Fast food and takeaway outlets toolkit

Takeaways Toolkit Tools, interventions and case studies to help local authorities develop a response to the health impacts of fast food takeaways A London Food Board and Chartered Institute of Environmental Health publication Based on a consultancy report by Food Matters Updated June 2014 In 2010 the issue of fast food takeaways hit the headlines when a number of London Boroughs introduced new approaches to planning regulation in an attempt to control the proliferation of fast food outlets. These measures sparked debate and prompted a number of high profile legal challenges. This toolkit has been created in response to these debates. It was felt by members of the London Food Board and the Chartered Institute of Environmental Health (CIEH) that there was a need to gather the evidence on the case for action and to help local authorities understand the range of tools at their disposal in tackling the public health impacts of fast food. It also aims to show that there is both a carrot and stick approach to this issue – that engaging positively with takeaways to help them improve their business competitiveness as well as the healthiness of their food is as important as developing clear planning guidance and It is hoped that this toolkit will provide the information necessary for local authorities to build their own programme of activities to improve the health of the food on offer in their high streets. Each local authority will have different needs and some activities will suit some more than others. It is also envisioned that the most effective response will entail action on a number of fronts that will reinforce each other and build the widest possible base of support for improving the diet of local populations. Fast food has become a defining symbol of the modern age. As the pace of life has increased so has our hunger for fast, convenient and takeaway foods. As traditional modes of shopping have declined the high street baker and butcher have been replaced by global chains and local, independent fast food stores. These are often seen by town centre planners as an important part of the economic vibrancy of a high street. Often run by local entrepreneurs, many from ethnic minority communities and employing local people they fulfil an important local economic and community function. However, as the modern world begins to wake up to the threat of a growing obesity epidemic more and more people have been turning their attention to the impact this food has on the health of the population. There is much to be done at a London and national level to tackle the problem of rising levels of obesity. This is but one initiative amongst many. The London Food Board and the CIEH welcome the opportunity to work with a wide range of stakeholders in this endeavour and hope that this toolkit can be a catalyst for strengthening partnerships to affect positive change in the long term. Rosie Boycott and Graham Jukes The London Food Board, the CIEH and the Mayor of London are acutely aware of the impact that access to unhealthy food is having on the rising rates of obesity and health inequalities. Fast food takeaways are by no means solely responsible for this crisis. In fact the problem is multifaceted and complex. Attempts to tackle the problem will in turn need to be complex and require a whole systems approach. However, what is clear from the outcomes of the research that has gone into this toolkit is that fast food takeaways provide a source of some of the unhealthiest food that is available within our communities. If progress is to be made in curtailing the rising levels of obesity within the population the London Food Board and the CIEH believe that action is needed to limit the availability of the worst examples of this food – especially to vulnerable communities such as children. Action to address the public health impacts of takeaway food will necessitate both engagement with industry alongside increasing partnership approach across local authority services. The aim of the Takeaways Toolkit is to help local authorities to develop strategies and programmes to tackle the impacts of fast food takeaways in their local communities. The toolkit is specifically targeted at those working in environmental health, trading standards, public health, education and planning. This toolkit is a web based resource and is available on the CIEH Food Vision nd London Food Boa Recommendations
This toolkit recommends a three pronged approach.
1. Local authorities should work with takeaway businesses and the food industry
to make food healthier
Through the use of information, training and advice as well as promotion of awards and schemes such as the London based Healthier Catering Commitment we recommend that local authorities – through the Environmental Health Teams - support businesses to improve the healthiness of the food they offer while helping the business itself to save money. Environmental health teams working in local authorities are ideally positioned to work with takeaway businesses to encourage healthier eating and diets. EHPs visit a wide range of food premises on a regular basis to conduct food safety inspections giving them ‘an access route' to provide information, training and advice.
2. Schools should introduce strategies aimed at reducing the amount of fast food
school children consume during lunch breaks and on their journey to and from
We recommend a ‘stay on site' approach to lunches that can help prevent children from accessing unhealthy food at lunch time. At the same time we recommend schools engage in work that improves the quality of their school meals and dining experience to attract young people back to school meal provision. We also recommend that schools (including academies) adhere to the national nutritional standards as advocated by the School Food Trust. 3. Regulatory and planning measures should be used to address the proliferation
of hot food takeaway outlets
We recommend that local authorities utilise to the best of their ability existing regulatory resources to encourage good practice within the takeaway sector. This can include the introduction of street trading policies, increased enforcement of hygiene standards, waste regulations and odour control. In areas of over concentration of fast food takeaways or where vulnerable groups such as children and young people are a concern we recommend the promotion of clear guidance in planning policies that allow the restriction of fast food takeaways. These policies should be well thought through and evidence based. Boroughs who perceive take away proliferation as an issue should ideally articulate their approach to planning controls in their local development frameworks. This should be accompanied with a thorough articulation of the policy in a development plan document, supplementary planning document (SPD), or supplementary planning guidance (SPG). Boroughs where the local development framework has already been completed can look to develop SPGs or SPDs on this specific issue. How to use the toolkit The Toolkit is arranged into four sections and is not intended to be read in a single sitting. Rather, each section contains information that will help with the different stages of planning, developing and running local strategies and programmes. Section 1 – provides an overview of the research and evidence of the public health impacts of takeaway food outlets. Information is provided on: the growth of the fast food sector; how this increase in food outlets can contribute to the growing issue of obesity and other health problems in adults and particularly in children; and the health issues associated with a diet over reliant on fast food. Section 2 – provides an overview of the local and national policy drivers relating to food and health which have relevance to fast food takeaways and the school fringe. Understanding these policy drivers will help local authorities build their own case for action and design interventions that fit the legislative environment. Section 3 –gives information and guidance on how to develop evidence for a local case for action; how to develop an evaluation framework and local partnerships for supporting the implementation and monitoring of effective interventions, as well as case studies from a number of local authorities. Section 4 – looks at the range of tools available to local authorities and their partners that can help tackle the health impacts of fast food takeaways. These include: the use of planning controls to tackle the increasing numbers of fast food outlets; regulatory measures and linked voluntary initiatives; working with schools to reduce the likelihood of children eating fast food at lunch times and on the way in and out of school; and working with business to improve the healthiness of the food they offer and to help them reduce the impacts they can have on local communities due to problems associated with noise, litter and antisocial behaviour. This section also provides a comprehensive listing of examples of local interventions and includes links to locally developed resources. The case for action Local authorities need to be aware that fast food takeaway diets can be a contributing factor in the rise of childhood obesity and other major health problems.  Diet has changed markedly over the past two decades and one of the major changes has been more food eaten outside the home  Dietary change has included greater demand for fast food takeaways which frequently produce meals such as fried chicken and chips, which are high in fat, saturated fat and salt and low in fibre, fruit and vegetables  Fast food outlets are proliferating, with some evidence suggesting a correlation between increased density and deprivation.  The increase in fast food outlets will be a contributory factor in the growth of the obesogenic environment  There are particular concerns about the impact of fast food takeaways close to schools.  Diets high in sugar, fat, saturated fat, salt and low in fruit and vegetables are a major contributor to health problems including obesity, cardiovascular disease, type 2 diabetes, stroke and some cancers  Such ‘junk food' diets may also be a major factor in low levels of some micronutrients in children's diets  Fried fast food may contain unacceptable levels of trans fats, which significantly increase risk of cardiovascular disease  There is growing concern that ‘junk food' diets contribute to children's negative

Our changing diet
Diets and attitudes to food have changed markedly over the past two decades and continue to evolve. While on the one hand people aspire to eat more healthily, there is greater demand for convenience foods and the food we eat outside the home makes up an increasingly important part of our diet. The average person eats one in every six meals out of home. Men on average consume about a quarter of their calories when eating out, and women around a fifth. Takeaways provide just over a quarter of the food in the eating out market1. The average adult diet contains too much salt, saturated fat and sugar and less fruit and vegetables, whole grains and oily fish than is recommended for an optimum balanced diet. The average British child's diet is similarly unbalanced, but children tend to consume more In October 2011 the Scientific Advisory Committee for Nutrition (SACN) revised the energy intake recommendations for the first time in twenty years. The estimates for children up to age 10 have decreased, whereas they have increased for adolescents and adults of all ages. Despite these increased estimations for both adolescents and adults, most people are still eating more calories than the new guidelines recommend and not expending enough energy to use the surplus, with overweight and obesity being the net result. 1 The Strategy Unit (2008). Food Matters – Towards a Strategy for the 21st Century. The government's recommendation of eating at least 5 portions of fruit and vegetables a day was attained by only 25% of men and 29% of women in 2008. Among children age 2-15, only 19% of boys and 20% of girls met the 5-a-day target. Although over recent years the trend has been an increase in numbers of people attaining the 5-a-day target, Food Matters showed that low income groups eat on average one or more portions of fruit and vegetables a day fewer than the general population. This is all set in a backdrop of increasing food prices that have been passed down to the consumer. People on low incomes continue to devote a significantly greater proportion of their income to food than people who are better Such socioeconomic and age-specific differences in diet relate not only to price-sensitivity but also differing attitudes to food, as well as issues of food accessibility. The Burger Boy report published by Barnardos in 2004 identified that children's food choices were strongly influenced by gender and income-related media stereotypes. ‘Fast food' was identified by children as being the most tasty and desirable food. Children, with their positive attitudes to fast food honed by media stereotypes, together with the relative lack of parental control over what they eat, are likely to be at risk from the health threats posed by the fast food takeaway proliferation2. The rise of the fast food takeaway Consistent evidence indicates that fast food takeaway chains have flourished over recent years reflecting the nation's growing taste for highly palatable, energy dense, effortless food3. Studies demonstrate that this increase is concentrated in city centres and along arterial routes4, 5. In Coventry between 1978 and 2008, despite the number of traditional fish and chip shops dropping from 61 to 31, the total number of fast food outlets increased from 27 to 1416. An article appearing in the Guardian, Britain's fried-chicken boom, reports fried chicken as the fastest growing of all fast foods, with fried chicken sales growing by 36% between 2003 and 2008, compared to 22% for fast food sales as a whole7. A number of studies have found that takeaway food outlets are often located in areas of higher socioeconomic deprivation. The National Obesity Observatory (NOO) have found that although the concentration of fast food outlets and takeaways varies by local authority in England, there is a strong association between deprivation and the density of fast food outlets. With more deprived areas having more fast food outlets per 100,000 population8. The density of the ‘big four' fast food chains is greater in the more deprived areas in England and Scotland9. Research by the University of Leeds found that takeaways tended to be clustered in parts of the city where unemployment is highest10. A Food Standards Agency 2 Ludvigsen, and Sharma (2004). Burger boy and sporty girl: children and young people's attitudes towards food in school. Barnardo's. 3 Libman, Freudenberg, and O'Keefe (2010). A tale of two obescities: comparing responses to childhood obesity in London and New York City. 4 Macintyre S, McKay L, Cummins S, Burns C. 2005. Out-of-home food outlets and area deprivation: case study in Glasgow, UK. International Journal of Behavioral Nutrition and Physical Activity 2(1), 16. 5 Caraher, Lloyd, and Madelin (2007). Fast-Food in Tower Hamlets. City University, London. 6 McDonalds and Allegra Strategies (2009) Eating out in the UK 2009: A Comprehensive Analysis of the Informal Eating Out Market. Allegra, London. 7 The Guardian, Friday 18 February 2011.
