Childhood obesity-brave and bold action Contents

1 Introduction

1.The scale and consequences of childhood obesity demand bold and urgent action. We believe that if the Government fails to act, the problem will become far worse. We urge the Prime Minister to make a positive and lasting difference to children’s health and life chances through his childhood obesity strategy.

The scale of inequality

2.Children’s weight and height are measured when they start school in reception and again in their final year of primary school, through the National Child Measurement Programme. The data produced by this programme have identified not only the scale of the problem but the stark health inequality which threatens to blight the lives of the most disadvantaged children.

3.One fifth of children are overweight or obese when they begin school, and this figure increases to one third by the time they leave primary school.1

Figure 1: Prevalence of overweight and obese children combined, by school year, England 2013/14

Source: National Child Measurement Programme 2013–14

4.Childhood obesity is also strongly linked to deprivation—the most deprived children are twice as likely to be obese both at Reception and at Year 6 than the least deprived children.2 According to Public Health England the trend over the last eight years shows a widening of inequality in excess weight and obesity prevalence in both school years.3

Figure 2: Prevalence of obesity by deprivation decile in Reception (aged 4–5 years) and Year 6 (aged 10–11) years, 2013/14

Source: National Child Measurement Programme 2013–14

5.Whilst children who are overweight and obese are now being identified, few effective interventions are in place to help them, and few obese children become adults of normal weight.4 While researching and developing programmes to help children lose weight is clearly important, the difficulties in this area make it all the more vital to focus on prevention of obesity in children. The lifetime physical and emotional consequences for obese children can no longer be ignored. Public Health England describe the risks:

Being overweight is associated with increases in the risk of cardiovascular disease, diabetes and some cancers. It is also associated with poor mental health in adults, and stigma and bullying in childhood. We know that poor diet has a direct impact on health: an estimated 70,000 premature deaths in the UK could be avoided each year if UK diets matched nutritional guidelines.5

6.The health inequality which results from obesity between the richest and poorest children reinforces the need for policies that will have an impact right across society but include measures which will help the most disadvantaged young people. According to Public Health England, health marketing—information campaigns aimed at promoting healthier choices—generally tend to help those who are already engaged with health, and “may therefore only serve to widen health inequalities”.6

Costs of obesity

7.Treating obesity and its consequences alone currently costs the NHS £5.1bn every year. It is one of the risk factors for type 2 diabetes, which accounts for spending of £8.8 billion a year, almost 9% of the NHS budget. The wider costs of obesity to society are estimated to be around three times this amount.7 By contrast, the UK spends only around £638 million on obesity prevention programmes.8

Source: Public Health England; RCPCH

Calorie reduction

8.Obesity in children is principally caused by excess calorie intake relative to energy expenditure, from a number of sources. Exercise—or lack of it—is thus an important factor but it would be a mistake to imagine that childhood obesity can be prevented solely by increasing physical activity. It is crucial that excess calorie intake also be addressed. Whilst excess calories come from fats as well as carbohydrates, and overall reduction should address the entirety of children’s intake, dietary sugar in particular plays a major and avoidable role. Sugar also matters because of its impact on children’s dental health.

Sugar consumption and childhood obesity

9.New guidelines on sugar consumption were issued in July 2015 by the Scientific Advisory Committee on Nutrition (SACN). They recommended that sugar should account for a maximum of 5% of energy intake for adults and children. Currently it accounts for around three times this proportion of children’s energy intake.9

Source: SACN; NDNS

10.Children are also consuming too much sugar in absolute terms, as these data starkly demonstrate10:

Figure 3: Average daily non-milk extrinsic sugars (NMES) intake (g), 2008/09–2011/12: actual vs. recommended

Source: SACN; NDNS

11.The chart below from Public Health England shows that soft drinks are the largest single source of sugar for children.11 PHE has backed SACN’s recommendation that the consumption of sugar-sweetened drinks should be minimised by both children and adults.12

Figure 4: Where do children (age 4–18) get the most sugar from?

