The childhood obesity strategy
BMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i4613 (Published 25 August 2016) Cite this as: BMJ 2016;354:i4613All rapid responses
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Going for Gold!
The past few weeks have witnessed the release of the UK Government’s Childhood Obesity Strategy1, reports of athletic success from Team GB at the 2016 Olympics, a further article supporting the health benefits of physical activity2 and a Lancet comment calling for multifaceted approaches to addressing obesity across all sectors of society3. However, little connection was made between them. Consequently, an opportunity was lost to harness any synergistic impact that could have emerged from their association. Such a separation of related works can result in fuelling conflicts of interest, watered-down or single-faceted approaches, mixed and confusing messages and further delays in achieving common outcomes. Considering the health sector is being tasked with addressing, what can seem like, insurmountable challenges and operating in an era of austerity and limited resources, continuing to work in silos is wasteful.
As discussed in the recent BMJ4 and Lancet editorials5, the Childhood Obesity Strategy is far from achieving a culture in which we are all responsible, instead choosing to either repeat what has been said previously or place further burden on those already trying to address this epidemic. The mixed reception of the strategy is likely to send unclear and confusing messages to the very people who it was designed to guide and benefit. This contrasts strongly with the tone of Public Health England’s (PHEs) Everybody Active, Every Day, an evidence-based approach to physical activity, released in 20146. The PHE strategy impresses upon us the need for urgent, radical cultural change to become a world in which physical activity is embedded in our daily lives. It emphasises that this task is the duty of all sectors and disciplines including “professionals in spatial planning, design, development, landscaping, sport and leisure, social care, psychology, the media, trade unions, transport, education and business ”6. It stresses that positive change in relation to physical activity “needs to happen at every level, in every region’ and “be measurable, permanent and consistent”6.
The achievement of Team GB demonstrates the impact of culture, political will and the involvement of multiple sectors. As a nation we expect success and take great pride in our place on the Olympic medals table. There are very clear objectives to be achieved: through various disciplines, a nation strives to excel. A multifaceted approach is essential to achieving this success: diet, exercise, environment and equipment, knowledge, mental support and wellbeing are just some of the key ingredients, not to mention the financial investment of approximately £4.1 million in funding per medal won. Furthermore, there is always a recognised timeline - we do not postpone the date of the Olympics because goals have not been realised. Lastly, training is assessed frequently with well-defined markers of progress; it is doubtful that the progress of the Olympians is assessed only every 6 months as is currently suggested for the overview of the implementation of elements of the Childhood Obesity Strategy1. Table 1 illustrates the reward that a focussed, multi-faceted, financially supported investment has delivered for Team GB. This success is then juxtaposed with the ineffectiveness of current policies in delivering good health metrics for the remainder of the UK adult population (Table 1).
We should rightfully celebrate the success of our Olympians who, in many respects, have “punched above their weight” by finishing so high in the medal table. However, we should also be inspired by the evidence-based, multifaceted approaches used to achieve our Olympic success and model our approaches to public health similarly. It is time we made our ambitious challenges surmountable. We must strive to make the aims of such strategies as PHE’s ‘Everybody Active Every Day’ a reality for all. It is achievable and it is the responsibility of everyone, from health professionals to the government to the media, to instil that belief and culture. We can turn the tables; we can move more, we can combat obesity and like our athletes in Rio, we must and can go for gold!
References
1 HM Government, Childhood Obesity A Plan for Action, 2016, https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil... Accessed 26 Aug 2016.
2 Kyu HH, Bachmann VF, Alexander LY, et al. Physical activity and risk of breast cancer, colon cancer, diabetes, ischemic heart disease, and ischemic stroke events; systematic review and dose-response meta-analysis for the Global Burden of Disease Study 2013. BMJ 2016; 354:i3857
3 Freedhoff Y and Hall KD. Weight loss diet studies: we need help not hype. Lancet 2016; 388: 849-851
4 Knai C, Petticrew M, Mays N, Editorial: The Childhood Obesity Strategy, BMJ 2016;354:i4613
5 UK Government won't step up to the plate on childhood obesity. Lancet 2016; 388: 841
6 Public Health England, Everybody Active, Every Day, An evidence-based approach to physical activity. October 2014, https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil... Accessed 31 Aug 2016.
Competing interests: No competing interests
The childhood obesity strategy
I find it hard to understand why medical authorities ignore easily accessable published information of medical nature linking the worldwide obesity pandemic to deranged sugar metabolism, hyperinsulinemia, pre-and diabetic states, and the mass use of vaccines, antibiotics and painkillers/antipyretics.
Instead they reach for the unproven link to the alleged high sugar consumption in the form of sweet fizzy drinks and other sweetened food items. Instead of providing well-researched advice they resort to financial punitive measures to be used against the manufacturers/distributors of such products.