8 National Obesity Observatory website. Obesity and the Environment: Fast Food Outlets 9 Macdonald L, Cummins S, Macintyre S (2007) Neighbourhood fast food environment and area deprivation—substitution or concentration? Apetite 49:251-254. 10Fraser L and Edwards K (2010) commissioned study found that eating out at a chip shop was associated with lower socio- economic position, lower dietary knowledge and worse dietary indicators11. However, the question of whether socially deprived areas have more fast food outlets and less access to cheap healthier food remains contentious with some research indicating that not all poor communities are disadvantaged in this way. In Glasgow, for instance, fast food outlets are not concentrated in poorer residential areas, but instead in the central business district, West End, in retail parks and along arterial roads12. Takeaway foods often have high levels of salt, sugar, fat and saturated fat. Consumer group Which? tested the calorie, sugar, saturated fat and salt found in Chinese, Indian and pizza takeaways and rated each meal against the recommended daily allowance. Researchers found that a single Indian takeaway could contain as much as 23.2g of saturated fat, more than the recommended 20g maximum allowance a woman should eat in a day13. It is well known that a diet high in salt, sugar, fat and saturated fat can contribute to a number of negative health outcomes including obesity. Obesity is a growing worldwide problem and the United Kingdom is no exception to this. Energy dense ‘junk food', increasing portion sizes, the drinking culture and sedentary lifestyles all contribute to the growing problem of obesity. The National Obesity Observatory estimated the cost to the UK economy of overweight and obesity to be £15.8 billion per year (2007)14. In 2008, almost a quarter of adults (24% of men and 25% of women aged 16 or over) in England were classified as obese (BMI 30kg/m2 or over). A further 42% of men and 32% of women were classified as over weight (BMI 25kg/m2 up to BMI of 30kg/m2). Amongst children age 2-15, 16.8% of boys and 15.2% of girls were classed as obese while 14.6% of boys and 14% of girls were classified as overweight15. Overweight and obesity are linked to many health risks and risk tends to increase with increasing BMI and waist size. Obesity-related health problems include type 2-diabetes, cardio vascular disease and some cancers16, 17. Higher rates of obesity have been associated with living in a low income or deprived area. The National Child Measurement Programme (2011) for example, demonstrates that childhood obesity is closely linked to socioeconomic deprivation. However, the specific causal factors have not yet been established and can as yet only be surmised18. 11White D et al (2002). Do Food Deserts exist? University of Newcastle. 12 Macintyre S (2007) Deprivation amplification revisited; or, is it always true that poorer places have poorer access to resources for healthy diets and physical activity? International Journal of Behavioral Nutrition and Physical Activity 2007, 4:32. 13Which? (2008) Pilau Talk. 14 Butland, Jebb, Kopelman P, et al. (2007). Tackling obesities: future choices – project report (2nd Ed). London: Foresight Programme of the Government Office for Science. 15 Statistics on obesity, physical activity and diet: England (2010). The NHS Information Centre. 16 Dietz W (1998). Health consequences of obesity in youth: Childhood predictors of adult disease. Pediatrics 1998;101:518–525. 17 Must, and Anderson (2003). Effects of obesity on morbidity in children and adolescents. Nutr Clin Care 2003;6:1;4–11. 18 National Child Measurement Programme: Child obesity statistics for PCT clusters (2011). National Obesity Observatory. A number of studies have linked the fast food environment and health19, though a clear relationship between fast food restaurants and obesity rates is less obviously demonstrated. For example, one study has suggested that living close to fast food takeaway outlets is not associated with rates of obesity and weight gain20, whereas other studies have found that an increased density of fast food restaurants is directly related to increased BMI21 and that having a fast food outlet within 160m of a school is associated with a 5% increase in Other aspects of an energy dense, nutritionally imbalanced diet can also contribute to the risk of disease. High levels of salt contribute to increased blood pressure, a risk factor for stroke. Saturated fats can increase levels of cholesterol in the blood, which is a risk factor for coronary heart disease (CHD). Trans fats can also raise cholesterol in the blood and are potentially more dangerous than saturated fats as trans fats lead to a lowering of the "good" HDL cholesterol as well as raising the "bad" LDL cholesterol. "On a per calorie basis, trans fats appear to increase the risk of CHD more than any other macronutrient, conferring a substantially increased risk at low levels of consumption (1 to 3 percent of total energy intake)"23. Despite many larger food companies pledging to remove artificial trans fats from their products on a voluntary basis, there remains a potential health risk from trans fats found in food sold by independent fast food takeaways. The World Cancer Research Fund compiles information on diet relating to cancer and makes recommendations based on the current weight of evidence. They have found that high levels of salt in the diet can increase the risk of stomach cancer24. In recent years there have been a growing number of studies looking at the effects of various aspects of diet on behaviour, in particular the behaviour of children25. Some evidence is stronger than others in this fast developing, but still fairly young area of research. One study conducted by Southampton University on behalf of the Food Standards Agency was so conclusive, it prompted them to alter their advice on artificial additives26. The study showed that some artificial additives in combination, in particular certain colours and one preservative sodium benzoate, could have a significant detrimental effect on the behaviour of children prone to hyperactivity. A voluntary ban on the six food colours identified by the Southampton University research was agreed by Ministers in November 2008. Behaviour problems have been linked to imbalances of different types of fats27. A lack of dietary omega-3 (found primarily in oily fish) is thought to be associated with negative 19 USDA Nutrition Evidence Library 20 Dolton P. (2010). Childhood obesity in the UK: is fast food a factor? Lessons to Take-Away Conference. 30 June 21 Mehta NK, Chang VW. Weight status and restaurant availability: a multilevel analysis. American journal of preventive medicine 2008;34(2):127-33. 22 Currie; DellaVigna; Moretti; Pathania (2010). The Effect of Fast Food Restaurants on Obesity and Weight Gain. American Economic Journal: Economic Policy, Vol 2, Number 3, August 2010, pp. 32-63(32). 23 Mozaffarian D et al (2006) Trans Fatty Acids and Cardiovascular Disease. New England Journal of Medicine 24 World Cancer Research Fund 25 Food and Behaviour Researc 26 Food additives and children's behaviour (2008). Food Standards Agency 27 Associate Parliamentary Food and Health Forum (2008). The links between diet and behaviour: the influence of nutrition on mental health. behaviours including depression, anxiety, anger, hyperactivity and impulsive behaviour28. Trans fats in the diet are suggested by some to be linked to negative behaviour. Any effect on brain chemistry is of particular concern in children since the brain continues to develop through the teens so is likely to be more susceptible. Low levels of other micronutrients in the diet have also been associated with negative mood and behaviour, for example folic acid and zinc26. Recent results from the National Diet and Nutrition Survey (NDNS)29 identified children's average intakes as being below the Reference Nutrient Intakes (RNIs) for some minerals, in particular, iron, magnesium, potassium and selenium. Selenium is important for the immune system and may affect susceptibility to infection; low iron can cause difficulty in concentrating, tiredness and poor cognitive performance. Further information on the links between diet and behaviour are available on the Food and Behaviour Research website24. The prevalence of dietary related diseases varies between different ethnic groups in the UK. The British Heart Foundation have reported that heart attack rates are higher for South Asians compared to the rest of the population and stroke rates are higher in the Black ethnic group than in the White ethnic group. Black Caribbean, Indian, Pakistani and Bangladeshi men have considerably higher rates of diabetes than the general population. Comparisons of obesity between ethnic groups is difficult since fat is stored in different ways amongst different ethnic groups. Also, body shapes and heights differ and height skews BMI30. 28 Hibbeln J (1998). Fish consumption and major depression. The Lancet. 351: 1213. 29 National Diet and Nutrition Survey. Department of Health 30 Ethnic Differences in Cardiovascular Disease (2010) British Heart Foundation. Resources Statistics on obesity, physical activity and diet: England, 2010 Dietary Recommendations for Energy (SACN) Food Matters- Towards a Strategy for the 21st Century Burger Boy and Sporty Girl (2004) British Heart Foundation World Cancer Research Fund Food and Behaviour Research Britain's Fried Chicken Boom (Feb 2011) The Guardian Food Standards Agency artificial additives study (2007) This section summarises the local and national policy drivers relating to food and health which have relevance to fast food takeaways and the school fringe. Understanding these policy drivers will help local authorities build their own case for action and design interventions that fit the legislative environment. Policies are also a good source of up to date evidence of the harm being caused and the need for actions and where these should best be targeted.
Relevant Directives/Recommendations
National policy drivers Coalition Government
Prevention of cardiovascular
disease at population level Progress towards a low-salt diet needs to be accelerated as a matter of urgency  Ensure food producers and caterers continue to reduce the salt content of commonly consumed foods  Ensure low-salt products are sold more cheaply than their higher salt equivalents  Clearly label products which are naturally high in salt and cannot meaningfully be reformulated  Discourage the use of potassium and other substitutes to
Saturated fat
 Reduce population-level consumption of saturated fat.
 Encourage manufacturers, caterers and producers to reduce substantially the amount of saturated fat in all food products. If necessary, consider supportive legislation. Ensure no manufacturer, caterer or producer is at an unfair advantage as a result  Create the conditions whereby products containing lower levels of saturated fat are sold more cheaply than high saturated fat products. Consider legislation and fiscal levers if necessary
Trans Fats
 Ensure all groups in the population are protected from the harmful effects of Industrially Produced Trans Fatty Acids (IPTFAs), since certain sections of the population may be consuming a substantially higher amount of IPTFAs than average (for instance, those who regularly eat fried fast-food)  Eliminate the use of IPTFAs for human consumption  Establish guidelines for local authorities to monitor independently IPTFA levels in the restaurant, fast-food and home food trades using existing statutory powers (in relation to trading standards or environmental health)  Encourage the use of vegetable oils high in polyunsaturated and monounsaturated fatty acids to replace oils containing IPTFAs. Saturated fats should not be used as an IPTFA substitute
Fast food outlets
• Empower local authorities to influence planning permission for food retail outlets in relation to preventing and reducing CVD • Encourage local planning authorities to restrict planning permission for takeaways and other food retail outlets in specific areas (for example, within walking distance of schools). Help them implement existing planning policy guidance in line with public health objectives • Review and amend ‘classes of use' orders for England to address disease prevention via the concentration of outlets in a given area
Implementation of CVD Prevention Programme
A comprehensive regional and local CVD prevention programme is set out in the guidance, with action to be  City region partnerships  Government regional offices  Local authorities  Local strategic partnerships  Non-governmental organisations, including charities and community groups  Strategic health authorities The Public Health Responsibility States:  The Government's approach to improving health should be wider than simply considering what Government can do, and is based on the following actions: Positively promoting ‘healthier' behaviours and Adapting the environment to make healthier choices Strengthening self-esteem, confidence, and personal  The Responsibility Deal taps into the potential for businesses and other organisations to improve public health and to tackle health inequalities through their influence over food, physical activity, alcohol, and health in the workplace  Businesses signing up to the ‘deal' will sign up to 5 core commitments, collective pledges and individual pledges. Current work is focused on large food providers but the Department of Health are planning on rolling the programme out to small businesses if results from the evaluation of the programme are favourable Healthy Lives, Healthy People: A States: call to action on obesity in  Government, local government and key partners to act to change the environment to support individuals in changing their behaviour  From 2013, upper tier and unitary local authorities will receive a ring-fenced public health grant to fund their new public health responsibilities. Local areas will have the freedom to spend money in the way they think will best meet the needs of their community, achieves public health outcomes and is in line with specific conditions that will be attached to the use of the grant  Opportunities for local government include: Making the most of the potential for the planning system to create a healthier built environment Working with local businesses and partners to increase access to healthier food choices  Effective local action on obesity requires a wide coalition of partners to work together in order to create an environment that supports and facilitates healthier choices by individuals and families  Partners to be given the opportunity to play their full part – e.g. by building on the part that the food and drink industry can play through the Responsibility Deal, particularly in relation to helping to reduce our collective  Local government to be given the lead role in driving health improvement and harnessing partners at local level as set out in Healthy Lives, Healthy People and, giving it freedom to determine the local approaches which work best for local people and for specific population groups facing the greatest challenges  The approach turns on its head the perception, held by some, that obesity is Government's problem to solve: "The solution lies in each of us taking responsibility for our health and taking appropriate action to manage our weight, with local and central government, and a wide range of delivery partners, providing integrated and tailored support to help us with a challenge which many of us struggle to tackle alone."  