Written evidence from Health Action Campaign to the House of Commons Health and Social Care Committee 2019
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 research into how best to reduce childhood obesity, in particular what can be learned from initiatives that have successfully reduced childhood obesity around the world.
As a member of the Obesity Health Alliance we share the concern of fellow members that fuller and more rapid implementation of the government’s Childhood Obesity Plans is needed, in order to mitigate some of the effects of the current obesogenic environment. However, our main focus in this submission is what next steps the government should take in order to effectively tackle childhood obesity.
1. The government clearly needs to continue the direction set out in its Childhood Obesity Plans and to implement all its proposals, in full, if it is begin to reduce the current obesogenic environment. This may not be enough to reduce childhood obesity (which is why further action is needed). However, the measures proposed have health benefits and are likely to slow the rise in childhood obesity.
2. To achieve further progress the government needs to recognize the importance of action in the formative early years (including protecting babies from added sugar in infant formula) – not least because some of the successful initiatives in other countries have specifically focused on the early years.
3. To increase the impact of these top down measures, successful initiatives around the world suggest there’s a need to encourage and support complementary bottom up, locally based initiatives, which (adopting a whole systems approach) empower communities and the people in them to begin to reduce childhood obesity.
4. In our written evidence to the Committee in 2018 we identified local/targeted initiatives which had reduced childhood obesity in other countries, with the potential to be adopted or adapted for use here in the UK. These were:
- EPODE (Ensemble Prevenons L’Obesite Des Enfants) in France
- JOGG (Jongeren op Gezond Gewicht) in the Netherlands
- TCOCT (The Children’s Obesity Clinic Treatment) in Denmark
5. One challenge for national governments is how to scale up initiatives like these, whose success may have depended, at least in part, on local factors and specific individuals and organisations. Fortunately, EPODE provides a positive example. Its approach has now been applied in many French towns and has influenced and inspired successful initiatives in e.g. the Netherlands, South Australia and Scotland.
6. The value of ‘whole system’ community-based approaches and/or approaches targeted at those at greatest risk has been emphasized by the success of further similar initiatives around the world, including:
- HENRY (Health Exercise Nutrition for the Really Young) in Leeds
- OPAL (Obesity Prevention and Lifestyle) programme in South Australia
- The Overcoming Obesity Programme in the Finnish city of Seinajaki
- WIC (Women Infants and Children programme) in the USA
7. There may also be lessons to be learned from the sustained action taken by the Scottish government over a number of years. This achieved a reduction in the proportion of boys (but not girls) at risk of obesity between 2012 and 2017 – although a rise in 2018 has placed these gains at risk.
8. In a political environment which tends to view either markets and individual consumer decisions on the one hand or State regulation on the other as the major levers for change, we recommend adding a third dimension i.e. the importance of encouraging active and empowered communities as a catalyst for health behaviour change, as crucial partners if childhood obesity is to be successfully tackled.
Reducing childhood obesity – what works
1. England, Scotland, Ireland, Denmark, Finland, Mexico and New Zealand are some of the countries with national childhood obesity plans. Similarities often include plans for:
- Food and beverage reformulation to reduce excess sugar and calorie consumption
- Improved food and menu labelling to help consumers make informed choices
- Restrictions on the marketing of unhealthy foods to children
- School food regulations to improve nutrition standards
- National dietary and physical activity guidelines
- Social marketing campaigns encouraging healthier eating and physical activity
2. Some countries, including Mexico, Hungary and the UK have used tax increases to encourage consumers away from high sugar/calorie products and encourage manufacturers to reformulate their products.
3. These top down initiatives often appear to produce health benefits by encouraging healthier diets or more physical activity (particularly beneficial when this occurs in more deprived areas) and may also have helped slow the rise in childhood obesity. However, following sustained government action, only Scotland had seen a national reduction in childhood obesity (at least among boys).
Can we learn from Scotland?
4. Scotland had seen a decline in the proportion of children aged 2-15 at risk of obesity over a number of years. This was largely due to the significant decline amongst boys, from 20% in 2012 to 12% in 2017. Sustained action over a number of years seems at least partly responsible:
- Between 2008-2011, Healthy Weight Community Programmes were delivered across eight local areas in Scotland1.
- Between 2008 – 2014 The Route Map for Preventing Overweight and Obesity also provided over 20,000 child healthy weight programmes2.