The true published evidence points to early childhood medical interventions.
As demonstrated in my BMJ rapid response (Obesity: A major problem of our times; 12 January 2009), Hannik and Cohen 1978) in an article titled “Changes in plasma insulin concentration and temperature of infants after pertussis vaccination”, presented at the Third International Symposium on pertussis, reported that [two months old] babies given the DPT vaccine developed small but significant increase in plasma insulin within 8 hours of the vaccine administration.
Glaser et al.(1993) published an article “Persistent hyperinsulinemia/hypoglycemia in infancy – long term octreotide treatment without pancreatectomy”. Pediatrics 123: 644-650.
The epidemic of diabetes in small children was documented by Classen JBV (1996: NZ Med J; 24 May:195) and Classen JB and Classen DS (1999) “Association between type1diabetes and Hib vaccine) published in BMJ; 319:319: 1133).
Acetaminophen (paracetamol) was shown hepatotoxic even at therapeutic doses (CFW 1973.”Acetaminophen: potential pediatric hazard. Pediatrics; 52 (6): 883), yet parents are generally advised to use it ”as needed” to alleviate pain after vaccination, and to suppress even a moderate fever, although orthodox medical research warns about the fallacy and dangers of such efforts (Hull 1989,:Fever – the fire of life”. Arch Dis Child; 64: 1741-1747; Havinga 1997, “Giving paracetamol for fever is unnecessary”, BMJ;315:1692-1693).
Antibiotics are used in animal industry to enhance the protein production and weight in animals.
Children develop ear infections (Craighead 1975. Report of a workshop: Disease accentuation after immunisation with inactivated microbial vaccines: (J Infect Dis; 1312 (6): 749-754) after vaccination and may be given several rounds of antibiotics by the age of one year. These have the same effect on children as they have on young animals: they make them fat, large and muscular.
The fattening effect of antibiotics was unwitingly demonstrated by Garly et al.(2006. Prophylactic antibiotics to prevent pneumonia and other complications after measles; community based randomised double blind placebo controlled trial in Guinea-Bissau.BMJ,doi:10.1136/bmj.38989.AE published 23 October 2006) in a developing country.
They wrote: The group that received prophylactic antibiotics had less pneumonia and conjunctivitis and had significantly higher weight gain after inclusion.”
It is always prudent and productive to study medical literature.
Competing interests: No competing interests
Libya is one of the affluent countries which has an obesity pandemic.
Obesity is reported to be present in around 30.5% Libyan adults,16.9% of children aged 5 or younger (Ministry of Health 2009), and 6.1% of children aged between 10 and 18 (Ministry of Health 2008). The rate of obesity progressively increases with age, from 4.2% in those aged between 10 and 12 to 46% in those aged between 55 and 64 (Ministry of Health 2009; 9). The mean BMI in Libyan adults is 27.7 kg/m2 (26.4 kg/m2 in men and 29 kg/m2in women), and the mean waist circumference is 93.3 cm. There was no significant difference between male and female children with regard to overweight or obesity (WHO,20079); however, obesity was almost two times more common among Libyan women than men (21.4% vs. 40.1%) (Ministry of Health,2009, Rao GM, Morghom,1985), whereas overweight was more prevalent among men than women, a trend being observed worldwide (Flegal et al. 2010; Al-Nozha et al. 2005). This is because women tend to lead more sedentary lifestyles than men and also because women in Libya indulge in binge eating as they spend much time at home and also attend more social gatherings, which are usually associated with consumption of and an abundance of food. Also, hormonal factors might play a role in accumulation of fat in women than in men.
Genetic predisposition
Studies of twins suggest the existence of genetic factors in human obesity. The percentage of obesity that can be attributed to genetics varies, depending on the population examined, from 6 to 85% (Yang W, Kelly T, He 2007). It is postulated that certain ethnic groups, in an equivalent environment, may be more prone to obesity than others (Wells 2009). This is because of what is called ‘thrifty gene hypothesis’, where the genetic make up of certain ethnic groups gives them the ability to benefit from rare periods of food abundance by storing energy as fat, an ability valued during times of varying food availability but disadvantageous in the modern life, which offers stable food supplies (Neel 1962). Surprisingly, obesity is much more prevalent in Libyan adults than in Tunisian adults (Ministry of Health, 2009, International association obesity, 2010) despite both populations having more or less the same genetic background, which raises the possibility of environmental factors as the main cause of the increased prevalence of adult obesity in Libya.
Diet
Energy intake and composition of diet play a major role in the pathogenesis of obesity. Total calorie consumption has been found to be related to obesity. From the late 1960s to the early 2000s, the average calories available per person per day have increased in Libya (FAO 2005).
