Time for the UK to commit to tackling child obesityBMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j762 (Published 22 February 2017) Cite this as: BMJ 2017;356:j762
All rapid responses
Hanson and colleagues are quite right to call for further action to tackle the obesity epidemic.(1) It should be noted that the original brief government plan was billed as “a start” and not “the final word” (2) and we believe it is now time to build on this and develop a comprehensive long term strategy.(3) Such a strategy should contain at least three “Es”: environmental change; education and enforcement. This multicomponent methodology has been utilised successfully for other child public health topics, for example, accident prevention.(4)
We agree that focusing purely on individual responsibility is unhelpful. Such approaches have in the past led to “victim blaming” where individuals can feel disempowered in obesogenic environments.(5) At the moment many children, particularly those from lower socioeconomic groups, are growing up in environments that encourage excessive weight gain and obesity. We need to create supportive environments where the healthier choices are the easier ones.
The second “E”, education is important for the children themselves and key professionals who can support them. Schools are one place where there is tremendous potential to maintain and promote the health of children. Personal, social and health education (PSHE) can be used to promote and maintain the health of children but unfortunately PHSE provision has been declining for a number of years. A crucial first step here is making PSHE statutory in all schools. Teachers, school nurses and catering staff all have parts to play in creating health promoting schools, however if they are to be effective they will need training and support.
Multi professional training has in the past been available to update staff, increase commitment and to promote future collaborations. There is the opportunity to enlist a wide range of people including: catering managers; dietitians; doctors; environmental health officers; and health and safety officers. Food policy action groups could also be established in each authority to plan and coordinate multiagency action and ensure that there is concerted effort.
In the past such training and multi-agency groups have been facilitated by public health staff.(6,7) However, many local authority public health departments will need increased resources to undertake this important work: a “radical upgrade” is needed.(8,9) Well-resourced departments would be able to lead, support, and drive forward improvements in child health.
The third “E” is enforcement and concerns the use of legislation, regulations or standards to promote healthier behaviour, products or environments. Although it may to some sound controversial, public health law does have a successful well-established history. Introducing compulsory standardised simple labelling on food and drinks and tackling advertising in the mass media are just two ways that this approach can be used to tackle this epidemic.(10)
We believe that the government is ethically bound to protect children and one important aspect of this is reducing the risk of obesity.(11) A failure to act will have considerable health, social and economic consequences in the future. It is essential that the government acts now and provides the increased commitment and leadership needed to tackle this childhood epidemic.
1) Hanson M, Mullins E, Modi N. Time for the UK to commit to tackling child obesity. BMJ 2017;356:j762
2) Department of Health. Guidance: childhood obesity: a plan for action. 2016. www.gov.uk/government/publications/childhood-obesity-a-plan-for-action.
3) Watson M and Lloyd. Taxing sugar should be just one element of a multifaceted campaign BMJ 2015;351:h4388.
4) Watson M C and Errington G. Preventing unintentional injuries in children: successful approaches. Paediatrics and Child Health.2016; 26(5), 194-199.
5) Thompson S. The Essential Guide to Public Health and Health Promotion. Abingdon: Routledge, 2014.
6) Health Education Authority. Take Heart. Good Practice in Coronary Heart Disease Prevention. London: Health Education Authority, 1990.
7) Project Health. Bulletin 6. Special Edition. Peterborough’s Food Policy. Peterborough: Health Education Service, 1990.
8) NHS England, Public Health England, Monitor, Care Quality Commission, Health Education England. Five year forward view. 2014. www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf.
9) Watson M C and Lloyd J. Need for increased investment in public health BMJ 2016;352:i761.
10) BMA. Food for thought: promoting healthy diets among children and young people. London: BMA, 2015.
11) WHO. Report of the Commission on Ending Childhood Obesity: implementation plan. Report by the Secretariat for the 140th Session of the WHO Executive Board. Geneva: WHO, 2017.
Competing interests: No competing interests
More than a quarter of children in England and Wales have overweight and, worryingly, obesity prevalence is as high as 15% (1, 2). Mark Hanson and colleagues (3) are absolutely right to highlight the desperate need for, and the persistent bureaucratic barriers to, concerted multimodal measures to actively reduce child obesity rates, not just halt their increase.
