
(health promotion is usually evaluated in the short
term but the objectives are often long-term)
• Attributing cause and effect – interventions are often
multi-agency and multi-intervention
Developing a local strategy
 Box 5.7 Checklist for setting local • Changes over time may occur for reasons independent
indicators of the intervention or there may be a long chain of
events between intervention and effect.
• Define target/problem/standard or criteria
• Establish aim – defined by clients or institution 5.8.2 Monitoring frameworks
concerned with needs/rights
• Define who is responsible for the achievement of A series of monitoring frameworks could be developed as
the move towards the target a management tool for project planning. The frameworks
• Define whose interventions are you measuring should:
• Set a timeframe – devise framework in which the
indicator is to be targeted • Enable the identification of the local targets in relation
• Assess availability and quality of data to the national NSF CHD goal
82
• Formulate a monitoring system to collect data
• Decide on form (eg a rate of change expressed • Specify objectives set as a contribution to the target
as a proportion or the setting of a standard as a
way of assessing the quality of a service or • Outline the interventions planned to achieve it
interaction)
• Set baseline or reference data to standardise • Derive indicators to monitor change.
indicator
• Test indicator, if possible, or set date for review Illustrative monitoring frameworks are provided in Table
5.9 (pp83–86).
Box 5.8 Examples of indicators used
in public health

• Shifts in policies or practices such as policy

statements
• Awareness among the public, NHS and LA employees
• Access to services, equity
• Participation or drop out rate
• Levels of client satisfaction
• Changes in individual knowledge, awareness and
self efficacy
• Changes in behaviour
• Health status, quality of life (QOL) and quality
adjusted life years (QALYs)
• Community changes (eg decrease in fear of local
crime, reduced levels of racial or sectarian violence)
• Environmental changes (eg increase in the
number of cycling routes)
• Partnership working (eg evidence of partnerships
with the community and evidence of increased
involvement over time, equitable involvement of
different community groups)
• Advocacy (eg unpaid media coverage, policy
setting and implementation)
• Quality of services eg interaction between health
professional and client
• Quality of life and sustainability indicators (LA 21
indicators)

Coronary heart disease: guidance for implementing the preventive aspects of the NSF
 Table 5.9 Illustrative monitoring frameworks

NSF CHD GOAL and OHN TARGET Contribute to the target reduction of deaths from circulatory disease of up to 200,000 lives in total by 2010

To reduce the average percentage of total food energy derived by the population from saturated fatty acids
LOCAL TARGET based on COMA (1991, 1994) to no more than 10% and total fat to no more than 35% by 2005. To increase the consumption of fruit
and vegetables to five portions a day by 2005.

OBJECTIVE INTERVENTION INDICATOR SOURCE RESULT

To increase the Comprehensive and regular Percentage of people who agree that they can find fruit Local survey 2000 2000: 54%
availability of supply of fruit and vegetables to and vegetables at an affordable price locally. 2001: 58%
healthier food all sections of the population 2002: 62%
products to the with locally organised initiatives Increase in awareness and access to locally grown
local population and community owned retailing produce from community allotment and growing
(food co-ops). schemes by 10%.

Increase in proportion of community owned retailing Observation/local

schemes established (eg, baseline 2000: one in five survey
localities; 2002: one per locality).

Evidence that people on low incomes find farmers’

markets useful. Focus groups

To encourage the Better provision of adequate Percentage of the local population who are able to state Previous national 1996: Males 14%
consumption of nutrition messages. correctly at least three of the following ways of examples: Females 17%
tasty, healthy achieving a healthier diet: (1) eat lots of fruit, vegetables HEMS (1996, 1998)
foods, including or salad, (2) cut down on fatty or fried foods, eat grilled 1998: Males 15%
fruit and food, (3) eat lots of fibre, cereals, wholemeal food and Females 17%
vegetables, (4) eat lots of starchy foods such as bread, potatoes,
among low pasta or rice. Base: 16–74 years old
income groups
Increase in consumption of fruit and vegetables and National Food Survey
starchy foods, decreased consumption of fats among
social classes IV and V.