Source: Public Health England

12.SACN concluded that “the higher the proportion of sugar in the diet, the greater the risk of high energy intake” and that “drinking high-sugar beverages results in weight gain and increases in BMI in teenagers and children.”1314 Sugar-sweetened drinks account for 29% of sugar consumption amongst children of 11–18 years, and around 16% for younger children, and for adults.15

13.It is no surprise that, in addition to its findings on the relationship between sugar, energy consumption and BMI, within its key conclusions SACN states that “high levels of sugar consumption are associated with a greater risk of tooth decay”. 16 12% of 3 year olds now have tooth decay, rising to 28% of children by the time they turn 5.17 Dental caries are the most common reason for children aged between five and nine to be admitted to hospital—some 46,500 children and young people under 19 were admitted to hospital for a primary diagnosis of dental caries in 2013–14.18 SACN also concludes that consuming too many high-sugar drinks increases the risk of developing type 2 diabetes.19

14.Public Health England state that a high sugar intake is associated with deprivation. The National Diet and Nutrition Survey found higher sugar intakes in adults in the lowest income group compared to all other income groups. Consumption of sugary soft drinks was also found to be higher among adults and teenagers in the lowest income group.20

Public Health England’s sugar reduction evidence review

15.We decided to undertake this inquiry at the end of July, in the expectation that Public Health England’s evidence review of sugar reduction interventions would be published in time to inform the inquiry. We intended the inquiry to serve as a platform from which the findings of Public Health England’s evidence review could be publicly discussed and scrutinised. We were therefore disappointed that Public Health England initially refused to publish the evidence review, stating that an agreement had been reached with Government to publish it at the same time as the Government’s childhood obesity strategy. We felt that the failure to publish would be a major impediment to proper scrutiny of the review, and we called the Chief Executive of Public Health England to explain his position to us.

16.We welcome PHE’s reconsideration of its decision and subsequent agreement to publish, which we consider was in the public interest. However, we note that publication of the review did not occur until two days after we finished taking oral evidence, so we were unable to scrutinise its findings in detail with our witnesses, or indeed with Public Health England itself. We consider the placing of the evidence review in the public domain ahead of the Government’s strategy to be an important step in allowing scrutiny of its findings by the public and wider health community. The PHE report will enable informed public debate on the balance between addressing the current damage to children’s health and the wider acceptability of political choices and evidence base for changes to an environment that leads to obesity.

17.Public Health England’s review of interventions to reduce sugar consumption, building on the SACN report, is a major publication commissioned to inform Government policy in many areas which are relevant to childhood obesity. It provides the most comprehensive analysis of measures to reduce sugar consumption to date. That is why a substantial part of our inquiry and this report have been devoted to consideration of these interventions. However, the remit of Public Health England’s review was not to consider interventions to reduce childhood obesity, but interventions to reduce sugar consumption throughout the whole population. Sugar is not the sole contributor to excess calories and increasing BMI, and in formulating a childhood obesity strategy the Government will need to adopt a broader approach than the PHE report, and should consider calorie intake as a whole. Whilst interventions to reduce calorie intake are likely to benefit all ages, we urge the Government to ensure that the strategy includes measures targeted to deliver the most benefit to children and young people and especially those at greatest risk.

The role of physical activity

18.Physical activity has a huge range of health benefits for people of all ages, whether they are a normal weight, overweight, or obese. Children fare even worse than adults in meeting physical activity guidelines, and this situation seems to be worsening.21

Source: Health Survey for England

19.Children’s physical activity levels need to be improved, and our predecessor Health Committee’s report on The Impact of Diet and Physical Activity on Health made a series of recommendations to improve physical activity levels for both adults and children.22

20.We reiterate and endorse the findings of our predecessor’s inquiry that exercise has enormous benefits for children’s health and wellbeing irrespective of their weight. We call on the Government to increase provision for physical activity in childhood and consider this an important part of a strategy to tackle obesity. We urge the Government, however, not to lose sight of the clear evidence that measures to improve the food environment to reduce calorie intake must lie at the heart of a successful strategy, as these measures are likely to have a greater overall impact on childhood obesity levels.

