APPENDIX 24
Memorandum by Child Growth Foundation
(OB 40)
INTRODUCTION
1. The Child Growth Foundation is the UK's
national charity fighting to ensure that the growth of every child
is regularly assessed and, co-incidentally, is responsible both
for the creation and design of all the UK's paediatric growth
charts. We welcome the Health Select Committee Inquiry into Obesity
and request that its Terms of Reference are brought to focus on
children as much as on adults. Because Professor Philip James
and Dr Laurel Edmunds will probably advise you more eloquently
than we could on the awful health implications, terrifying rise
and insidious causes of childhood obesity, our Submission will
look to the immediate future and demand that action is now taken
urgently to stem the epidemic that it now is and suggest an area
where this immediate action could begin. The suggestion is not
intrusive and neither is it disproportionately expensive when
the horrendous cost of obesity to the UK is considered. We have
already begun to discuss trialing the concept with the Sure
Start Unit and the Department of Health but would be impressed
if the Inquiry felt the idea, or elements of it, could be fast-tracked
for more direct implementation. The following paragraphs begin
by summarising the project before continuing by identifying the
two charts that could underpin its progress. We would be happy
to supply further copy or refer to them orally if the Inquiry
should so desired.
WHAT CAN
BE DONE
ABOUT OBESITY?
2. In the Foundation's opinion society has
missed the boat if children arrive fat at Reception Class. Our
concept is, therefore, that Whitehall and health care providers
should make every possible effort to ensure that, during the pre-school
years, children never become obese in the first place. Parents,
paediatricians, politicians and the press should never have to
wring their collective hands if, at school, childrens' weight
gets progressively more unmanageable. The pre-school years is
the only age when children are so constantly under the influence
of either their parents or health professionals whose joint responsibility
it must be to ensure that they do not become unhealthily. Since
children are the future of the State it is the Government that
must assume ultimate responsibility for their health and Whitehall
shirks this responsibility every time it cites " nannyism
" as a euphemism for being unwilling to orchestrate how that
health should be achieved.
3. When individual politicians privately
state that they might not get re-elected if they tell their constituents
that their kids are fat—as they do—how much better
would they feel to be associated with a programme which empowers
parents to keep their children a healthy size?. Incidentally,
such a positive approach would also get health professionals off
the hook by not having to tell their patients' parents that their
children may be stuck with fatness for life. Although we would
insist that any child be treated who is already obese, or even
approaching obesity, it would be obviously much better [and infinitely
cheaper] to acknowledge that prevention is always better than
cure.
4. Whilst attention has quite rightly been
directed towards sustaining the healthy eating/activity of schoolchildren
and beyond, the Foundation feels babies and toddlers have been
relatively forgotten. In doing so an opportunity has been missed.
Consider, if you will, the analogy that could made with the religious
society that believes that if you fire the imagination of children
when they are young, you have got them for life. If you can imaginatively
fire children into a healthy lifestyle at the pre-school age,
might you not also have them for life and equip them to stand
up to the forces that would have them eat and drink unhealthily?
In fact, the infant's lifestyle may have been determined years
earlier when its parents-to-be were themselves at school?. The
Foundation would request that the Inquiry looks long and hard
at the lack of provision for education in parenting, the understanding
of food and food preparation in the National Curriculum. In particular,
the current guidelines governing school meals should be seriously
questioned as also should the Government's failure to deliver
its "promise" on physical activity in school. If a single
illustration were needed to confirm Whitehall's inactivity to
tackle obesity, it is the continued absence of any National Curriculum
amendment to provide every child with the two hours per week of
enjoyable, structured physical activity to which they are entitled.
5. Though it is only now in paragraph 5
that the Foundation has referred to physical activity, we are
well aware that physical activity may be even more important that
diet and nutrition in the toddler years. Peer review Papers are
beginning to identify that obesity is not solely the province
of adults and school age children but may be identified from even
earlier ages: it may be joke in bad taste but researchers have
confirmed that the Telly Tubbies are being increasingly watched
by sofa-bounded telly tubbies. Playgrounds in which children can
run around and burn off their calories are much needed and fortunately
need none of the area required by larger, though increasingly
less numerous, sports fields. They should be relatively easy to
plan into every neighbourhood. If possible, every street should
have one.
CHARTS
The above are general measures that the Inquiry
should consider be provided by the State. Pivotal to success,
however, is the specific help and encouragement that can be given
to every parent to get their children off to a healthy start.
It is here that the Foundation is proposing that two of its charts
be used to monitor that start and give every parent a record of
health that they could share with their children. If promoting
their use might at first seem like a marketing ploy to the cynical
reader, it should be remembered that the Child Growth Foundation
is a non-profit making charity regulated by the Charity Commission.
