Calorie labelling to reduce obesityBMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l6119 (Published 30 October 2019) Cite this as: BMJ 2019;367:l6119
All rapid responses
The obesity health challenge and anthropometry-related interventions: A role for cumulative growth scores (CGS) in postnatal age (PNA) determination of exclusively breastfed infants beyond calorie labelling
There are several Reports disposing Obesity as a ‘Public Health Challenge’ and a ‘Public Health Emergency’ [1-5]. Some other Reports indicate Obesity as assuming ‘Epidemic Proportions’ as a ‘Public Health Problem’ and from the extant ‘Interventions’ which, unfortunately, have yielded rather unsatisfactory ‘Outcomes’ with the persistence of Obesity as a ‘Public Health Challenge’ [6-10]. The ‘Obesity Health Scourge’ is a ‘Multi-faceted Problem’ which obviously has been addressed with ‘Multiple Approaches’ to the ‘Solution’! The ‘Approaches/ Obesity Interventions’ programmatically explored ‘Energy Balance Management’ through Individual Healthy Eating and Increased Healthy Physical Activities, Institutional-Government-Community ‘Programmatic Diagnostic Screening Initiatives’ which focused on Anthropometric Measurements: Body Weight, Waist Circumference, Waist/ Hip Ratio, Body Fat Composition and Body Mass Index. The ‘Anthropometric Interventions’ were geared towards achieving Healthy Weight Reduction Goals. Other ‘Obesity Interventions’ explored ‘Obesity Research Enterprise’ identifying and investigating useful ‘Anti-Obesity Drugs’ for ‘Pharmacological Interventions’ [11,12]! The plethora of ‘Multi-faceted Approaches’ to the ‘Obesity Health Scourge’ include other ‘Anti-Obesity Interventions’: Various ‘Gastric Bypass Procedures’/ ‘Bariatric Surgeries’ undertaken as part of the ‘Comprehensive Obesity Intervention Programmes’ and ‘Obesity Research Endeavours’ which have investigated the ‘Aetiological Contributions’ of ‘Gene-Environment Interaction’ and ‘Developmental Stresses and Plasticity’ to the ‘Obesity Scourge’ through improved understanding of the ‘Developmental Origins of Health and Disease Hypothesis (DOHAD Hypothesis)’ and the ‘Foetal Origins of Adult Diseases Hypothesis (FOAD Hypothesis)’ [13-16]! Further explored in these ‘Aetiological Contributions’ are various complex interacting conceptualized ‘Obesity Spheres’: Genetic, Metabolic, Behavioural, Cultural, Environmental and ‘Gene-Environment Interaction’/ ‘Genomics’!
In a recent Communication, attention was drawn to ‘Obesity Interventional Inequity’ ! The potential usefulness of focusing attention and resources on ‘Breastfeeding Interventions’ in addressing the ‘Obesity Challenge’ could hold some promise in eclipsing the ‘Obesity Interventional Inequity’. The ‘Anti-Obesity Approach’ which highlights the ‘Pre-FOAD Hypothesis’ has ‘Breastfeeding’ (‘Exclusive Breastfeeding (EBF)’ and ‘Optimal Breastfeeding (OBF)’) as the ‘Starting Locus’ [17,18]! The ‘Breastfeeding Contribution’ to the ‘Anti-Obesity Interventions’ is better appreciated from a deeper understanding of the ‘Three Hits Hypothesis’ regarding ‘Developmental Plasticity’, ‘Intrauterine Body Programming’, ‘Postnatal Body Programming’ and the predisposition to Obesity [19,20]. There are the ‘Genetic’, ‘Intrauterine’ and ‘Postnatal’ ‘Contributors’ as ‘Hits’!