Developing a local strategy

83
 84
NSF CHD GOAL and OHN TARGET Contribute to the target reduction of deaths from circulatory disease of up to 200,000 lives in total by 2010

To reduce the average percentage of total food energy derived by the population from saturated fatty acids
LOCAL TARGET to no more than 10% and total fat to no more than 35% by 2005. To increase the consumption of fruit
and vegetables to five portions a day by 2005.

OBJECTIVE INTERVENTION INDICATOR SOURCE RESULT

To develop a Provision of breakfast clubs in An increase in the number of selected schools who Data from LEAs and
‘whole school’ selected schools. provide breakfast clubs; an increase in the number of schools
approach to schoolchildren in selected schools who eat breakfast;
healthy eating percentage of schools addressing healthy eating through
a ‘whole school’ approach.

Quality of provision Observation/audit

Coronary heart disease: guidance for implementing the preventive aspects of the NSF
The school includes education An increase in the number of schools with a policy on Liaison with local
on healthier eating, practical healthy eating (including snacks) at school. healthy schools
cooking skills and basic food programme
safety practices in the taught coordinator
curriculum.
Evidence of review and efficient use of resources. Audit

Policy guidelines for eating Increase in number of schools selling fruit in tuck shops Feedback and data
healthy snacks in schools. to 6–11 year olds and 11–16 year olds; sales data: fruit from teaching staff,
as a proportion of all snack items sold in schools. pupils, catering staff
and parents

Evidence that initiatives are sustainable. Observation

 NSF CHD GOAL and OHN TARGET Contribute to the target reduction of deaths from circulatory disease of up to 200,000 lives in total by 2010

To improve the health of people aged 65–75 years by increasing the length of their lives and the number of
LOCAL TARGET
years free from illness by 2010.

OBJECTIVE INTERVENTION INDICATOR SOURCE RESULT

To reduce the Home based programme with Health Survey for

Percentage of older people who state that they are able
impact of heart health visitor with telephone England (annual)
to enjoy day to day activities.
disease and prompting to encourage walking
stroke (check effectiveness) Local survey
Percentage of older people who find it difficult to get
around the house on their own. adaptation of
To increase questions;
awareness of the Percentage of older people who have walks that last for HEMS (1998).
importance of at least 15 minutes but less than 30 minutes.
physical activity
for older people
Health Survey for
Improve community involvement Involvement of older people in planning; proportion of England (annual);
To promote
and relations by Support Your older people who help out with: local survey/
mental as well
Neighbourhood scheme. • Meals on wheels qualitative data from
as physical
• Day centres for the elderly run by council or voluntary neighbourhood fora.
well being and
organisations
reduce isolation
• Voluntary organisations
• Help at another service.

Quality of life measurement.

Evidence that older people feel a sense of control and Case studies
involvement with initiatives.

Developing a local strategy

85
 86
NSF CHD GOAL and OHN TARGET Contribute to the target reduction of deaths from circulatory disease of up to 200,000 lives in total by 2010

Increase the proportion of the local population who are physically active at a moderate intensity level for at
LOCAL TARGET
least 30 minutes on five or more days of the week (from a local baseline) by 20%.

OBJECTIVE INTERVENTION INDICATOR SOURCE RESULT

To increase levels Walk in to work out initiative
of physical (Mutrie et al. 1999).
activity
Review of local policies/facilities
that encourage physical activity;
recommendations for action.
Percentage of those involved in the programme who Local survey data
continued to walk to work after six months.
Decrease in the proportion of the sedentary local Local survey data
population by 5% from baseline of 27% (men) and
28% (women).

An increase in the policies such as pedestrian precincts, LA 21 indicator

allowing bicycles to be taken on trains. information

The number and quality of physical facilities available for Local survey data

Coronary heart disease: guidance for implementing the preventive aspects of the NSF
physical activity such as bike tracks, walking paths,
public swimming pools; increase in the percentage of
journeys made by walking.