ENCOURAGEMENT OF
BREASTFEEDING WITH
"BREAST FROM
BIRTH" CHARTS
6. The Government should be unequivocal
in its support for the mother who wants to breastfeed and seek
more directly to persuade every mother-to-be that one of its benefits
is to be a steadying influence on weight gain throughout the early
years of childhood. Research has demonstrated that infants exclusively
breastfed in the early months are significantly less likely to
be obese than those fed by formula milk by bottle [Armstrong
J, Reilly J J Lancet 359: 2003-2004] In our estimation Whitehall
could emphasise this benefit by directing that the Foundation's
Breast From Birth first year weight charts become the standard
charts for the UK in preference to our current charts compiled
from mixed feeding protocols. These current charts do not reflect
the distinct weight gain pattern by breastfed babies with the
result that they frequently fail to maintain their correct centile
position. This in turn worries the mother who believes that her
milk is inadequate and that her baby is failing to thrive. The
net outcome is that many mothers then switch to formula feeding
and thereby deny the infant the considerable attributes of human
milk.
7. At a stroke, the inclusion of the Breast
From Birth chart in every child's Personal Child Health Record
[PCHR] would signal to every mother that breastfeeding is the
right start in life—both for her child and for herself.
Furthermore, the inclusion would not cost the NHS a penny more
since the charts would simply replace the current PCHR charts
and cost the same. There is no question about their validity and
practical application [Acta Paed 2002, 91: 1296-1300] and
they have been accepted in principle by all the UK's appropriate
medical bodies. The Department of Health has not yet formally
been approached to endorse the charts and it may be that the Inquiry
feels that this is a step now worth taking. The UK has one of
the more dismal breastfeeding rates in Europe and the Government
is committed to a yearly increase of 2%. If Breast From Birth
charts could increase the percentage further, this single
anti-obesity measure might have lasting benefit.
PROGRESSIVE USE
OF BODY
MASS INDEX
WITH "BMI/WAIST
CIRCUMFERENCE" CHARTS
8. A second measure that the Foundation
would like to propose for the Inquiry's consideration concerns
the positive use of body mass index [BMI], an internationally
accepted measure of fatness which could pinpoint the shape of
every child in the country. We feel that the calculation of children's
BMI should now become mandatory for both individual identification
and for public health measures from the age of two years. Professor
Philip James first suggested in 1996 that Scottish schoolchildren
should be assessed as a measure to identify the rise of obesity
north of the border but the Government ignored the idea. It should
not be lost on the Inquiry that Scotland now has an even worse
problem than the South and, in 2003, Whitehall should not overlook
that the use of BMI in schoolchildren as a public health measure
has been approved by the recent publication of the 4th edition
of Health For All Children [HFAC4], the policy document
for UK child health. HFAC4 states that the growth data from the
mandatory school entry health could be turned into a BMI score
for every child though it stops short of advocating that BMI be
used as a school age screen for obesity in those children. We
welcome the public health aspect —and would like to see
BMI data collected periodically throughout school for that purpose—but
we regret that it is not recommended as a screen.
9. The specific public health use of the
BMI data would be to map every area of the UK where targeting
obesity needs to be implemented. At every health contact where
growth [length/height and weight] is assessed, a BMI could be
automatically produced to feed the local IM & T systems that
would generate the colour-code, post-coded maps which would be
ideal for the task. Because the maps could be generated year-on-year,
local authorities would have a rolling audit by which to measure
their success—or failure—of their work.
10. As stated above, we believe that BMI
assessment should begin at two years because it is the age by
which the RCPCH recommends that severely and progressively obese
children be referred for treatment [RCPCH weight management
2-18yrs guidelines] and at which every UK should have a health
assessment [RCPCH Monitoring the Health of our Nation's Children].
It is also the age at which the International Obesity TaskForce
[IOTF] believes it possible accurately to define overweight/obesity.
Indeed, the Foundation believes that the IOTF definitions should
even replace the UK's traditional definitions since the latter
may be unhelpful by exaggerating the prevalence of obesity. This
is not to imply that the epidemic is any the less concerning but,
at 18 years of age, there is significant disparity between the
UK definition of obesity [BMI 29] and the WHO internationally
agreed of definition of BMI 30.
11. Because BMI is a clinical concept and
the current medical charts are neither child friendly nor likely
to be understood by them, the Foundation has produced "cartoon"
BMI charts for inclusion in the child's PCHR which show the "healthy
eating/activity" target area he/she should be aiming for.