The recent Communication on ‘Calorie Labelling’ to reduce Obesity is instructive ! Restaurants and Cafes are expected to ‘Label the Calorie Content’ of the Foods and Drinks on their ‘Menu’ to assist in the desired ‘Healthy Energy Consumption Patterns’ of the Populace . Also, Food Manufacturers are expected and encouraged to increase the ‘Low-Calorie Products’ with appropriate ‘Calorie Labelling’ presented to the Populace towards improving ‘Outcomes’ with the ‘Anti-Obesity Interventions’ [23,24]. Interesting as this ‘Calorie Labelling’ is, it further contributes to the ‘Energy Consumption Balance Management’ but we need more ‘Approaches’ which focus on the highlighted ‘Obesity Interventional Inequity’!! We will, therefore, refocus attention and discourse on ‘Breastfeeding-related Issues and Interventions’!!!
Therefore, we explore the ‘Postnatal Evaluation’ for ‘Optimal Promotive Care’ of Exclusively Breastfed Infants and the several Nomograms which have been reported to assure ‘Anti-Obesiogenic Promotive Care’ [25-28]! The ‘New Growth Standards’ were an imperative for the proper ‘Growth Monitoring and Promotion’ of Exclusively Breastfed Infants giving the peculiar growth patterns of Breastfed Infants in the era of the Baby-Friendly Hospital Initiative (BFHI). The ‘Growth Monitoring and Promotion (GMP)’ is an integral ‘Component’ of the ‘Child Survival Interventions (CSI)’ . Appropriate ‘Postnatal Age (PNA)’ determination is an important requirement for the ‘Appropriate Use’ of the ‘New Growth Nomograms’ and, indeed, all ‘Growth Nomograms’!
In developing Countries with poor ‘Health Records’ and ‘Low Average Adult Female Literacy Levels’, and where many parents may not accurately recall the ‘Birth Dates’ of their Infants as may also be observed in the ‘Camps of Motherless Babies’ especially among ‘Internally Displaced Persons (IDPs)’, ‘Immigration/ Refugees Camps’ and ‘Rehabilitation/ Settlement Camps’, the ‘Postnatal Age (PNA)’ may not be readily available or accurately documented! As stated previously, the ‘Accurate Postnatal Age’ of the Infants is a necessity for the proper use of the ‘New Nomograms’ developed specifically for Exclusively Breastfed Infants [25-28]! To address the difficulties in developing Countries and the ‘Various Camps’ with infants, the ‘Cumulative Growth Score (CGS)’ was developed and reported for the ‘Estimation of Postnatal Age (PNA)’ among Exclusively Breastfed Infants ! The ‘Cumulative Growth Score (CGS)’ is a ‘Composite Score’ computed from the ‘Postnatal Score (PNS)’ assigned to each of the four ‘Anthropometric Parameters and Measurements’ for Exclusively Breastfed Infants: weight, head circumference, mid-arm circumference and length. With the Cumulative Growth Score (CGS), the Postnatal Age (PNA) is estimated with reasonable accuracy and the Exclusively Breastfed Infants are enabled to benefit from the ‘Pre-FOAD Hypothesis’ Approach with the ‘Coupling’ of the ‘EBF-OBF Dyad’ and the ‘Child Survival Interventions (CSI)’/ ‘GOBIF3E2TH’ . This amplifies the relevance of the ‘Postnatal Component’ of the ‘Three Hits Hypothesis’ [19,20]! This is the ‘Thrust’ and ‘Subsumption’ within the ‘Pre-FOAD Hypothesis’ as an ‘Antidote’ to the ‘Interventional Inequity’ towards the rational deployment of appropriate and adequate ‘Obesity Armory Components’ to manage and control the persisting ‘Obesity Health Scourge’. Here is the compelling role for the ‘Cumulative Growth Score ((CGS)’ in the accurate Estimation of the ‘Postnatal Age (PNA)’ of Exclusively Breastfed Infants!