To increase Provision of information and Percentage of health professionals and leisure service Previous example: % 1995 1996 1997
the level of guidance to professionals. workers who correctly identify the recommended HEA Evaluation of
awareness physical activity message Health and Leisure GP 3 0 4
among health
Professionals 1995, Practice
professionals on
the amount and 1996, 1997. nurse 2 3 7
type of physical Leisure
activity needed workers 33 40 42
for a beneft to Health
health promotion 3 4 5

Source: Adapted from Morgan, A. and Ford, K., 1998. A series of health promotion monitoring frameworks for use in demonstrating contribution to national targets: a discussion
document. Unpublished.
5.10 Further sources of information
Partnerships
Advice and information is available from the Health and Social Care
Joint Unit in the Department of Health and information is available at
http://www.doh.gov.uk/jointunit/partnership.htm
Audit Commission, 1998. A fruitful partnership: effective partnership
working. London: Audit Commission (may be ordered on tel: 0800 50
20 30).
Geddes, M., 1998. Achieving best value through partnership. London:
DETR.
NHSE, 1998. Health improvement programmes: planning for better
health and better health care. HSC 1998/167 LAC 98(23). London: NHS.
NHSE, 1999. Planning for health and health care: incorporating
guidance on health improvement programmes, service and financial
frameworks, joint investment plans and primary care investment plans.
HSC 1999/244 LAC 99(39). London: NHS.
Plamping, D., Pratt, J. and Gordon, P., 2000. Practical partnerships for
health and local authorities. British Medical Journal, 320, 1723–1725.
http://www.bmj.com/
Pratt, J., Plamping, D. and Gordon, P., 1998. Partnerships: fit for
purpose?. London: King’s Fund.
Russell, H. and Killoran, A., 1999. Public health and regeneration:
making the links. London: HEA.
Watson, J., Speller, V., Markwell, S. and Platt, S., 2000. The Verona
benchmark: applying evidence to improve the quality of partnership
working. International Journal of Health Promotion and Education, 7,
17–23.
Best value
The Audit Commission publishes a number of reports on best value.
Some of these can be directly accessed through their website:
http://www.audit-commission.gov.uk
Local Government Improvement and Development Agency (IDeA)
has placed many resources relating to best value on line:
http://www.idea.gov.uk
Community and public involvement
Audit Commission, 1999. Listen up! Effective community consultation.
London: Audit Commission (may be ordered on tel: 0800 50 20 30).
Summary and management paper available from:
http://www.audit-commission.gov.uk/ac2ss.first.htm
Useful wallchart included in the main publication but can be obtained
by tel: 020 7828 1212.
Cohen, J. and Emanuel, J., 2000. Positive participation: consulting and
involving young people in health-related work. A planning and training
resource. London: HEA.
87
DH, 1999. Patient and public involvement in the new NHS.
London: DH. http://www.doh.gov.uk/involve.htm
DETR, 2000. Preparing community strategies: draft guidance to local
authorities from the Department of Environment, Transport and the
Regions. London: DETR.
Local Government Improvement and Development Agency (IDeA) has
placed many resources relating to best value on line. This includes a
document dealing with consultation:
http://www.idea.gov.uk/bestvalue/consult/main.htm
National Consumer Council, Consumer Congress and Service First Unit,
1999. Involving users: improving the delivery of healthcare. London:
Cabinet Office.
National Consumer Council, Consumer Congress and Service First Unit,
1999. Involving users: improving the delivery of local public services.
London: Cabinet Office.
Northern and Yorkshire Region NHS Executive, 1999. NHS primary care
group’s public engagement toolkit. Durham: Northern and Yorkshire
Region NHS Executive.
http://www.doh.gov.uk/pub/docs/doh/toolkit1.pdf
Rifkin, S., Lewando-Hundt, G. and Draper, A., 2000. Participatory
approaches in health promotion and health planning.
London: HDA.
Service First Unit, 1999. An introductory guide: how to consult your
users. London: Cabinet Office.
Service first publications can be found through the Cabinet Office
website: http://www.cabinet-
office.gov.uk/servicefirst/index/publications.htm#policy
Developing a local strategy
 Health needs assessment
HEA, 1999. Indicators of good practice: an organisational self-
assessment tool. London: HEA.
Sustain, 2000. Reaching the parts. Community mapping: working
together to tackle social exclusion and food poverty. London:
Sustain, in association with Oxfam’s UK Poverty Programme.
Indicators and monitoring
88
Bowling, A., 1991. Measuring health: a review of quality of life
measurement. Milton Keynes: Open University Press.
Buck, D., Godfrey, C. and Morgan, A., 1997. The contribution of
health promotion to meeting health targets: questions of measurement,
attribution and responsibility. Health Promotion International, 12 (3),
239–250.
Cheadle, A., Sterling, T., Schmid, T. and Fawcett, S., 1995.
Evaluating community based nutrition programmes: comparing
grocery store and individual level survey measures of program
impact. Preventive Medicine, 24 (1), 71–79. The indicators are shown on
http://www.faculty.washington.edu/cheadle/cli/
Funnell, R., Oldfield, K. and Speller, V., 1995. Towards healthier
alliances: a tool for planning, evaluating and developing healthy
alliances. London: HEA.
Hawe, P., Degeling, D. and Hall, J., 1990. Evaluating health