We will favour interventions that equip people to make the best possible choices for themselves, rather than removing choice or compelling change  Focusing on children alone will not adequately address the existing and growing burden of adult overweight and obesity  Given the different levels of risk faced by different groups, it is vital that action on obesity reduces health inequalities. Particular attention needs to be given to specific socio-economic and ethnic groups and to disabled people and people with mental health needs  "While we do not believe it is right to remove choices or mandate what people should eat or drink, there are some groups in society where there is a clear duty of care and more stringent action by Government and others may be warranted, especially in relation to children or other vulnerable groups."  Power and initiative to be put in the hands of schools themselves. The Government's role is to support schools to tackle obesity and other lifestyle issues by helping them to access the best evidence and through professional development Localism Act 2011 The Localism Act contains a number of proposals to give local authorities new freedoms and flexibility to meet local people's needs. This includes:  A ‘general power of competence' which will give local authorities more freedom to take action in the interests of their areas, reflecting the priorities of local people  Provisions to make the planning system clearer, more democratic, and more effective. Neighbourhood planning will allow communities, both residents, employees and business, to come together through a local parish council or neighbourhood forum and say where they think new houses, businesses and shops should go – and what they should look like These powers provide local authorities with greater opportunities to address the development of new fast food outlets in their local area. Public Health Outcomes Central to the Government's approach to the new public health arrangements in England is to move away from targets and focus instead on outcomes. The Department of Health has published the Public Health Outcomes Framework which sets out a comprehensive plan of the outcomes and the indicators that will apply. It is essential that local authorities, Clinical Commissioning Groups (CCGs) and Health and Wellbeing Boards have regard to this outcomes framework in setting the local health and wellbeing strategy as future performance will doubtless be measured against its content. The public health outcomes framework offers a broad range of opportunities to improve and protect health across the life course and to reduce inequalities in health by tackling determinants of lifestyle diseases. Many of the proposed indicators are relevant to fast food takeaways including:  2.12 Excess weight in adults  2.17 Recorded diabetes  4.3 Mortality from causes considered preventable  4.4 Mortality from all cardiovascular diseases Health and Social Care Act 2012 The Health and Social Care Act places local government at the core of the health and care service with statutory responsibility for commissioning public health services:  The Marmot agenda, addressing the wider determinants of health and wellbeing through a life-stages approach will be the basis for the new public health service  Directors of Public Health will lead the new service within local authorities  Local authorities are tasked with establishing health and wellbeing boards. Through these boards local authorities will work with local partners, including the NHS, to determine local joint health and wellbeing strategies to meet the needs of their local area  Local authorities and new Clinical Commissioning Groups (CCGs) will be under a legal duty to involve their local communities in producing the local strategy and the Joint Strategic Needs Assessment which will underpin it National Planning Framework The National Planning Policy Framework provides a framework within which local people and their accountable councils can produce their own distinctive local and neighbourhood plans, which reflect the needs and priorities of their communities. The framework replaces all other national planning documents (previously 47 separate documents) and aims to make the planning system less complex and more accessible, and to promote sustainable development. The framework also supports neighbourhood planning, as laid out in the Localism Act. With regard to health, the framework states that planning  Take account of and support local strategies to improve health, social and cultural wellbeing for all, and deliver sufficient community and cultural facilities and services to meet local needs  Local planning authorities should work with public health leads and health organisations to understand and take account of the health status and needs of the local population (such as for sports, recreation and places of worship), including expected future changes, and any information about relevant barriers to improving health Supplementary planning documents (SPDs) can be used to provide further guidance for development on specific sites, or on particular issues, such as design and can be taken as a material consideration in planning decisions. The framework does not over-ride existing SPDs as long as they are not in conflict with it. Local planning authorities should assess the likely cumulative impacts on development in their area of all existing and proposed local standards, SPDs and policies that support the development plan. The use of SPDs to limit development of fast food outlets is specifically recommended in Healthy Lives, Healthy People. National policy drivers Labour Government
Tackling Obesities: The
This report examines where councils can use their local Foresight Report and leadership role to positively change obesity levels and create Implications for Local healthier environments.  Local authorities to employ 'place-shaping' - to model effective leadership in responding to the major challenge  A bold whole systems approach is critical and one that requires integrated policies and actions with local authorities taking a wider strategic role using their powers and influence creatively to make a difference  Local authorities to use their Sustainable Community Strategy as a critical planning tool to develop a local strategy to reduce obesity Food Matters: Towards a One of the key strategies identified was "making it easier for Strategy for the 21st Century consumers to make healthy choices when eating out".  Catering commitments - working with caterers to provide healthier options to consumers. Including reducing the amount of fat, salt and sugar in popular dishes and providing a wider range of healthier options  Engaging small businesses – guidance was developed for different sectors, such as fish and chip shops, and Indian restaurants, and which provided simple, practical actions small business owners can take to make the foods they offer to consumers healthier. (See the section on for more information) The Strategic Review of Health Policy objective: Create and develop healthy and sustainable Inequalities in England post places and communities: 2010 (The Marmot Review) 1. Prioritise policies and interventions that reduce both health inequalities and mitigate climate change, by: Improving the food environment in local areas across the social gradient. 2. Fully integrate the planning, transport, housing, environmental and health systems to address the social determinants of health in each locality. Policy objective: Strengthen the role and impact of ill-health 1. Implementing an evidence-based programme of ill health preventive interventions that are effective across the social gradient. 2. Improve programmes to address the causes of obesity across the social gradient. 3. Focus core efforts of public health departments on interventions related to the social determinants of health proportionately across the gradient. Local policy drivers for London The Mayor is committed to working with partners to:  Motivate and enable Londoners to adopt healthier behaviours and engage in lifelong learning  Promote community development approaches to improve health, and actively support the role of the third sector The Healthy Schools London programme launched in April 2013 helps support London's schools to provide an environment and culture that helps their pupils grow up to be a healthy weight, and support their wider health and Central to this programme is an award scheme sponsored by the Mayor of London. There are three levels of award: Bronze, Silver and Gold. The tiered structure of the award is designed to help schools to progressively build on their policies and practice over a period of time. Report recommends:  Use zoning authority, land use review and other municipal authority to limit access to fast food and the promotion of unhealthy foods to children  Use zoning, tax incentives, and city owned property to increase the availability of healthier, affordable, and culturally appropriate food in neighbourhoods where it is  Implement a universal free school meal programme with nutritional standards that promote health With regard to planning and health:  The detailed design of neighbourhoods is also very important for health and well-being. This can be complemented by other measures, such as local policies to address concerns over the development of fast food outlets close to schools  This approach of controlling numbers of fast food outlets in sensitive locations is further endorsed in the London Plan's Town Centre Retail SPG (Draft). See One of 5 Strategic Objectives:  To improve Londoner's health and reduce health inequalities via the food they eat Local policy drivers Health and Wellbeing Boards At the local level, the new public health structures put local government in charge of driving health improvement and addressing the wider determinants of health. Health and wellbeing boards are statutory bodies and the key vehicle for bringing about this system change. They have a duty to produce a joint health and wellbeing strategy (JHWS) for the local area. This JHWS will determine polices for improving the health of local populations and the Marmot review principles will be at the heart of the strategy. These policies will feed down into individual Council's corporate objectives and actions. Health and wellbeing boards will promote joined up commissioning that will support integrated service provision by pulling together the work done by the NHS, social care, housing, environmental health, leisure, transport services Joint Strategic Needs The priorities for local Health and Wellbeing Strategies will be Assessment (JSNA) informed through a JSNA. Most areas are working to improve their JSNAs to reflect requirements laid out in the white paper ‘healthy lives, healthy people'. The JSNA now requires:  An assessment of assets, such as community resources, as well as an assessment of need  Wider stakeholder representation to ensure that services will be shaped by local needs  Broadening to include areas not previously considered such as housing, environmental health and transport.  A move from presentation of data only, to more detailed analysis, prioritisation and recommendations for evidence based interventions The importance of addressing childhood obesity features in many JSNAs and the need for review offers an excellent opportunity to ensure that work with fast food takeaways is taken into account. 31 The Local Government Association and Department of Health have published a very useful resource "From transition to transformation in public health" which outlines the new structures for public health in England. See: Developing a case for local action  Comprehensive summaries of the evidence for tackling obesity and the associated health risks at a local authority level are available and can be summarised to produce a case for  Research studies and surveys can help local authorities build a case for taking action to reduce the impact of fast food takeaways in their area  Joint Strategic Needs Assessment Reports and local health, lifestyle and deprivation statistics can help build a picture of area specific issues  Small surveys and mapping exercises are easy to organise and can be built into local capacity, by being carried out by Food Safety Teams  Larger research studies carried out in collaboration with local academic institutions can produce more in-depth data but may need additional funding  Successful interventions require overall leadership and a steering group to bring together all partners and help coordinate, plan and monitor implementation  A monitoring and evaluation process is essential to assess the effectiveness of interventions and to help develop practice-based evidence to inform future work.  Some studies that have been carried out are highlighted in this section, with additional commentary on the value of these studies and any lessons learnt

The need for evidence
A wide range of reviews and reports are available at the national and regional level which summarise the evidence of the health risks associated with obesity. These include: the Nice Public Health Guidance on the prevention of cardiovascular disease at population level32; the Foresight Report on tackling obesity33; and the reviews and evidence briefings highlighted in the National Obesity Observatory34. Many of the reports detailed in the Policy Drivers section and in the Resources section of each chapter of this toolkit will also help. A case for action should be built on an understanding of your local area and the health needs of the local population must be considered alongside a review of national evidence. A good starting point is the Joint Strategic Needs Assessment reports on the health and wellbeing needs of your local authority area. These will provide quantitative and qualitative information to support your case for action. Tproduces health profiles for local authorities and for counties. The profiles include statistics such as childhood and adult obesity, health inequalities and areas of deprivation. Each profile includes a map showing levels of deprivation within the locality, which is a useful tool to use alongside an exercise mapping the location of fast food takeaways within the area. 32 National Institute of Clinical Excellence (2010). Prevention of cardiovascular disease at population level. NICE Public Health Guidance 25 33 Aylott J et al (2008). Tackling Obesities: The Foresight Report and Implications for Local Government. Sheffield Hallam University. 34 National Obesity Observatory Theprovides Neighbourhood Statistics on wide ranging topics including health, income and lifestyles, economic deprivation and ethnic mix. Developing a project to gather evidence Research studies and surveys help to understand the problem in your area and to build up a case for local action. Existing studies, like those described in the section below, can act as useful models to develop local evidence gathering projects. Conversations with other local authorities who have carried out their own projects can be helpful to find out what worked for them and what improvements they might make if they repeated the exercise. Look out for conferences on takeaways which enable the exchange of research information and ideas between local authorities. Local academic institutions can be valuable partners for bigger projects in order to develop robust protocols and to analyse data. Dieticians or public health nutritionists are also important partners in advising on nutritional analysis and current evidence based healthier eating guidelines. Environmental Health Officers and Trading Standards Officers are often well placed to carry out research involving fast food outlets because they are already likely to have contact with the proprietors. Surveys and research studies can be broadly divided into:  Nutritional analysis  Dietary analysis  Analysis of purchasing behaviours Some studies may include two or more of these techniques. Mapping looks at the numbers and concentration of certain types of food outlets. Nutritional analysis looks at the nutritional composition of foods. This can be done by biochemical analysis or by analysis using food composition tables (which can be less accurate). Dietary analysis looks at the nutritional content of the food consumed by individuals over a single meal, a whole day or multiple days. This can be done by analysis using food composition tables of food diaries and food frequency questionnaires, or by the biochemical analysis of food samples. Analysis of purchasing behaviour can involve: surveyors visually observing and recording purchases, interviewing consumers and retailers, completion of questionnaires by consumers and retailers, and by examining till receipts. Thewebsite features a useful section on evidence gathering. Partnership and local leadership Successful interventions are likely to involve a multi-agency group to help coordinate, plan and monitor implementation. Identifying who needs to be involved, and investing time and effort in developing relationships with these people, is vitally important. This involves both setting up a steering group or core team who will take responsibility for driving the project forward, and identifying and developing constructive links with other key stakeholders who have an important role to play35. 