Children's nutrition: a global emergency

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Children's nutrition a global emergency

• Philip James

LSHTM and Chair of IOTF and the Presidential
Council of the Global Prevention Alliance
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Malnutrition a continuing outrage
TMRU, Kingston, Jamaica, Christmas 1966
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Elimination malnutrition a global deficit in
policies and priorities
UN Millennium report. James et al. Food Nut
Bulletin 2000, 21Supplment 3
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WHERE IS THE PRIORITY ?
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Lifecycle the proposed causal links
Epigenetic susceptibility to chronic diseases if
diet becomes inappropriate
Higher mortality rate
Impaired mental development
Baby
Elderly
Inadequate growth
Low Birth
Weaning
Malnourished
Untimely / inadequate
Weight
Frequent infections
Inadequate food, health care
Inadequate food, health care
Child
Stunted
Reduced mental capacity
Woman
Malnourished
Pregnancy
Low Weight
Adolescent
Inadequate food, health care
Gain
Stunted
Higher maternal mortality
Reduced mental capacity
Adapted from James et al. SCN Millennium Rep.
Food Nutrition Bulletin, 2000, 21, 3S.
Inadequate food, health care
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British wartime feeding based on novel
nutritional concepts
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The transformation of agriculture an issue of
fundamental national security
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• A quarter-pound cheeseburger, large fries and a
  16 oz. soda provide
• 1,166 calories
• 51 g fat
• 95 mg cholesterol
• 1,450 mg sodium

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1900 2000 Prevalence of overweight and obesity
for 5 - 15 yr old Australian children
Norton K et al, Int J Pediatr Obes 2006
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Projected overweight (incl. obesity) rates for
school age children
Wang and Lobstein, IOTF, 2006.
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Nutritional Contrasts
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Childhood overweight obesity
Lobstein et al., Obesity in Young Children. 2004,
Obesity Reviews 5 (Suppl. 1), 485
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The impact of inappropriate Western diets on most
of the world's susceptible populations health
systems already overwhelmed
Diabetes, strokes, heart disease,
cancers arthritis
Fat Baby
Elderly
Normal/high growth
High Birth
Early Weaning
Untimely / inadequate
Weight
Frequent fast foods
Rapid
weight gain
Inadequate physical activity
Inadequate health care system
Abdominalobesity
Woman
Reduced play and social isolation
o/w or obese
Pregnancy
Glucose intolerance/ diabetes
Poor school conditions
Reduced fertility CVD, HT Cancers
Early onset Type 2 Diabetes
Reduced job opportunities
Adapted from James et al. SCN Millennium Rep.
Food Nutrition Bulletin, 2000, 21, 3S.
Inadequate obstetric care
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The increasing risk of adult coronary heart
disease if adults in childhood ( 7-13 yrs) had
modest weight increases
Copenhagen school children's study of 276,835
children measured from 1955 - 1960 with National
Death and Hospital Discharge Registries. Hazard
relates to one BMI Z score linearly related to
events at all ages but hazard ratio progressively
increases with age during childhood.
Baker, Olsen Sorensen. NEJM 2007, 357 2329-32
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The keys to success in the food business and in
obesity and chronic disease prevention

• Price

• Availability

• Marketing

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Fundamental changes in physical activity
inevitable and optional changes

• Inevitable
• Rural to urban transition
• Labour changes
• Mechanisation/computerisation of standard work
  also home duties e.g. cooking, washing, cleaning
• Optional
• Urban building policies high intensity or US
  style sprawl?
• Road and community design
• Office supermarket location policies
• Car policies versus preference for
  cyclists/pedestrians
• Policies on free spaces for children's play
  lighting for safety e.g. for older people
• Park/leisure/sports facilities/school PA lessons
• Ease of transport of perishable foods into
  towns/cities

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Obesity time watching TV overwhelms leisure
activity in Australia
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Leisure time sport activity
Increasing TV time
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Average BMI for each group
TV time
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22
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High
Moderate
Inactive
Low
Total daily physical activity
Adapted from Salmon, Bauman et al IJO 2000
24600-606
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Individual responsibility
Complementary approaches to obesity chronic
disease prevention
e.g. Focus on Health Education campaigns
selectively help upper socio-economic groups
Changes to the "toxic" environment

• Progressively adapt all towns/cities to favour
  pedestrian/cycling as norm with car restrictions
• Nutritional standards for food in all government
  facilities/schools eliminate trans fats
  catering on Finnish scale fruit veg. within
  meal costs
• Limit/abolish all marketing to children
• Selectively increase costs of high fat/sugary
  products soft drinks
• Social/employment/medical policies for breast
  feeding as the norm

Adapted from Puska P, 2001
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Prevalence of obesity in schoolchildren in
Singapore weight (kg) for height (m) gt120
16 14 12 10 8 6 4 2
1976 1978 1980 1982 1984 1986
1988 1990 1992 1994 1996 1998 2000
New growth charts used since 1994. Source
Ministry of Health, Singapore
Dramatic response to intense focus on obese
children's diet and physical activity
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Marketing to Children
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Manipulating children's behaviour evidence from
the UK government's systematic analysis

• Food industry promotions
• Can confuse nutritional knowledge, e.g.
  whether fruit is in product
• Change food preferences
• Change purchasing behaviour
• Influence choice and consumption by brand
• Alter balance of food categories eaten

Hastings Report, UK Food Standards Agency, 25th
September, 2003.
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The most cost-effective community (not national)
interventions in Australia
Intervention Cost in Australian for each
DALY saved Restrict TV advertising 4 Soft drink
intervention at school 3,000 Walking buses to
school 770,000 Cycling (travel SMART
schools) 260,000 After-school community
programmes. 90,000 Doctors targeting the
overweight children 32,000 School multiple
interventions, but no physical education 14,000
Add Physical Education 7,000 School
education to reduce TV viewing 3,000 Family-based
program for obese child 4,000 School program
targeting overweight obese children 3,000 Medica
l treatment with drugs, e.g. Orlistat 14,000
Victoria State Analyses Sept 2006
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Strategies for combating childhood obesity

• Protecting children at least up to 12 yrs
• Breast feeding
• Proper weaning practices
• Regulated child minders food and play
• Legislate on all forms of marketing TV, radio,
  text messages, internet, food product labelling,
  games etc.
• School environment major changes needed
• Supermarket practices
• Pricing policies affect school aged children
• Policies on density of available fast foods
  outlets in town centers

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The interest and influences of different
stakeholders
Lobstein T Analyses based on UK Food
Commission's experience and new EU policy work.
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Five Practical Priorities

• Major drive to increase/ sustain breast feeding
  facilities at work important maternal leave
  cultural change
• Marketing restrictions (not just TV advertising)
  - statutory for children adolescents rights of
  child extend to 18 yrs
• Control of food in nurseries, all school
  facilities and school environment avoid choice -
  all foods of high nutritional quality
  facilities to allow spontaneous play - not TV
• Fruit and vegetable availability routine in
  canteens and restaurants (within main cost)
• Transformation of physical facilities for
  spontaneous leisure time activity urban design
  changes with novel traffic policies pedestrian
  only areas immediately adjacent to
  houses/apartments

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