Planet Munch Healthy Lifestyle Programme - tackling childhood obesity through creative education

Childhood obesity is one of the most important health/social issues facing the UK. Due to obesity, today’s children may not live as long as their parents. Preschool is a critical period when lifestyle habits are laid down and potentially taken into later childhood/adulthood affecting long-term health. Interventions that aim to improve lifestyle behaviours (diet and physical activity) most strongly associated with obesity development are recommended by NICE as the best strategy for prevention.  These should include at least one family member and based in the community for ease of access to families.  To address this we developed the TrimTots, healthy lifestyle programme for preschool children and their families.

The main objectives were:

• To develop a healthy lifestyle programme that was feasible and acceptable to children, families and early years’ practitioners.
• To evaluate feasibility and efficacy of the intervention using a RCT design.
• To identify barriers and facilitators for families engaging in the intervention.
• To optimise the programme and evaluate in a larger population using a cluster RCT design
• To make the programme more widely available
• To disseminate the findings to the health and research community

Together with Herts County Council we worked to identify areas with high incidence of obesity as per Year 6 Child Measurement Programme.  Working closely with Children’s Centre Managers we developed a hub and spoke model allowing the programme to reach as many families as possible through providing delivery centres and several feeder centres. A travel budget was available to enable families to access sessions in centres out of their immediate locality.  The programme was therefore accessible to more people and better value for participating children’s centres as a group of centres were able to share staff and resources to support programme delivery. In our initial pilot we delivered 2 sessions per week which was reduced to two when we found that it was too difficult for families with young children to attend two sessions per week, one session per week was also preferred by children’s centres who found it hard to dedicate two session (staffing and venue) into an already busy timetable.

Despite the scale of the problem, there are few evidence-based interventions to help prevent/treat obesity in preschool children.

Prevention of childhood obesity is a major public health priority in the UK. Currently one in four children is overweight before starting school, with lower-income communities with high levels of social deprivation being particularly severely affected. Given the significant impact of obesity on health care costs, short- and long-term health outcomes, and general development and psychological well-being, there is an urgent need for evidence-based interventions that can help families adopt healthy dietary and lifestyle habits from an early age, and so reduce the long-term risk of obesity and its consequences.

 In its most recent guidance (2015), the UK body monitoring health interventions in the NHS, NICE, recommended that commissioners and funders investigate evidence-based, clinically effective and cost effective approaches to lifestyle weight management for children younger than 6 years. This project aims to deliver such a community-based programme in Children's Centres, where obesity is higher than the national average. Thus the programme is designed specifically to target hard to reach families, who currently have little or no nutrition education,  poor practical skills (e.g. poor understanding of  healthy cooking, reading food labels, and strategies to encourage healthy eating in toddlers), and in whom lifestyle factors present barriers to behaviour change.

A clear scientifically proven need: Recent national policy documents (NICE, guidelines for the prevention of obesity, the Chief Medical Officer's report on child health in the UK, published October 2013, the recent House of Commons Health Committee Report – Childhood Obesity – Brave and bold action, published November 2015), and numerous scientific studies (Wang, 2012) have highlighted the major threat of obesity in young children to their short- and long-term health, as well as to the health and economic well-being of the nation.  As suggested by the 'Early Bird' study from Plymouth (Gardener, Paediatrics, 2009) most excess weight is gained before starting school and therefore prevention of obesity should begin early in childhood. The preschool period is a critical period for the development of dietary and behavioural habits that affect long-term health (Northstone, 2005).

Planet Munch sessions are delivered as a collaboration between Trim Tots CIC & community delivery partners in a range of family friendly spaces including; gyms, hospitals, schools, family health & community centres. In the initial pilot phase for the RCT our first families were recruited by referral (GP, Health Visitor or Centre Manager).

The first was a pilot study conducted in 'high risk' children who were either already overweight (defined as BMI ≥ 91st centile on the UK 1990 growth reference 12 or whose weight had crossed upwards by at least one centile space (upward centile crossing) and were at risk of becoming overweight. The RCT tested the feasibility of the intervention in a community based setting in children aged 1-5 years.