Infant feeding in Libya
Breast-feeding is shown to be associated with a lower risk of overweight. Exclusive breast-feeding during the first 3 or more months of infancy reduces the risk of overweight in childhood (Hediger et al 2001; Harder et al 2005). In Libya, the rate of artificial feeding is between 5.7% and 40.3% (Baccush Nayak 1992; Maghoub, Stephens 1972), and 47.88% of mothers breast-feed their infants for less than 1 month, whereas 28.18% breast-feed their children for 1–3 months (Baccush and Nayak 1992). This may partially explain the high rate of obesity in children aged 5 or younger in Libya (Ministry of Health 2008).
Libyan diet
Epidemiological data suggest that a diet high in fat is associated with obesity. There is a dearth of recent and nationally representative data on food consumption in Libya.
In 1996, Al-Arbah reported that cereals, oil, and sweeteners provided the largest shares of energy, 41, 12, and 11%, respectively (Al-Aarba1996). Food and Agriculture Organization (FAO) analysis of yearly production, import, and consumption shows that the staple Libyan diet is wheat (bread, couscous, and pasta). Rice is another major staple in Libya (Neel 1962). The Libyan diet is low in vegetables and fruits (Ministry of Health 2009). According to the FAO, the quantities of food consumed between 1967 and 2001 have increased 1.5 times, from about 2,061 kcal daily to 3,327 kcal daily, which is well above population energy requirements of 2,144 kcal/capita/day. This means a Libyan adult consumes daily an extra 1,183 kcal.
In 2001, according to the FAO, the proportions of main energy sources in the Libyan diet were 62% of carbohydrates, 27% of fat, and 11% of proteins (FAO 2005). Yet, we think that the contribution of fat to proportion of energy in Libyan diet is higher (Najah 1995), which is comparable with consumption of fat in Western countries. Furthermore, over the last decade or so, Libyan diet has become more influenced by Western food culture, and Libyans are now consuming more diets high in sugar and saturated fat in the form of fast foods (burgers, cola, etc.).
Lack of physical activity
Sedentary lifestyle lowers energy expenditure and promotes weight gain. Worldwide, there has been a marked shift toward less physically demanding work. Currently, about 44% of Libyan adults do not get sufficient exercise (51.7% of women and 36% of men) (7). We think this is mainly because of increasing dependence on mechanical transportation and greater availability of effort-saving equipment domestically. Also, the increase in television viewing time, use of computers, and video games could be other possible contributors to the rise in the prevalence of obesity in Libyan children and adults.
These are some of the factors that are associated with Obesity in Libyan children.
(References)
Competing interests: No competing interests
Childhood obesity is a major concern all over the world. In recent years, numerous obesity control strategies have been advocated by several agencies. We read the insightful editorial of Knai C (BMJ 2016) who explained current status of childhood obesity in UK and recommended remedial measures to control this menace. However, this non-communicable disease process seems to continue unabated worldwide.
Experiences in Jamaica:
Globally about 10% of school children 5–17 years are reported to be overweight or obese. Childhood obesity continues to be a serious problem in Jamaica as well. Overweight/obesity prevalence among children six to ten years old in NEHR of Jamaica is 17.7% with older children and girls having higher rates. (Be Blake-Scarlett et al. 2013). Another study in Jamaica, reported that more than 11 per cent of children, 10 to 15 years old, and 35 per cent of teenagers, between 15 to 18 years, were classified as overweight or obese. (Harvey K. 2012)
During our community service programme from All American Institute of Medical Sciences, Jamaica, we conducted a small scale population-based study at St. Elizabeth, Black River, Jamaica, which revealed that lack of opportunities for open field exercise or playgrounds for outdoor games are major causes for this problem.
Most of the urban children are now busy with their computer games or cell phones while rural children are not getting opportunities for outdoor games.
Moreover, inclination to high calorie diets and fast food habits made affluent school children overweight since early childhood.
Obese youths are more likely to be vulnerable to risk factors for cardiovascular disease, such as high cholesterol or high blood pressure. Obese youths are also more likely than those of normal weight to become overweight or obese adults in due course of time, and therefore likely to be more susceptible to associated adult health problems, including ischemic heart disease, type-II diabetes, cerebral strokes and several types of cancers. (Harvey K. 2012).
Despite existing challenges and limitations in our knowledge base regarding altered responses of our own body system and resultant impact on cancer genes, we need to continue to examine the relationship between obesity and cancer. (Pramanik J. BMJ 2007) Moreover, childhood obesity causes decreased release of growth hormone leading to growth retardation.
Socio-economic consequences:
It is estimated that health problems related to childhood obesity will put an extraordinary burden on national health budget. There may be higher demand for large number of paediatrics specialty hospitals all over the country escalating expenses on child health too.
