National Assembly for Wales

Children and Young People Committee

CO 16

Inquiry into Childhood Obesity

Evidence from : Royal College of Paediatrics and Child Health

The Royal College of Paediatrics and Child Health (RCPCH) welcomes this invitation to provide evidence to the Welsh Government Children and Young People Committee inquiry into childhood obesity.

We have taken the opportunity to consult with our members in Wales – practicing paediatricians - who have been able to provide insight from a local clinical perspective to support the strategic recommendations of the RCPCH.

The Welsh Government has declared its vision for Public Health in Wales with ‘Our Healthy Future’. The RCPCH strongly supports the implementation of national planning or legislation to achieve:

· Reduced inequities in health

· Increased physical activity

· Reduced unhealthy eating

The College in Wales believes strongly that whilst it is necessary to tackle the presenting obesity problem, it is imperative to work strategically to reduce obesity in the future. Controlling childhood obesity is about safeguarding Welsh children’s futures. If a young person is overweight at 18 years empirical evidence suggests that person will continue to be overweight in adulthood.

1. Overview

Whilst there is general belief amongst most healthcare professionals that the recent rise in obesity in children in Wales is starting to plateau, or at least slow, it is evident that obesity is a major problem in Wales. Recent statistics, supported by anecdotal evidence, suggest 35% of children between 2 and 15 are overweight or obese[1]. Childhood obesity is fundamentally a public health issue, but is by no means an issue unique to Wales. The prevailing obesity pandemic is something that threatens much of the western world.

Paediatricians tend to see only the tip of the Welsh obesity iceberg because the majority of overweight children and young people are managed within primary care. They often see obese children only at the point where morbidity has been reached and patients are presenting with obesity related conditions such as diabetes, breathing difficulties, etc. By this time weight management is more complex and even if successful, can result in further medical issues such as excess skin removal.

We recognise there are areas where health inequalities are evidenced by obesity, and these need to be addressed. However, we are of the belief that obesity affects the whole of Welsh society, with significant sectors of the population presenting as overweight across the demography. We would encourage the Welsh Government to aim any strategic solution holistically at the Welsh population.

As a College, we acknowledge obesity is a difficult issue to successfully address, with multiple causes and no ‘one fits all’ solution. Clearly prevention is infinitely preferable to treatment.

2. Existing initiatives and schemes

We have picked out 3 initiatives and schemes most familiar to our Members – MEND, Flying Start and the Child Height Measurement Programme.

It is also worth highlighting that the RCPCH responded to the recent Public Health Bill for Wales consultation. We support this proposal and see it as a framework to allow the Welsh Government to tackle major public health issues such as obesity on a cross-departmental basis.

2.1.MEND

Our clinicians are familiar with the national MEND programme initiative, and whilst such schemes are welcome, our members have reported issues with the referral process for the scheme. Schemes are not easily accessible to some parts of the population, and paediatricians experience difficulty in knowing where to refer patients. The scheme has limited geographical availability, and even if available in an area, this is not always accessible due to limited transport opportunities, especially for low income families.

Feedback has also indicated that referrals to this service are constrained by the age limitations of the scheme. Clinicians identify a gap in weight management programmes for young people between the ages of 13 years (when MEND finishes) and 16 years (minimum eligibility for ‘adult’ programmes e.g. ‘weightwatchers’).

We also have concerns that whilst such schemes are successful for children who are already obese, they do not address the need for programmes dealing with obesity prevention.

2.2.Flying Start

The Welsh Government’s targeted early years programme for deprived families with children under 4 years is welcome. Ensuring that children received proper nutrition from an early age is crucial and the RCPCH is a strong advocate of breast feeding to ensure good nutrition and weight management amongst babies.

Anecdotal evidence from amongst RCPCH Members suggests results for Flying Start are patchy, but we welcome the Welsh Government’s commitment to further funding to extend the scheme and improve results.

2.3.Child Height Measurement Programme

The RCPCH is has developed the UK growth charts 2-18 years and strongly advocates their use for, amongst other things, assessing a child’s BMI. The charts are accompanied by education materials for healthcare professionals and are available here: http://www.rcpch.ac.uk/child-health/research-projects/uk-who-growth-charts/uk-who-growth-chart-resources/uk-who-growth-ch-0

In England, the National Child Measurement Programme (NCMP) has provided very useful data on prevalence of overweight and obesity in childhood the ages of 6 and 11. The programme is delivered through schools and achieves almost universal coverage. It also provides an opportunity for interventions to be explored with children whose weight is of concern. Recent proposed changes to the collection of NCMP will also mean that children’s weight can be tracked from the age of 6 to the next measurement at 11, providing a further rich seam of data. The data for NCMP is analysed by the National Obesity Observatory and is available to view here: http://www.noo.org.uk/NCMP

The RCPCH welcomes the Welsh Government and Public Health Wales introduction of the Child Measurement Programme for Wales initiative which it is hoped will produce data to support and supplement the NCMP.