Only Exclusively Breastfed Infants with accurately determined PNA can benefit from the ‘Promotive Intervention’ of using the ‘New Growth Nomograms’ and optimize the ‘Postnatal Component’ of the ‘Three Hits Hypothesis’ as part of the ‘Anti-Obesiogenic Interventions’! The relevant Tables (Including the Definitions of the Postnatal Scores (PNS)) and the Figure (Chart for Computing Postnatal Age (PNA) from the CGS) are accessible from the ‘Award-winning Poster Presentation’ at the 19th Annual International Conference of the Academy of Breastfeeding Medicine (ABM) held in November 2014 in Cleveland, Ohio, United States of America ! The ‘Anthropometric Interventions’ in the ‘Multi-faceted Approaches’ to addressing the ‘Obesity Health Challenge’ have been previously reported and also disposed in this Communication. The Cumulative Growth Score (CGS) for the appropriate estimation of Postnatal Age (PNA) of Exclusively Breastfed Infants in the first six months of life presents additional role/ usefulness for ‘Anthropometric Interventions’ in the ‘Anti-Obesity Approaches’ and, connecting with Breastfeeding and the ‘Pre-FOAD Hypothesis’, contributes to efforts to minimize the ‘Obesity Interventional Inequity’ and ultimately assure a reduction in the ‘Obesity Health Challenge’!
1. Rodgers A, Woodward A, Swinburn B, Dietz WH. Prevalence trends tell us what did not precipitate the US Obesity epidemic. Lancet Public Health 2018; 3:e162-163. PMID 29501260
2. Finucane MM, Stevens GA, Cowan MJ, Global burden of Metabolic Risk Factors of Chronic Diseases Collaborating Group (Body Mass Index). National, regional and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9.1 million participants. Lancet 2011; 377:557-67.
3. Skinner AC, Ravabakht SN, Skelton JA, Perrin EM, Armstrong SC. Prevalence of obesity and severe obesity in US children, 1999-2016. Pediatrics 2018; 141:e20173459.
4. Ayton A, Ibrahim A. Obesity is a public health emergency. BMJ 2019; 366:l5463 of 13th September 2019.
5. Eregie CO. Obesity as a Public Health Emergency: A Look at the ‘Pre-FOAD Hypothesis’ as a Panacea for the ‘Interventional Inequity’. https://www.bmj.com/content/366/bmj.l5463/rr-0 of 4th October 2019.
6. Hill JO, Peters JC. Environmental contributors to the Obesity epidemic. Science 1998; 280:1371-1374.
7. World Health Organization. Obesity: preventing and managing the global epidemic. Geneva: WHO; 1998.
8. Jeffrey RW. Public health strategies for obesity treatment and prevention. Am J Health Behav 2001; 25:252-259.
9. Campbell K, Waters E, O’Meara S, Summerbell C. Interventions for preventing obesity in Children. Cochrane Library, Issue 2. CD001871. Oxford: Update Software; 2002.
10. Crawford D. Population strategies to prevent obesity. BMJ 2002; 325 (7367):728-729.
11. Reilly JJ, Wilson ML, Summerbell CD, Wilson DC. Obesity: diagnosis, prevention and treatment; evidence-based answers to common questions. Arch Dis Childh 2002; 86:392-394
12. Orzano AJ Scott JG. Diagnosis and treatment of obesity in adults: an applied evidence-based review. J Am Board Fam Pract 2004;17 (5):359-69
13. Barker DJ. The developmental origins of adult disease. J Am Coll Nutr 2004; 23:588S95S
14. Armitage JA, Poston L, Taylor PD. Developmental origins of obesity and the metabolic syndrome: the role of maternal obesity. Front Horm Res 2008; 36:73-84
15. Calkins K, Devasker SU. Foetal origins of adult disease. Curr Probl Pediatr Adolesc Health Care 2011; 41 (6):158-176
16. World Health Organization. Launch of the Healthy Life Trajectories Initiative (HeLTI): an International DOHaD Research Collaboration. WHO; Geneva; 2017
17. Eregie CO. Programming the End from before the Beginning: Juxtaposing Technology with the ‘TEA Triad’. 106th Inaugural Lecture, University of Benin, Benin City, Nigeria. University of Benin Press; 17th December 2009.