The role of the food environment

21.While adults have a responsibility for their own health choices, Public Health England’s report makes it clear that today’s food environment makes it increasingly difficult to make healthy choices, and presents a strong case for reforming the food environment:

Most of us know in broad terms what we should eat to have a healthy, balanced diet; however, the average diet in the UK is poor and is not in line with current advice. This is at least partly because most of our food choices are habitual and automatic and we exert little self-control over what and how much we eat ….23

While consumer messaging and education and the provision of clear information are important, and people’s level of concern around sugar is high, a number of independent reports—including Foresight and those from McKinsey and the Organization for Economic Cooperation and Development (OECD)—have highlighted that in order to be effective in tackling obesity, and particularly to help the poorest in society, activity needs to go beyond health messages and information to consumers. Actions need to be taken to address the structured drivers of obesity. In the case of achieving sugar reduction, this would mean focusing on the environmental drivers including advertising and marketing, price promotions, sugar levels in food and food availability.

The whole food environment and culture has changed slowly over the last 30 to 40 years. There are now more places to buy and eat food which is, in real terms, cheaper, more convenient, served in bigger portion sizes and subject to more marketing and promotions than ever before. Add to this a seemingly continually expanding out of home sector (including restaurants, takeaways and fast food restaurants, cafes and coffee shops) where, overall, less action has been taken to improve the food offered than through retail and manufacturers. It is clear that health campaigns and information to consumers, such as that provided through Change4Life and on food labels, cannot deal with this alone and a greater degree of action is needed.

The UK has led the world on the diet and health agenda in areas such as salt reduction, action in schools to improve the food provided and the nutrition criteria that govern TV advertising to children. We now look to do the same with action to reduce sugar intakes.24

Our recommendations for action

22.The recommendations we make in this report have a strong focus on changing the food environment, reflecting the evidence we have heard. Physical activity has enormous benefits, regardless of weight, but encouraging people to increase their physical activity levels alone is unlikely to have an impact on the obesity crisis. Several of our recommendations relate to reducing sugar in people’s diets. This reflects the evidence presented by SACN that sugar has a significant impact on obesity, and that children are consuming up to three times the recommended maximum intake. This is not to ‘demonise’ sugar, which we fully recognise is not the only source of calories in diet nor the only cause of childhood obesity. An effective response to childhood obesity should also consider actions to reduce dietary fat and calorie intake more broadly.

23.Childhood obesity is a complex problem which will need action across a number of areas. However in our view the complexity of the problem should be used as an argument for bold, decisive and urgent action, not an argument against it. Reflecting the evidence we heard, we have made recommendations in nine different areas. No one single area offers a solution in itself, but we see a strong case for implementing changes in all of these areas. They are:

24.We believe that a full package of bold measures is required, and share Jamie Oliver’s view that:

This opportunity is very important. Being gentle and polite is not the way to have a progressive obesity strategy. We need to be big, bold and brave.26

25.Other witnesses reinforced this view:

We have to wake up to the scale of the challenge. It is huge. We have to have a proportionate response. That means far bigger, bolder steps… Frankly, I do not think we have the luxury of being able to pick and choose and say “Well, we prefer not to do something on that. I don’t think we will look at it now”. Wake up. We have to focus on all of these and we have to take action across a whole breadth of areas. It is far too casual to think we can just park this on the sidelines as something we are not going to look at right now.27

