Memorandum by the Child Growth Foundation
(WP 96)
1. Will the White Paper's proposals enable
the Government to achieve its public health goals?
1a. In a word, it's "questionable"
as far as far as childhood obesity is concerned. We still
do not know exactly how HMG plans to combat the epidemic. Despite
very publicly setting itself the Public Service Agreement [PSA]
target of halting the year-on-year rise of obesity among children
under-11 by 2010, HMG tells us still to await a Delivery Plan
before finally (?) discovering how the PSA is planned to be delivered
[p 178]. Unless the Committee has a draft preview copy of the
document or is scheduling its Inquiry until a date after the Plan
is expected to be published [9 March] it may be in no better position
to comment on the strategy than we. One certainty remains, however,
and that with 2010 now less than five years away, the strategy
will have to be dramatic.
1b. It is true that the White Paper does
have firm proposals—ie the increase in school nurses—but
when the all nurses are not anticipated to be in post until 2010,
we wonder how HMG thinks halting the rise to be possible. It will
be increasingly impossible if HMG waits for NICE to publish its
advice on the identification, prevention and management of obesity
in 2007. Another two years will have been squandered confronting
the problem with only three years remaining to clear up the mess.
1c. Identification of obesity could actually
start to-morrow in the age range that really matters—birth/four
years. Tackling the likelihood of obesity in pre-schoolers—where
opportunities for successful intervention and prevention are considerably
higher than in primary school—should be the real target
to be addressed. At this age there is a veritable army of health
visitors, nursery nurses, practice nurses etc to nip the first
signs of unhealthy weight gain in the bud. The Chief Medical Officer
for England [CMO] identified these health care professionals by
name when he recommended the action they should take in his 2002
Annual Report but, by virtue of staging an average of two growth/obesity
training courses per week throughout the country, the Foundation
knows that virtually nothing has been done to implement the CMO's
wishes. Indeed, when he recommends that Public Health Observatories
also produce regular public reports audit progress, the White
Paper appears to condone the PHOs' inaction by not anticipating
any reports until 2006!
1d. Tragically, we believe that HMG may
actually have damaged the chances of ultimately winning the fight
against childhood obesity by setting such a ludicrous 2010 target
date. Though there must be political reasons for it having done
so, the likely result of failure to achieve anything comprehensive
by that date will be that everyone gets "switched off"
and the epidemic will continue inexorably to increase with it
off a priority list. The Foundation believes that HMG should have
had 20/20 vision—opting to halve the childhood obesity rise
by 2010 and then halting it by 2020. This is no less than its
approach to eradicating poverty and is an approach which has a
better chance of success.
2. Will the proposals be appropriate, effective
and represent value for money?
2a. Hopefully they will be all of these
but this can only be conjecture at this stage. If a lot of the
promises listed in CHOOSING HEALTH are implemented with vigour
and common sense, the Foundation believes that they could have
substantial long-term pay-offs.
2b. For instance, we believe that if the
Delivery Plan confirms that HMG has accepted the Committee's recommendation
for an annual BMI measurement in [primary] schools the outcome
could be invaluable. Though CHOOSING HEALTH does not specifically
state that it has [see p 86], a workshop on BMI that met in London
before Christmas heard that the DH/DfES were actively talking
about it. For the first time, therefore, Directors of Public Health
will have yearly prevalence data on which to base their health/environmental
planning initiatives to curb obesity at local, regional and national
level but also a rolling audit to quantify how they are working
out. In addition, the yearly screen should identify the early
signs of overweight/obesity developing in primary school since
one cannot be certain that its roots of obesity are put down pre-school.
A third attribute to a yearly BMI screen is that children who
have a more traditional endocrine [growth] abnormality may also
be picked up sooner: the UK does not have an enviable record for
the early detection of such problems.
2c. What the Delivery Plan must do is state
who is taking the measurements and, if it is teachers, who will
train them and equip them to do a proper "medical" job
**. Given that they are trained and properly kitted out the Foundation
would welcome teachers being given the job since yearly measurements
also have considerable "educational" advantages. Growth
projects [ie studying how little flowers and bunny rabbits etc
grow] take place annually in every UK primary school: what could
be more natural therefore when working up to National Curriculum
Key Stages 1 and 2 maths and science attainment standards than
to handle dynamic growth data from the pupils themselves?
— The weighing equipment used will
have to conform to the EEC Directive regulating weighing for medical
purposes. This is not as straightforward as it would seem . .
.
2d. Measurement by teaching staff is the
only solution since, in its First Inquiry, the Committee was hoodwinked
by the Minister of Public Health into believing that there were
enough medical staff to do it [Vol 1 p99 and see copy of letter
to your Committee, 9 June 2004]. School nurses cannot even complete
the single school entry growth screen recommended by Health
for All Children and the CMO's National Screening Committee
let alone multiple measurements. HMG has for years deluded itself
into believing that its Healthy School Policy can be delivered
with only 2,500 school nurses to cover approximately 25,000 schools
which why more nurses [2-3 times more!] should be scheduled for
2010.