35 National Social Marketing Centre. Planning Guide. Ideally the steering group will have decision-making powers and report to the chief executives or senior managers of the organisations involved. The group may be involved in the processes for joint strategic needs assessment, local development frameworks, various commissioning groups or the health and wellbeing partnership boards36. It is also important to designate a senior-level lead to drive forward implementation. Many areas have set up food partnerships to develop a strategic approach to food in the local area. These bring together community organisations, statutory agencies, local businesses and individual residents and provide practical examples of successful local partnerships. Examples include:  The Camden good food partnership  Brighton and Hove food partnership -  Bristol food policy council -  Wigan healthy business team - To maximise the effectiveness of interventions it is essential to develop a monitoring and evaluation framework. The aim of evaluation is to identify the strengths and weaknesses of an intervention, determine if it is having an impact, and measure its return on investment. The evaluation method should be decided earlier in the planning process and should gather the type of data that will allow you to measure success or failure against the original aims and objectives. The key areas to evaluate should be agreed among the partners to reflect their different agendas. It is also important to ensure adequate funding is set aside for As well as the outcomes, the actual process of the intervention should be assessed. All of this information can be combined in an evaluation report setting out the original objectives, the methods used, the outcomes identified and recommendations for further action. There are a number of useful resources to help develop an evaluation that is realistic and fit for purpose. These are listed in the Resources section below and include the National Social Marketing Centre (NSMC) planning guide, the National Obesity Observatory resources on evaluation and the Department of Health healthy weight, healthy lives toolkit for developing local strategies. Using these methods and materials will help standardise evaluations and the published evaluation report will be an important addition to the evidence base from which others can learn and innovate further. Specific studies related to fast food takeaways 36 National Institute for Health and Clinical Excellence (2008). How to put NICE guidance into practice to improve the health and wellbeing of communities: Practical steps for local authorities. Interim report. Below are some of the studies that have been carried out involving fast food outlets and takeaway restaurants, which can be referenced in the evidence stage of making a case for  All fast food retailers need to be taken into consideration when assessing the impact of food bought within the school day on children's diets. ‘Junk food' such as crisps, sweets, cakes, biscuits and fizzy drinks need to be considered alongside fast food takeaways  School children often visit local shops to buy food before and after school as well as lunchtimes, if they are able to leave school then. Children who are allowed out of school at lunchtime visit local shops more frequently than children who are not  Children often purchase food from fast food takeaways several times a week  Fast food takeaways, newsagents, bakeries and local restaurants may target pupils with cheap, unhealthy special offers  Mobile fast food vans often target schools at lunchtimes and at the end of the day  Children may walk 800m or more to access shops at lunchtime  Children access food along their school journey as well as in the school fringe. In London children can hop on a free bus to reach the cheapest takeaway  School stay on site policies and cashless lunch systems reduce opportunities for school children to make purchases in the school fringe  Fast food takeaway meals tend to be high in calories, fat, saturated fat and salt.  Saturated fats are the most commonly used fats for deep fat frying in fast food  Fast food takeaway businesses may use a small number of cheaper suppliers and may be limited on their purchasing options Research Studies
Report details
Main findings
Brighton and Blackpool were at the top of the table with 46 and 40 junk food outlets This was a mapping per secondary school respectively. exercise which examined the ratio of ‘junk food The urban average per school was 25 outlets' to secondary compared to the rural average of 19. schools in 149 local The ‘North' average differed little to the ‘South' average with 24 and 23 outlets per school respectively. The School Fringe  A level of under-reporting of food eaten of more than 30% was identified This study looked at what from pupils' diaries and from school children buy from questionnaires compared to observed shops within the school  Fringe purchases contained on average 38% of calories from fat, compared with the Dietary Reference Value  Total carbohydrate intake was roughly on target at 52%. Much of that, however, was sugar. Salt was relatively low but pupils additionally added salt to takeaway products. The main problem of fringe purchases was seen to be high sugar  Overall pupils who bought food on the school fringe did so on average six times a week, or more than once a day. Those who were unable to leave the school at lunchtime still used the shops on average 3.6 times a week and the suburban sixth formers used the shops 8.8 times a week on average  Independent takeaways targeted school children with special offers, tending to be high in fat  There are 41.8 fast food outlets and sweet shops per school in the London Borough of Tower Hamlets Hot Food Takeaways near  Large volumes of pupils leave the Hove City Council school premises at lunchtime and purchase a variety of ‘unhealthy' foods This study examined the including chips, soft drinks including food purchasing behaviours energy drinks and chocolate of secondary school children  Hot food takeaways, newsagents and within the school fringe at supermarkets were all equally lunchtimes in Brighton and influential on the unhealthy food Chicken and Chips – What's London Borough  All samples were high in energy, salt, fat and saturated fat. For trans fats, the samples divided clearly into two This survey looked at groups, those with high levels of trans samples of chicken and fats and those with low levels (<10%) chips from fried chicken  This polarity relates to the difference in shops within the Borough of frying oil used, and those with high levels of trans fats could be using a hydrogenated vegetable oil for frying, possibly one called AVR-60 The School Foodshed  627 fast food outlets (FFOs), newsagents and grocery stores were The study aimed to gain as classed as selling ‘junk food' in Tower wide a picture as possible on the eating and buying  FFOs were concentrated along main behaviour of school children thoroughfares and tended to be in in London Borough of areas of higher deprivation Tower Hamlets, from fast  Older children tended to purchase food food outlets found within on the way to school in place of the school fringe and along breakfast including crisps, chocolate the journey to school.  The majority of schools operated closed gate policies at lunchtime so few purchases were observed then  Purchases after school tended to be high sugar and fat items such as crisps, fizzy drinks, ice-cream, muffins, chicken wings and chips.  Some children reported saving their ‘dinner money' to buy food from a takeaway on the way home from  22 children keeping food diaries recorded eating from FFOs, totalling 66 fast food takeaway meals and 20 sit down takeaway meals in one week, with a massive 16 meals attributed to  Children who reported low fruit and vegetable intake also had a higher percentage of their energy coming Fish and chips with a side  All samples except for two samples of order of Trans fat: The boiled rice and one sample of chicken nutrition implications of curry contained trans fats eating from fast food  Most of the samples contained trans outlets: a report on eating fats below the maximum out in east London recommended level of 2% of energy requirements, one sample contained This research investigated the percentage energy contribution as provided by trans fat from takeaway food in a teenage population in London Borough of Tower Hamlets. Kebab Houses and Burger Consensus Action  The majority of sample meals were Bars Feeding Our School on Salt & Health high in salt, fat and saturated fat and Children Unhealthy Meals had two or more red traffic lights This research analysed the  Only two meals, a chicken burger with nutritional content of school Environmental lettuce and a jerk chicken and rice, children's most popular contained only medium or low levels of meals bought from these and had only amber and green takeaway shops near 45 schools in 16 London  Many of the takeaway items were higher in fats and salt than comparable meals from fast food chains and markedly different to the schools nutritional guidelines  Trans fats were generally well within intake guidelines at low levels, with the exception of a few samples with noticeably higher levels Survey of the Composition Local Government  Meals were energy dense and high in of Certain Types of  The average energy per meal was 1405 Calories almost 3/4 of the daily This survey analysed the recommended energy intake for a nutritional content of Chinese and Indian  Despite the high levels of saturated takeaway foods surveyed in fats, 84% of the takeaways said they local authorities in England, were using low saturate vegetable oils Wales and Northern Ireland. and only 6% reported using butter  The average sweet and sour chicken was lower in fat (44.8g) and saturated fat (7.58g) than the Indian meals but higher in salt (7.12g). The average energy per meal was 1525 Calories, over three quarters of the daily recommended energy intake for a  A small but significant number of Tikka Masala sauce samples contained above the legally permitted levels of some artificial colours. These colours (Sunset yellow, Ponceau 4R) are among those that the Food Standards Agency recommended that children prone to hyperactivity should avoid An inconvenient sandwich:  Most businesses used a small number the throwaway economics of trusted suppliers. They used of takeaway food suppliers who would deal in small enough quantities to suit the business This study looked at how  They tended to use at least one big the nation's habit of casual wholesaler that delivered e.g. Booker, eating out of the home sits Nilla, JJs, as well as micro suppliers with the ideal of creating a and local shops when they ran out of more sustainable food things before the supplier could deliver system. As part of the  The interviewees felt that their choice research a sample of south of goods was limited by what the London independent café suppliers stocked and takeaway owners were  Choices were based on what interviewed about the customers wanted and were prepared factors that influenced their to pay and what the wholesalers had purchasing choices from  Some takeaways were served by a single supplier who met all their needs and was prepared to give them credit when they did not have the cash The Public Health Observatory Health Profiles Office of National Statistics – Neighbourhood statistics Food Vision - Evidence Gathering National Social Marketing Centre - Planning Guide National Obesity Observatory – Resources on Evaluation Department of Health – Healthy Weight, Healthy Lives: Toolkit for developing local strategies Lessons to Takeaway Conference Takeaways Unwrapped Conference School Food Trust Temptation Town The School Fringe The School Food Shed: a report on schools and fast food outlets in Tower Hamlets. Fish and chips with a side order of Trans fat: The nutrition implications of eating from fastfood outlets: a report on eating out in east London CASH - Kebab Houses and Burger Bars Feeding Our Children Unhealthy School Meals Local Government Group – Survey of the composition of certain types of takeaway food New Economics Foundation – An Inconvenient Sandwich Choosing Interventions Impacts of fast food outlet proliferation and opportunities for action The diagram above outlines the range of problems caused by the proliferation of fast food takeaways and indicates the possible entry points where local authorities can target interventions to tackle their health impacts. For best results, local authorities should consider a coordinated approach taking actions across a range of these settings. For example using planning activities alongside interventions with business to improve the health of food they offer and with schools to limit the impacts on children.  The Localism Act 2011 provides local authorities with more freedom to take action in the interests of their areas and could therefore make it easier to restrict the development of hot food takeaways  Several local authorities have developed supplementary planning documents (SPDs) to restrict the development of new A5 fast food premises within the school fringe  Many students are prepared to walk further than 400m to purchase food at lunchtime, the distance set as the exclusion zone by many local authorities  In London school children can take advantage of free public transport to reach fast food outlets outside the exclusion zone  The 400m exclusion zone is only relevant to lunchtimes and the time immediately before and after the school day. It does not take into account purchases along the school route
Many local authorities have developed planning policies which include actions to restrict the numbers of hot food takeaways based on planning guidance issued by the last Government. The Coalition Government has sought to simplify planning policy and localise decision making through the Localism Act 2011 and the National Planning Policy Framework. Whilst these changes will require local government to re-examine the compatibility of existing local plans with the revised framework, the changes are unlikely to require any significant change to existing approaches to restrict the numbers of fast food outlets. As outlined in the Policy Drivers section, the freedoms and flexibility to meet local communities needs could provide local authorities with greater opportunities to address the development of new fast food outlets in their area.