5. Though it is difficult to establish definitive cause and effect, the results suggest that sustained national action can help produce positive lifestyle changes. Unfortunately, 2018 saw an increase to 17% in the proportion of boys at risk of obesity, indicating the need for continued action3.
Why has progress been slow in most countries?
6. Government action is important to help tackle obesogenic environments: for instance, by:
- influencing the types of food available and affordable
- restricting the advertising of HFSS products to children
- encouraging and enabling more physical activity
- providing the information and support to help parents make healthy choices for themselves and their children.
7. However, these have clearly not been enough to reverse the rise in childhood obesity globally. One possible reason is that governments typically underestimate the scale of the forces encouraging obesity. For example, in 2018 the government allocated £4.5 million to Change4Life to fund the promotion of healthy snacks4. This seems impressive until it is seen in context. For example, the advertising budget for Kit Kat, (a single chocolate bar and just one of a plethora of non-healthy snacks being advertised in any one year) is £5 million a year (with £10 million being allocated in one recent year).5
8. Examples of not recognizing the scale of action required include:
- too little action being taken, too late (an obvious criticism of England’s Childhood Obesity Plans). This includes not enough approaches being taken; and seeking to discourage HFSS (high in fat, sugar and salt) consumption but not taking enough action to make healthier food affordable, accessible and attractive
- action being taken at too low a level (for instance, relying on voluntary approaches rather than regulation, or setting tax levels on HFSS products too low to achieve significant behaviour change).
The need to combine top down and bottom up approaches
9. We suggest a further explanation. Top down policies from governments need to combine with bottom up, community-based approaches. These create a holistic, ‘whole systems’ response on the scale needed to begin to combat the otherwise pervasive effects of modern obesogenic environments. They often prove particularly effective when targeting more deprived areas, which are otherwise usually at greatest risk of obesity.
10. These bottom up community- based approaches sometimes fall through a gap in the political agenda. Parties of the right tend to assume the market will provide solutions and focus on informed decision making by individual consumers. Parties of the left tend to assume the State will provide solutions and look to top down regulation to provide solutions. Both approaches have merit but both fail to recognize an important third dimension i.e. that we are social animals, influenced by our relationships with our immediate peers - and therefore the importance of communities. As recent bookslike The Third Pillar and Alienated America have insightfully identified, societies ignore the importance of active communities at their peril6.
11. Conversely, as evidenced by the successful local initiatives described below, community- based initiatives have so far proved the main examples of successfully reducing childhood obesity. In a broader health context, as the C2 Beacon project in Falmouth has demonstrated, community involvement is key to developing healthy communities7. Engaging with and empowering local stakeholders and children/families within communities can help achieve inclusive, sustainable, lifestyle and behaviour change, adapted to local contexts and taking account of existing social, environmental and cultural factors.
Examples the government can build on
12. Reducing childhood obesity in an obesogenic world is clearly a major challenge. Fortunately, governments can now learn from a range of more local, regional or targeted initiatives which have begun to reduce rates of childhood obesity. As well as EPODE in France, JOGG in the Netherlands and TCOCT in Denmark these now include:
- Health Exercise Nutrition for the Really Young (HENRY) in Leeds
- The Overcoming Obesity Programme in the Finnish city of Seinajoki
- The Obesity Prevention and Lifestyle (OPAL) programme in South Australia
- The Women, Infants and Children programme (WIC) for some 7 million low income pregnant women and new mothers in the USA
13. Key features of these programmes usually include:
- addressing the wider influences on children’s diets and physical activity by incorporating initiatives throughout school, home and community environments.
- support for parents, families and early years professionals as children’s food preferences and lifestyle choices are established in the early years.
- engagement of influential stakeholders from central to local level, such as businesses, local government, schools, early years centres, health professionals, parents and communities.
- Enabling and empowering the capacity-building of local communities to help improve environments for children.
Scaling up local initiatives
14. One challenge for national governments is how to scale up initiatives like these, where success may have depended, at least in part, on local factors and specific individuals and organisations. Fortunately, EPODE provides a positive model here, having shown it is capable of being applied and adapted in a range of different countries8. For example, its approach has now been applied in many French towns and has inspired successful initiatives in the Netherlands, including in cities like Amsterdam and Rotterdam (JOGG), in South Australia (OPAL) and in Scotland (Healthy Weight Communities)9,10,11.