2e. It is not clear from HMG's response
to your First Inquiry if BMI data will be sent to parents despite
your recommendation and the even stronger recommendation made
in the US blueprint "Preventing Childhood Obesity" [IOM
Washington DC 2005]. Will parents receive it or won't they? According
to experts at a high profile BMI workshop held in London pre-Christmas,
it might be both ethically and legally wrong for data to be withheld.
As a parent group the Foundation would view keeping such data
from the family as "nannyism" in the extreme.
3. Does the necessary public health infrastructure
and mechanisms exist to ensure that proposals will be implemented
and goals achieved?
3a. The White Paper acknowledges that its
proposals will be delivered only if the right [number] of people,
with the right skills are in place. Given that HMG knows that
the NHS is 40% short on public health practitioners, it needs
to satisfy the Committee that it will aggressively recruit and
train these staff. Community and hospital dieticians should be
as far up the list as school nurses but with midwives coming not
far behind. Dr Laurel Edmunds who advised you on your First Inquiry
may also have told you of the need to have a completely new kind
of health professional—a "lifestyle" nurse whose
job it would be to support mothers-to-be and new mothers give
their children the best start possible. If a Committee member
knows of a "doula", this is the kind of professional
that we have in mind. We see great advantages in vetting "grannies"
to become doulas—or something akin to being so—since
experienced grannies are women who should have all the experience
of a doula but are free from responsibility of bringing up their
children. own. Increasingly grannies are wanting to get back into
the workplace.
3b. HMG must clarify how it thinks a new
child health promotion policy, trumpeted in the National Service
Framework for Children and supported by the White Paper, will
help to deliver its target. As currently published, the policy
would be quite incapable of identifying any early sign of obesity
either before or after the child has entered school. Though the
Foundation has little time for growth monitoring recommendations
in the traditional manual for child health promotion, Health
For All Children [OUP January 2003], it is immensely preferable
to the new programme. This calls for neither weight, length/height
or BMI measurements to be taken until school entry and for none
afterwards. HMG knows full well that the best opportunities to
nip obesity in the bud are during the pre-school years [see above]
yet follows a programme that ignores them. Rapid weight gain in
the child's first year of life is the first risk age for later
obesity and the period before the adiposity rebound [c 3½-4
years in children with a high BMI] is a second.
3c. Little of the White Paper addresses
the key issue of prevention in the years before birth. The Foundation
is now of the opinion that we need to be teaching much more carefully
the schoolchildren of to-day to become responsible parents of
the future. We would like to see children exposed to breastfeeding
[literally] from primary school onwards so that this fashion of
infant feeding is second-nature to them by the time they reach
adulthood—and we need to teach them to prepare first foods
and cook as well. The December BMI workshop heard horror stories
of infants being fed puréed Chinese take-away and three
year-olds being given baby food because it was simpler to grab
if off supermarket shelves! We acknowledge that the majority of
UK parents do find their way to acquire parenting and lifestyle
skills "on the job"—but a significant number may
not. A bit of schooling wouldn't come amiss for anybody and the
National Curriculum needs to be adjusted accordingly.
3d. The Committee was kind enough to credit
the Foundation in its First Report re physical activity [Vol 1
p 72] and we despair that the White Paper's proposals are still
woefully inadequate. Again its promises are too late if not too
little. Since the Foundation is working with sports specialists
and the Central Council for Physical Recreation, all of whom have
indicated will be making their own submissions to you, we will
carp no further. It must be said however that the importance of
pre-school play "play" has not been properly touched
on in the White Paper and the £200 million already previously
promised to Frank Dobson's play review has, allegedly, also not
been delivered.
3e. The Foundation would also like to see
further positive fiscal measures being used to encourage parents
to give their children the best start in life as recognised by
Wanless. The "Healthy Start" programme, providing disadvantaged
pregnant women and mothers of young children with vouchers for
fresh food and vegetables is a step in the right direction but
incentives to comply with other HMG measures should also be considered.
The Foundation is particularly pleased to see the White Paper
promise that it will reimburse local authorities fully for any
extra costs they face as a result of the policies in the White
Paper. Undoubtedly, the Wanless' Reports have stung HMG into acknowledging
that if we don't invest now the UK will reap the cost of obesity
heavily in the future. The Foundation believes that £½
billion per annum is the figure required.
4. footnote: As an illustration
of how CHOOSING HEALTH gives the impression that HMG neither understands
nor may care little about obesity in childhood, the Foundation
would refer to Chapter 6 Paragraph 62. In a section exclusively
devoted to children, adult BMI values for overweight/obesity
have been inserted. Whitehall may choose to brush this aside as
an error of little consequence but, even to the casual observer,
it calls into question whether some people at the Department of
Health really are on top of their subject. It is vital that everyone
realises that the static adult BMI values should never apply to
children and the Foundation would be grateful if the Committee
highlighted the children's ranges by illustrating its 2nd Inquiry
Report with a UK paediatric BMI chart.
February 2005
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