Written evidence on childhood obesity from Health Action Campaign to the House of Commons Health and Social Care Committee 2018
Health Action Campaign is a public health charity, whose guiding principle is that prevention is better than cure. In this submission we draw on our health economics research into the role of food and the food industry and our follow up research into how best to reduce childhood obesity.
Our focus in the submission is what the priorities should be for further action by the Government – including what the most effective interventions might be to reduce inequality.
We fully support the analysis and recommendations in Childhood Obesity brave and bold action. However, new evidence has now become available which makes tackling childhood obesity more feasible. We very much hope the government will wish to act on this new evidence
1. There are now at least three proven programmes known to reduce childhood obesity:
- EPODE (Ensemble Prevenons l’Obesite Des Enfants) in France.
- JOGG (Jongeren op Gezond Gewicht) in Holland.
- TCOCT (The Children’s Obesity Clinic Protocol) in Denmark.
Each of these successful initiatives has adopted a sustained, systematic, joined up approach, rather than separate ad hoc initiatives, either in a community setting (EPODE and JOGG) or a clinical setting (TCOCT). Each has reduced levels of childhood obesity, including in socially disadvantaged groups, thereby helping reduce health inequalities. For example, following the JOGG model, the Deputy Mayor of Amsterdam led a programme which, in just three years, reduced the number of overweight and obese children by 12%
We therefore recommend that the government:
- Convene a multi-partner task force, with a remit to reduce pre-school obesity in three pilot areas, within the lifetime of a single Parliament, by adopting coordinated evidence-based approaches.
- Give a health remit to all the Elected Mayors (not just four, as at present); and then make available a Tackling Obesity Fund that Elected Mayors can bid for to develop sustained, systematic, joined up local programmes.
2. To tackle health inequalities action is needed upstream i.e. to address the food-related root causes of obesity. That’s because downstream initiatives, like health education and promotion, often increase health inequality rather than reduce it. As Public Health England has identified, 42% of working age adults are unable to understand and make use of everyday health information. Our three upstream recommendations are:
- Broaden food tastes (to include bitter as well as sweet), in order to make healthy diets palatable. As tastes are initially acquired in the womb and in the earliest years of life, encourage pregnant mothers to adopt a more varied diet and then to breast feed; and encourage baby food manufacturers to produce food that includes bitter as well as purely sweet tastes.
- Provide government funding for research to explore if more diverse gut microbiota can help control weight, as initial research suggests potential here.
- Continue to ensure food companies reduce levels of sugar and salt and increase dietary fibre. There has been a recent focus on sugar as a significant contributor to obesity. However, salt and refined carbohydrates also increase the risk.
3. The food and beverage industry is now approaching a tipping point. Developments in food technology (including ways of reducing sugar and salt content without affecting taste and without the use of artificial alternatives) are combining with an increasing public desire for healthier food (reported by all the main consumer research organisations) and increasing reputational risk to food and drink companies perceived to be resisting the move to healthier products. As a result, we recommend:
- The government’s Industrial Strategy should include the aim of enabling the UK to achieve global market leadership in the production, marketing and sale of healthier food.
- To incentivize the move to healthier products, the more than a billion pounds a year corporation tax relief on food and drinks industry R & D should be re-focused on R & D to develop healthier food and drink.
Reducing Childhood Obesity – What works
There are now at least three proven programmes known to reduce childhood obesity:
- EPODE (Ensemble Prevenons l’Obesite Des Enfants) in France.
- JOGG (Jongeren op Gezond Gewicht) in Holland.
- TCOCT (The Children’s Obesity Clinic Protocol) in Denmark.
Each of these successful initiatives has adopted a sustained, systematic, joined up approach, rather than separate ad hoc initiatives, either in a community setting (EPODE1 and JOGG2) or a clinical setting (TCOCT3). Each has reduced levels of childhood obesity, including in socially disadvantaged groups, thereby helping reduce health inequalities. EPODE and JOGG don’t rely on individual, ad hoc initiatives, for instance in schools. Instead they take a holistic ‘whole system’ approach. They aim to identify and address all the causes of childhood obesity and to get everyone working together to tackle the causes - parents, schools, health professionals, communities, businesses, central and local government.
Some of the activities undertaken are not necessarily new and some have already been taken in the UK. The difference and the key to success is that these activities do not take place in isolation, but as a combined effort, within and supported by the community, with strong and sustained political and financial support from local authorities and central government. Combining these approaches gives both EPODE and JOGG the power to combat the many powerful forces that might otherwise encourage unhealthy diets and lifestyles and enable childhood obesity to continue to grow.
This ‘whole system’ approach has been already shown to reverse the trend of obesity in rural towns4, as well as reducing childhood obesity by as much as 12% in just a few years in a major city5.
