In recent years Britain has become a nation where overweight and obesity in both adults and children is increasingly common. This good practice guidance was produced at the request of many of our colleague medical advisers who are increasingly being asked for guidance on obesity by adoption and fostering agencies.

PRACTICE NOTE: OBESITY AND SUBSTITUTE CARE

1. Introduction

1.1 This good practice guidance was produced at the request of many of our colleague medical advisers who are increasingly being asked for guidance on obesity by adoption and fostering agencies. It is not a definitive guide to the assessment and management of obesity in adults or children nor will it provide an answer in every case.

2. Background

2.1 In recent years Britain has become a nation where overweight and obesity in both adults and children is increasingly the norm. By 2050, the Foresight Project indicated that 60% of adult men, 50% of adult women and about 25% of all children under 16 could be obese. The NHS costs attributable to overweight and obesity are projected to double to £10 billion per year by 2050. The wider costs to society and business are estimated to reach £49.9 billion peryear at today’s prices. (1)

2.2 The Foresight Project also predicts that successfully tackling obesity will require a long term, large scale national commitment. The current prevalence of obesity in the population has been at least 30 years in the making. This will take time to reverse and it will be at least 30 years before reductions in the associated diseases are seen.

2.3 Foresight’s work indicates that a bold whole system approach is critical – from production and promotion of healthy diets to redesigning the environment to promote walking, together with wider cultural changes to shift societal values around food and activity. This will require a broad set of integrated policies including both population and targeted measures and must necessarily include action not only by government, both central and local, but also action by industry, communities, families and society as a whole.

2.4 The evidence is clear that policies aimed solely at individuals will be inadequate and that simply increasing the number or type of small scale interventions will not be sufficient to reverse this trend. Significant effective action to prevent obesity at a population level is required.

2.5 Childhood and young adulthood are critical stages in the development of behavioural patterns that will affect their health in later years. It is concerning that The National Children’s Bureau (2005) (2) noted in the past 10 years, obesity in 6 year olds has doubled to 8.5% and has trebled in 15 year olds to 15%. Current trends suggest that around 8% of obese 1–2 year old children will be obese when they become adults, while 80% of children who are obese at age 10–14 will become obese adults, particularly if one of their parents is also obese. (1) Foresight

3. Measuring Obesity and Overweight in Adults and Children

3.1 The National Institute of Clinical Excellence (NICE)(3) defines obesity using Body Mass Index (BMI). This is a person’s weight in kilograms, divided by their height in metres squared (kg/m²). BMI is categorised by NICE as follows:

Classification	BMI (kg/m2)
Healthy weight	18.5–24.9
Overweight	25–29.9
Obesity I	30–34.9
Obesity II	35–39.9
Obesity III (morbid obesity)	40 or more

3.2 Not all obese individuals are at increased risk of cardiovascular disease. Those with abdominal obesity are however at significantly increased risk.(4) Waist measurement and hip/waist ratio are indicators of a cluster of metabolic abnormalities that increase risk of cardiovascular disease and diabetes. The authors believe that it is worth identifying these individuals at an early stage so that they have the opportunity to address their increased health risks.

3.3 A waist measurement greater than 100cm in men and 90cm in women indicates abdominal obesity and the group who are at high risk of future serious health problems.(5) The waist-to-hip ratio is worked out by dividing the measurement of the waist (just above the umbilicus) by that of the hips at their widest point. For men, a ratio should ideally not be over 0.90; for women, that figure is 0.85: the higher the number above these values, the greater the risk of heart disease.

3.4 BMI should be interpreted cautiously in highly muscular individuals as it is not a direct measure of adiposity. In these individuals hip/ ratios will be normal.

BMI and Hip/ Waist ratios can both be calculated quickly and easily using a number of on-line calculators. (www.bmi-calculator.net/waist-to-hip-ratio-calculator/)

3.5 In children over 2 years of age, the BMI is a better indicator of overweight or underweight than a weight measurement alone. The new UK/WHO growth charts for children, which include BMI charts, are available on line at www. growthcharts.rcpch.ac.uk. A child whose weight is average for their height will have a BMI between the 25^th and 75^th centiles whatever their height centile. A BMI above the 91^st centile suggests that the child is overweight. A child with a BMI above the 98th centile is clinically obese.