However, while we vehemently seek appropriate discussion and delivery of anti-obesogenic medicine (population-level) interventions, we must not forget about the young individuals who cannot and will not be helped by such an approach. When obesity is severe (i.e. BMI ≥40 kg/m2, or ≥120% of 95th percentile), lifestyle and pharmaceutical interventions are unsuccessful (4). These individuals get lost within, or worse, left outside of health care systems that struggle find a successful response. There is evidence that obesity will both significantly shorten the length (5) and worsen the quality (6) of these young people’s lives. With long-term evidence recently emerging supporting the efficacy of adolescent bariatric surgery in reversing and improving weight, quality of life and cardiometabolic risk factors, including type 2 diabetes, dyslipidaemia and hypertension (7-9), it is now essential that this vulnerable group is not left as a lost tribe. Instead, we must learn in the UK from lessons in Sweden (8) and the US (7,9), where adolescent bariatric surgery programmes have been developed over the past decade. Prevention and treatment are not mutually exclusive; both are essential in what will almost certainly be a ‘hundred-years war’ on child obesity.
1. Boodhna G. HSE 2013: Children's BMI, overweight and obesity. Health Survey for England; Health, social care and lifestyles. 12013.
2. Bailey L. Child Measurement Programme for Wales 2014/2015: Public Health Wales NHS Trust; 2016.
3. Hanson M, Mullins E, Modi N. Time for the UK to commit to tackling child obesity. Bmj. 2017;356:j762.
4. Kelly AS, Barlow SE, Rao G, Inge TH, Hayman LL, Steinberger J, et al. Severe obesity in children and adolescents: identification, associated health risks, and treatment approaches: a scientific statement from the American Heart Association. Circulation. 2013;128(15):1689-712.
5. van Dam RM, Willett WC, Manson JE, Hu FB. The relationship between overweight in adolescence and premature death in women. Annals of internal medicine. 2006;145(2):91-7.
6. Schwimmer JB, Burwinkle TM, Varni JW. Health-related quality of life of severely obese children and adolescents. Jama. 2003;289(14):1813-9.
7. Inge TH, Courcoulas AP, Jenkins TM, Michalsky MP, Helmrath MA, Brandt ML, et al. Weight Loss and Health Status 3 Years after Bariatric Surgery in Adolescents. The New England journal of medicine. 2016;374(2):113-23.
8. Olbers T, Beamish AJ, Gronowitz E, Flodmark CE, Dahlgren J, Bruze G, et al. Laparoscopic Roux-en-Y gastric bypass in adolescents with severe obesity (AMOS): a prospective, 5-year, Swedish nationwide study. The lancet Diabetes & endocrinology. 2017;5(3):174-83.
9. Inge TH, Jenkins TM, Xanthakos SA, Dixon JB, Daniels SR, Zeller MH, et al. Long-term outcomes of bariatric surgery in adolescents with severe obesity (FABS-5+): a prospective follow-up analysis. The lancet Diabetes & endocrinology. 2017;5(3):165-73.
Competing interests: I work in the field of bariatric surgery.
Educating the public.
Public engagement and change of public behavior is difficult and in Glossop we have been engaging patients and public through the encouragement of patients and families access to their medical records and through public and professional mixed public meetings. ( http://www.htmc.co.uk/pages/pv.asp?p=htmc0317 ) .
We find that the patients and public respond to positive measures and interest and to peer pressure. People don't live their lives in isolation and working with groups of peers is more likely to produce change than working with individuals. We are increasingly sharing information about the basic causes of illnes associated with obesity, diet and lack of exercise - mitochondria. .
Although it is well established that physical activity increases mitochondrial content in muscle, the molecular mechanisms underlying this process have only recently been elucidated. Mitochondrial dysfunction is an important component of different diseases associated with aging, such as Type 2 diabetes and Alzheimer’s disease. Mitochondrial biogenesis is influenced by environmental stress such as exercise, caloric restriction, low temperature, oxidative stress, cell division and renewal and differentiation. Mitochondrial biogenesis is accompanied not only by variations in number, but also in size and mass. It is well established that physical activity increases mitochondrial content.