promotion. Sydney: Maclennan and Petty.
Kendall, L., 1998. Local inequalities targets. London: Kings Fund.
Macleod Clark, J., Latter, S., Maben, J. and Franks, H., 1997.
Promoting health through primary health care nursing. London: HEA.
Morgan, A., Buck, D. and Godfrey, C., 1996. Performance indicators
and health promotion targets. York: Centre for Health Economics,
University of York.
Mutrie, N., Blamey, A. and Whitelaw, A., 1999. A randomised
controlled trial of a cognitive behavioural intervention aimed at
increasing active commuting in a workplace setting. Edinburgh: Chief
Scientist’s Office of the Scottish Executive.
Ziglio, E., 1996. Indicators of health promotion policy: directions for research.
In: B. Bandura and I. Kickbush, eds. Health promotion research: towards
a new social epidemiology. Copenhagen: WHO Regional Office for Europe.
Coronary heart disease: guidance for implementing the preventive aspects of the NSF
The HDA has commissioned the Office for National Statistics to develop
and validate a module of questions to measure a range of components
of social capital. These questions will be used to measure social capital
at a national level in the General Household Survey 2000/2001. The
questions will investigate areas such as the strength of voluntary
organisations, norms of neighbourliness, reciprocity and trust and
infrastructure resources, community networks and attitudes to
community involvement. Some HAZs are using this questionnaire in
their local surveys to enable them to make comparisons between
their local area and the national average. Further information on this
project can be obtained from Antony Morgan (antony.morgan@hda-
online.org.uk) or Caroline Mulvihill (caroline.mulvihill@hda-
online.org.uk) at the HDA.
The National Centre for Health Outcomes Development
(http://nww.nchod.nhs.uk/) provides relevant data and information on
measurement tools for public health. It is a key source of information on
assessment of health and outcomes of health interventions at individual,
HA, Hospital and Community Trust, PCG/PCT and LA levels for the
English NHS and the government. The website contains information on
a range of indicators relevant to CHD, for example fat consumption,
mean adult BMI and smoking statistics.
HEA, 1997. Health and lifestyles: guide to sources. London: HEA.
A technical supplement to follow the white paper, Saving lives: our
healthier nation (DH, 1999), is currently being drafted. It will suggest
some measures of progress to monitor the strategy, draw together
information on data sources, and signpost relevant initiatives and
references which may be helpful to those involved in monitoring
progress at national or at local level. A short draft version is currently
available on the OHN web site, situated at http://www.ohn.gov.uk (look
under ‘OHN’, then ‘Technical’), which will be regularly updated and
supplemented with additional material as appropriate.
StatBase ® http://www.statistics.gov.uk/statbase/mainmenu.asp
StatBase ® is an on-line database which holds a large selection of
Government statistics. It also provides descriptions of all the UK
Government Statistical Service’s data sources, derived analyses, all its
statistical products and services and all the relevant contact points.
Social Exclusion Unit, 2000. Measuring deprivation: a review of indices
in common use.
http://www.cabinet-office.gov.uk/seu/2000/pat18/Depindices.htm
This Working Paper was produced to inform, and support the work of
the Social Exclusion Unit’s Policy Action Team (PAT) 18 on Better
information. It reviews the most commonly used deprivation measures
and highlights some of the issues surrounding their use.
Social Exclusion Unit, 2000. Report of PAT 18: Better information.
London: The Stationery Office.
OHN indicators
Data to measure progress towards OHN indicators are collected by
local directors of public health. Many of these are also applicable
to the NSF CHD indicators. The OHNiP database:
(http://www.ohn.gov.uk/database/database.htm) holds information on a
wide range of projects and initiatives that in different ways contribute
to the aims of the OHN health strategy. The database can be searched
by health keyword, target audience, government initiative or zone and
setting.
The Health Survey for England has covered cardiovascular disease (1998)
and ethnic minority groups (1999), published by The Stationery Office.
The full text of the CHD survey is available at http://www.official-
document.co.uk/document/doh/survey98/hse-00.htm and information
on the ethnic minority survey is at
http://www.doh.gov.uk/public/hs99ethnic.htm
In 2000 the survey will focus on older people.
Health Education Monitoring Survey (HEMS)
The 1998 HEMS includes a measurement of social capital. The survey
contains six questions whereby a neighbourhood social capital score can
be calculated (Rainford L., Mason V., Hickman M. and Morgan, A.,
2000. Health in England: investigating the links between social
inequalities and health. London: The Stationery Office).
HAZnet: http://www.haznet.org.uk
Evidence is a key feature in the work of HAZs and HAZnet works
towards creating and disseminating an evidence base for new ways
of working. HAZnet has a database of area-based initiatives, local
evaluation projects and other research specific to HAZs, which may
also be of relevance as case studies for the NSF CHD.
LA 21. Local indicators of sustainable development.
http://www.environment.detr.gov.uk/sustainable/localind/nutshell/index.htm