Local authorities employing a Supplementary Planning Document
Planning regulations have been employed by several local authorities to restrict the opening of new hot food takeaway outlets. This has been done through the development of their own Supplementary Planning Documents (SPD) focusing on hot food takeaways (class A5 premises). An SPD expands on policies found in Unitary Development Plans and other national and regional guidance. Whilst not having the same status as a development plan, an SPD forms material consideration in the determination of a planning application. An SPD must conform to local plans and core strategies, but case law can also provide material consideration and can contribute to its content. In general, SPDs have sought to restrict:  The clustering and over concentration of hot food takeaways  The proximity of hot food takeaways to schools, sixth form colleges, parks and youth In doing so, the SPDs aim to tackle environmental and health issues posed by the proliferation of hot food takeaways. Environmental issues include: litter, noise, bad smells, disposal of waste, attraction of vermin, parking and traffic, gathering of people and antisocial behaviour, as well as changing the appearance of an area. Health issues: the main focus has been on the impact of energy dense, high fat takeaway food on child obesity and the related health concerns such as type 2 diabetes and coronary Some of the criteria used in Local Authority SPDs are shown below: Criteria for assessing A5 Planning Applications
1. Over concentration: Within primary, secondary and retail parade zones no more than 5% of units shall consist of A5 units. Within tertiary zones and outside designates centres no more than one A5 unit will be allowed within 400m of an existing A5 unit. No more than two A5 units should be located adjacent to each other. Between individual or groups of hot food takeaways, there should be at least two non A5 units. 3. Proximity to schools, youth facilities and parks: With regard to proposals which fall outside designated town centre and local parade locations, hot food takeaway shops will be resisted where the proposal will:  Fall within 400m of the boundary of an existing school or youth centred facility.  Fall within 400m of a park boundary 4. Highway safety 5. Protection of Residential Amenity:  Applications within close proximity to residential units will be refused where it is considered that there may be significant adverse impacts in terms of noise, vibrations, odours, traffic disturbance, litter or hours of  This also applies to application for the change of use of existing premises to hot food takeaways 6. Hours of Operation 7. Odours and Cooking Smells 8. Disposal of Waste Products 10. Safety, Crime and Anti Social Behaviour 11. Accessibility Planning permission for new hot food takeaways (Class A5) will not be granted in the hot food takeaway exclusion zone. This is where proposals fall within a 400m boundary of a primary or secondary school. Planning permission will only be granted for a hot food takeaway outside of the hot food takeaway exclusion zone provide that: • It is within Barking Town Centre, Dagenham Heathway, Chadwell Heath and Green Lane District Centres or one of the Neighbourhood Centres • It will lead to: No more than 5% of the units within the centre or frontage being hot food takeaways No more than two A5 units being located adjacent to each other There being no less than two-non A5 units between hot food • A £1,000 levy requirement for developers of new hot food takeaway outlets to make a contribution under a Section 106 agreement. These funds will be used to provide investment for initiatives to tackle childhood obesity, including support for operators to consider healthier options, recipes and ingredients Planning permission will only be granted provided it is located: • Within the defined town centres of St Helens or Earlestown, or • Beyond a 400m exclusion zone around any primary or secondary school and sixth form college either within or outside Local Education Authority Where a hot food takeaway is to be located within a town, district or local centre, it should not result in: • More than 5% of the units with the centre or frontage being hot food • More than two A5 units being located adjacent to each other. • Any less than two non-A5 units being individual or groups or hot food • The proportion of A1 uses in primary retail falling below 75% Local authority planners have not all chosen to use the same criteria for restricting A5 premises likely to be easily reached by children. Whereas Waltham Forest included primary and secondary schools, youth facilities and parks, Barking and Dagenham included only schools, stating in their SPD that "Given the extent of the exclusion zone around schools it is deemed unnecessary to implement further buffers around parks, children centres and leisure centres. Indeed mapping conducted by the Council indicates that the exclusionary zone imposed around schools will encompass these sensitive sites" St Helens have chosen to include sixth form colleges as well as schools in their SPD criteria. Barking and Dagenham additionally introduced a £1,000 levy in their SPD, applicable to any A5 premises for which planning permission is granted.
Issues for consideration
 A 400m exclusion zone was chosen as the distance that could be walked in 10 minutes. However students may well walk further than 400m to purchase food at lunchtime37. In London, where transport is free for school children, they may hop on a bus after school to visit the nearest cheap fast food outlet38  Waltham Forest's SPD aimed to tackle only the problem of class A5 hot food takeaway outlets, but not other classes of premises. Many other non-A5 businesses within the 37 The Brighton Survey ‘Hot Food Takeaways Near Schools' recorded food purchasing activities of school children within an 800m zone around each secondary school, and estimated that 800m was a 10 minute walk. 38 Helen Clark, Area Manager Food Team at Wandsworth Environmental Services reported, "We found anecdotally and observationally that the children would travel some distance on the buses to go to a particular takeaway. All London school children get free travel on the buses so it is not possible to compare with areas where they have to pay for transport. Some children may choose to travel nearer to home, or to a cheaper outlet before buying a take away rather than buying from the nearest outlet to school. Although we have no clear evidence you would have to be careful when considering implementing for example takeaway free zones around schools if it's just a free bus trip to the nearest takeaway." school fringe offer cheap, energy dense, nutrient poor food, but it would not be possible to control these with the same planning restrictions39  Class A1 premises can undergo change of use without planning permission, for example from funeral director to sweet shop  The 400m exclusion zone is only relevant to lunchtimes and the time immediately before and after the school day. It does not take into account purchases along the school route  The use of SPDs by local authorities has not as yet, been evaluated and the impact on obesity and other health issues remains unknown  However, following adoption of an SPD in July 2010 by the London Borough of Barking and Dagenham , no new hot food takeaways have been permitted in the borough and eight hot food takeaway applications have been refused. The SPD is now being promoted as one approach to controlling the number of fast food takeaways in an area. It is a Department of Health ‘Promising Practice Case Study' and is featured on the Obesity Learning Centre website.
Choice editing
‘Choice editing' is a means of editing consumer choice by removing products that may have a negative impact on health. Planners could theoretically employ choice editing by granting planning permission only to hot food takeaways that comply to certain nutritional criteria for the products they sell e.g. by restricting the calorific values of portions of food or the percentage of fat in food products. This type of intervention remains controversial and we are not aware of any examples where it has been implemented.
Case studies

London Borough Waltham Forest
The London Borough of Waltham Forest was the first council to develop an SPD specifically to tackle the health impacts of hot food takeaways, by restricting their development around ‘the school fringe'. The Borough worked closely with London Metropolitan University, whose research on shops forming ‘the school fringe' found that:  These shops are popular with students  The nutritional quality of the food available is generally poor  A significant proportion of students' fat, salt and sugar intake comes from the food they  Some shops use ‘student offers' specifically to target school children Public consultation on fast food takeaways highlighted objections to the detrimental effects of the proliferation of takeaways, both to the local environment and to health. To tackle the problem posed by hot food takeaways, planners led on setting up a hot food takeaway corporate steering group. This included representatives from:  Spatial planning (chairing the group)  Development management and planning enforcement  Food standards  The Food in Schools programme  NHS Waltham Forest, the local PCT 39 In the Brighton Survey, students were frequently observed buying ‘junk food' from non-A5 shops, most commonly chocolate and energy drinks. One A1 shop sold foot long hot dogs with a cup of fizzy drink for £1. Information from the academic research and pubic consultation were used together with existing planning policy guidance to develop a hot food takeaway SPD. The SPD tackled the issues of over concentration, clustering as well as proximity to schools, youth facilities and The SPD sought to deal with both the environmental problems and the potential health risks to children. The SPD states that ‘planning permissions will not usually be granted for Hot Food Takeaway shops which fall within a 10 minute walking distance from the boundary of either a school facility, any youth facility or any designated parks'. The 10 minute walking distance was seen to be equivalent to 800 metres as the crow flies. Taking into consideration the physical barriers encountered while walking, for example buildings and road crossings, the council considered 400m a more likely to represent a 10 minute walk. In the first year following the adoption of the SPD, the council turned down five applications for new A5 premises including one which went to appeal, when the decision to refuse planning permission was upheld. Since 2009 when the council adopted the SPD 82 percent of planning applications for fast food outlets have been refused40. In January 2012 the Planning Inspectorate rejected an appeal by the American fast food chain Dominoes pizza against a decision to decline planning permission for a new store within the borough. It is important to note that to date the council has only won appeals on the basis of over concentration, potential noise nuisance, likelihood of anti-social behaviour and parking problems rather than on the basis of public health impacts. This is despite the fact that the borough's SPD uses health as an issue as well other environmental impacts and the issue of over concentration. The reason for this according to Councillor Clyde Loakes the Cabinet Member for Environment is that the health impacts are harder to prove than the other impacts. The borough has developed a Health Inequalities Strategy, and planning forms an integral part of this. Waltham Forest recognises that restricting new hot food takeaways from opening is only a small part of an overall approach to reducing unhealthy eating and that it is important for planners to work closely with other departments, such as environmental health and the PCT (now working together as a Public Health Team). Currently environmental health officers and dieticians are involved in the Healthier Catering Commitment for London, running workshops for fast food businesses on healthier fast food and encouraging food businesses to take part in the Healthier Catering Commitment Scheme. As a host borough for the 2012 Olympics Waltham Forest is coordinating food offer on land adjacent to the Olympic park. The borough has made it a prerequisite that a food business be signed up to the HCC before they are able to be offered a food concession at these venues.
London Borough of Tower Hamlets
In 2010 a High Court case to challenge a decision by Tower Hamlets local authority to grant planning permission to open a new hot food takeaway hit the headlines. This experience and the process subsequently entered into provides an illuminating example of a local authority journey to develop a comprehensive and evidenced based approach to the public health impacts of fast food takeaways41. Tower Hamlets did not have any supplementary planning guidance concerning the development of fast food takeaways in the proximity of schools when the "Cable Street" 40 Waltham Forest News Issue 58, 23 January 2012 41 Much of the information for this section was garnered from the excellent research commissioned by Tower Hamlets called: Tackling the Takeaways: A new policy to address fast food outlets in Tower Hamlets" case, as it came to be known, came to the fore. The case related to a planning application that had been submitted involving a change of use from a grocery shop (class A1) to a hot food takeaway (class A5). The premises was close to a secondary school, which ran a healthy living programme, including advice to pupils on healthier eating. The application was assessed against the development plan, which comprised both the London Plan and the Tower Hamlet's Unitary Development Plan (UDP). Neither the London Plan nor the UDP contained any policies which restricted hot food takeaways because of their proximity to schools. Additionally, the council did not have any supplementary planning guidance on this issue and there was no national government planning guidance. The Planning Officer's report stated, ‘The adjacent school is trying to promote healthy eating to its pupils, and the introduction of a takeaway establishment would encourage poor eating habits.While this is a valid concern, it is not a material planning consideration that can have weight in determining this application against council policy '. Planning permission for the change of use was granted by the planning committee in April 2009, based on the recommendations of the Planning Officer. This decision was challenged (R (Copeland) v London Borough of Tower Hamlets [2010]) and the High Court found that councillors had been incorrectly told that the impact of the change of use on a local secondary school's healthier eating programme was not capable of being a material consideration that could have weight in the determination of the planning The decision found that the Planning Officer had been wrong in stating that the proximity of a hot food takeaway to the secondary school was not capable of being a material consideration. The presiding judge stated, ‘In my judgment a consideration is "material", in this context, if it is relevant to the question whether the application should be granted or refused; that is to say it is a factor which, when placed in the decision-makers scales, would tip the balance to some extent, one way or the other.' The Strategic Committee took into account the Judge's ruling and refused planning permission. In early 2011, the applicant lodged an appeal against this ruling. The inspector decided to uphold this appeal and planning permission was ultimately granted. In granting planning permission the inspector noted:  The specific location of the application was not considered to be ‘over-concentrated' with A5 uses. This was corroborated through a Council Land Use Survey  No evidence was provided demonstrating that "the location of a single take-away within walking distance of schools has a direct correlation with childhood obesity, or would undermine school healthier eating policies"  "There are no adopted or emerging local policies that would support refusal of the proposal in this location, or which seeks to take forward the Government advice in ‘Healthy Weight, Healthy Lives', which seems to seek to control a proliferation of such outlets near schools" This final decision prompted London Borough of Tower Hamlets to undertake a detailed piece of research into what their response should be to future A5 applications. The approach that this report formed part of has been described by Tim Madelin a Senior Public Health Strategist at NHS Tower Hamlets as holistic42. The approach includes the development of new planning guidance through the Local Development Framework's Managing Development 42 Conversation with Tim Madelin 23/03/12 (MD) Development Plan Documents (DPD) which set restrictions on new A5 development. However, it also includes a wide range of supporting interventions that encourage healthier lifestyles within the borough with specific actions to improve the health of food and increase access to healthier foods. The DPD outlines an approach to A5 planning applications which is based on the thorough research within the Tackling the Takeaways report. It restricts the development of new A5 uses to specific areas (mainly town centres) and places restrictions on the number of A5 premises in any town centre to 5 percent of the total shops. It also allows "the proximity of an existing (or proposed) school and/or local authority leisure centre" to be taken into consideration43. The Core Strategy already adopted by Tower Hamlets outlines the basis for this DPD under Creating Healthy and Liveable Neighbourhoods through "seeking to reduce the over-concentration of any use type that detracts from the ability to adopt healthy lifestyles"44. The DPD is currently under consultation and is due to go through examination in public in autumn 2012. Simultaneously the borough is supporting and promoting initiatives to improve the food on offer through takeaway outlets and to increase the availability and access to fresh fruit and vegetables. The borough has been at the forefront of piloting the Healthier Catering Commitment for London (a scheme aimed at improving the health of the boroughs food outlets including takeaways) and the Buy Well project which aims to increase the access to fresh fruit and vegetables through the borough's convenience stores45.