4. The Long Term Effects of Obesity in Adults

4.1 Obesity is a complex, multi-systems disease which not only has a significant impact on physical health but also on psychosocial well-being. Obese people can also experience substantial impairments in their quality of life, including their mental health. The multiple implications of obesity are shown in figure…..

[insert image obesity.gif]

4.2 Smoking significantly increases all the associated risks of obesity. Current smoking or a history of having given up smoking in the preceding 12 months significantly increases cardiovascular risk. All overweight and obese individuals should be strongly advised to stop smoking. The impact of obesity on health is increased by lack of regular exercise. Regular exercise which includes 20 minutes of activity (sufficient to increase the heart rate to over 100 beats per minute) at least three times per week will reduce cardiovascular risk. Obese individuals often lead highly sedentary lifestyles and will need sustained encouragement to change. Lindsay (2002) states that excessive alcohol intake (more than 22 units per week) increases the risk of serious cardiovascular events, whilst moderate alcohol intake (8 units per week) might decrease it. (6)

4.3 A family history of premature cardio-vascular heart disease (myocardial infarction or sudden death) at or before 55 years of age in father or other male first degree relative or at or before 65 years of age in mother or other first degree female relative is known to increase the risk. Men of 45 years or over and women of 55 years and over (or post menopausal) are at increased risk of cardio-vascular disease.

4.4 Applicants with any of the following are classified as being at very high risk for disease complications and mortality (over 20 per cent five-year risk of cardiovascular disease):

• established coronary heart disease
• type 2 diabetes
• sleep apnoea
• renal dysfunction
• familial hypercholesterolaemia or other inherited dyslipidaemias

4.5 Tables have now been devised to quantify more precisely the risk of cardiovascular disease in any individual. (7)(Joint British Recommendations, 2000) They are intended to offer general practitioners reliable advice on the need for lipid-lowering drugs and also to indicate when aggressive treatment of high blood pressure is indicated. (See calculating risk later in this note.)

 

5. The Effects of Obesity in Children

5.1 Wake (2008) REF 8 systematically reviewed the consequences of obesity in Australian children. These included:

• overweight and obese school aged children may experience more daytime tiredness, snoring, less night time sleep and more injury related morbidity than non overweight children
• obese, but not overweight children were 72% more likely to have additional health care needs compared with non-overweight children in particular an increased tendency to asthma
• overweight and obese preschoolers do not appear to experience more health morbidities than their non overweight peers. This suggests that intervention at school entry has the potential to prevent onset of childhood morbidities associated with obesity before they develop

5.2 Obese children appear more likely to experience psychological or psychiatric problems than children of normal weight. Obesity could make a child more reluctant to take part in physical exercise and exposes them to increased risks of bullying from other children.

5.3 In addition in the short term paediatric obesity has been associated with liver disease, cardiovascular risk factors, asthma, diabetes (types 1 and 2) and orthopaedic abnormalities.(8)

5.4 Evidence linking childhood obesity to adult disease and premature mortality is difficult to obtain and is currently limited. However, systematic review and critical appraisal is supportive of the hypothesis that paediatric obesity has adverse effects on health in childhood. (9)Reilly

5.5 Clearly, the increasing prevalence of obesity in childhood, is very likely to translate into greatly increased levels of obesity among adults, rendering them more susceptible to chronic, life-threatening illness.

5.6 Children should therefore only have fast foods as avery occasional treat as they are heavily loaded with sugar,0 fats and salt, all of which can be harmful to the long-term health of children if eaten in excess.

6. General Principles for Dealing with Applicants

6.1 The final decision regarding the approval of adopters and foster carers is a social services’ decision not a medical one. It is ultimately made by the Agency Decision Maker on the recommendation of the adoption and fostering panels.

6.2 Although health information is important, it is not the sole criterion on which panel judgments should be made. Medical reports are given to panels to assist in the matching of prospective parents with vulnerable children. They must not be used to exclude all but the very fit. It is absolutely essential that the agency medical adviser does not see their role as one of accepting or rejecting a particular applicant purely on health grounds. Doctors may be pressurised by social workers, who have additional concerns about a family, to reject applicants on purely health grounds, but theymust resist this temptation.

6.3 There are three guiding principles in dealing with difficult health issues:

• Parenting capacities are more important than perfect health
• The welfare of the child is paramount
• Honesty and openness in dealing with applicants is essential

6.4 Parenting involves more than good health. It requires evidence of a prospective parent’s values, attitudes, life experiences, commitment and flexibility in responding to the needs of individual children.