The DETR has recently launched a handbook, Local quality of life counts,
which offers ideas for measuring sustainable development and quality of
life in local communities. The handbook gives a menu of 29 indicators
from which local authorities may wish to consider using a selection for
reporting in their LA 21 and community strategies. A number of these
indicators are also applicable to the NSF CHD. These include 15 headline
indicators that are intended to make up a ‘quality of life barometer’,
which will be used to measure overall progress, including success in
tackling poverty and social exclusion and expected years of healthy life.
The handbook also provides advice on indicator development for:
• Access to key services (i.e. medical services and shops)
• Mode and average distance of travel to work
• Percentage of school children travelling to and from school by
different modes
• Recorded crime per 1,000 population, fear of crime, social
participation, community well being and social and community
enterprises (social capital).
Neighbourhood statistics
Following the recommendations of the Social Exclusion Unit’s Policy
action team 18: better information, a set of standard neighbourhood
statistics covering the social exclusion characteristics of a neighbourhood
will be collated annually. This work will be led by the Office for National
Statistics and will be coordinated across Government departments and
89
with local government and other public, private and voluntary sector
organisations who collect relevant information so as to avoid duplication
and minimise costs. It is envisaged that this information will be available
down to ward level. Information will be collected within nine suggested
domains which include access to services, community well being/social
environment, crime, economic deprivation, education, skills and
training, health, housing, physical environment and work deprivation.
Evaluation
The HDA has produced a practical toolkit on evaluation. It outlines the
purpose and principles and describes the variety of approaches to
evaluation. In addition it provides guidance on quantitative and
qualitative research methods, developing recommendations and
dissemination of findings. This toolkit will be available on Evidence Base
2000 on the HDA website (http://www.hda-online.org.uk/evidence) in
autumn 2000.
Funnell, R., Oldfield, K. and Speller, V., 1995. Towards healthier
alliances: a tool for planning, evaluating and developing healthy
alliances. London: HEA.
Meyrick, J. and Sinkler, P., 1999. An evaluation resource for healthy
living centres. London: HEA.
Thorogood, M and Coombes, Y., 2000. Evaluating health
promotion: practice and methods. Oxford: Oxford University Press.
5.11 References
Audit Commission, 1999. Listen up! Effective community consultation.
London: Audit Commission.
DETR, 2000. Preparing community strategies: draft guidance to local
authorities from the Department of the Environment, Transport and
Regions. London: DETR.
Developing a local strategy
 DH, 1999. Saving lives: our healthier nation. London:
The Stationery Office.
DH, 2000a. National service framework for coronary heart disease:
main report. London: DH.
DH, 2000b. National service framework for coronary heart disease:
Chapter 1. Reducing heart disease in the population. London: DH.
DH, 2000c. The NHS plan. A plan for investment. A plan for reform.
London: The Stationery Office.
90
DH, 2000d. Implementation of Health Act partnership arrangements.
HSC2000/10 LAC2000/09. London: DH.
Geddes, M., 1998. Achieving best value through partnership.
London: DETR.
Gillies, P., 1998. Effectiveness of alliances and partnerships for health
promotion. Health Promotion International, 13 (2), 99–121.
Hawe, P., Degeling, D. and Hall, J., 1990. Evaluating health promotion.
Sydney: Maclennan and Petty.
HEA, 1995. Promoting physical activity: guidance for commissioners,
purchasers and providers. London: HEA.
HEA, 1997. Health and lifestyles: guide to sources. CD ROM.
London: HEA.
Kendall, L., 1998. Local inequalities targets. London: King’s Fund.
Coronary heart disease: guidance for implementing the preventive aspects of the NSF
NHSE, 1998. Health improvement programmes: planning for
better health and better health care. HSC 1998/167 LAC 98(23).
London: NHS.
NHSE, 1999. Planning for health and health care: incorporating
guidance on health improvement programmes, service and
financial frameworks, joint investment plans and primary care
investment plans. HSC 1999/244 LAC 99(39). London: NHS.
Nichols, V., 1999. The role of community involvement in health
needs assessment in London. London: HEA.
Plamping, D., Pratt, J. and Gordon, P., 2000. Practical partnerships for
health and local authorities. British Medical Journal, 320, 1723–1725.
Rogers, A., Popay, J., Williams, G. and Latham, M., 1997.
Inequalities in health and health promotion: insights from the
qualitative research literature. London: HEA.
Russell, H. and Killoran, A., 1999. Public health and regeneration:
making the links. London: HEA.
Watson, J., Speller, V., Markwell, S. and Platt, S., 2000. The
Verona Benchmark: applying evidence to improve the quality of
partnership working. International Journal of Health Promotion
and Education, 7, 17–23.
Ziglio, E., 1996. Indicators of health promotion policy: directions for
research. In: B. Bandura and I. Kickbush, eds. Health promotion
research: towards a new social epidemiology. Copenhagen: WHO
Regional Office for Europe.
Appendix
Contributors