London Borough of Newham
Early in 2012 a decision by the London Borough of Newham to turn down an application to grant planning permission for a new fast food takeaway was upheld by the Planning Inspectorate. The appellant wanted planning permission to change a premises from retail class A1 to A5 (hot food takeaway). The Planning Inspectorate gave four reasons for the decision to reject the appeal of which two were over concentration and healthy lifestyles. The Inspector found that Newham's Core Strategy aimed to ensure town and local centres are ‘vibrant, vital and valued,' and aims to prevent non-retail uses, particularly hot food take- aways from clustering or reaching disproportionate levels. In this case there were three other A5 premises within a short distance of the appeal premises. It was felt that the proposal would add to local clustering and was therefore contrary to the Core Strategy. The appeal was also turned down on the basis of the impact on healthy lifestyles. The inspector found that the National Planning Policy Framework as well as the London Plan both confirm the important role that the planning system can play in facilitating social interaction and creating healthy, inclusive communities. This was carried through to the Core Strategy for Newham with the objective of promoting healthy lifestyles, reduce health inequalities, and creating healthier neighbourhoods. The Core Strategy also identified the need for healthy eating to take account of the cumulative impact of hot food take-away premises. It was identified in the justification for the policy that the number of hot food take-away premises is a matter of public concern and indicated that a 400m exclusion zone around existing or proposed secondary schools for such take-away uses would help influence young peoples' access to such food. In this case the Council had indicated that the appeal site was within 400 metres of St. Bonaventures Secondary Catholic School. The 43 Tower Hamlets Managing Development (MD) Development Plan Document pg 22-23 44 Tower Hamlets Core Strategy pg 50 building was therefore within one of the Council's preferred ‘exclusion' zones for such hot food take-away use.
Ways Forward
 Include restrictions for the development of hot food takeaways in forthcoming development of Neighbourhood Plans  Introduce levies and ‘choice editing' provisos in planning policy for hot food takeaways which are granted planning permission
Healthy Placewebsite set up by the National Heart Forum focusing on the legal measures that can enable local authorities to develop healthier Waltham Forest SPD background - Local Government website Hot Food Takeaway Supplementary Planning Document – Waltham Forest Saturation Point – Barking and Dagenham SPD Supplementary Planning Document for Hot Food Takeaways – St Helens Council Tackling the takeaways: A new policy to address fast-food outlets in Tower Hamlets National Planning Policy Framework Healthier Catering Commitment for London London Borough of Newham Planning Appeal Decision Regulatory measures and linked voluntary initiatives  In addition to planning controls, the regulation of street trading can be used to limit areas where fast food vans operate i.e. prevent targeting of schools  Alongside adoption of planning controls a number of local authorities have also increased enforcement of environmental health and waste regulations  Relationships with local takeaway businesses can be improved by involving environmental health and trading standards more positively with the businesses, for example by running training workshops and food award schemes  In London, environmental health officers can become involved in the Healthier Catering In addition to planning policies, local authorities can use other regulatory measures to regulate the sale of ‘fast food'. Introduction of street trading policies and increased enforcement of hygiene standards, waste regulations and odour control are examples of actions taken by some local authorities to minimise the impact of takeaway food businesses on the local community.
Street trading policies
Such measures include:  Introduction of a street trading policy to restrict the operation of mobile fast food vans, particularly around schools  Using street trading policy to ensure that at least one healthier option appears on a street trader's menu Mobile fast food units are not governed by planning policy, but can be controlled by the granting of street trading licences by local authorities and regulated by environmental health and trading standards officers. Local authorities have the power to restrict the areas where mobile vans trade by designating streets as ‘prohibited', ‘consent' or ‘licensed' with respect to street trading. If a local authority passes a resolution to make some streets prohibited, then no street trading can take place in those areas. This can be a means of regulating fast food vans around the school fringe. When a local authority designates streets as licensed or consent streets, they can regulate the number of street traders in that area. In doing so, a local authority can restrict fast food vans and give preference to those offering healthier
Focused enforcement of environmental health and waste regulations
Fast food takeaways can generate high levels of litter, noise, odour and traffic disturbance. A number of local authorities have taken a holistic approach to reducing the impact of takeaway food businesses on the local community by ensuring that alongside planning controls, there is increased enforcement of environmental health and waste regulations. Actions include:  Ensuring businesses have adequate facilities for storage of waste and are aware of the requirements of the Environmental Protection Act 1990 and the Environmental Protection Act (Duty of Care) Regulations 1991 as amended. Where necessary, fixed penalty notices are served  Problems arising from the disposal of fat, oil and grease are closely monitored and businesses are made aware of the Water UK guidance on the ‘disposal of fats, oils, grease and food waste'  Controlling litter by ensuring that fast food businesses are aware of their responsibility to keep litter bins regularly maintained and emptied and that surrounding areas remain free of litter. If a build up of litter can be directly linked to a fast food business, Street Litter Control Notices are served
Issues for consideration:
 Regulatory measures may alienate businesses. The owners of takeaway businesses may
feel that the only contact they have with local authority officers is negative and restrictive. Use of voluntary incentives may be more productive in changing food offers e.g. Healthier Food Awards etc  Regulatory changes in street trading licences will only apply to a street trader from when they next apply to renew their licence
Case Studies

Leicester City Council
After being approached by the Head Teachers of some schools, Leicester City Council introduced a new Street Trading Policy in 2008 to prevent burger vans trading outside school gates. The council does not allow any trading to take place outside schools, apart from the sale of ice creams, which is permitted only at the end of the school day. The policy states that, "There will be a general presumption against street trading, particularly in the vicinity of schools. For the purposes of this policy, a location is ‘in the vicinity' of a school if it is situated such that pupils may be encouraged to walk to it during a break from school, or immediately before or after school." Anyone trading without a licence faces a fine of up to £1,000.
Guildford City Council
Guildford introduced a street trading policy which requires at least one healthier meal option to be provided on the menus of street food vendors. Examples of healthier options are set down in the policy document.
London Borough of Hillingdon
Hillingdon Council has passed a passed a resolution under Section 37(2) the London Local Authorities Act 1990 (as amended), prohibiting itinerant ice cream trading in the vicinity of schools and nurseries. One of the reasons cited for introducing this prohibition was that ice cream trading in the vicinity of schools contradicted dietary recommendations and the aims of the Healthy Hillingdon Schools Scheme. Itinerant ice cream trading is prohibited in any street, or part of streets or side streets within 65 metres of any exit used by children from the following premises:  Primary Schools  Under 5 Centres  Day Nurseries  Secondary schools  Special Schools Glasgow City Council
The Big Eat schools pilot study aimed to encourage pupils to stay on site at lunchtime. A survey relating to this study demonstrated that burger and ice-cream vans parked outside many schools at lunchtime were selling burgers, ‘Pot Noodles', sweets and fizzy drinks. School staff and parents had repeatedly expressed concerns over the presence of these vans, which were seen to undermine healthier eating. Whilst The Big Eat project was underway Glasgow City Council introduced a licensing policy to restrict these vans, so that they could not operate within 300 metres of a school. However, this exclusion zone only became applicable to vans when the licences were renewed. Throughout the pilot study vans remained outside seven of the eight pilot schools. A preliminary report on the impact of the 300 metre exclusion zone recommended that a further review of the licensing policy should take place to determine whether an extension of the exclusion zone would be desirable.
Waltham Forest
The London Borough of Waltham Forest reports that, alongside its use of Supplementary Planning Document (see planning section), it has increased its regulation of hygiene standards and waste regulations relating to class A5 hot food takeaway premises, resulting in a number of them being closed down for regulatory breaches. In practice though, closure was a temporary measure for most premises, which re-opened once they had made changes to meet the required hygiene standards. Closure of premises in these circumstances is the most extreme measure for situations which present an imminent health risk, for example rats on the premises, and requires environmental health officers presenting evidence to a magistrate. On average, around one premises a month is forced to close. More often, officers work with the proprietor to reach required standards without closing the premises. Waltham Forest did report a galvanizing effect of the profile of the SPD that led to the establishment of a hot food takeaway corporate steering group that included representatives from special planning alongside development management and planning enforcement, food standards, the food in schools programme, and NHS Waltham Forest46. According to Councillor Clyde Loakes Cabinet Member for Environment at the London Borough of Waltham Forest this has been one of the real benefits from the development of the SPD. Different agencies in the borough are now working better together to tackle the issue and the boroughs planning policies are now benefiting from the fact that they use public health evidence to back up their case. For example, the mental health impact of betting shops is currently being used to help develop planning guidance that seeks to control the proliferation of these premises47. 47 Email conversation with Councillor Clyde Loakes, Cabinet Member for Environment, London Borough of Waltham Forest July 2012
Water UK – Disposal of Fats, oils, grease and food waste: best management practice for catering outlets Healthy Placewebsite, set up by the National Heart Forum, focuses on the legal measures that can enable local authorities to develop healthier environments. See in particular licensin Leicester Council Street Trading Policy Guildford Council Street Trading Policy London Borough of Hillingdon Itinerant Ice Cream Sales Prohibition Glasgow City Council The Big Eat Waltham Forest regulatory measures The Healthier Catering Commitment Working with schools  Local authority planning and other regulatory measures can be more effective if action is also taken by local schools  Stay on site policies and cashless systems reduce opportunities for pupils to spend lunch money on junk food  Improving the eating environment, quality of school food and the ease of purchasing can help achieve pupils' buy-in for school meals
Schools policies
The studies in the ‘How can I gather evidence' chapter, clearly highlight that school children who leave school at lunchtime to purchase food are exposed more times to opportunities to buy high calorie, high fat and high sugar foods, than those who remain on school premises and eat school food at lunchtime. There is a range of measures schools can take to promote and improve the types of food their pupils eat during the school day. Schools can improve their food, the ease with which pupils can purchase school food and the environment where pupils eat their lunches. They can also work with local businesses to improve the choices available to pupils within the The National Healthy Schools Programme (NHSP) was a major support structure for implementing healthy eating (and drinking) in schools. The NHSP advocates the whole school approach to successfully develop and implement healthy eating activities in schools – both in and outside the curriculum. The programme was jointly funded by the Department of Health and the Department for Children Schools and Families and was supported by a network of 9 regional coordinators and 150 local programmes. It aimed to support children and young people in developing healthy behaviours, raise pupil achievement and promote social inclusion. The Coalition Government has withdrawn support for this programme but the tools and planning aids are still available on the Department for Education website48. However, the Mayor of London and the Greater London Authority have resurrected the scheme in London under the Healthy Schools in London banner. You can find out more information regarding this from thewebsite49. We recommend that the reader also visits theto see what is already happening in your local There are time and resource implications involved in introducing these policies. However, the school community has an essential role to play in the provision and promotion of a healthier diet. Schools will see benefits including improved levels of wellbeing, behaviour, concentration and also attainment on introducing some of the following initiatives. Importantly, there is much greater potential for success if a local authority aims to introduce any of the policies mentioned in this toolkit e.g. planning restrictions, by also working with their school communities to implement some of the following initiatives. Cashless systems and incentives
Cashless Catering Systems use information technology to remove the handling of cash at the point of sale and to speed up food service. Schools can choose a system that meets their specific requirements with a pupil recognition system of their choice. See the School Food Trust website for an Independent Review of Cashless Catering Systems and for case studies Incentivising students to make healthier food choices can be supported and enhanced through cashless cards systems. A long standing example is the Fuel Zone, a web-based points reward scheme that promotes the uptake of the healthier options programme in Glasgow, aimed to revamp the image of the school meals service and reward healthier
Closed gate / stay on site policies
Closed gate / stay on site policies are introduced in secondary schools in an attempt to restrict pupils leaving the school grounds at lunchtimes. At some schools these policies are applied across all ages, but most schools vary the policy across age groups with decreasing restriction with increasing age. The top four reasons cited for introducing stay on site policies in the School Food Trust Schools Food Panel Ninth Survey of Head Teachers in 2009 were: 1. The safety/security of students 2. To promote healthier eating/to control what they eat 3. Community relations/to prevent trouble with local residents/ to prevent students causing nuisance issues in local community 4. To encourage use of school meals facility
Improvements to canteen environment
The uptake of school meal services is significantly affected by the quality of the canteen
environment. A good canteen environment, including line / queuing organisation; cleanliness of canteen seating area; and playing of music and improved décor can make a significant difference to how children experience the lunchtime period. In addition flexible spaces are key to accommodating all secondary school pupils for lunches. Schools should consider whether the space on site is being used to its best potential to accommodate the maximum number of pupils for on-site lunches.
