Focus on the prevalence of childhood obesity, the scientific and social issues behind it, and how we can reverse the trend. (Pub: Optimum Nutrition, Summer 2007)
Media attention on the 14-stone eight-year-old Connor McCreaddie earlier this year yet again raised a very important but uncomfortable question: are the parents of obese children to blame for overfeeding them and, as such,’unfit for purpose’?
A report by Unicef places Britain’s youngsters among the most unhappy and neglected when compared with other industrialised nations (*1). Each new generation drinks more alcohol, takes more drugs and has more underage sex than its European neighbours. Family breakdown, educational failure and poor health need to be set against the backdrop of a much wider context: a society free of duties and limitations, yet bloated with rights and excesses that have institutional approval. Maybe childhood obesity could be regarded as a symptom of this crisis.
The limited availability of data has prompted claims that the ‘epidemic’ of obesity has been overmedicalised to support the commercial interests of the diet and drug industries.(*2) The majority of researchers, however, insist that the recent increase in childhood obesity is significant (see box 2 below). The prevalence of overweight and obese children has escalated dramatically in the UK — and in other industrialised countries — with a marked increase in the trend since the mid-1980s.(*3)
Some research says that, among UK children, the rates of obesity have tripled over 20 years, and one in 10 six year-olds is now classified as obese.(*4)
The Forecasting Obesity to 2010 report by the Department of Health (*5) predicts that if current trends remain unchanged, one million children in the UK will be obese by 2010, and half of all children could be obese by 2020.(*6) Perhaps the most disturbing of all is the fact that an entire generation is likely to have a shorter average life expectancy than its parents. (*7)
THE MEASURE OF IT
While the body mass index (BMI) is the most widely used definition of obesity in adults, normal growth patterns in children alter the relationship between age, weight and height, meaning there is no single ideal BMI. For a child, an obesity assessment is usually made by referencing an individual BMI to age 8 and gender-specific percentile charts.
Both the National Institute for Clinical Excellence (NICE) and the Department of Health use this method for the assessment and monitoring of individual children and for screening whole populations.(*8) Obese children are defined as those with a BMI greater than the 98th centile of the UK 1990 reference chart for age and sex, while overweight children are those with a BMI greater than the 91st centile of the reference chart.(*9) Ultimately, the precise cut-off percentiles which define obesity are less important than their consistent use when calculating trend data.
One of the greatest disadvantages the current parenting population has is perhaps a lack of awareness about the consequences that obesity can have for children in later life. Nicola McKeown, Connor McCreaddie’s mother, has been quoted in the press as saying: “When a child won’t eat anything else, you have to feed them what they like. He is well cared for. It is just the fact that he has totally demented me wanting to be fed constantly.”(*10) Is it as simple as a wake- up call? Would a wider understanding among parents of the risks of associated chronic degenerative diseases (see box 3 below) be enough of an impetus to generate improvements?
Genetic predisposition does go some way to explain why some people find it more difficult to lose weight than others. Variations in the apolipoprotein A5 gene identified by US researchers,(*11) and the FTO gene (which was reported in the media as the discovery of the ‘fat gene’) recently identified in European populations,” (*12) are thought to determine our risk of obesity, and that of polycystic ovarian syndrome (PCOS). Belonging to certain ethnic groups for example, South Asian (*13),also puts people at a higher risk and, in the future, isolating specific genotypescould prove useful in developing individual dietary guidelines.
However, an accelerated increase in the condition over the last two decades suggests gene expression is influenced by dietary and environmental factors. Risk factors associated with childhood obesity are a high intake of heavily processed, energy-dense foods and sugar-rich drinks, large portion sizes, a sedentary lifestyle and a lack of regular exercise.(*14)(*15) Being in lower-income groups may increase this risk further (*16) and, if children have overweight orobese parents, they are far more likely to become obese themselves.(*17) Latest research also shows that the prenatal environment and maternal nutrition during pregnancy have important roles to play.(*18)(*19)
Finally, children’s exam and expectation-driven lifestyles without enough time for sleep and relaxation (just doing nothing) must share part of the blame.