91
This guidance has been developed in consultation with a range of professionals through a workshop and critical
review. The HDA would like to thank them for their cooperation.

Researched and written by

Health Development Agency

Hugo Crombie Public health adviser, physical activity

Karen Ford Head of public health advice and learning
Caroline Mulvihill Research and development specialist
Lesley Owen Public health adviser, smoking
Karen Peploe Public health adviser, food and nutrition
Hilary Whent Head of public health advice and learning
Patti White Public health adviser, smoking
Tricia Younger Head of action zone development

London School of Hygiene and Tropical Medicine

Dalya Marks Research fellow

Margaret Thorogood Reader in public health and preventative medicine

Freelance consultants

Isobel Bowler Health policy consultant

Lynn Stockley Nutrition consultant

Appendix
 Reviewers

Waqar Ahmad Professor of primary care research, Nuffield Institute, University of Leeds
Danila Armstrong Health development manager, NHS Executive, London
Amanda Avery Community dietitian, Community Nutrition Group, British Dietetic Association
Janet Baker Deputy regional director of public health, NHS Executive, West Midlands
Clive Bates Director, Action on Smoking and Health
Yve Buckland Chair, Health Development Agency
Jennie Carpenter Head of public health strategy and function in and through the NHS, DH
Gill Cowburn Senior researcher, Health Promotion Research Group, BHF
Adam Crosier Research and development specialist, HDA
Aliya Darr Research fellow, Nuffield Institute, University of Leeds
92
Mike De Silva Policy officer, DH
Nick Dean Acting head, Health Strategy Branch, DH
Elizabeth Dowler Public health nutritionist, University of Warwick
Laurel Edmunds Senior researcher, Health Promotion Research Group, BHF
Claudette Edwards Public health adviser, black and minority ethnic groups, HDA
Carl Evans CHD/smoke prevention team, DH
Charlie Foster Senior researcher, Health Promotion Research Group, BHF
Mollie Foxall HAZ CHD lead, Manchester Health Authority
Jeff French Director of planning, partnerships and communication, HDA
Alison Giles Policy development officer, NHF
Madeline Garraway Public health adviser, older people, HDA
Lucy Hamer Development adviser, HImPs, HDA
Lesley Hammond Health promotion officer, Environmental Services Division, Wycombe District Council
Dominic Harrison Regional health development specialist, HDA (northwest region)
Nick Hicks Strategy unit team member, DH
Melvyn Hillsdon Lecturer in health promotion, London School of Hygiene and Tropical Medicine
Jane Huntley Head of workplace health, HDA
Paul Lincoln Director, NHF
Richard Longbottom Senior planning manager, Bradford Health Authority
Jeanette Longfield Coordinator, Sustain
Susan Martin Deputy branch head PH2, DH
Ann McNeill Freelance consultant
Dawn Milner Senior medical officer, DH
Antony Morgan Head of health information, HDA
Mike Rayner Director, Health Promotion Research Group, BHF
Sheela Reddy Nutrition division, Food Standards Agency
Imogen Sharp Branch head, CHD/stroke prevention, DH
Dave Shields Health development manager, Southampton City Council
Viv Speller Director of health improvement, HDA
Cathy Stillman-Lowe Public health adviser, oral health, HDA
Carolyn Summerbell Reader in human nutrition, School of Health, University of Teeside
Catherine Swann Research and development specialist, HDA
Marilyn Toft Head of schools and young people, HDA
Nikki Wade Health development specialist, Cambridgeshire Health Authority
Sheila Webb Consultant in public health, Bradford Health Authority
Jean Woodhouse Health promotion officer, Northumberland Health Authority
Lynn Young Community health adviser, Royal College of Nursing

