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BMS3058

BMS3058:)International)and)Public)Health)Nutrition) Assignment)1:)Childhood)Obesity) Deadline:)6th)March)2018) ) PART 1: Briefly outline the scale of the chosen problem in the UK using data from key sources. Discuss any relevant current UK policy/strategies/targets, including their evaluation. Childhood Obesity; a key public health issue Childhood obesity (CO) is one of the top public health challenges in developed and developing countries and shows increasing trends through the years1. Increasingly, children grow up in obesogenic2 environments disrupting the energy balance equation and predisposing them to excess calorie intake and lack of energy expenditure. Cheaper, more readily available, energy dense and nutrient-poor foods advertised by marketers and screen-based sedentary leisure activities encourage weight gain in young children and their families. It is a significant driver behind a variety of conditions like endocrine or pulmonary diseases, Type-2 diabetes, hypertension3 and two major killers of the modern world; cardiovascular diseases (CVD) and cancers thus can affect the physical health of children3. Obesity is often related with the children’s self-esteem4, depression5,6, affecting their psycho-social health status7 and educational attaintment8,9. Obese children are 5 times more likely to become obese adults10, subsequently providing a burden on health and the economy1. In 2013 United Kingdom was placed in the top 10 amongst 34 countries for prevalence of overweight and obesity in boys and girls aged 12 to 19 years old11 and it cost the NHS £5.1 billion in 2014/201512

Prevalence of childhood obesity in the UK and trends over time A range of sources used by the government to estimate the scale of CO is summarised in Table 1. Although all methods carry limitations, statistics from the National Child Measurement Programme (NCMP), which measures a much greater proportion of children, is assumed more precise than Health Survey for England (HSE) and is mostly used for comparisons in this report (Table 2). Furthermore, the way the NCMP survey separates estimates statistics for children in reception (aged 4-5) and year 6 (aged 10-11) revealed double the cases and the need for stronger actions to tackle CO in older children. In 2016/2017 CO ranged from 9.6% to 20.0% in Reception and Year 6 children respectively13. Over the last 10 years, prevalence increased by 1-3% for both age groups, although values are subject to underestimation due to low participation in years 2006-200914. Although BMI is a good overall estimate for general adiposity, it does not account for a portion of children within the normal range but with abnormal fat distribution and central adiposity, which are often more representative of metabolic health, therefore might be subject to underestimation15,16. The National Diet and Nutrition Survey (NDNS)17 might be more appropriate to understand the quality of children’s diets. In 2012/13-2013/14, the majority of children aged 11-18 did not meet recommendations for fruit, vegetables and oily fish. No improvement was observed in saturated fat 1 !

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intake and although reduced trends in consumption was seen for sugar-sweetened drinks and non-milk extrinsic sugars, intake still exceeded recommendations17. Lastly, a strong relationship between obesity and most deprived regions and ethnic minorities was observed (See part 2)13,18,19.

TABLE 1 Prevalence of childhood obesity in England according to different sources and their key characteristics and considerations. Sample size

Considerations

*BMI through Height and weight measurements

Over one million children in reception (45years) and year 6 (1011years)

Annual survey first started in 1991

Survey through an interview, selfcompletion booklet (815years), nurse visit for more measurements and samples

About 2000 children 215 years old living in private households.

- Larger sample size and more precise than HSE - Accounts for variations in sex, local authority, region and levels of deprivation. - Data from private and special schools are not analysed - Smaller sample size and less precise than NCMP - Regular Information not available elsewhere

Health Profiles22

Annually produced reports since 2006 and interactive tool

Existing data from various sources is collected in one place on a range of indicators

Sample size of source data is collected from

- Concise comparisons between local authorities, help the government prioritise and plan services

NDNS17

Annual survey first started in 1992 and run continuously since 2008

Quantitative information on food consumption, nutrient intake and nutritional status

Around 1000 people per year aged 1.5 years and over living in private households, 2 children categories: a) pre-school children (1.5-4.5years), b) young people (4-18 years)