Lunchtime - extending and staggering
During the lunch break, children need to be able to eat nutritionally-balanced, appealing meals in a comfortable, enjoyable environment. They are then more likely to benefit from the break and return to the classroom refreshed and ready to learn. Research demonstrates that pupils' health, development, behaviour and performance is better served by enhancing or extending the lunch time period rather than by shortening it. Extending break times can also increase uptake and minimise food wastage. Evidence suggests that increases of as little as five minutes have been shown to improve these factors. Evidence from providers has highlighted one hour and fifteen minutes as a good length of time for lunch as it allows staggered sittings. This is a key factor as many schools (e.g. Victorian buildings) have far more pupils on roll than the school was originally built to accommodate.
Grab and go lunches
In many secondary schools, grab and go or sandwich options are very popular, and the
proportion of pupils choosing a hot main meal consequently may be lower. It is important that the ‘average school lunch' accurately reflects the eating habits of the school population, and all pupils are given the opportunity to select their lunch from provision that conforms to the food-based and nutrient-based standards. The Children's Food Trust has developed a Recipes for Success guide for Grab and Go lunches:
Vending machines
Vending machines are a common sight in secondary schools across the country. They have been introduced for a number of reasons; to provide drinks and food snacks to pupils at breaks and lunch period; to generate income for the school; help students stay hydrated; and to offer choice (the aim of which is help keep pupils on site at lunch time). Vending provision should adhere to the 2007 food-based government standards. This includes restricting the amount of foods and drinks offered in the vending machines containing high levels of sugar, fat and salt. See the report below for details of guidelines and a review of vending provision before and after the introduction of the food-based standards. The Health Education Trust have developed a series of practical guidance for schools on food and drink vending: Meal deals
To try to encourage school meal take-up some schools work with their local authority to offer parents and children meal deals whereby the regular price of the school meal is subsidised for a period. (See Bolton case Study on the Children's Food Trust website.) Schools, local authorities and local businesses work in partnership to either develop healthier food deals or actively promote healthier foods (for examples seeon p22).
Case Studies

Islington's Free School Meals for Primary Schools policy (FSM)
The London Borough of Islington's Health and Wellbeing Review Committee believes that access to good food is vitally important to all school children and is conscious that nutrition in schools provides an ideal opportunity to make a difference to children's diets. In recognition of this, in September 2009 Islington Council took the decision to introduce Free School Meals (FSM) for all nursery and primary pupils. The initiative was first piloted with 6 schools which were chosen on the basis of highest and lowest percentage of FSM; highest and lowest take-up of meals; and schools being in different geographical areas of the borough. The pilot scheme required all parents to formally register for FSM as the schools funding formula and many grants are allocated based on national FSM eligibility. The initial budget allocated to the pilot included increased infrastructure costs such as kitchen facilities and equipment, increased administrative costs, and the estimated increase in FSM costs. Before the Free School Meals policy was introduced, take-up across the 6 schools was 63%. By October 2010 this had risen to 80%. The individual schools ranged between 62% to 95%. The success of this initiative Anecdotally and through statistical evaluation the initiative has been a success. This has been demonstrated through the rollout of the programme across the borough. The significant increase in school meals uptake was largely due to the fact that school meals were being offered free universally. However, a number of other important factors supported and maintained this increased uptake including:  Efforts of school staff to make the initiative work  The support of the new school meals provider – Caterlink  The introduction of new national minimum standards for healthier eating Other contributing factors Other existing initiatives supporting the increase in uptake included:  A high percentage of Breakfast Clubs in the borough (80%)  97% of Islington schools already having healthier schools status  29 primary schools with family kitchen  Food and exercise choices and body image education  Applying national guidance to all foods in schools  Encouraging and increasing the amount of cooking in Food Technology Curriculum In addition, the move from food based to nutritional standards allowed for more opportunity to develop the menu and putting systematic quality monitoring systems in place enabled the schools to monitor the caterer. The new policy on universal free school meals also overcame the difficulty of eligibility and stigma which accompanies FSM provision targeted at pupils from low income families. Data from the School Food Trust 2011-12 shows that average take up across all Islington primary schools is now 84.5 percent. This compares with the national average that year for England of 46.3 percent50. Expanding the success to secondary schools Based on the success of this programme of universal FSM in primary schools Islington Borough Council wants to see a similar increase in up-take of school meals in secondary schools across the borough. The Health and Wellbeing Review Committee recognises that this will not happen without wider interventions - the need for the educational focus to be expanded to cover not just meals, but lessons in nutrition, cooking, the relationship between nutrition, health and exercise, and including a complementary physical exercise programme as part of the school timetable i.e. for schools to adopt a ‘Whole School Food' policy. Supporting factors to successful healthier food uptake in schools  Pupil involvement with the choice of food supplied  Head Teachers to enter into a dialogue with their meals provider  Clear school meal specification and effective monitoring of the contract  School cooks sharing knowledge across different schools to enable different food  Clear links between food and health, weight, wellbeing, behaviour, concentration, performance and also attainment  Attractive presentation of food is vital  Closed gate policy  Good canteen environment, including line / queuing organisation; cleanliness of canteen seating area; playing of music and improved decor  Extended break times (evidence suggests one hour and fifteen minutes as a good length of time for lunch as it allows staggered sittings)  The restriction of hot food take away outlets near schools and other public amenity spaces, and recommend the introduction of a Supplementary Planning Document (SPD) For further details School Meals: Current Take-Up in Primary and Secondary Schools, and a Review of Secondary School Nutrition, including the Environmental Factors Impacting on Secondary School Meal Take-Up, Report of the Health and Wellbeing Review Committee London Borough of Islington, March 2011.
Staying on site - The ‘Big Eat In'
Scottish children and young people follow a diet that is less healthy than their European counterparts. There are increasingly high levels of childhood obesity. There is recognition that the school community has an essential role to play in provision and promotion of a healthier diet amongst Scottish children and young people. In addition, research suggests that working with secondary school age children is more complicated and is less successful than working with primary school age children. In August 2009, in an attempt to address this, Glasgow City Council Education Services in collaboration with other stakeholders in the schools sector introduced a one-academic-year pilot project across 8 Glasgow secondary schools. The aim of the ‘Big Eat In' (BEI) was to encourage S1 (year 7) pupils to stay within the school grounds, eat a healthier lunch and participate in a lunchtime activity. The pilot was based on an encouragement model rather than a regulatory or rule based approach. Each pilot school drew up its own individual implementation plan, establishing a package of initiatives to provide a positive incentive for S1 (year 7) pupils remaining on the school premises. Initiatives varied from school to school and included recreational physical activity, sport and lunchtime clubs, as well as provision of access to school libraries and informal The general consensus (backed up by quantitative data demonstrating that school meals uptake had been consistently higher during the pilot) was that the pilots were a great success. However there were factors that diminished the success of the pilot and that would continue to be problematic in relation to whether the food school children eat is healthier or less healthy namely wider healthier food policy initiatives. The Scottish Government Route Map Towards Healthy Weight has called for policy responses that "go beyond individual initiatives requiring systemic and far-reaching change in infrastructure, environments, culture and social norms." Factors determining long-term success  Closed gate policy - It was viewed by the majority of the school staff respondents that introducing a closed gate policy would be impractical and inadvisable. This was due largely to the fact that all other year groups were still allowed off site and could bring food back for the year 7 students. Perhaps more significantly, it was hard to police the school gates and having a closed gate policy would have implications on staffing levels  Restricting access to off-school food premises - food vans and shops in close proximity to the schools were perceived as undermining healthier eating. A Glasgow City Council licensing policy was introduced in January 2009 imposing a 300 metre exclusion zone for any mobile street trader operating near secondary schools However, this policy can only be applied to traders renewing or applying for a new licence and had not been fully embedded before the start of the ‘Big Eat In'. An initial analysis of the licensing policy suggested further research was needed to assess the potential long-term impact of such


For a range of school policy and initiatives see the Children's Food Trust For case studies see the Children's Food Trust Soil Association Food for Life Partnership For case studies where the Whole School Approach has been addressed, see Food For Life: For School Meals see: Health Education Trust Health Education Trust healthy vending guidance : Glasgow case study The Big Eat In Evaluation Hungry For Success Evaluation Working with businesses  Working with businesses through training or awards schemes helps build a positive relationship with them  A multi-department approach works best involving nutrition professionals as well as environmental health or trading standards officers  It is useful to consult catering professionals (e.g. from your local catering college) to ensure that healthier eating advice is appropriate for the cooking techniques used by a business  It is important to ensure that any healthier eating advice and reformulation is appropriate for public settings
Small local food businesses can often provide an economic boost to an area, they employ local people and use local suppliers51. Environmental Health and Trading Standards departments in local authorities have extensive experience of working with businesses to help implement good practice, Codes of Practice and self regulation and are therefore well placed to provide assistance to takeaway food businesses to improve the healthiness of the food they offer. There are a number of strategies that can be employed to support fast food outlets improve the healthiness of their food, which broadly fall into the categories of training and award schemes. It is important when delivering training or setting standards for awards schemes that the information presented to businesses:  Is based on sound evidence-based information and current government health  Is appropriate to the type of food that is being prepared at the fast food outlet and the limitations of the catering facilities  Takes into consideration the availability of products from the wholesalers normally used  Is sensitive to the taste and price requirements of customers  Overall is a financially viable option and ideally saves the business money
Working with fast food outlets on healthier fat frying choices
When advising caterers on the use of fats, both health issues and the cooking properties of fats need to be considered. It is important that those preparing and delivering training or awards schemes are clear on these factors. Some information that is currently being used by local authorities takes only the health properties of fats into consideration without balancing this with the cooking methods that are to be employed. Advice to takeaway businesses should include:  The type of cooking oil to use – advice and recommendations need to be balanced with price, stability, nutrition and flavour.52, 53, 54 51 The New Economics Foundation (2010). An inconvenient sandwich. 52 British Heart Foundation (2007). Reducing your blood cholesterol. Heart Information Series No. 3.  The care of cooking oil  Frying temperature and cooking times  Cut of chips  Draining of fat after cooking The FSA advice sheets ‘tips on chips' provide guidance for businesses55 and local authorities56 on techniques for cooking healthier chips. The National Heart Foundation of New Zealand have produced a policy statement and background paper on deep frying chips and is a source of more detailed information on the types of fats used and healthier frying
Training for small businesses
Training support and advice can help businesses make small changes to what they offer- to improve particular aspects of their food. The training could be facilitated by community dieticians and nutritionists, environmental health officers, trading standards officers or catering professionals, depending on the nature of the training. Ideally a nutrition expert and someone with a catering background should develop the training together, in order to ensure that the health messages delivered are appropriate for the catering methods employed. There have been cases where health messages delivered have been inappropriate for the cooking techniques used by a catering outlet. Useful areas to cover in training include:  Basic healthier eating knowledge – evidence based government backed advice including unhealthy fats versus healthier fats, reducing fats, sugar and salt, artificial additives that may affect children's behaviour, portion sizes  Healthier (wholesale) purchasing choices – based on which wholesalers are commonly used by the business  Healthier cooking techniques and reformulation of recipes – such as healthier frying techniques, salt and sugar reduction, removing artificial colours and MSG  Nudge techniques – small changes to the takeaway environment that will positively affect customer's choices e.g. reducing the number of holes in a salt shaker, placing bottled water at eye-level in a fridge and sugared drinks in less obvious view
Awards and Catering Schemes
Healthier food awards and catering schemes are ways of incentivising businesses to attain specific standards around healthier eating. Many local authorities use environmental health officers to run the schemes alongside their Food Hygiene Rating Schemes. To achieve good levels of take-up for the awards, businesses need to feel it is in the interests of their business to achieve an award. So far, interest from takeaway businesses 53 Scientific Advisory Committee on Nutrition (2007). Update on trans fatty acids and health. Position statement by the Scientific Advisory Committee on Nutrition 54 Department of Health (2012). Tips to remove artificial trans fats for small and medium sized businesses – additional information for local authorities 55 Tips on Chips – Food Standards Agency advice sheet for officers 56 Tips on Chips – Food Standards Agency advice sheet for businesses 57 Mackay S (1999). Techniques and Types of Fat used in Deep-Fat Frying: A policy statement and background paper. National Heart Foundation of New Zealand has generally been less than other caterers, particularly the fried food takeaway businesses. Evaluation still needs to be completed for schemes currently running to see how the awards have increased the healthiness of food available, the purchasing behaviours of customers, and whether they provide adequate incentives for businesses to make changes. As with the training and advice, healthier awards criteria need to be drawn up by both health and catering professionals so that they encourage healthier changes that are viable in a catering environment.