Coronary heart disease: guidance for implementing the preventive aspects of the NSF
Glossary

93
ACoP Approved Code of Practice HEMS Health education monitoring survey
AGPNM Association of General Practitioners of HEPA Health-enhancing physical activity
Natural Medicine HLC Health living centre
ASH Action on Smoking and Health HlmP Health improvement programme
HSC Health Services Circular
BHA British Hypnotherapy Association HSE Health and Safety Executive
BHF British Heart Foundation
BMEG Black and minority ethnic groups ICM Institute of Complementary Medicine
BMI Body mass index IDeA Improvement and Development Agency
BSH British Society of Hypnotherapists IOTF International Obesity Task Force

CA Consumers’ Association LA Local authority

CDC Center for Disease Control and Prevention LACA Local Authority Caterers’ Association
CHD Coronary heart disease LA 21 Local Agenda 21
COMA Committee on the Medical Aspects of Food LDL Low density lipoprotein
and Nutrition Policy LEA Local education authority
LGA Local Government Association
DETR Department of Environment, Transport and LTP Local transport plan
the Regions
DfEE Department for Education and Employment MAFF Ministry of Agriculture, Fisheries and
DH Department of Health Food

EAZ Education action zone NGO Nongovernmental organisation

EH Environmental health NHF National Heart Forum
EHO Environmental health officer NHS National Health Service
EU European Union NHSE National Health Service Executive
NHSS National Healthy Schools Standard
FLI Food and low income (database) NOF New Opportunities Fund
NRT Nicotine replacement therapy
GP General practitioner NSF National Service Framework
GSL General sales list NSF CHD National Service Framework for Coronary
GTP ‘Green’ transport plan Heart Disease

HA Health authority OFSTED Office of Fair Standards and Training in

HAZ Health action zone Education
HDA Health Development Agency OHN Our Healthier Nation
HDL High density lipoprotein OHNiP Our healthier nation in practice (database)
HEA Health Education Authority OTC Over the counter

Glossary
 PAF Performance Assessment Framework RSA Retail Services Association
p&p Postage and packing
PAT Policy action team SACN Scientific Advisory Committee on Nutrition
PCG Primary care group SBT Simple behavioural therapy
PCT Primary care trust SCOTH Scientific Committee on Tobacco and Health
PE Physical education SIGN Scottish Intercollegiate Guidelines Network
PHC Primary health care SMAP School Meals Assessment Pack
PR Public relations SNAG Schools Nutrition Action Group
PSHE Personal, social and health education SRTS Safer routes to school
PTA Parent–teacher association STAG School travel advisory group

QALY Quality adjusted life year UK United Kingdom

94
QOL Quality of life USA United States of America

RCT Randomised controlled trial VIRSA Village Retail Services Association

RDA Regional Development Agency
RPHNutr Registered Public Health Nutritionist WHO World Health Organization

Coronary heart disease: guidance for implementing the preventive aspects of the NSF