TCOT starts in a clinical setting. It was developed by a paediatrician in the town of Holbaek in Denmark. It has already treated 1,950 patients and helped 70% of them to maintain normal weight6. It is now being rolled out to eight other districts in Denmark. At the beginning of the programme, children are admitted to hospital for 24 hours for extensive testing, including body scans to measure their body fat. They also answer a detailed questionnaire about their eating habits and behaviour patterns. Each child then receives a personalised treatment plan which targets 15-20 daily habits and includes follow up meetings with relevant health professionals. TCOCT sees obesity as a chronic disease with a fiercely defending hormone system. Hence the need to assess the patient as a whole. Without this the body may counteract the weight loss by reducing energy cost or taking in extra calories in order to regain weight.
What TCOCT shares with EPODE and JOGG is a recognition that obesity is a serious condition, with major health implications, with many forces in modern society combining to increase the risk. To tackle this therefore requires a significant, sustained, joined up approach.
Tackling health inequalities through upstream interventions
To tackle health inequalities action is needed upstream, to address the food-related root causes of obesity, including both the quantity and the quality of food consumed. That’s because downstream initiatives, like health education and promotion, often increase health inequality rather than reduce it. As Public Health England has identified, 42% of working age adults are unable to understand and make use of everyday health information – and this figure rises to 61% if numeracy skills are also required for comprehension7.
Research confirms this. “Upstream” interventions appeared to decrease inequalities, and “downstream” “Person” interventions, especially dietary counselling seemed to increase inequalities. That was the verdict from a systematic review of 36 studies into interventions intended to promote healthy eating, published in 20158. Our assessment is that three upstream areas appear particularly worth the government pursuing.
Firstly. broadening food tastes (to include bitter as well as sweet), in order to make healthy diets palatable. Because both amniotic fluid and breast milk contain molecules derived from the mother’s diet, learning about flavours in foods begins in the womb and during early infancy. This early experience serves as the foundation for the continuing development of food preferences across the lifespan9. A systematic review of 20 different studies, published in 2015, concluded that exposure to bitter and specific tastes increased the acceptance of these tastes10. While a review of early taste experiences and later food choices, published in 2017, concluded that starting in the prenatal period, a varied exposure through amniotic fluid and repeated experiences with novel flavours during breastfeeding and complementary feeding increase children’s willingness to try new foods11. So encouraging pregnant mothers to adopt a more varied diet and then to breast feed is an important ‘upstream’ first step. We recognise that behaviour change isn’t necessarily easy to achieve. However, pregnancy is a time when women are especially likely to seek, expect and act on information and support from health professionals; and our own research suggests that pregnancy is one of the trigger points in women’s lives when they consider adopting healthier lifestyles.
Not all mothers breast feed. So baby food manufacturers need to produce food that includes bitter as well as purely sweet tastes. This is important because a study by Glasgow University, published in 2015, looked at 329 commercial baby foods (CBFs) containing fruit and vegetables in their name. It found the fruit and vegetable content of CBFs mainly consists of fruits and relatively sweet vegetables12. The lead researcher, Dr Ada Garcia, commented, ‘The risk is that while parents may think commercial baby foods are introducing their children to healthy vegetable tastes, actually they are mainly reinforcing preferences for sweet foods.’
Secondly, the importance of reducing the sugar content of food is already clear and needs no further rehearsal. However, the government also needs to continue to push to reduce salt consumption (to a minimum that doesn’t compromise food safety). A systematic review of 18 studies, published in 2017, found that higher sodium consumption was associated with greater BMI and greater waist circumference13. It has been known for some time that salt increases thirst, leading to increased fluid consumption – and where the fluid is sugar sweetened beverages this adds calories without reducing appetite, thereby contributing to weight gain. However, new research, published in 2015, showed a consistent significant association between salt intake and BMI, waist circumference and body fat mass independent of total energy intake and sugar-sweetened beverage consumption14. This suggests that salt may contribute to obesity through means other than simply the knock-on effects from increasing thirst. Conversely dietary fibre appears to help control weight. This is partly explained by fibre’s ability to help us feel full quicker and keep us feeling full longer15. One review of 50 studies estimated that increasing fibre intake by 14g per day was associated with a 10% decrease in energy intake and a 2kg weight loss over a four-month period16. Taken together this suggests the government should continue to encourage suppliers to reduce levels of sugar and salt and increase levels of dietary fibre in mass produced food.
Initial research also suggests that more diverse gut microbiota are good for both our health and our weight – and that this can be encouraged through prebiotic foods17. As most studies so far have been in animals, more research is needed in people to be sure of this. To accelerate research findings we would suggest this as a priority for Research Council funding.