26.As no single measure exists that will be sufficient to tackle childhood obesity, we need to use all the tools in the armoury to address this problem, introducing a wide range of policies which individually may lead to relatively small health gains, but which collectively will turn the tide. What may look like small gains at individual level multiply to more significant impacts across the whole population. Measures must include those which will lead to positive outcomes in those children who are most affected rather than further widen existing health inequalities. Rather than letting ‘the perfect be the enemy of the good’ and waiting for the development of a complete evidence base to support any interventions, the Government should adopt a precautionary principle, given that the risks to children’s health and futures are clear. A discussion paper on options for tackling obesity published in November 2014 by the McKinsey Global Institute gives the following view:

We should experiment with solutions and try them out rather than waiting for perfect proof of what works, especially where the intervention is low risk.28

27.In our view, the evidence is sufficiently strong to justify introducing all the policies we recommend. Rather than wait for further evidence to follow from international experience, we urge the Government to be bold in implementing policy, with the assurance of rigorous evaluation and sunset clauses if found to be ineffective.

28.Our recommendations generally affect England, reflecting the remit of the Department of Health and its associated public bodies, whose work we are charged with scrutinising. They will nonetheless have implications for policy in other parts of the United Kingdom. We call on the Government to work with the devolved administrations on the implementation of our recommendations, for the benefit of children across the UK.

1 Health and Social Care Information Centre, National Child Measurement Programme - England, 2013-14, Dec 2014

2 Public Health England, Sugar Reduction – the evidence for action, October 2015, pp 9-10

3 Public Health England (COS0002) para 12

4 Q276

6 Public Health England, Sugar Reduction – the evidence for action, October 2015, p41

7 Public Health England, Public Health Matters blog, Expert interview: New sugar recommendations, 17 July 2015 (accessed 20 November 2015)

8 Royal College of Paediatrics and Child Health, Tackling England’s childhood obesity crisis, October 2015, p4

9 Public Health England, Sugar Reduction – the evidence for action, October 2015, p11

10 Scientific Advisory Committee on Nutrition press notice, Expert nutritionists recommend halving sugar in diet, 17 July 2015; Public Health England, National Diet and Nutrition Survey,May 2014, Table 5.4

11 Public Health England, Public Health Matters blog, Expert interview: New sugar recommendations, 17 July 2015 (accessed 20 November 2015)

12 Scientific Advisory Committee on Nutrition press notice, Expert nutritionists recommend halving sugar in diet, 17 July 2015; Public Health England press notice, PHE urges parents to cut sugary drinks from children’s diets, 17 July 2015

13 Scientific Advisory Committee on Nutrition press notice, Expert nutritionists recommend halving sugar in diet, 17 July 2015

14 BMI stands for Body Mass Index and is calculated as the body mass in kilogrammes divided by the square of the height in metres.

15 Public Health England, Why 5%? – the science behind SACN, July 2015, p6

16 Scientific Advisory Committee on Nutrition press notice, Expert nutritionists recommend halving sugar in diet, 17 July 2015

17 Public Health England, press notice, PHE urges parents to cut sugary drinks from children’s diets, 17 July 2015

18 Royal College of Surgeons Faculty of Dental Surgery, The state of children’s oral health in England, January 2015, p5

19 Scientific Advisory Committee on Nutrition press notice, Expert nutritionists recommend halving sugar in diet, 17 July 2015

20 Public Health England, Sugar Reduction – the evidence for action, October 2015, p12

21 British Heart Foundation, Physical Activity Statistics 2015, pp29-30

22 Health Committee, Sixth Report of Session 2014-15, Impact of physical activity and diet on health, HC 845

23 Public Health England, Sugar Reduction – the evidence for action, October 2015, p27

24 Public Health England, Sugar Reduction – the evidence for action, October 2015, p40

25 We define “unhealthy” as foods or drinks that are high in fat, salt or sugar

26 Q142

27 Q184, q213

28 McKinsey Global Institute, Overcoming obesity: An initial economic analysis, November 2014, ‘In brief’

© Parliamentary copyright 2015

Prepared 27 November 2015