18. Eregie CO. Breastmilk, Breastmilk Substitutes (Including Infant Formula) and Infant Microbiome: Still more Justification for the Prohibition of Advertisement of Breastmilk Substitutes (BMS). https://www.bmj.com/content/364/bmj.l1279/rr-6 of 4th April 2019.
19. Loos RJF. Recent progress in the genetics of common obesity. Br J Clin Pharmacol 2009; 68 (6): 811-829
20. Li X, Zhang M, Pan X, Xu Z, Sun M. ‘Three Hits’ Hypothesis for Developmental Origins of Health and Disease in View of Cardiovascular Abnormalities. Birth Defects Res 2017; 109 (10):744-757
21. Kaur A, Briggs ADM. Calorie labeling to reduce obesity. BMJ 2019; 367:l6119 of 30th October 2019
22. Long MW, Tobias DK, Cradock AL, Batchelder H, Gortmaker SL. Systematic review and meta-analysis of the impact of restaurant menu calorie labeling. Am J Public Health 2015; 105:e11-24
23. Bleich SN, Economos CD, Spiker ML et al. A systematic review of calorie labeling and modified calorie labeling interventions: impact on consumer and restaurant behavior. Obesity (Silver Spring) 2017; 25:2018-44
24. Theis DRZ, Adams J. Differences in energy and nutritional content of menu items served by popular UK chain restaurants with versus without voluntary menu labeling: A cross-sectional study. PLoS One 2019; 14:e0222773
25. Eregie CO. A normative growth standard of upper arm measurements for exclusively breastfed infants. E Afr Med J 2000; 77:5-7.
26. Eregie CO. Exclusive breastfeeding and infant growth studies: Reference standards of head circumference, length and mid-arm circumference/ head circumference ratios for the first six months of life. J Trop Pediatr 2001; 47:329-334.
27. Garza C, de Onis M. The WHO Multicentre Growth Reference Study Group. Rationale for developing a new international growth reference. Food Nutr Bull 2004; 25 (1 Suppl): S5-S14.
28. de Onis M, Garza C, Onyango A, Martorell R (eds.). WHO Growth Standards. Acta Paediatr 2006; 95:1-104.
29. Eregie CO. UNICEF Consultancy Report. 1996 World Breastfeeding Week Celebration. UNICEF Nigeria, Lagos; 1996
30. Eregie CO. Clinical Evaluation of Exclusively Breastfed Infants: The Value of a Cumulative Growth Score (CGS) for the Estimation of Postnatal Age (PNA). Breastfeeding Medicine 2014; 9 (Suppl 1):S-9.
Professor Charles Osayande Eregie,
MBBS, FWACP, FMCPaed, FRCPCH (UK), Cert. ORT (Oxford), MSc (Religious Education),
Professor of Child Health and Neonatology, University of Benin, Benin City, Nigeria,
Consultant Paediatrician and Neonatologist, University of Benin Teaching Hospital, Benin City, Nigeria,
UNICEF-Trained BFHI Master Trainer,
ICDC-Trained in Code Implementation,
*Technical Expert/ Consultant on the FMOH-UNICEF-NAFDAC Code Implementation Project in Nigeria,
*No Competing Interests.
Competing interests: No competing interests
“Calorie labeling in restaurants and obesity” - your cover of 2nd November 2019.
Let us not beat about the nutritional bush, and persist in missing the wood for the trees.
Professor Nina Teicholz is not alone in having analysed and reported, with savage and humorous probity, the discredit into which the CICO fantasy (Calories In Calories Out) has fallen, and the consequent miseries this fixation has visited upon countless individuals.
More than calorie-count upon restaurant menus, their macro-nutritive identification must be fully spelt out: proteins, fats and carbohydrates. For therein lies the rub. Yudkin was right, and Keys in error. It behooves us all responsibly to bring to term the carbohydrate bonanza first ignited by the 1977 US dietary recommendations, demonizing fats - and ushering in the era of mounting carbohydrate intake and increasing insulin resistance in our patients - in all of us.
Dr. Georges S. Kaye
Competing interests: No competing interests