In the near future, it may be difficult to find physically fit young adults for recruitment to the armed forces or to represent the country in international athletic competitions or outdoor games.
We recommend developing well organized national schemes with governmental support to promote healthy diet programmes, regular exercise and also encourage school children in outdoor games like cycling, swimming, etc.
Conclusion:
“To win a battle our soldiers must be roused to anger”....
Therefore, we need to organize and promote massive public awareness program to create general awareness and educate parents about impending health hazards due to childhood obesity which is preventable. Governmental agencies may make it compulsory for fast food companies to label their food packets with stickers like ‘High caloric fatty foods are harmful for health’.
We observed (unpublished observations) that the majority of rural people are unaware of the risk factors related to childhood obesity, while urban parents are often found to be knowledgeable and understand the consequences of this avoidable health condition. Despite available resources to control obesity in urban areas, many parents are not interested in persuading their children to control disproportionate weight gain. It is a matter of our concern that we often ignore the "spare tire" around our waist and become victim of a number of debilitating diseases inadvertently. (Pramanik J. BMJ 2007)
“A stitch in time saves nine”.....
We need to implement preventive measures to control childhood obesity while promoting awareness campaign about preventive strategies to control this menace.
As a humble step forward, with our limited resources and manpower, we propose starting a campaign for a swimming training program for Black River High School students in our swimming pool in AAIMS, St. Elizabeth campus, and carefully monitoring progress (knowledge, attitude and practice) at regular intervals with the aim of controlling childhood obesity in our local community in Jamaica.
References:
1. Knai C. Editorial: The childhood obesity strategy: BMJ 2016; 354:i4613.
2. Blake-Scarlett BR. et al. Prevalence of overweight and obesity among children six to ten years of age in the North-East Health region of Jamaica West Indian med. j. vol.62 no.3 Mona Mar. 2013.
3. Harvey K. Gov’t Tackling Childhood Obesity (September 7, 2012) http://jis.gov.jm/govt-tackling-childhood-obesity/
4. Pramanik J. A mini review: Indicator of higher cancer risk--Increased BMI or Excess hidden visceral fat depot ?? BMJ 2007;335:1134
5. Pramanik J. A point of view: Hidden obesity?? --A matter of our serious concern!! BMJ 2007;335:1107
Competing interests: Prof.Dr.Jogenananda Pramanik MBBS.MD Dean of Post Graduate Studies, Lincoln University College, Malaysia is the collaborator and supervisor for school health programme; and Dr. Ram Chalasani President of All American Institute of Medical Science, St.Elizabeth, Jamaica is the patron for this school health programme..
Re: The childhood obesity strategy.
I do not know about strategy. I see the distant objective. Dimly. There are some suggestions. Here goes.
1. The successful campaign by Dr John Ashton against sugary drinks was great. The Chancellor agreed to levy a tax; he said that the money raised would go to providing playing fields to schools.
Since the object of slapping the tax was to DISCOURAGE the purchase of these drinks, it follows that if successful, there would not be any money left for purchasing playing fields.
SUGGESTION: All playing fields sold to property developers be compulsarily purchased for a notional penny.
The parliament should pass a law prohibiting building erection on any playing fields.
2. Do the anti-sugar agitators realise that even "fruit juice" cartons very often contain added sugar? That tins of baked beans contain added sugar?
SUGGESTION: Public health educators! Please look at some tins and cartons in your kitchen or in the supermarket. Then get moving and get rid of it.
3. There is one supermarket, giving away free drinks - tea and coffee - in cartons.
SUGGESTION: Ask all such businesses to make a charge for the sugar. Five pence per spoonful.
4. Most of you gentlemen and ladies engaged in public health research, teaching and work , are exttremely busy. Meetings too.
SUGGESTION: Prohibit working lunches. Spend thirty minutes eating slowly, CHEWING each morsel, then have a drink of water, not beer. Difficult? Yes. Many years ago, 1970s, I made myself highly unpopular by agitating against working meetings lubricated with beer. But ultimately, my fellow doctors saw it made sense. Since I was known to have an occasional glass of wine, they could see that I was not a member of the National Temperance League, nor that I had " taken the pledge" that some of my Irish acquaintances had done.
5. Most obesity is I accept, " man-made". But compare the school health service records from 1950 onward. I believe you will find confirmation that the children/ teenagers today are not only bulkier, but also much taller. Why?
SUGGESTION. Request the Institute of Child Health to conduct research on the causes.
The epidemiologists, public health experts at Public Health England and elsewhere are requested to knock down the fore-going.
Thank you
Competing interests: I would like more space in trains and planes - slimmer posteriors would be helpful.