6.5 If initial medical information raises serious concerns, agencies should consider an early health /social services discussion of any contentious health issues. Full discussion at an early stage, supplemented with the advice of the medical adviser, can be extremely useful for social workers, highlighting areas where the panel will require further information when the case returns for final approval.

6.6 Medical advisers and social workers need to remember that adults whose application is turned down by an agency have a right to request a reconsideration of their application and a right to know on what grounds they were rejected. Hence doctors and social workers should be scrupulously open and honest from the beginning.

6.7 It must always be remembered that in most cases it is a couple, not an individual, who come forward to be considered for adoption. Social workers and medical advisers need to consider carefully the illogical situation of rejecting a healthy, well-motivated applicant because of health problems in their partner. Where one applicant has significant health risks, the assessment must focus on the motivation and abilities of both partners and their support networks.

6.8 The aim of substitute care is to provide needy children with secure, stable, permanent carers. Medical advisers and agencies need to have the same high standards of health for foster carers as for adopters.

6.9 All of this must be balanced against the large numbers of waiting children, particularly older children, sibling groups, children from black minority ethnic cultures and children with other special needs.

 

7. Specific Issues around Obesity in Substitute Carers

7.1 There are currently no national guidelines regarding obesity in foster, adoptive or kinship carers. The authors believe that this should be addressed by both health and social services as all the available evidence suggests that this problem will only increase with time.

7.2 We fully acknowledge that many excellent substitute carers are obese. There is also a national shortage of both foster carers and adopters. However all current Government guidance in this area emphasises the importance of securing optimum health for looked after children. Care Matters: Transforming the lives of children and young people in care (DfES 2006) states that:

7.3 ‘As the corporate parent of children in care the State has a special responsibility for their wellbeing. Like any good parent, it should put its own children first. That means being a powerful advocate for them to receive the best of everything and helping children to make a success of their lives’

7.4 In addition, the National Minimum Standards for Fostering Services  2011  emphasized the importance of health promotion awareness for foster carers both in relation to their own health and that of children in their care.

7.5 We fully recognise that the risk of placing a child in a household where one or more of the adults is obese is only one factor in the complex process of the holistic assessment of a child’s needs.

7.6 We are also mindful of the importance of not disrupting stable placements, which are otherwise meeting the needs of a child. However, it is the responsibility of the placing agency to ensure that any health risks to the child are identified, brought to the attention of their carers and measures put in place to reduce the impact of the problem.

7.7 Agencies have a primary responsibility to ensure where relationships are established between a child and a carer that these are maintained for as long as the child needs them. It is however a tragedy for a child, who has already experienced significant losses, to then lose a foster, adoptive or kinship carer because of preventable illness or premature death.

7.8 Adoption agencies have to take into account the Government view that there should be no “blanket” bans when considering applications from prospective adopters. The issue is not therefore one of banning prospective adopters and new carers, but of engaging with them, providing information, advice and education about healthy diets and active lifestyles.

7.9 As the problem of obesity in the UK increases, agencies will have to balance the positive elements of any placement against the negative health impact of an obesogenic family environment. Starting now to address the importance of healthy lifestyles in all the families of looked after children will not only protect the long term health of our children and their carers, but also reduce potential problems for agencies in the future.

 

8. Children

8.1 Anecdotal evidence suggests that obesity in children in the care system is not common. Research into this important area of child health is urgently needed.

8.2 It must however be remembered that looked after children often have a complex relationship with food. Looked after children may have been deprived of adequate food as part of a pattern of neglect or as a form of punishment. Many young children come into care with disordered eating patterns, both under and over eating. These young people are at increased risk of eating disorders in adolescence, because of their high level of unresolved emotional difficulties.

8.3 Any discussion of weight and food should be handled with great professional sensitivity. There is little to be achieved in distressing a young person who then refuses to return for any further health guidance.

8.4 It is important to recognize however that many children will not be used to a healthy and varied diet and will not have had the opportunity to engage in adequate physical activity. Time, imagination and patience will be needed to support them to adapt as part of the adjustment which comes with entering care.

9. Recommendations

9.1 Recommendations to Social Workers and Panel members

9.1.1 It is poor practice when the decision about whether to accept an obese applicant is totally delegated to the medical adviser. Social workers and panels also have an important role to play.