Following the successful completion of the pilot treatment study a second RCT was conducted in a wider population to include children not overweight or at increased risk of becoming so. 105 children were recruited between June 2008 and December 2010 (Table 3). 90 children consented and completed baseline measurements. 88/90 (98%) children with BMI above the 91st centile or upward crossing in centiles for weight were randomly assigned to either immediate intervention (n = 46) or waiting list control (n = 42) groups (Figure 1). The mean attendance for the programme was 73%. 64/88 (73%) children (mean age 2.5 years) provided measurements before and after completing the intervention.

Families, with at least one preschool child and their parent or usual carer, attend 24 weekly sessions lasting two hours. Each session includes activities that are effective in engaging this age group including; nutrition, themed art and craft, interactive music and movement, imaginary play, physical activity, healthy snack time and practical adult session designed to equip participants’ with the knowledge and tools for a healthier future.  Behaviour change is encouraged by setting SMART (Specific, Measurable, Attainable, Realistic and Timely) goals for parents/carers relative to each session. 

The content of the programme was trialled in a live community setting and tweaked to reflect the needs of participating families. The order of activities was changed, the music became a well love element of the programme and the sessions were extended to reflect feedback as the families loved opportunity to dance together. The children receive a cd as take home to support continuance of moving together in the home environment much earlier in the programme than in the initial phase. The creative content and activities are designed with the whole family in mind, we are able to accommodate other children when necessary in holiday periods or where necessary.

Guidance for prevention, management and treatment of obesity was issued from the National Institute for Health and Care Excellence (NICE) in 2006 and reiterated in 2013. This body recommends that interventions for childhood obesity should include advice on achieving a healthy diet, address lifestyle risk factors within the family and social settings, and incorporate strategies for behavioural change. Importantly, interventions must include at least one other family member. 10, 11 NICE guidelines also recommend that nurseries and childcare facilities should minimize sedentary activities and provide regular opportunities for active play and structured physical activity.

A lack of provision to address this need: According to NICE (2015) evidence based interventions to treat or prevent obesity in preschool children in the UK (e.g. evaluated using a randomised controlled trial or that assess whether the impact of the intervention is sustainable in the longer term, beyond the period of intervention) are lacking.  Furthermore, NICE guidelines recommend that interventions for obesity are multi-component, and address lifestyle within the family in a community and social setting.  Planet Munch is currently the only healthy lifestyle programme for young children that meets all the requirements of the NICE guidelines with its effectiveness demonstrated by the RCTs published in the Lancet.  Local input into the programme design and delivery: The local need for this project has been highlighted by statistics for overweight and obesity in the communities where it has been previously delivered, which report that about 25% of children are overweight and 10% obese (more than the UK average). This data has been reinforced through our consultation with clinicians, Children’s Centre managers and public health experts from Camden and Islington, Lambeth and Hammersmith who have highlighted the lack of evidence-based weight management services for referral of local families.  Finally, the programme has been developed in collaboration with the following organisations, which have identified the need for Planet Munch, helped in its delivery and evaluation, and expressed an interest in its continuation in the local area:

There is an estimated cost of £500 per family depending on numbers in attendance at sessions.

Programme funding 10k contribution to programme delivery from -

Herts County Council, Camden Health and Wellbeing Team and West London Zone.

The UCL Institute of Child Health, GOS supported initial development and RCT'S. 

Danone - programme delivery at RCT stage.

Health and Social Innovators and Numbers4Good - Accelerator programme, business development package - financial modelling and practical business coaching non-cash investment.

Planet Munch was evaluated using the highest quality study design, a Randomised Controlled Trial. Families able to attend for 24 weeks, were assigned randomly to participate straight away or join a waiting list and take part after the first group had completed. Effects of both groups were compared. Two trials were conducted; one focusing on children already at risk of obesity and another in all preschool children. Planet Munch reduced obesity risk, improved diet and benefited health, by lowering blood pressure. Some benefits (lower body mass index (BMI)/obesity) were evident 2 years after completion, demonstrating longer term effects.

Results have been reviewed by experts and published as an abstract in The Lancet.  Evaluation is ongoing through rigorous data collection and analysis. 

What our parents say

“Very interactive, fun, friendly and informative!”

“Good activities for the Children and introduced us to new foods”

“Great food ideas, dance and music sessions”

“Enjoyed the programme very much.”