3. Recommendations

The RCPCH is playing a leading role in the Academy of Medical Royal College’s obesity campaign and fully backs the recommendations of the Measuring Up report published in February 2013.

The recommendations fall into three main categories:

· Actions to be taken by the healthcare professions

· Changing the ‘obesogenic’ environment

· Making the healthy choice the easy choice

Whilst the AoMRC report focuses on obesity across the life-course, many of the proposed actions are aimed at children; the premise being that if we get it right with children, so the health effects will be felt into adulthood.

The following recommendations, relating specifically to tackling childhood obesity, rest on the acknowledgement that just as there is no one single cause of obesity, so there is no one single solution for beating it. It is not the fault of any one government, organisation or individual that childhood obesity levels in the UK are amongst the worst in Europe, but believe that it is the responsibility of healthcare professionals, government, the food industry, educators and individuals to address the obesity crisis head on.

As previously highlighted, the RCPCH strongly advocates an ‘all-Wales’ approach to tackling obesity. Whilst there are clear links between low income families and obesity levels, obesity is increasingly becoming a problem that affects the whole population. As such, the steps to tackle it should be holistic.

1. Skilling up the workforce

In-line with AoMRC report, we recommend that the Medical Royal Colleges, Faculties and other professional clinical bodies should promote targeted education and training programmes within the next two years for healthcare professionals in both primary and secondary care to ensure ‘making every contact count’ becomes a reality, particularly for those who have most influence on patient behaviour.

This involves appropriate training courses, e-learning materials and practical guidance on how to manage obesity in children that is available across the healthcare profession for both primary and secondary care clinicians.

The College welcomes the systematic standardised approach to measuring the heights and weights of school reception children by Public Health Wales Observatory Child Measurement Programme. We would recommend that this be extended to measure schoolchildren as they enter secondary school (i.e. the age of 10) as is the case in England.

In addition, children should be weighed and measured at every presentation to a health professional (outpatients; health visitors, etc) and feedback provided to the parent/carer about whether the child is within a healthy range. If they are not, advice should be give and where appropriate referrals to weight management services (see below).

2. Referral to weight management services

As outlined in the AoMRC report, we want to see NHS Wales invest £100m in the next three financial years to extend and increase provision of weight management services, mirroring the existing provision of smoking cessation services. In our view, this should include both early intervention programmes and, greater provision for severe and complicated obesity, including bariatric surgery. Adjustments could then be made to the Quality and Outcomes Framework, providing incentives for GPs to refer patients to such services.

Currently, the availability of weight management services is variable, with significant geographical variation.

3. The school environment

We want to see the Welsh Government mirror steps being taken in England to introduce a new statutory requirement on all schools to provide food skills, including cooking and growing – alongside a sound theoretical understanding of the long-term effects of food on health and the environment from the 2014/15 academic year.

There needs to be a long term strategy so that children are educated about nutrition in schools in a way that has been absent in recent years and this knowledge can be passed on to future generations.

Schools and organisations have a responsibility to control portion size and access to unhealthy foods. The College acknowledges the non-statutory actions by the Welsh Government to promote healthy eating in schools and welcomes the draft Healthy Eating in Schools (Nutritional Standards and Requirements) (Wales) Regulations as part of the Healthy Eating in Schools (Wales) Measure 2009. We urge the Welsh Government to fulfil their undertaking to implement the timetable for commencing the provisions in the Measureand for introducing regulations for food and drink provided in secondary schools, special schools and pupil referral units by September 2013.

4. Educating parents

Children are hugely influenced by their parents’ behaviours – and getting into good eating habits early is crucial to healthy weight gain in infants right through to adulthood. A parent's role in shaping a child's lifestyle and emotional wellbeing during the early years is vital. Children identified as obese before the age of three not only face a greater chance of having life-long weight issues, but are also more at risk of being plagued with serious health complaints, ranging from joint problems and heart failure to psychological conditions.

It is important that the early years workforces (including health visitors, midwives etc) are adequately ‘skilled up’ to deliver basic food preparation skills to new mothers and fathers, and to guide appropriate food choices.