Case Studies

London Healthier Catering Commitment
The Chartered Institute of Environmental Health has worked with partners the Greater
London Authority (GLA) and the Association of London Environmental Health Managers (ALEHM) to develop a pan London healthier catering scheme. The scheme is aimed at businesses that work in the fast food sector but can be adapted to other commercial businesses such as pubs and restaurants, and it can be modified by individual London boroughs so that it fits with their local business profile. Catering businesses participating in the scheme are assessed either at the same time as the routine food hygiene inspection, or as part of a separate visit carried out by their local Food Safety Team. Criteria the businesses are assessed on include:  Choices of fats and oils  Frying techniques  Use of low fat alternative dairy products  Salt and sugar reduction  Availability of fruit and vegetables and wholegrain in menus  Appropriate portion sizes  The promotion of healthier eating to customers Businesses meeting the required criteria are able to display a Healthier Catering Commitment sticker on their premises. Businesses are reassessed at least every two years. The Healthier Catering Commitment also provides guidance to businesses on healthier food preparation through written information on the website, including advice on oils and fats, salt reduction and specific advice for Chinese and fast food businesses. The London Borough of Richmond evaluated their implementation of the pilot phase of this programme in early 2012. They sent samples from a fish and chip shop that had taken part in the programme and as a consequence had changed the type of cooking oil they used in their chip fryer. Before and after the change the saturated fats content of the chips were tested and it was found that the chips cooked in the new oil had 8 times less saturated fats than those cooked in fat previously used by the establishment58.
Kirklees Healthy Choice Award – Criteria for Takeaways
The Kirklees Healthy Choice Award is a partnership initiative between Kirklees Environmental
Services and Kirklees Primary Care Trust, and incorporates the 5-A-Day Campaign. The 58 Nutrinsight (2012) Healthier Catering Commitment London Borough of Richmond Whitton and Heathfield: Pilot Project February – May 2012 Award is a way of acknowledging local businesses that provide food and who appropriately fulfil the following criteria:  Maintain high standards of food hygiene  Offer healthier food options (including retail of food, e.g. supermarkets) Application for the Award is open to all businesses providing food, e.g. catering outlets, supermarkets, sandwich shops, takeaways, restaurants, cafes, pubs, child minders, play- groups, canteens, hotels, schools, (including breakfast and after-school clubs) nurseries, residential/care homes and local food manufacturers within Kirklees. The award scheme includes a separate set of nutrition criteria for takeaway outlets. Businesses can qualify for a bronze, silver or gold award, depending on how they score against the set criteria. Takeaway criteria include:  Use of liquid oil in preference to hard fats  Use of semi-skimmed and skimmed milk  Vegetarian options  Availability of bottled water and reduced sugar drinks  Serving dressings and sauces on the side of dishes  Provision of healthier option dressings  Salt reduction  Wholegrain options  Healthier children's menu items
SWERCOTS Fast Food Toolkit for Indian and Chinese food
The SWERCOTS Fast Food Toolkit was piloted by Trading Standards officers throughout Central and South West England in local authorities that are part of SWERCOTS or CEnTSA. SWERCOTS is a partnership of 15 local authority trading standards services, who work together to maximise the benefits of regional collaboration and to enable each partner to be more effective in the delivery of locally responsive services. The pilot Fast Food Toolkit is located on the SWERCOTS website. It provides various resources for Indian and Chinese restaurants to help them serve healthier food. The toolkit features:  An introductory film featuring John Vincent, founder of Leon restaurants, focussing on making small changes and using nudge and ‘health by stealth' tactics to improve menus  Downloadable PDF files with information on adjusting menus, allergens, food hygiene (in English and Chinese)  Top tips for Indian and Chinese restaurants with ££ icons to highlight where healthier changes could also save businesses money A review was carried out to see how regulatory services and businesses got on with the pilot toolkit for Indian and Chinese restaurants. Whilst Local authority feedback was generally positive the take up by businesses was quite varied across the two regions involved. Many businesses struggled to see what the incentive was for them to adopt the "healthier menu" approach. The two regions are now collecting feedback from consumers about what they wish to see in terms of "healthier options" at Chinese and Indian takeaways. It is planned that this evidence, along with some case studies, would be used to show business how such changes would be of benefit to them, and would potentially make the toolkit more appealing to its key audience. Another issue relating to the project was that no trade associations for Indian and Chinese restaurants were found to work in partnership with to develop the toolkit.
Belfast City Council Healthier Chinese Menu Project
Belfast City Council wanted to reach Chinese restaurateurs and work with them to help them improve the healthiness of their menus. Although traditional home cooked Chinese food does tend to be healthy, they found that chefs had adapted Chinese dishes to suit customer tastes: high in fat, salt and sugar and larger portion sizes. Food in Chinese restaurants also tends to have added monosodium glutamate, which contributes to salt intake and can cause adverse reactions in some people. The Council called upon the Chinese National Healthy Living Centre, the Chinese Welfare Association and the Chinese Chamber of Commerce to help them recruit businesses for their project. Belfast Health and Social Care Trust and the Food Standards Agency Northern Ireland were also involved in the project. The Council's Food Safety Team have organised a Chinese Master Chef competition, which has been running for two years. The team also ran training courses for chefs on preparing healthier Chinese food. Pages on the Council's website dedicated to the project feature healthier tips, recipes and a video from the training with commentary in two languages.
Wigan Healthy Business Award
In December 2007, NHS Ashton, Leigh and Wigan commissioned Wigan Council to develop
and deliver a Healthy Business Award (HBA) programme to improve the nutritional profile of food available in the Borough by working intensively with local business and settings that serve / provide food and thus contribute to preventing these chronic diseases. It would also contribute to reducing health inequalities by targeting hard to reach groups, and the businesses that serve them. The Healthy Business Award incorporates targeted interventions to ensure the award is inclusive and appropriate for different settings. The team maximise engagement with businesses through the economic downturn by making the changes cost neutral, and developing a marketing edge for businesses by offering healthier food which is affordable to both the business and consumer. The programme is delivered by a multidisciplinary team that include specialists in nutrition, food safety, trading standards, food science and engineering, catering and communications. The intervention seeks to make food provision more nutritionally balanced in order to bring local diets more in line with recommended nutritional guidelines that could yield significant health and economic benefits, by working with businesses to:  Reduce salt, e.g. in stock, gravy, processed food  Eliminate trans-fat through hydrogenated vegetable oils  Reduce the energy density of foods (where appropriate)  Reduce fat, especially saturated fat, by altering cooking practices, recipe reformulation and offering products without added fat e.g. butter on sandwiches  Increase fruit and vegetable use e.g. by bulking dishes and making them easier to  Increase fibre intake e.g. wholegrains The impact of the award on the takeaway food sector:  In pre and post intervention sampling of standard portions of battered fish and chips - Typical reduction in fat content AND saturated fat content by 27%  According to statistical estimates, a cut in saturated fat intake by 2.5% of energy could lead to 18 premature deaths avoided and 165 Quality Adjusted Life Years gained in the  Salt reduction of 47% - due to the combined effects of the HBA programme and the FSA's Salt Reduction programme  This work has been recognised at a national level and is included in the FSA ‘Tips on Chips' advice sheets for chip shops and local authorities53, 54 Tips on Chips – Food Standards Agency advice sheet for officers Tips on Chips – Food Standards Agency advice sheet for businesses The Chip Shop Group New Zealand on-line training Techniques and Types of Fat used in Deep-Fat Frying – National Heart Foundation of New Kirklees Healthy Choice Award This award is also featured on the Food Vision website London Healthier Catering Commitment SWERCOTS Fast Food Toolkit for Indian and Chinese Food Pilot Site Belfast Healthier Chinese Menu Project Wigan Healthy Business Award This Award is also featured on the Food Vision website This toolkit is intended to help local authorities and their partners, understand the issues around, and reasons for, focusing on takeaway catering outlets as a means of increasing community health and wellbeing. We hope this guidance helps inspire and support the development of local initiatives focusing on takeaways. We would welcome any case studies that enhance the toolkit and help us to achieve these aims. So if you have already acted on this issue and have an innovative local case study please send details tand the food vision officer will be in touch or for London t Chartered Institute of Environmental Health (CIEH) Chadwick Court London Food Board Greater London Authority The Queen's Walk 21 November 2012: Version 1 13 June 2013: Version 1.2 (update to hyperlinks) 17 June 2014: Version 1.3 (update to hyperlinks) ISBN: 978 1 906989 62 0


Microsoft word - ijabbr-2014-1017

Available online at h International journal of Advanced Biological and Biomedical Research Volume 2, Issue 1, 2014: 110-116 Investigation on the using of linco-spectin solution for in ovo administration in chicken embryo Hadi Tavakkoli1*, Amin Derakhshanfar2, Sajedeh Salandari3 1*Department of Avian Medicine, School of Veterinary Medicine, Shahid Bahonar University of Kerman, Kerman, Iran 2 Department of Pathobiology, School of Veterinary Medicine, Shahid Bahonar University of Kerman, Kerman, Iran 3 School of Veterinary Medicine, Shahid Bahonar University of Kerman, Kerman, Iran

Associate Professor Catalina Liliana ANDREI, PhD "Carol Davila"University of Medicine and Pharmacy E-mail: [email protected] Associate Professor Claudiu HERTELIU, PhD The Bucharest Academy of Economic Studies Professor Crina SINESCU, PhD "Carol Davila"University of Medicine and Pharmacy THE USE OF QUANTITATIVE TECHNIQUES IN THE ANALYSIS OF GEOGRAPHICAL FEATURES REGARDING PATIENTS WITH ACUTE CORONARY SYNDROMES