The Childhood Obesity Plan – Chapter 2: a missing ingredient
15. We fully supported the Plan’s proposals and are disappointed at the delay in implementing some of them. At the same time there were also missed opportunities in the Plan, particularly in addressing the early years of children’s lives, which we believe merited a section of the Plan in its own right. This would have included the value of breastfeeding, the need to avoid added sugar in baby foods (as recommended by England’s Chief Medical Officer) and the importance of the first thousand days of life, as a crucial period in children’s development.
16. The Plan states Ofsted school inspectors “will research into a curriculum that supports good physical development in early years”. However, it fails to recognise that childcare and early year settings have a significant formative role in influencing children’s diets. The diets of children under 5 still contain high levels of sugar and salt and the socio-economic differences in overweight and obesity from the most and least deprived areas are also evident from as early as three years of age.
17. Though there is some reassurance in the use of Healthy Start vouchers targeting families on lower incomes to improve access and intake of healthier food, there are no specific targets for reducing inequality between the most and least deprived areas.
18. The Committee is already aware of successful initiatives such as EPODE, JOGG and TCOCT, all of which were mentioned in its May 2018 report Childhood obesity: time for action. The case studies below are therefore ones not previously mentioned in the Committee’s 2018 report.
Health, Exercise, Nutrition for the Really Young (HENRY), Leeds
19. HENRY is an evidence-based intervention to support young children from an early stage to help prevent obesity. The early years are a key window of opportunity as children develop food and lifestyle habits which can track into later childhood and adulthood. On this basis, HENRY supports families, early years practitioners, communities and local authorities to make positive lifestyle changes which can have positive impact on children. These include improved nutrition, parenting skills, breastfeeding support and physical activity.
20. In 2008, Leeds made the early years the priority in their long-term child obesity strategy, embedding HENRY at the core of family support and workforce development, with delivery through community-based children’s centres in the most deprived communities. HENRY has now been credited with helping successfully reduce obesity among children aged 4-5 in Leeds, where the programme has been running across the city for over 8 years. The proportion of children who are obese fell from 9.4% in 2009/10 to 8.8% in 2016/17, with this reduction predominantly among the most deprived children12. In children aged 10-11, obesity rates remained unchanged in Leeds, despite increasing in other English cities during this time.
Seinajoki Overcoming Obesity Programme
21. The City of Seinajoki in Finland launched the Overcoming Obesity Programme for 2013-2020, based on the country’s National Obesity Programme13. It involved collaboration with childcare settings, education, nutrition, recreation and urban planning departments to promote healthier environments, access to healthy dietary choices and information and encourage physical activity among children 0-12 years of age. Key actions taken have included:
- sugary snacks being eliminated and healthier lunches provided in childcare centres, with help from nutritionists
- improvement in school playgrounds, assisted by the urban planning department
- heart healthy school nutrition
- the recreation department implementing more physical activity in schools
- the health department introducing annual health checks in schools
- parent education on healthy eating and healthy parenting (including ‘move more and spend less time with gadgets’)
22. Among children aged 5 in Seinajoki, overweight and obesity reduced from 17% in 2009 to 10% in 2015. Similar reductions in overweight and obesity were also observed among primary school children, with a 5.3% reduction in first graders and 7.9% reduction in fifth graders. There was a small increase in overweight and obesity between 2012-2015 among these age groups but overall theproportion of children overweight and obese aged one and five years has decreased since 200914.
23. The programme illustrates that childhood obesity can be reduced through the high-quality delivery of a multi-scale intervention in a city, integrating all sectors involved in influencing children’s health from an early age.
WIC (Women, Infants and Children programme) in the USA
24. This program helps almost 7.3 million low income pregnant, postpartum and breastfeeding women, infants and children up to 5 years of age by providing access to healthy food, nutrition education, breastfeeding promotion, support for nursing mothers and provision of health and social service referrals.
25. From 2010 to 2014, there was a statistically significant decrease in obesity among children aged 2-4 who were participating in WIC, with rates declining from 15.9% to 14.5% nationally and across all racial and ethnic subgroups. These reductions were statistically significant in 31 states15. The Centers for Disease Control and Prevention (CDC) reported the decrease in obesity among the WIC program to have been assisted by USDA’s revision of the WIC food package in 2009 (leading to healthier food environments in low-income neighbourhoods), CDC’s Early Childhood Education (ECE) and State Public Health Actions16.
Web links are provided, to ensure ease of access for Committee members
Our written evidence was published on the Parliament website - http://data.parliament.uk/writtenevidence/committeeevidence.svc/evidencedocument/health-and-social-care-committee/childhood-obesity-followup-2019/written/106205.html