9.1.2 All prospective adoptive, foster and kinship carers must have an initial health assessment by their general practitioner. This is an invaluable opportunity for a health review. It offers applicants an opportunity to re-evaluate their lifestyle and for the general practitioner to recommend intervention which offers positive long-term benefits. Most agencies will have encountered applicants whose undiagnosed hypertension or diabetes was first picked up during a routine medical examination.

9.1.3 Obese individuals frequently suffer from social stigmatisation and discrimination and the relevance of obesity to the health assessment of prospective carers is inevitably controversial. It is, however, paramount that the social worker raises any concerns about weight with applicants at an early stage and advises them it will be an issue for the panel to consider. The applicant should also be advised by the social worker that the medical adviser will want to write to their general practitioner and that they may have to have further investigations. It is important that any concerning medical information is addressed during the assessment process before being presented to panel.

 

9.1.4 The following important factors will not necessarily emerge during a routine medical examination, but must be evaluated and evidenced prior to any decision:

• Does the applicant want to lose weight? Successful weight loss depends very largely on motivation. An unmotivated applicant is unlikely to lose weight. Their previous history of successful and unsuccessful weight loss attempts is important.
• What is the applicant’s understanding of the causes of obesity and how it contributes to ill- health?
• What is their attitude to physical activity, both for themselves and any children placed with them? What is their capacity to engage in physical activity? Do they become breathless climbing one flight of stairs? Could they chase a toddler who runs towards a road? Are these applicants able to provide a child with at least 60 minutes or more of physical activity every day?
• What is the applicants understanding of a healthy diet for their family? Are any other family members overweight or obese? Have previous children placed with this applicant gained excessive weight?
• Does the applicant have the time and/or resources to achieve successful weight loss?

9.1.5 The conclusions of this discussion should be minuted and made available to any matching panel so that they can be considered again when a specific child is considered.

 

9.2 Recommendations to Agencies

9.2.1 Agencies should set in place a long term strategic framework to ensure that the recognised health risks and consequences of obesity in carers and children are incorporated into routine practice and decision-making. From April 2008, tackling child obesity became a national priority for all Primary Care Trusts working with their local partners.

9.2.2 The importance of a healthy lifestyle, diet and exercise, should be included in all initial training for foster carers and prospective adopters. These discussions should be ongoing throughout the approval and review process. Agencies should provide regular training and information on the health implications of obesity for Fostering, Adoption and Permanency Panels

9.2.3 Healthy lifestyle should be discussed at all household reviews where either carer has a BMI or if a child is gaining excessive weight in the placement.

9.2.4 Carers/Residential home staff/social workers should be advised not to use food as a reward or pacifiers for children and young people especially those with behaviour difficulties.

9.2.5 Social workers should not entertain children and young people in care at venues where fast food and food high in sugar, fat and salt is the only available option. Local Authorities should ensure that the quality of food in residential homes is nutritionally adequate for the needs of growing children.

9.2.6 All Local Authorities should make available free or reduced- price leisure activities for looked after children and their ‘host’ families to encourage physical activity.

9.2.7 In kinship placements, which are of particular concern to medical advisers, the additional health risks to the child of being placed in a household where there are carers who are overweight need to be carefully balanced against the other benefits of the placement for the child.

9.3 Recommendations for Medical Advisers – Adults

9.3.1 An informal survey of medical advisers in 2009 showed that 96% of those surveyed would like guidance in this area because they considered that the problem was increasing. Although 61% had medical concerns about obese applicants these concerns were nearly always discounted by social workers and panel members. There was general agreement that any guidance for doctors should take into account both the level of obesity and the presence of complications.

9.3.2 Whilst few doctors thought that BMI alone should be the sole criteria for assessment, there was a consensus that as BMI increases, a cut off point should be considered such that an application might be deferred.

(I) Applicants with BMIs between 35 and 40:

9.3.3 Waist measurement or hip/waist ratio as recorded on the BAAF adult health form should be used to identify applicants who are at high risk of obesity related complications. A waist measurement of more than 100cms in a man and 90cm in a woman increases cardiovascular risk 20 fold even in the absence of other complications REF 5 (ref National Heart Lung and Blood Institute 1998) These applicants need to be aware that they have a particularly high risk form of obesity .