This is analogous to the gold star principle that children get
for good behaviour: if gold stars littered the goal at which the
children are aiming, the cartoon would be doing its job.
RECRUITMENT AND
TRAINING
12. In making this submission the Foundation
requests that the Inquiry recommends an immediate increase in
the recruitment, retention and training of NHS staff without whom
any programme to tackle obesity could be lost. The recent announcement
by the Royal College of Nursing that the UK still has a shortage
of hospital nurses could have also have cited the shortage of
midwives, health visitors, school nurses and dieticians. Any or
all of them have daily contact with children between birth—four
years and could have a direct impact of keeping them in shape.
In some cases the shortfall is scandalous. In some UK urban areas
the establishment of health visitors can be as low as 60% and
the Foundation is amazed that the Department of Health, administering
a "Healthy Schools Programme" still appears not to know
precisely how many school nurses work in the UK. Your Inquiry
in 1996 couldn't obtain a figure and the nurses' trade union,
CPHVA, appears to be unsure of their number even in 2003. Worse
still, it has been driven to enlist the help of the Mother's Union
to press for the perceived 20% [500 persons] under-establishment
for which the DoH is responsible.
13. It is not just the recruitment however
that is urgently needed but the improved quality of their training.
It would be completely wrong to tar all nurses with the same brush
but, taking breastfeeding as an example, the overall lack of knowledge
and quality support to families by midwives and health visitors
is almost indictable. The professions know this themselves [even
the UNESCO Baby Friendly Initiative has admitted as much] but,
seemingly, they can do nothing about the situation until Westminster
acknowledges that such an appalling situation has to be rectified.
HFAC4 lists training above all its other growth recommendation
in a tacit acknowledgment that current training standards are
woeful.
14. It is at this point that the Foundation
must refer the Inquiry to Dr Laurel Edmunds' concept of a "lifestyle"
nurse who would specialise in the increase of healthy measures
for young children. It would steal her thunder even to attempt
a job description in these pages: Dr Edmunds assuredly will be
more succinct in her description.
RESEARCH
15. Although the Foundation believes the
time has come to tackle obesity with action rather than research,
research is still necessary. We take no comfort from the fact
that professionals researching obesity are now approaching us
for funding—a small charity by anybody's standards—because
the appropriate authorities [the Department of Health, Medical
Research Council etc] have told them that no money exists for
such work. In our opinion, the Inquiry should demand that the
UK has a properly financed obesity-related research base because
we still do not understand much of the causes and effects of obesity.
SUMMARY AND
CONCLUSION
16. We deeply regret that the Government
appears to have made little progress to combat obesity following
the National Audit Office's Report "Tackling Obesity in England"
[8 February 2001] and the Public Accounts Committee's Ninth Report
[17 January 2002]. Whatever the DoH may be doing following the
NAO/PAO's joint "directive" that it leads a cross-cutting
Departmental approach to prevent/treat obesity, it appears to
be doing it virtually in secret and at a snail's pace. This may
be because "no-one in the DoH is taking obesity serious"
[personal communication—Prof Al Aynsley-Green, UK National
Director for Children's Services] and proof of this may be
found in the preliminary NSF/Children document "Emerging
Findings" [April 2003]. This consultation document does not
rate obesity as a target worth considering and, indeed, hardly
mentions the problem. The Foundation's view is that Professor
Aynsley-Green was obliquely referring to DoH Ministers and senior
officials when, at last Autumn's Great Ormond Street's 150th anniversary
celebrations, he described a "bunkered" approach to
children's health issues.
17. Most vital of all is that the Inquiry's
conclusions are considered by the Children's TaskForce for adoption
in the National Framework For Children due to be published in
December 2003. Word on the street has it that the Framework will
be the executive instrument for child health for the next 10 years
and that anything excluded from it will just not be addressed.
The TaskForce seems to have set a consultation deadline of early
July before publicly closing its doors to comment but this deadline
must be extended to consider the Inquiry's Report.
18. The Foundation's underlying fear is
that already the Government's inaction will produce scarcely a
dent in the NAO's predicted loss to the UK through obesity by
the end of the decade. In 2000 the Government agreed that a figure
of £3.5 billion per annum could be printed in the NAO Report
yet we are half-way through 2003 with hardly a sign that any of
that figure will be reduced. In the interim Whitehall has to tackle,
amongst other things, the huge problems of curbing TV advertising
to children, proper food labelling on children's foods and enforceable
levels for fat, sugar and salt content in food content. In these
areas considerable sums of money will be required to achieve success
but it is money that must be spent. The UK can afford it. Indeed
it cannot afford not to afford it.
April 2003
| 