-Enables trends data -Allows estimated consumption of fruit and vegetables, oily fish, sugar sweetened soft drinks, saturated fatty acids, non-milk extrinsic sugars, vitamins, minerals and iodine

FFS23

Annually published since 1940. Originally known as the National Food Survey and renamed in 2000

Self-reported diaries and receipts of all food and drink purchases for two weeks

Around 5000 households surveyed every year

Trends of intake

NCMP13,20

HSE20,21

Frequency/ Year started Annually collected/ launched in 2005/06

Information collection

NCMP, National Child Measurement program; HSE, Health Survey for England; NDNS, National Diet Nutrition Survey; FFS, Family Food Survey *BMI, Body Mass Index above the 91st and 98th centile suggests an overweight and clinically obese child respectively24

TABLE 2 Ten-year trend of childhood obesity prevalence according to the National Child Measurement Program !

2

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and Health Survey for England since 2006/2017. Year 2005/06 is not included due to low participation. NCMP25

2016/17

Prevalence (%) Reception Year 6 9.6% 20.0%

Sample size (children) Reception Year 6 629,359 556,452

2015/16

9.3%

19.8%

625,326

544,615

2014/15

9.1%

19.1%

610,636

531,223

2013/14

9.5%

19.1%

587,336

514,275

2012/13

9.3%

18.9%

587,678

489,146

2011/12

9.5%

19.2%

565,662

491,118

2010/11

9.4%

19%

541,255

495,353

2009/10

9.8%

18.7%

526,499

499,867

2008/09

9.6%

18.3%

506,169

497,680

2006/07

9.9%

17.5%

435,927

440,489

HSE 26 Prevalence (%) Sample size (children) 2-15 years old 16% Interview: 2,056 Nurse visit: 1,117 14% Interview: 5,714 Nurse Visit: 1,297 14% Interview: 2,003 Nurse visit: 1,1249 15.5% Interview: 2,185 Nurse visit: 1,455 14% Interview: 2,043 Nurse visit: 1,203 16.5% Interview: 2,007 Nurse visit: 1,257 16% Interview: 5,692 Nurse visit: 1,327 15.5% Interview: 1,147 Nurse visit: 807 17% Interview: 7,521 Nurse visit: 2,464 16% Interview: 7,257

NCMP, National Child Measurement Program; HSE, Health Survey for England; NDNS, National Diet and Nutrition Survey; FFS, Family Food Survey

UK policies/ strategies/targets The government has introduced several policies, strategies and targets in order to tackle CO, which became apparent through scientific evidence, public pressure, advocacy groups, media and celebrities. The evolution of government policy to tackle obesity, shown in table 3 led to the development of various policy actions27, summarised in Table 4. However, since CO is rising, they have mostly proven ineffective (Figure 1). Even-though obesity was trending in government policies since 1980s27; an exclusive focus on children; “Childhood Obesity: A plan for Action”12 was not published until 2016, which targets elimination of the problem within the next 10 years. The strategy focuses on 14 recommendations and involves action of industry, businesses, the public sector, school and health care professionals, with a great focus on reducing sugar intake (Table 5). Denmark, Hungary, France and Finland have already introduced a sugar-sweetened beverages (SSB) tax, reducing consumption by 4-10%28. Therefore the soft drink industry levy introduced by the Childhood Obesity Plan may effectively reduce SSB consumption12 and subsequently obesity rate29. Although this policy raises public concern about the scale of the problem, it is one of the shortest policies produced and has been criticised as lacking realistic expectations, since only the sugar tax levy does not rely on voluntary action30. As a proof of content, previous voluntary action strategies such as the (R&D) in 201131, showed no effectiveness in reducing CO prevalence, and re-introducing32 it will not tackle the problem. Marketing, advertising and high-sugar products price promotions, are more common in the UK than any other European country, have shown to increase high sugar food consumption by 6% overall33. 3 !