High levels of the stress hormone cortisol maintain the fight-or-flight response, increasing levels of fat and glucose in the bloodstream. Long term, most of that extra energy is stored as abdominal fat — hard to get rid of as tummy fat starts acting like a hormone- secreting organ with a mind of its own.(*20)
HOW DID WE GET HERE?
During the late paleolithic era, hunter- gatherers were genetically near identical to modern humans, but were physically very active, seeking food and shelter. They had variable access to healthy fats, protein and low-glycaemic whole foods all rich in micronutrients and fibre.(*21)(*22)
By contrast, modern people lead a very sedentary, ‘centrally heated’ existence, their diet consisting of foods unknown to our ancestors: breads, pasta, cereals and rice (many of them refined), dairy products, alcohol, added salt, refined sugars, treated vegetable oils — and meat with an increased fat content.(*23)
THE ABILITY TO STORE ENERGY FROM STARCHY FOODS AS BODY FAT MIGHT HAVE BEEN USEFUL IN THE PALEOLITHIC ERA BUT IT IS CLEARLY A DISADVANTAGE IN MORE AFFLUENT SOCIETIES’
Since 1945, our diet has become increasingly refined, energy-dense and micronutrient poor. The higher the energy density, the more likely it
is that people consume more than they need. During and shortly after the war, the population relied on homegrown produce. Less meat, fat, eggs and sugar were consumed than before, and the ‘National Loaf’ was introduced, which was less refined and contained a higher percentage of fibre.(*24) Meanwhile, young children and expectant and nursing mothers received free, from the state, cod liver oil, orange juice and milk.
Now, our modern diet and lifestyle, and our ‘obesogenic’ environment, with all its urban planning, labour-saving devices and transport policies,(*25) and the industrialised farming methods which have altered the composition of our foods,(*26) are evidently at odds with our genetic requirements. The ability to store as body fat or glycogen the energy in starchy, fatty foods would have been useful in paleolithic times, when food was often scarce, but in our modern, affluent societies, it is a disadvantage.
MODERN DAY CULPRITS
A key discovery in research is that obesity is characterised by chronic, low- grade inflammation.(*27) Adipocytes (fat cells) secrete a variety of inflammatory markers, but not all fat has the same effect. Visceral belly fat (the fat around internal organs) is particularly efficient at secreting high levels of the pro- inflammatory molecule interleukin-6, which promotes insulin resistance.(*28)
Exposure to phthalates found in soaps, plastics and pesticides has also been linked to abdominal obesity and insulin resistance.(*29) Other hormone- disrupting industrial pollutants include heavy metals, solvents, polychlorinated biphenyls, organophosphates and bisphenol A (BPA).(*30)(*31) In 2002, Masuno et al found that even low levels of BPA combined with insulin increased fat cell formation and enhanced fat storage. BPA is used in plastics and packaging and, worryingly, baby bottles heated in microwaves may even leach BPA straight into the infant’s milk.(*32).
US researchers recently identified yet another intriguing factor in fat deposition. Gordon et al demonstrated that gut bacteria in obese humans and mice were more efficient at converting complex polysaccharides into simple sugars than the gut bacteria in lean subjects.(*33)(*34) They also discovered that the bacterial flora in obese individuals improved the host’s ability to store fat, but reduced their ability to burn it off. The symbiotic relationship with our microbial flora might have served us well when food was scarce, but we now have little need for gut bacteria that excel in extracting calories from food.
We all know that childhood obesity is increasingly common in the UK, but just how prevalent is the problem?
A Health Survey for England study showed that, in the decade between 1995 and 2005, the prevalence of obesity among boys aged from two to 15 rose by 75 per cent and among girls by almost 50 per cent.(*60) Meanwhile, Obesity Among Children.(*61)updated in 2006, revealed the following:
- The prevalence of overweight and obesity among boys and girls is very similar, with both sexes showing gradual increases.
