A public health crisis
Childhood obesity has risen dramatically in recent decades. It is now a major public health problem – increasing the risk of type 2 diabetes, cardiovascular disease, some cancers and possibly even dementia.
In 2016, the UK government announced a new health plan to reduce childhood obesity within the next ten years. Measures include introducing a soft drinks levy, reducing sugar in children’s products, making school food healthier and increasing children’s physical activity. These are all welcome. However, the plan has been since criticized as weak and watered down due to intense lobbying by the food and drinks industry. For example, the plan relies mainly on voluntary action rather than regulation and no limit has been placed on the TV advertising of food high in sugar, salt and fat during peak time family viewing.
Time for a whole system approach
If the UK’s Childhood Obesity Plan doesn’t go far enough, how can we reduce childhood obesity and is there any hard evidence this will work? Fortunately there are two initiatives elsewhere in Europe which have successfully reduced childhood obesity – in one case in rural towns and in the other in a major city. What they have in common is that they don’t rely on individual, ad hoc initiatives, for instance in schools. Instead they take a holistic ‘whole system’ approach. Put simply 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. A whole system approach has been already shown to reverse the trend of obesity in smaller rural communities in France, as well as reducing childhood obesity by as much as 12% in just a few years in a major city in Holland.
EPODE (Ensemble Prevenons l’Obesite Des Enfants - Together Let’s prevent Childhood Obesity)
First launched in 1992 in two French communities, EPODE has since expanded to more than 500 communities worldwide. EPODE relies on a clear methodology in order to bring about results and employs a multiple stakeholder approach: both at a central level (ministries, health groups, NGOs and private partners) and at a local level in the community (political leaders, health professionals, families, teachers, local NGOs and local business community). The main four pillars of the methodology are
1) Gain formal political commitment from leaders of the key organizations, which influence policies both on national and on local level.
2) Ensure sufficient resources are available to fund both central support services and local implementation.
3) Provide social marketing, communication and support services for community practitioners.
4) Evidence-based approach to implementing and evaluating the programme.
Since 2011, EPODE International Network is additionally providing support and resources to the growing number of communities that recognized that the multi-stakeholder approach is the way to successful change.
What does a whole system approach mean for EPODE? Activities in projects based on the EPODE methodology include:
- social marketing campaigns on different topics (the importance of hydration, a balanced diet, physical activity through play, and sleep)
- the development of tools for educators to help them carry out activities
- activities for the whole community (e.g. a Vitality day – an opportunity for parents to spend a fun day with their children while being physically active).
- introduction of a “Vitality pass” in order to encourage families to participate in events supporting healthy lifestyle
- Action on fruits, a kindergarten programme where children are introduced to different types of seasonal fruit
- The installation of sport and recreational facilities in the communities
In themselves these were not necessarily new public health interventions. The difference and the key to the success of the project is that these activities did not take place in insolation, but as a combined effort, within and supported by the community, with strong support from local authorities (both political and financial). Combining these approaches gave EPODE the power to combat the many powerful forces that might otherwise encourage unhealthy diets and lifestyles.
Jongeren op Gezond Gewicht- JOGG (Young people at a Healthy Weight)
This is a Dutch movement that encourages all people in the community (city, town or a neighborhood) to make healthy eating and exercising an easy and attractive lifestyle option for young people. The JOGG foundation has been established at a national level with the aim to provide advice and training on how to successfully implement the approach in the local community. Currently, 84 municipalities around Netherlands are using it.
The main pillars that have facilitated successful implementation are similar to the EPODE methodology:
- Political and governmental support. As well as commitment and established structures at a national level, healthy weight as part of healthy lifestyle has been included in relevant policy documents and main decision-makers at a local level are personally interested in and involved in the movement. For example, the Deputy Mayor led the initiative in Amsterdam, with all-party support.
- Cooperation between the private and public sectors. Both can be included in local projects and can contribute their resources (financial, communication etc.)
- Social marketing. There is a strong focus on taking into account the user’s perspective and identifying barriers and facilitators for healthy lifestyles, and adapting the intervention to fit local target population’s needs
- Scientific support and evaluation: process and outcome evaluation are taking place in order to monitor the success of implementation and effect – and adapting the intervention accordingly
- Linking prevention and health care: overweight children are identified early through prevention activities and then taken care of in a healthcare setting
One of the most successful municipalities using this approach is Amsterdam. With almost one in five children in the city being overweight, the municipality started the Amsterdam Healthy Weight Programme in 2013. The programme is focusing on the factors most closely related to healthy weight: healthy nutrition, enough exercise and adequate sleep.
Amsterdam understands that if a change is to be made, there needs to be more than just a focus on individual factors influencing behaviour, but also on the environment. In their view, the healthy life of children is a shared responsibility for everyone who has any kind of influence on children’s environment - from parents, to neighbours and teachers in the immediate environment, and to legislators and the food and drinks industry.
Some concrete actions and interventions the city has implemented or is working on implementing include:
- Healthy primary school policies: only tap water is allowed during breaks, no more sugary beverages; and children get extra PE lessons by a trained teacher
- Education on healthy choices for parents; with special programmes to address the first 1000 days of a child’s life – encouraging young mothers to live healthily in pregnancy and offer their child a healthy lifestyle from birth
- Medical professionals trained to talk to parents about healthy choices
- Community initiatives such as healthy cooking classes with kids
- Sports clubs offering cheaper memberships to children from lower socio-economic backgrounds
- Some food companies taking attractive elements off their packaging;
- Supervision over adherence to marketing rules transferred from the food industry to an independent body.
- City planners exploring the possibilities of designing a ‘healthy city’ that, by design, invites all its inhabitants to move more
The effects of the coordinated efforts are already visible. Between 2012 and 2015, the percentage of overweight children (aged 2-18) fell from 21% to 18,5%, including a decline among vulnerable groups with low socio-economic status. Amsterdam now has a long-term strategy with an allocated budget to achieve their mission of a healthy weight of all children in Amsterdam by 2033, when the first generation of healthy children will become 18.
Fortunately the importance of a whole system approach is beginning to be recognized now in the UK (including the recent Go Golborne project taking place in the Royal Borough of Kensington and Chelsea, which is also based on EPODE methodology). There is still a long way to go in comparison to some other countries but this is a positive first step forward.
- If we're serious about wanting to tackle childhood obesity we need to take a whole systems approach. This means putting children’s health at the forefront - as a shared responsibility for all stakeholders. Focusing on single interventions in single settings isn't enough. We need to focus on the different causes of childhood obesity, understand how they interconnect and then take action to tackle them.
- Policians and local authorities need to realise just how serious a problem there is and put tackling childhood obesity much higher up the agenda.
- A social marketing approach can be a very useful tool. To change behaviour, interventions need to take into account the perspective of each target group and adapt the interventions to make healthy behaviour easy and accessible for them.
- Public health authorities and practitioners need to get everyone on board – working with local authorities, schools, healthcare providers, communities and families, as well as with parts of the private sector in order to make a real difference.
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