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The exclusion of marketing strategies and the complete absence of saturated fat recommendations17 puts the proposed policy in a disadvantaged stage. Furthermore, 4 out of 14 recommendations (7-10 table 5) focus on minimising obesogenic2 environments in schools. However, non-school environments were proven to contribute more to obesity prevalence34,35. Systematic monitoring and formal reporting against clear targets is essential for policy evaluation36, preferably from an independent agent37. However, a robust evaluation method is not mentioned in the majority of the recommendations (Table 5) and inconsistent, vague progress reports36 were stated in the past.

Childhood Obesity Prevalence (%)

25

20

15

10

Public(Health( Responsibility(Deal( (2011)( Healthy(Lives,( Healthy(People( (2010)(

Healthy(Weight,( Healthy(Lives((2008)( Choosing(A(Better( Diet((2005)(

Childhood(Obesity( Plan((2016)(( Revised(EatWell( Guide((2016)((

!Reception Year!6

5

20 16 /1 7

20 14 /1 5 20 15 /1 6

20 09 /1 0 20 10 /1 1 20 11 /1 2 20 12 /1 3 20 13 /1 4

20 06 /0 7 20 07 /0 8 20 08 /0 9

0

Period (Years)

FIGURE 1. Childhood obesity trends over time based on National Child Measurement Program statistics and examples of government introduced policies to tackle childhood obesity. Increasing trend of childhood obesity is almost doubled in Year 6 (aged 10-11) compared to Reception (aged 4-5) children. TABLE 327 Examples of national UK policy/strategy introduced by the government to tackle childhood obesity shown in chronological order including type of policy and main target. Year

Strategy/policy

Type

Main Target

1999

Saving Lives: Our Healthier Nation

White paper

Obesity in general but mentioned children too

2004

Choosing health: making healthier choices easier

White paper

Focus on individual lifestyle changes (fiscal, legislative, environmental, commercial)

TABLE 3 CONTINUED27 !

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Examples of national UK policy/strategy introduced by the government to tackle childhood obesity shown in chronological order including type of policy and main target. 2005

Choosing a Better Diet: A Food and Health Action Plan

White paper delivery plan

Reduce diet-related disease prevalence and reduce obesity

2008

Healthy weight, healthy lives

Cross-government strategy for England

Promote healthy food, physical activity, health at work, effective treatment and support in overweight and obese individuals

2010

Healthy Lives, Healthy People

White Paper

Ambition: Achieve a downward trend in levels of excess weight in children

2011

Public Health Responsibility Deal

Competition based

-Voluntary, image and reputational enhancement than public health improvement if not properly implemented and monitored32

2016

Childhood Obesity Plan

Government plan introducing soft-drinks industry levy

14 recommendations for tackling childhood obesity

2016

Revised Eatwell Guide

Eat-well plate renamed to Earwell Guide

-Exclusion of high fat, salt and sugar foods from the purple section - Hydration recommendation included - Adjusted size of some sections to meet current recommendations

TABLE 4 27 Examples of national UK policy actions to tackle childhood obesity in chronological order Social Marketing 2009

Change4Life

2010

Start4Life

- Focus on children under 11 years, support families to make healthier decisions about food and activity - Maternal and children (>5 years) health campaign - Part of Change4Life

Early Year Interventions 2004

Healthy Child Programme

- Healthy eating and increased activity to reduce obesity

Schools Interventions 2003

Physical Education and Sport for Young People

- School Sport Partnerships introducing 3hours of high quality PE per week

2003

School Travel Plan

2004

School Fruit and Vegetable Scheme

- Cycle storage facilities, training initiatives, safety equipment (highvisibility jackets/ helmets) - Free piece of fruit and vegetable for children aged 4-6

2012

Change4Life School Sports Clubs

TABLE 4 CONTINUED27 !