- The highest increase in obesity is shown to be among children aged between eight and 10 years old.
- The lowest incidences of child obesity are found in Yorkshire and the Humber (11.4 per cent) and the South East (13.4 per cent), with the highest being in the North East (18.3 per cent) and London (18.2 per cent).
- Children living in inner-city areas are more likely to be obese (around one in five) compared to those children living in all other types of area.
- Levels of childhood obesity are 5 per cent higher among children living within the most deprived areas (16.4 per cent) compared with the least deprived areas (11.2 per cent).
- Incidences of childhood obesity are lowest in managerial or professional households (12.4 per cent) and highest among semi-routine and routine households (17.1 per cent).
- In households where both parents are overweight or obese, 19.8 percent of children will be obese — compared with 6.7 per cent of children living in households where neither parent is overweight or obese.
WORKING ON IT
Along with waistlines, the treatment costs for obesity-related illnesses are expanding and becoming a drain on NHS resources. Current estimates are that the cost to the UK economy is around £7bn per annum, and rising.(*35) Depending on the degree by which a person is considered overweight, the NHS will recommend a combination of interventions: diet, exercise, behavioural therapy, drug treatment (anti-obesity drugs orlistat and sibutramine are as a general rule only prescribed to children aged over 12 if other therapies are not working) and, if all else fails, surgery.
Three Government departments — for Health, Education and Skills, and Culture, Media and Sport — are working to tackle childhood obesity through a complex delivery chain that links a wide range of organisations and partnerships and is mobilised at national, regional and local level. Current programmes include diet and exercise, support for breastfeeding, pedometers, food and sport in schools, food labelling, food promotion and advertising restrictions.
However, there has been some concern that Government targets will not be met unless there is clear leadership and guidance.(*36) Such a complex delivery chain could result in poor coordination, inefficient use of resources, excessive paperwork and, ultimately, delayed progress. As funding allocated to meet child obesity targets is not ring-fenced, primary care trusts (PCTs) could even allocate money for child obesity to address other priorities. Additionally, there is some unease, according to a National Audit Office report, that”raising awareness of obesity may have the potential to stigmatise obese and overweight children.”(*37)
In March this year, Public Health Minister Caroline Flint launched the Healthy Living Initiative, a programme to “help families lead healthier lives” following a review by the Medical Research Council (MRC) which identified various problem areas.(*38)
Dr Toni Steer, a nutritionist at the MRC and co-author of the review, says: “People know about healthy eating, but they aren’t translating that knowledge.” Although some parents may simply not recognise that their child has a weight problem, others find a healthy lifestyle time-consuming and believe children won’t eat the food they have prepared — as in the case of Nicola McKeown. Other typical barriers are external pressures which undermine healthy food (such as television advertising) as well as limited opportunities for active lifestyles. Dr Steer suggests that none of us is going to solve the problem of obesity in the short term, and that rather it will have to be tackled over the long term, possibly decades.
Clearly, reducing obesity is now a Government priority and further initiatives are expected over the next 12 months. The message appears to be: find the weapons of mass obesity and eliminate them, using performance- driven targets and multi-component interventions.
The danger is that so many different initiatives might actually cause overload, confusion and finally indifference or, worse still, hopelessness.
So far, after all, the Government’s top-down solutions have failed to halt the steady rise in childhood obesity.