This should include support and advice from breastfeeding through to weaning and portion sizes across the age groups:

Encouraging breastfeeding

· According to a recent study by Nottingham University School of Nursing, Midwifery and Physiotherapy Breastfeeding during the first six months of a baby's life can reduce the chances of that child becoming overweight by as much as 15%.

· Despite almost three-quarters of new mothers breastfeeding their baby during the initial weeks, less than half continue to do so by the time the child is six to eight weeks old – the lowest rate in Europe. The fact that Britain is not only the most obese nation but also the country with the lowest breastfeeding statistics on the continent is no coincidence

Healthy eating

· For children progressing on to solid foods, attention should be drawn to how healthy eating can be more cost-effective for families. Educating parents about nutritional ingredients, how to cook healthy meals and appropriate portion sizes for their children is only the beginning. The onus is also on the government, food manufacturers and advertising companies, as well as those involved in childcare, to ensure that families – regardless of their budget – can afford healthy food and provide a balanced diet for their children

· We recommend the exploration of a tax on foods that are high in saturated fat, salt and sugar, with appropriate measures taken to ensure this doesn't disadvantage low-income families. At the moment, unhealthy foods are cheaper than healthy products and we don't want that to be the case

We would recommend that these recommendations are included in the Welsh Government’s ‘Flying Start’ programme, as referred to in section 2.

5. Physical activity

Physical activity is important not only for children to maintaina healthy weight, but also aiding their mental and emotional development. However, we would emphasise the central role of appropriate nutrition and healthy eating as the key driver for weight loss.

Engaging with parents and working alongside them to ensure their children are physically active is a key part to achieving a healthy lifestyle.

Parent should be aware that to keep fit and healthy, toddlers should be active for at least three hours a day, which for many young children can easily be acquired during play. Walking to nursery, playing a physical game and even exploring their surroundings are small but effective ways of ensuring a pre-schooler has adequate exercise.

6. Tackling the obesogenic environment

The environment has a huge influence on eating habits, in particular those of children. It is our belief that action should be taken on two main fronts to tackle the ‘obesogenic environment’ – the surroundings that influence the obesity of individuals - and help make the healthy choice the easy choice.

A ban on advertising of foods high in fat, sugar and salt before the watershed of 9pm

The role of this advertising is restricted in the UK, but RCPCH agrees with the Children’s Food Campaign and other bodies who have argued that the current regulations on the advertising of unhealthy foods are insufficient to protect children’s health. These restrict advertising of food high in fat, sugar and salt “during children's airtime and around programmes with a disproportionately high child audience”[2], but do not include other programming that may be viewed by a large number of children such as soaps or sporting events.

Research from both the industry regulator OfCom, and independently from researchers at Newcastle University, have found this to be largely ineffective. Indeed, the latter “found that exposure of children to advertisements for ‘less healthy’ foods was unchanged following their introduction”, arguing that the “restrictions did not achieve their aim and this is likely to be because they only applied to a very small proportion of all television broadcast”[3]. Meanwhile the OfCom evaluation of the restrictions found that the regulations only reduced exposure to advertising of unhealthy food for children by 37%, and for older children (10-15 year olds) only 22%[4].

Reducing the proximity of fast food outlets to schools, colleges, leisure centres and other places where children gather

Progress on education and behaviour within Welsh schools in relation to healthy lifestyles has been good. However, we are concerned about the anomaly found in some schools where licencing practices mean councils actually end up undermining their own efforts in the schools by allowing the expansion of outlets which sell food that is high in salt, sugar and saturated fats which in effect pull children away from healthy eating.

The AoMRC obesity inquiry heard how often schools are undercut by the local chip and chicken shop with its ‘pocket money’ prices. Older children understandably want the freedom of going off site at lunchtime but it is extraordinary that the local authority which is trying to encourage a child to have a healthy lifestyle in school allows an environment which nudges them to do precisely the reverse.

We recommend learning from councils such as Waltham Forest and Tower Hamlets in London and cities like Liverpool where strategies have been introduced to limit the number of fast food outlets near schools.

Portion sizes

Our Members also express concern about the availability of oversize portions of fizzy drinks and food in food outlets. This is not confined to commercial outlets but can also be evidenced in institutions such as schools and hospitals. There is a tendency, for a proportion of the population, to believe that eating to excess is normal and appropriate. This further supports the case for more education about healthy eating to the whole population, coupled with education about the implications of unhealthy eating.

[1] Statistics for Wales; Welsh Health Survey 2011

[3] Adams et al (2012) “Effect of Restrictions on Television Food Advertising to Children on Exposure to Advertisements for ‘Less Healthy’ Foods: Repeat Cross-Sectional Study”, PLoS ONE 7(2): e31578.