- Increase physical activity levels in less active primary and secondary school children

5

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Examples of national UK policy actions to tackle childhood obesity in chronological order From 2014

Cooking Skills

- Principles of healthy eating, basic cooking techniques

Changing the Food Environment Television Advertising Restriction 2007

Voluntary Scheme for Front-of pack Nutritional Labelling of food and drink products

- Advertising television restrictions for high fat, sugar, salt products in pre-school and primary school programs - Front of pack labelling for most pre-packed food - Colour coding scheme

TABLE 512 The Childhood Obesity Plan: Plan for Action 2016, plans, aims and their proposed evaluation method. Fourteen recommendations to tackle childhood obesity, including soft drinks industry levy. Childhood Obesity Plan

Aims

Evaluation method

1) Soft drinks industry levy

- £10 million a year to school healthy breakfast clubs - Soft drinks industry levy due implementation in April 2018 - Remove sugar from products commonly used by children by 2020 - Reducing portion size or shift to lower sugar alternatives

- Progress will be evaluated by PHE in March 2018

3) Support business make healthier products

- Collaborative research and development (R&D) competition worth £10 million

- Evaluation method not mentioned

4) Update nutrient and profiling model

- Review the nutrient profile model to follow latest dietary guidelines - Strong effective model to encourage companies for healthier products - Continue work with Local Government - Association to ensure healthy food environment in public sector setting

- Evaluation method not mentioned

6) Re-commit to Healthy Start scheme

£60 million worth vouchers on low income families exchanged for fresh/frozen fruit, vegetables and milk and free vitamins

- Evaluation method not mentioned in the report

7) Physical activity every day for kids

- 30 minutes of moderate to vigorous physical activity a day at schools through 30min PE, - extra-curricular clubs, active break times - 30min non-school activity supported by parents- interactive online tool

- Evaluation method not mentioned in the report

8) Improve physical activity programmes for children

- Introduce high quality sport programmes - £40m investment for sport activities - Cycling and Walking Investment Strategy $300m investment

- Evaluation method not mentioned in the report

2) 20% sugar out of products

5) Make healthy options available public sector

- Interim reports on progress published and reviewed by Public Health England (PHE), every 6 months through analysis of sale reduction and food composition data

- Behavioural interventions by PHE, NHS England and BIT, track changes in purchasing behaviour revenue impact from sales

PHE, Public Health England; SACN, The Scientific Advisory Committee on Nutrition; NHS England, National Health Service England; BIT, Behavioural Insights Team; DfE, Department of Education, Ofsted, The Office for Standards in Education

TABLE 5 CONTINUED12 !

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The Childhood Obesity Plan: Plan for Action 2016, plans, aims and their proposed evaluation method. Fourteen recommendations to tackle childhood obesity, including soft drinks industry levy. 9) Create new voluntary healthy rating scheme for schools

- Encourage schools contribution - Annual competition to recognise schools with most impactful projects

- Evaluation through school inspection handbook by Ofsted

10) Make school food healthier

- DfE with support by PHE, will update School - Food Standards based on new government dietary recommendations Expand healthy breakfast clubs

- Evaluation method not mentioned in the report

11) Clearer food labelling

- Clearer visual labelling ie teaspoons of sugar

- Evaluation method not mentioned in the report

12) Support early years settings

- Children’s Food Trust: develop revised menus for early years 2017 C

- Evaluation method not mentioned in the report

13) Harness best technology

- Annual digital technology ‘hackathlon’ to produce innovative solutions

- Evaluation method not mentioned in the report

14) Enable HPCs to support families

- Encourage relevant training of health professionals

- Evaluation method not mentioned in the report

PHE, Public Health England; SACN, The Scientific Advisory Committee on Nutrition; NHS England, National Health Service England; BIT, Behavioural Insights Team; DfE, Department of Education, Ofsted, The Office for Standards in Education

PART 2: Focusing on Middlesbrough and Reading compare and contrast key indicators that relate to the chosen problem (i.e. a or b above). Outline the local population characteristics and relevant wider determinants of health in both locations that need to be taken into account when devising a local intervention to address the issue.

Population characteristics of people living in Middlesbrough and Reading that might contribute to childhood obesity prevalence Reading has a larger population tha...