WHO’S SAYING WHAT
Swamped by nutritional information, the general public may not be clear what advice to trust — and this is a tough problem for nutritional therapists. The British Nutrition Foundation (BNF) is a charity that advises the Government and the public on nutritional matters and provides schools with educational material. Although it does claim to be impartial, sponsors do include British Sugar, Cadbury, Nestle, Tate & Lyle, Unilever and Weetabix. Another large organisation that is funded by food and drink industry giants, International Life Sciences Institute (ILSI), lobbies national and internal agencies such as the World Health Organisation, and is potentially well placed to influence nutrition research and health policies.(*39)POTENTIAL PHYSICAL CONSEQUENCES OF CHILDHOOD AND ADOLESCENT OBESITY
|Organ System||Obesity-related disorders|
|Source: IOTF report (2004). See www.nhsdirect.nhs.uk/glossary for definitions|
|Orthopaedic||Slipped capital epiphyses|
|Orthopaedic||Blount's disease (tibia varia)|
|Orthopaedic||Increased risk of fractures|
|Neurological||Ideopathic intracranial hypertension|
|Gastroenterological||Liver steatosis / non-alchoholic fatty liver|
|Endocrine||Insulin resistance / impaired glucose tolerance|
|Endocrine||Type 2 diabetes|
|Endocrine||Polycystic ovarian syndrome|
|Cardiovascular||Left ventricular hypertrophy|
|Other||Systemic inflammation / raised C-reactive protein|
Public health messages can be confusing. The new NICE guidelines recommend basing meals on”starchy foods such as potatoes, bread, rice and pasta, choosing wholegrain where possible.”(*40) There is heavy emphasis on starchy carbohydrates and ‘wholegrain’ is not clearly defined. Antony Haynes, a nutritional therapist and author of The Insulin Factor, takes issue with this. He says: “The traditional food pyramid is flawed with its inappropriate emphasis on starchy carbohydrates — it ignores their effect on insulin. Sugar is more to blame than fat in the development of obesity — fat has a minimal effect on insulin. There is no evidence of a tribe or nation that has thrived or lost weight on a starch-rich diet.”
WITH JAMIE OLIVER BEING ‘THE MOST HATED PERSON AMONG 10-YEAR-OLDS’ IT SEEMS CLEAR THAT CHANGING THE ATTITUDES OF CHILDREN IS GOING TO BE AN UPHILL STRUGGLE
GETTING IT ALL WRONG
An over-reliance on fruit juices (rather than whole fruit) to provide a child’s recommended daily intake of fruit and vegetables may be equally misguided. The consumption of fruit juices in the UK is steadily increasing(*41) and has been linked to the development of child obesity(*42) — something that parents of obese children might well be surprised to hear. Less surprisingly, large portion sizes present another major risk factor.(*43) The current trend in super-size junk meals, huge packets of crisps, jumbo- size chocolate bars and bucket-size drinks shows no sign of abating.
Many diet products contain artificial sweeteners which, according to new research, may actually promote weight gain. One study at Texas University analysed data collected over eight years and found that people who consumed diet drinks gained rather than lost weight.(*44) Another study found that artificial sweeteners impair the body’s natural ability to gauge the calorie content in food and drinks. This could result in a tendency to overeat.(*45)
Food and drink labelling creates all sorts of pitfalls. Which? magazine (April 2007) confirmed that’low-fat’ foods are very often loaded with sugar and, as the labelling of sugar is not mandatory unless a product claims to be ‘low¬sugar’ and the true amounts are often disguised (listed as fructose, dextrose, glucose, lactose, sucrose and others), it is not particularly surprising that people continue to make bad food choices.
When key food industry players launched the Guideline Daily Amount food labelling system to challenge the Food Standards Agency’s simpler traffic light system, they succeeded in better disguising high amounts of salt, sugar and fat contained in their products.
While such defensive tactics by the food industry to protect profits might be understandable, the reluctance of governments to exert tighter control over nutritional content and marketing practices that harm children’s health is not.
