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22 February 2017 - British Medical Journal - Time for the UK to commit to tackling child obesity

Mark Hanson

The UK government published its report Childhood Obesity: a Plan for Action, after a protracted delay, on 18 August 2016, when parliament was in recess and the nation was focused on the success of Team GB at the Rio Olympics. The plan received very little media coverage or public response. There was, however, an immediate outcry from the medical and public health communities, who had hoped for much more. The draft version had been 50 pages in length, but the published plan ran to just 10 pages; strong actions were conspicuous by their absence, and the desired discussion of anti-obesogenic medicine had been watered down to an emphasis on voluntary actions by industry, consumers, and schools.

One of the most important omissions was reference to the recommendations of the World Health Organization Commission on Ending Childhood Obesity (ECHO). The final ECHO report, published in January 2016, was the culmination of about 18 months of evidence review and wide consultation. It was presented at the World Health Assembly in May 2016, where a decision was made to request the director general to develop an implementation plan to guide further action on the recommendations, in consultation with member states. The implementation report is now available.

A missed opportunity for global leadership

The ECHO report directs specific actions and responsibilities to governments of member states. By not referring to it in the obesity report, the UK government missed an opportunity to show global leadership in child health by announcing advance commitment to implementing some of the ECHO commission’s recommendations—for example, an industry levy on sugar sweetened beverages, nutrient profiling to identify healthy and unhealthy foods, clearer food labelling, and promotion of physical activity in schools. Other recommendations, such as stronger controls on advertising, mandatory food reformulation, and nutrition education were absent from the report.

What’s missing from the government’s plan?

Overweight and obese children are likely to remain so as adults, when they will be at greater risk of non-communicable diseases such as type 2 diabetes, cardiovascular disease, some cancers, asthma, and other atopic conditions. The economic consequences of child overweight and obesity relate not only to direct healthcare costs but to a range of indirect healthcare costs extending across the life course and reducing longevity. The government’s plan notes the short and long term damage to the health of individuals from obesity, but it fails to recognise that overweight and obesity in children and young people are driven by multiple modifiable biological, behavioural, environmental, and commercial factors, some of which operate before conception and birth. Nor does it recognise that the harm extends across generations. This failure represents a major lost opportunity for effective prevention.

Many communities typically affected by undernutrition are now experiencing overnutrition through changes in diet, sedentary lifestyles, and a lack of focus on promoting broader health. In these settings, the adverse health effects of poor maternal health and childhood stunting are amplified by the increased risk of later overweight and obesity. Furthermore, the rising prevalence of maternal obesity and gestational diabetes is driving childhood obesity in the next generation. Such problems are particularly acute in lower socioeconomic and educational attainment groups—those least equipped to meet the challenge. The government’s plan mentions the marked association between socioeconomic adversity and childhood obesity but not the steps necessary to tackle this growing inequity.

Interventions that might improve unhealthy trajectories initiated during early development are largely based on evidence from animal research or observational studies and small randomised controlled trials in humans. This is partly because some interventions can’t feasibly be randomised (for example, breast feeding) but also because outcomes are difficult to evaluate a long time after the intervention. In addition, reliable markers of risk of obesity are scarce. The government’s plan does not mention the necessity for strategic programmes of research and evaluation to strengthen the evidence base for population level interventions. The delegates at St George’s House thought it would be helpful for the scientific and political communities to agree on approaches to define interim policies for intervention based on existing evidence, and their robust evaluation, so that they can be fully accepted, modified, or rejected as appropriate.

The concept that obesity prevention is predominantly a matter of personal or parental responsibility has been particularly unhelpful. Infants and young children are wholly vulnerable to the actions of adults and to the broader societal factors that create an obesogenic environment, including the marketing practices of industry. For older children and young people, and their parents, a sole focus on personal responsibility is likely to result in guilt, resistance, denial, and perpetuation of the problem. Voluntary actions, ranging from people trying to lose weight to industry developing healthier products, have so far been ineffective in halting the rise in obesity, so the government’s emphasis on personal choices and voluntary measures by industry is especially disappointing. Fiscal and regulatory measures, such as taxes and regulations on the marketing and packaging of cigarettes, have brought enormous benefits to child and population health; governments should not hold back from taking such actions to protect children.

Healthcare professionals alone are not adequately positioned and do not have the resources to tackle this multifactorial, societal problem that spans government, industry, education, and the public. Additionally, healthcare in the adolescent and preconception periods; contraception; pregnancy planning; antenatal, pregnancy, and postpartum care; and child health are often fragmented and under-resourced. Other professionals such as nursery staff and school teachers, community pharmacists, health visitors, social workers, and dentists could assist in generating the wider cultural movement needed, especially in engaging hard-to-reach groups such as migrants and those with lower educational or socioeconomic attainment.

What can we do now?

Measures to tackle factors associated with childhood obesity that would benefit individual health, even though a causal relationship may be uncertain, should be put in place immediately. Surprisingly the government’s plan doesn’t mention any of these factors, which include avoiding parental smoking, reducing high pre-pregnancy body mass index, avoiding excessive gestational weight gain, and encouraging breast feeding.

Children have different metabolic set points depending, in part, on the intrauterine environment in which they develop. So a focus confined to calorie restriction or physical activity will give variable, and often disappointing, results. Weight and body mass index are easy indices to measure, but people are likely to appreciate a focus on health and fitness rather than just weight, and this may allow more nuanced and positive messages to be conveyed to the public. The government’s intention to promote physical activity is excellent, but it will be insufficient in isolation; the public, parents, children, and young people need education to improve nutrition literacy and awareness of the benefits of physical activity regardless of weight.

Constructive discourse with the private sector is essential to developing an effective response to the societal challenge of overweight and obesity in children and young people. The approach of national governments and international agencies has been inconsistent in its relations with industry, and some public health communities have resisted such engagement. Multinational corporations operate across national jurisdictions, so we need a wider global approach in which clinical, professional, and scientific organisations have a potentially powerful contribution to make. Engagement with industry needs to take into consideration trade issues and how to manage conflicts of interest. Engaging with industry may not be possible for organisations such as WHO, but the implementation plan for ECHO commits to developing guidelines for engaging with the private sector in consultation with member states.