9.3.4 Medical advisers should alert applicants and their general practitioners to the presence ofr other health factors identified on the medical form, e.g. cigarette smoking, hypertension, high cholesterol, diabetes, family history of cardiovascular disease; which could increase the risks of further morbidity and mortality. Treatment of these health issues could offer really positive health benefits even without weight loss.  Jackson (2000)(12) notes that any reduction of risk factors will lessen the risk of cardiovascular disease, whether or not efforts at weight loss are successful.

9.3.5 Applicants should be advised to visit their primary health care team to discuss their weight. It would be good practice for medical advisers to have standard letters to social workers which are also copied to the applicants and the general practitioner. Any comments about weight and health must be tactful and sensitive to the distress which might result.

9.3.6 Where further investigations are needed, they should be initiated in the spirit of promoting the health of the applicant rather than excluding them from further assessment or approval.

9.3.7 Treatment options for consideration will depend upon the individual and their own doctor’s advice but may include dietary changes, increasing physical activity, behaviour modification and drug therapy.

9.3.8 In cases where applicants or their general practitioners fail to take action, social workers and panels will have to balance the potential health implications for the carer and the child against the other benefits of that placement.

(II) Applicants with BMIs over 40:

9.3.9 NICE has recently identified obesity at this level as a very serious health problem, which cannot be ignored as part of an assessment. This group of patients is at high risk of significant morbidity and early mortality, which could impact on their ability to care for a child.

9.3.10 In order to reach a fair and balanced decision about this group of applicants it is essential that the following information is available to the medical adviser. Some of this information will be obtained from the general practitioner, some from the applicant’s health form and some from a good home based assessment by the social worker.

• Accurate family history with ages and causes of death in first degree relatives
• The results of relevant investigations (e.g. diabetes, fasting blood sugar, pretreatment cholesterol, accurate blood pressure ) - this will enable a cardiovascular risk to be calculated using one of the available on-line resources
• Accurate lifestyle information particularly around smoking and alcohol
• Whether other family members, particularly other children in the family, are either overweight or obese
• Information on the applicant’s understanding of the risks of their medical condition and their motivation and attitude to change

9.3.11 Carers with this degree of obesity must be referred back to their general practitioner with the expectation that the GP will follow NICE guidelines and refer the applicant for specialist services. This may well include consideration for medical and/or surgical treatment.

9.3.12 In this group, the final decision about the application must be made on an individual basis following a multi-agency discussion and be sensitive to the feelings of the applicant and the needs of the child. Agencies must appreciate that morbid obesity with complications is a very serious medical condition which might not be compatible with the physical and emotional challenges of substitute parenting.

9.4 Calculating Risk

9.4.1 Medical advisers must make risk assessments on sound evidence rather than prejudice. Risk predictions must also be interpreted in the light of any life style changes that are put into place, e.g. the successful treatment of hypertension or high cholesterol or stopping smoking. All these interventions will significantly reduce morbidity and mortality and offer really positive health benefits.

9.4.2 There are now a number of on-line calculation tools which calculate the risk of an individualhaving a heart attack or stroke in the next ten years. Most general practitioners in England and Wales use the QRISK^®2 Data. This is available at www.qrisk.org. and requires a knowledge of an individual’s age, sex, family history in first degree relatives, BMI, systolic blood pressure, cholesterol/HDL ratio, smoking history and whether they have diabetes, chronic kidney disease or rheumatoid arthritis. It is not suitable for people who already have a diagnosis of heart disease or stroke.

9.4.3 Assign is the cardiovascular risk score chosen for use in Scotland. This measure includes social deprivation as well as other risk factors. It is available at assignscore.com.

9.5 Recommendations for Medical Advisers – Children

9.5.1 All children and young people in care must have an annual health assessment. We strongly recommend that this assessment should always include a calculation of BMI which must then be plotted on the new UK/WHO growth charts for children. www.growthcharts.rcpch.ac.uk. These charts are essential in the assessment of all children and must be carried by all medical advisers and specialist nurses.

9.5.2 The BMI may occasionally give misleading results in children who are very stocky or muscular, especially boys. If there is any doubt a waist measurement should also be plotted on a standard reference chart. The routine measurement of waist size is not however recommended in children.