Dr Tim Lobstein, coordinator of the childhood and adolescent obesity research programme at the International Obesity Taskforce (IOTF) agrees. He says: “What should have been a battle between responsible governments and the food industry has instead ended up becoming an endless daily struggle between parent and child.” New school food standards came into effect from September 2006, restricting poor quality meat and junk foods high in salt, sugar and fat in school lunches.(*46) These standards are mandatory and OFSTED will be monitoring schools with regular inspections. By September 2007, food-based standards will apply to vending machines, breakfast and after-school clubs and tuckshops. New nutrient-based standards, specifying the nutritional content for all school meals, come into effect in 2008 for primary and 2009 for secondary schools.
Additional funding of £240m is being made available by the Department for Education and Skills from 2008 to 2011, but in reality this is just a drop in the ocean. The grant for school meals is not ring-fenced either, so schools and councils do not have to spend their money directly on healthier ingredients but can use it for staff training, kitchen equipment and facilities. According to recent media reports, the total amount of funding actually received per child per day for school meals is just 10p.(*47)
Short of knocking on the doors of schools or Local Education Authorities (and perhaps more of us should), there would seem to be little that a practising nutritional therapist can do to advise on children’s diets on a large scale.
However, in a rare move, in 2004, I was invited to visit a selection of local schools and report on the quality of school lunches. I was appalled by what the children were eating, but I gained a valuable insight into just how difficult it is to make changes within such tight budgetary restrictions. Nevertheless, I did make recommendations regarding the content and preparation of meals, drinks and snacks, many of which, I am pleased to say, were implemented.
For example, following comments I made on highly salted and reconstituted potato mash, and frozen vegetables that were ‘boiled-to-death’, the council’s Corporate Catering Department (*48) has introduced potato peeling and vegetable preparation machines. Fresh vegetables are now cooked on site — and they are all sourced from local suppliers. More salads are on offer too, and the school catering staff have started cutting up fruit and arranging it in creative ways, such as threading pieces onto straws like kebabs. Consequently, there has been a noticeably higher uptake in these foods and much less waste.
I also provided the council with a list of additives, preservatives and artificial sweeteners found in fruit and fizzy drinks which may cause adverse reactions in children. They complied with my recommendations and now only buy in fruit drinks that do not contain controversial chemicals.
Gina Gorvett, senior nutritionist with Scolarest, one of the UK’s leading catering providers in the education sector, says that it has been easier to implement new school food standards in primary schools because they had been improving menus gradually. “It has been far harder with the secondary schools as the clampdown was sudden — it just pushed kids right out of schools for access to junk food. If it had been done in a less heavy- handed way, we might have been able to capture more of the older pupils. Changes that dramatic are going to produce a negative effect.”
A news report stating that Jamie Oliver, champion of healthy school meals, was the most hated person among 10-year-olds (*49) also highlights the fact that changing attitudes among children really is an uphill struggle.
MOVING THINGS ALONG
Research from the Norwegian School of Sports Sciences in Oslo suggests that 90 minutes of exercise over the course of a whole day is required to help ward off obesity. (*49) Here in the UK, the current guidelines endorsed by the Department of Health are an hour of exercise per day. However, almost a third of boys and two fifths of girls are failing to achieve this level of activity. (*51)
Consistent exercise does appear to be an important factor in aiding long-term weight maintenance by enhancing insulin sensitivity (*52) and it also influences appetite regulation as people tend to overeat when sedentary. There is some evidence that physical activity alone, however, may not be as effective as it’s generally believed. Researchers from the EarlyBird Study in Plymouth say the rise in obesity is due to children’s worsening diets and increasing portion sizes rather than physical activity levels. (*53)
Childhood obesity is a multifactorial condition and it is widely recognised that an obese child can only be treated effectively long term when the family is ready to embark on appropriate lifestyle changes. (*54)(*55)(*56) Numerous local and national programmes have been set up to tackle the crisis. One is by Dr Paul Sacher, a specialist dietician based at Great Ormond Street Hospital. He has designed a programme that provides practical education in nutrition, physical activity, behavioural change and positive parenting. (*57) The MEND programme, as it is called, comprises 18 two-hour sessions over nine weeks. The results — revealed in April — were impressive, showing significant reductions in BMI and waist circumferences and reduced time spent in sedentary activities. (*58)
SIGN OF THE TIMES
According to researchers, children had healthier diets in the 1950s than in the 1990s. (*62) The steady increase in our consumption of frozen or chilled ready meals and the high levels of ‘hidden fats’ in convenience foods are partly to blame. Although the fat and overall calorie intake of children in the 1950s was higher, (*63) children were more active then and did not rely on the television, computer games and the Internet for their entertainment.