A tipping point for the Food and Beverage Industry
The government should take advantage of the fact that the food and beverage industry is now approaching a tipping point. Developments in food technology (including ways of reducing sugar and salt content without affecting taste and without the use of artificial alternatives) are combining with an increasing public desire for healthier food (reported by all the main consumer research organisations) and increasing reputational risk to food and drink companies perceived to be resisting the move to healthier products. Taking each point in turn:
Reformulation is a core skill for food companies, who can already vary the formulation of the ‘same’ product for different parts of the world (whether to cater for different regional tastes or different regulatory requirements). They can also call on the expertise of external organisations to help with reformulation – and we provide two examples of successful reformulation partnerships with universities below. Large companies typically also undertake ‘what if’ scenario planning. It is difficult to imagine that large food companies haven’t already planned for the need to produce healthier formulations, whether to meet changing consumer trends or public health requirements. This is not to suggest that reformulation is easy. However, it is increasingly doable.
A number of recent innovations illustrate this. M&S worked with Aberdeen University to develop their Fuller Longer range18. Tate & Lyle worked with Nottingham University to develop SODA-LO Salt Microspheres19. This turns standard sea salt crystals into free-flowing hollow salt microspheres, meaning that our tongues perceive the same salt taste from a lower volume of salt. Nestle have recently announced new chocolate bars with 30% less sugar than a typical chocolate bar, made possible by physically altering sugar to make it lighter and dissolve faster20. Meanwhile, Israeli company Doux Matok has developed flavour delivery particles21. By adding 0.3% of food industry approved silica, which the body naturally excretes, the remaining 99.7% sugar is perceived by our taste receptors as sweeter than an equivalent amount of conventional sugar. The food industry trade press reports that products containing flavour delivery particles will be available in European supermarkets from 201822. What is important about these new formulations of sugar and salt is that they don’t compromise taste (a major issue for both food companies and consumers) and remain sugar and salt. They thereby avoid the potential consumer resistance to artificial alternatives. We have no commercial involvement with any of the organisations mentioned and simply provide the information above to show options now available to the food industry, to enable it to mass produce healthier food.
An increasing desire for healthier food has been reported by all the main consumer research organisations in recent years. For example, in a 2015 global report, Neilsen note: ‘Consumers seek fresh, natural and minimally processed foods. Beneficial ingredients that help fight disease and promote good health are also important. Health attributes are most important to emerging-market respondents, who are also most willing to pay a premium for health benefits. Younger consumers are most willing to pay a premium for health attributes. Healthy categories are growing faster than indulgent categories, although there is still room for occasional treats in consumers’ diets’23. Research by global research firm IRI, published in 2017, confirmed this trend, noting that more than two thirds (72%) of shoppers in the UK are buying healthy food – with less salt, sugar, fat or calories24.
We have reported both global and UK trends because, as Grant Thornton’s Head of Food and Beverage Scotland notes. ‘You are never going to become a global player by producing goods just for UK retailers’25. We are already seeing some significant long-term trends. For example, global sales of bottled water have overtaken sales of fizzy drinks for the first time (according to beverage market research company Canadean), while in the UK, AG Barr, makers of the iconic fizzy drink Irn Bru is now selling more bottled water than carbonated drinks. As consumer tastes evolve, the reputational risk for companies unwilling to adapt continues to grow. As Credit Suisse Research noted in their 2013 report, Sugar consumption at a crossroads, ‘For companies with brands as strong as Coca-Cola or Pepsi, the biggest risk to sales growth and profitability is a negative public image’. What all this suggests is that healthier food isn’t just good for public health. It is important for the long-term business success of UK food companies – and therefore important for government to consider as a part of its Industrial Strategy.
The government should consider the following further action, to reduce childhood obesity in the UK:
1. Convene a multi-partner task force, with a remit to reduce pre-school obesity in three pilot areas, within the lifetime of a single Parliament, by adopting coordinated evidence-based approaches.
2. Give a health remit to all the Elected Mayors (not just four, as at present); and then make available a Tackling Obesity Fund that Elected Mayors can bid for to develop sustained, systematic, joined up local programmes.
3. Encourage pregnant mothers to adopt a more varied diet and then to breast feed; and encourage baby food manufacturers to produce food that includes bitter as well as purely sweet tastes.
4. Provide government funding for research to explore if more diverse gut microbiota can help control weight, as initial research suggests potential here.
5. Continue to ensure food companies reduce levels of sugar and salt and increase dietary fibre.
6. Include in its Industrial Strategy the aim of enabling the UK to achieve global market leadership in the production, marketing and sale of healthier food.
7. To incentivize the move to healthier products, the more than a billion pounds a year corporation tax relief on food and drinks industry R & D should be re-focused on R & D to develop healthier food and drink.
Our written evidence was published on the Parliament website at - http://data.parliament.uk/writtenevidence/committeeevidence.svc/evidencedocument/health-and-social-care-committee/childhood-obesity/written/81091.html - and the Committee referred to some of our evidence in its report.
Web links are provided, to ensure ease of access for Committee members
- https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1467- 3010.2007.00603.x