What our partners and commissioners say

“Many parents ask if they can carry on with Planet Munch because they are enjoying it so much and get so much from the session! Lovely feedback to hear!”  Week 21 - Amy Hageman – Centre Manager

 “I couldn’t recommend Trim Tots more, it’s such a great mix of fun crafts, wonderful dancing and useful education.” Sophie Thurner – Nutritionist

Planet Munch was designed alongside beneficiaries, commissioners, parents, children’s centre staff and early years leads (who formed the steering committee) to ensure the delivery model, experience and outcomes meet the needs of all parties, particularly families and local community in order to achieve a sustained impact. During delivery, parents and the steering committee have provided feedback which has been incorporated into the latest programme design: in particular, their ideas and suggestions about learning needs and possible barriers to participation.

Examples of changes that have been made following feedback include: adaptation of creative content to include more of the aspects most enjoyed by families, e.g. art became the first activity serving as an ice breaker, the musical content was expanded, rhymes and simple games were developed for the youngest children to enable engagement across the age range. The name was changed from TrimTots to Planet Munch removing reference to obesity that might cause distress to either children or their parents. A weekly optional supplementary session was removed as centres found this hard to accommodate and staff. TrimTots was found to be effective at improving health outcomes. Longer term follow-up, 1-2 years after taking part, found the effect on BMI to be sustained. Results have been published in the Lancet (Lanigan and others 2013).

Planet Munch was evaluated using the highest quality study design, a Randomised Controlled Trial. Families able to attend for 24 weeks, were assigned randomly to participate straight away or join a waiting list and take part after the first group had completed. Effects of both groups were compared. Two trials were conducted; one focusing on children already at risk of obesity and another in all preschool children. Planet Munch reduced obesity risk, improved diet and benefited health, by lowering blood pressure. Some benefits (lower body mass index (BMI)/obesity) were evident 2 years after completion, demonstrating longer term effects.

Results have been reviewed by experts and published as an abstract in The Lancet.  Evaluation is ongoing through rigorous data collection and analysis. 

What our parents say

“Very interactive, fun, friendly and informative!”

“Good activities for the Children and introduced us to new foods”

“Great food ideas, dance and music sessions”

“Enjoyed the programme very much.”

What our partners and commissioners say

“Many parents ask if they can carry on with Planet Munch because they are enjoying it so much and get so much from the session! Lovely feedback to hear!” Week 21 - Amy Hageman – Centre Manager

“I couldn’t recommend Trim Tots more, it’s such a great mix of fun crafts, wonderful dancing and useful education.” Sophie Thurner – Nutritionist

Planet Munch was designed alongside beneficiaries, commissioners, parents, children’s centre staff and early years leads (who formed the steering committee) to ensure the delivery model, experience and outcomes meet the needs of all parties, particularly families and local community in order to achieve a sustained impact. During delivery, parents and the steering committee have provided feedback which has been incorporated into the latest programme design: in particular, their ideas and suggestions about learning needs and possible barriers to participation.

Examples of changes that have been made following feedback include: adaptation of creative content to include more of the aspects most enjoyed by families, e.g. art became the first activity serving as an ice breaker, the musical content was expanded, rhymes and simple games were developed for the youngest children to enable engagement across the age range. The name was changed from TrimTots to Planet Munch removing reference to obesity that might cause distress to either children or their parents. A weekly optional supplementary session was removed as centres found this hard to accommodate and staff. TrimTots was found to be effective at improving health outcomes. Longer term follow-up, 1-2 years after taking part, found the effect on BMI to be sustained. Results have been published in the Lancet (Lanigan and others 2013).

Identifying the main challenges to engagement will allow development of more bespoke interventions.  We are currently working with local authority public health teams to adapt the programme to suit the needs of families based on e.g. ethnicity, taking into account cultural differences in lifestyle behaviours, in particular with relation to diet and physical activity.

We are developing and testing adapted versions of the programme e.g. using different methods to engage parents and children.

Plans for Spread:

Developing models to make the programme more widely available.

Working with the British Dietetic Association

On line training resources and signposting information will be made available.

There are plans to roll out training and over the next year.

There is further work required to support dietitians to put skills into practice. Plans to support this are under discussion with the BDA.

Next steps for the project are to identify and measure any impact on the health and wellbeing of the population. Success stories will be one example whilst plans for further projects to demonstrate impact need to be developed over the next 4-6 months.

The project has been shared with other professions across NUTH and it has informed the Trust's public health strategy.