Children now eat only half as much bread as in the 1950s, (*64) when brown bread was the norm, but consumption of rice and pasta has increased. (*65) In the past 50 years, there has been a decline in children’s consumption of vegetables. milk, fish and red meat, (*66)(*67) resulting in a poor intake of key nutrients, such as fibre, calcium, vitamins and iron. In the 1950s. children’s intake of vitamin C came mainly from vegetables, rather than from juices and drinks. (*68) In the 2004 Health Survey for England, which assessed fruit and vegetable consumption in five to 15-year-olds, only 13 per cent of boys and 12 per cent of girls had their five portions per day, with 10 per cent reporting that they had eaten absolutely no fruit or veg on the previous day. (*69)
In the 1950s, the majority of fat in the diet was saturated. (*70) The benefits of children now consuming semi-skimmed or skimmed milk and spreads containing unsaturated fats, however, are offset by their much higher intake of savoury snacks, fast foods and confectionery. (*71)
Today’s children obtain a high proportion of their energy from sugar — soft and fizzy drinks having replaced milk and tea, which was the most common drink for children 50 years ago. (*72) In fact, children living in Britain now consume more sweets and fizzy drinks than any others in Europe. (*73)
CONVEYING THE MESSAGE
Although morbidly obese children will typically be referred on to community dieticians or specialist outpatient clinics, nutritional therapists are increasingly treating children with severe weight problems. Effective intervention requires a holistic approach that includes both nutritional advice and a recognition of wider societal constraints affecting food choices and eating behaviour.
The most effective and long-lasting nutritional intervention is likely to be one that will restore impaired insulin sensitivity, increase physical activity as limit any exposure to allergens, stress and environmental pollutants.
In clinical practice, overweight and obese children and their families should be encouraged to eat regular meals — which is something that many do not achieve. They should also chew well, as hurried eating habits lead to overeating and foster digestive problems.
Portion sizes should be addressed and basic nutritional concepts should be explained to families — such as defining ‘wholegrain’, stressing the importance of fibre and protein to stabilise blood sugar, and explaining that omega-3 oils burn fat and turn off fat production.
Messages that people these days are bombarded with, such as’eat five a day’, are not effectively conveying important information. For example, not many members of the public would know that fruits and vegetables supply valuable antioxidant protection against various undesirable conditions. If they did, they might eat more of these foods. If they further knew that particular fruits and vegetables contain the plant protein osmotin, which may actually increase weight loss, (*59) then they would almost certainly eat a lot more of them!
People in the UK are fortunate that they can make real choices about what they eat. But the information upon which these choices are based is becoming much more biased towards producer interest, while the prevalence of various chemicals, such as artificial sweeteners and pesticides, makes them difficult to avoid.
Evolutionary experience and cultural tradition — passed down through a great many human generations — is gradually being replaced by the more questionable wisdom of the advertising jingle.
Obesity clearly does have some direct behavioural and chemical causes, but nevertheless, it might also be a symptom of a deeper societal malaise. It involves a society that believes it is perfectly alright to sell junk food to children, and it involves us tolerating businesses that influence national policies while, at the same time, suppressing informed dissent.
Unless these fundamental issues are openly addressed at EU level, the coffers of diet and drug companies will continue to swell, along with the bellies of our children. There is no quick fix but, as specialists in this area, nutritional therapists are in a privileged position to make a difference, especially since clients are self-referred and more motivated to ‘buy’ our message.
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