9.5.3 Children with a BMI above the 91^st centile are considered to be overweight, children above the 98^th centile are considered to be obese. The medical adviser/ specialist nurse should bring the situation to the attention of the foster carer, social worker and where appropriate the child/young person. For children in the care system who already experience considerable disadvantage, becoming obese in childhood could add to the well-recognized physical and mental heath problems they might face as adults.

9.5.4 Detailed guidance on the management of obesity in childhood is available from NICE (3)and all medical advisers and specialist nurses for looked after children should be familiar with this very helpful, evidence based report. They should also be familiar with the 2009 Department for Children Schools and Families Draft guidance on “Promoting the Health and Well Being of Looked after Children” (10)which contains advice on both diet and activity specifically for children in the care system and their carers.

9.5.5 Young people with a BMI over 40 should be referred to appropriate local services. The cornerstone of treatment involves lifestyle changes including changed eating patterns and increased exercise. Drug treatment is not generally recommended for children under the age of 12 years. For children aged 12 and over it should only be started by a specialist team. Surgical intervention is not generally recommended in children or young people. Bariatric surgery may be considered for young people only in exceptional circumstances, and if they have achieved or nearly achieved physiological maturity. (NICE, Dec 2006).

10. CONCLUSIONS

10.1 Obese adults are known to be at increased risk of significant health problems. These problems increase as obesity increases and are made much worse when secondary complications develop. Obese children are at risk of increased health problems and are at increased risk of becoming obese adults.

10.2 Health and social care have a responsibility to ensure the health and well-being of children in care and their carers. Hence they have a responsibility to identify and advise about obesity in substitute carers and in children and young people in the care system.

10.3 Despite the large amount of research into obesity, when it comes to the substitute care of children, there are a number of unanswered questions. As the percentage of obese adults in Britain continues to increase, four important questions remain unanswered and should be the subject of future research:

• Does obesity significantly limit a person’s ability to parent? Is an obese adult still able to provide a healthy environment for a child?
• Is there a physical and/or psychological impact on a child who is placed with obese substitute parents?
• Is there sufficient evidence to suggest that a child placed with obese carers, is at increased risk of developing obesity and its associated complications?
• What is the impact of this guidance on kinship care where health factors are often of low secondary consideration?

10.4 Medical advisers, social workers and panels will continue to struggle with this issue because they are working in an area where there is little evidence based research to support decision making. It is our hope that this practice note will introduce some consistency of practice and encourage research in this area.

10.5 Children in care deserve the best environment we can give them and starting to address the risks of obesity in their carers and themselves will help to give them an improved future physically and emotionally. Addressing obesity may be one of the most important things that any adult or child can do to protect their health and increase their life expectancy.

 

References

1. Foresight ‘Tackling Obesities: Future Choices’, Government Offices for Science 2007 http://www.foresight.gov.uk
2. The National Children’s Bureau Healthy Care Briefing March 2005
3. NICE Clinical Guideline 43, ‘Obesity - guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children’ December 2006
4. Després J-P, Lemieux I and Prud’homme D, ‘Treatment of obesity: need to focus on high risk abdominally obese patients’, BritishMedical Journal 322, pp 716–20, 2001
5. National Heart, Lung and Blood Institute (USA), Clinical Guidelines on Identification,Evaluation and Treatment of Overweight andObesity in Adults: The evidence report, USA: National Institutes of Health, September 1998
6. Lindsay, P and Hill, C.Objective assessment of vascular disease risk in prospective adoptive parents. Adoption & Fostering Volume 26 Number 1 2002 75
7. British Cardiac Society, British Hyperlipidaemia Association, British Hypertension Society and British Diabetic Association, ‘Joint British recommendations on the prevention of coronary heart disease in clinical practice: summary’, British Medical Journal 320, pp 705–08, 2000
8. *Comorbidities of overweight/obesity in Australian preschoolers: a cross sectional population study Wake, Hardy, Sawyer, Carlin – Arch Dis Child 2008 93 502-507
9. ABC of Obesity Childhood obesity Reilly JJ Wilson D BMJ vol 333, 9^th Dec 2006
10. Care Matters: Transforming the lives of children and young people in care (DfES 2006)
11. National Minimum Standards for Fostering Services (England 2002)
12. Jackson R, ‘New Zealand cardiovascular disease risk benefit prediction guide’, British MedicalJournal 320, pp 709–10, 2000

 

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