The metabolic syndrome is a constellation of metabolic disorders including obesity, hypertension, and insulin resistance, components which are risk factors for the development of diabetes, hypertension, cardiovascular, and renal disease.Pathophysiological abnormalities that contribute to the development of the metabolic syndrome include impaired mitochondrial oxidative phosphorylation and mitochondrial biogenesis, dampened insulin metabolic signaling, endothelial dysfunction, and associated myocardial functional abnormalities. Recent evidence suggests that impaired myocardial mitochondrial biogenesis, fatty acid metabolism, and antioxidant defense mechanisms lead to diminished cardiac substrate flexibility, decreased cardiac energetic efficiency, and diastolic dysfunction.
In addition to impairments in metabolic signaling and oxidative stress, genetic and environmental factors, aging, and hyperglycemia all contribute to reduced mitochondrial biogenesis and mitochondrial dysfunction. These mitochondrial abnormalities can predispose a metabolic cardiomyopathy characterized by diastolic dysfunction. Mitochondrial dysfunction and resulting lipid accumulation in skeletal muscle, liver, and pancreas also impede insulin metabolic signaling and glucose metabolism, ultimately leading to a further increase in mitochondrial dysfunction.
Interventions to improve mitochondrial function have been shown to correct insulin metabolic signaling and other metabolic and cardiovascular abnormalities.
It seems likely that many of the problems of cancers, metabolic syndrome, heart disease, diabetes, dementia and ageing are due to mitochondrial disease which we know responds well to exercise and better lifestyles. We are including education about mitochondrial biogenesis in our next public conference in Glossop on April 7th.
Competing interests: No competing interests
I am as keen as Hanson, Mullins and Modi to see the BRITISH population stop its double quick progress to rotundity. But the passion for world wide action (which really means more meetings with delegates from ELSEWHERE, meeting in a five star hotel, eating a modest meal (sherry, starters, a main meal of five dishes, claret, a dessert with white wine) and speechification) leaves me cold.
What food did I eat today? A wheat biscuit in the morning, a bowl of moog daal with a soft roll at lunch time, about fifty grammes of Ardennes pate and another roll this evening. Three oranges, three mugs of tea (yes, with sugar), three mugs of coffee (again with sugar). My weight is about 130 lb ( don't ask me in kilos) and I am about five foot eight and a half inches.
The market is over two miles away. The supermarket is two miles. Altogether too far to walk in my senescence.
When I go to the City Centre I see coin machines dispensing sweets (not there when MY children were small), a score of restaurants and take-aways, numerous coffee shops, and three or four dessert parlours.
There is a large supermarket which actually GIVES AWAY coffee or tea WITH SUGAR and MILK , if you like, in disposable mugs to anyone who flashes a loyalty card, but without even buying anything.
The shopping centre, the City Centre - of course they are there to make money
But I thought, in my ignorance, that the local Director of Public Health would be hopping mad about it. After all Dr John Ashton of the Faculty of Public Health created merry hell about sugary drinks - and succeeded.
To end, I beg Hanson, Mullins and Modi to leave the globe alone, and concentrate on The Corpulent Brits.
Competing interests: No competing interests
The authors are to be applauded for not letting the matter rest - excuse the pun. For the first time when making a rapid response, I feel I have some - admittedly anecdotal - observational evidence to add in a my occupational capacity. I've been a locum lollipop lady for over 12 years, and I'm in no doubt that there are more overweight primary schoolchildren now than when I started in December 2004. And certainly, as a layman, I see many who are obese. I've no idea what the causes are, though I speculate that as more mothers - who are sometimes overweight themselves - drive their children short distances to school, that cannot help. Occasionally these mothers, and fathers and others of course, cannot even get out of the car to drop them off, either because they apparently cannot be bothered or because they are not sufficiently mobile. Not only charity begins at home but also so does activity and diet. But I'm not sure that 10 a day is the answer to the latter.
Competing interests: No competing interests