Children's nutrition: a global emergency

1. Children's nutrition: a global emergency Philip James IPA WHF IDF IUNS IOTF LSHTM and Chair of IOTF and the Presidential Council of the Global Prevention Alliance

2. Malnutrition: a continuing outrage TMRU, Kingston, Jamaica, Christmas 1966

3. % underweight children in the world Millions of underweight & stunted schoolchildren IFPRI Projections with free market mechanisms Potential response on the basis of Thailand's achievements % World Food Summit goal Desired UN response with major change in policies Elimination malnutrition: a global deficit in policies and priorities UN Millennium report. James et al. Food & Nut Bulletin 2000, 21:Supplment 3

4. WHERE IS THE PRIORITY ?

5. Reduced capacity to care for baby Inadequate foetal nutrition 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 Woman Reduced mental capacity Malnourished Pregnancy Low Weight Inadequate food, health & care Adolescent 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

6. Cod liver oil Milk Orange juice British wartime feeding based on novel nutritional concepts

8. The transformation of agriculture: an issue of fundamental national security

9. 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

10. 40 Raw data 30 All data % overweight or obese 20 10 0 Year 1900 1900 1920 1940 1960 1980 2000 1900 – 2000: Prevalence of overweight and obesity for 5 - 15 yr old Australian children Norton K et al, Int J Pediatr Obes 2006

13. Global total Obese 74 mil. O/wt 287 mil. Prevalence e.g. US S.Arabia e.g. UK % e.g. China e.g. India Projected overweight (incl. obesity) rates for school age children Wang and Lobstein, IOTF, 2006.

15. Nutritional Contrasts

16. Prevalence % 35 Overweight Obese Overweight Obese Americas 30 25 Near & Middle East 20 Europe 15 10 World 5 Asia-Pacific 0 Sub-Sahara Childhood overweight & obesity Lobstein et al., Obesity in Young Children. 2004, Obesity Reviews 5 (Suppl. 1), 4–85

17. Reduced capacity to care for baby Disordered foetal nutrition Child overweight Adolescent O/W-obese 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

19. 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

21. The keys to success in the food business and in obesity and chronic disease prevention • Price • Availability • Marketing

23. 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

24. Obesity: time watching TV overwhelms leisure activity in Australia 28 Leisure time sport & activity Increasing TV time 27 26 Average BMI for each group TV time 25 24 23 22 21 High Moderate Inactive Low Total daily physical activity Adapted from Salmon, Bauman et al IJO 2000;24:600-606

25. 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

26. Prevalence of obesity in schoolchildren in Singapore weight (kg) for height (m) >120% % 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

27. Marketing to Children

28. 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.

29. The most cost-effective community (not national) interventions in Australia InterventionCost 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 Medical treatment with drugs, e.g. Orlistat 14,000 Victoria State Analyses: Sept 2006

30. 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

31. Health professionals 10 Advocacy orgs. Parents Ministry of Health Teachers Children Scientists 5 Church Ministry of Education Food inspectors Parliament Treasury Farmers Ministry of Trade 0 President Retailers Ministries of Transport & Agriculture Media -5 INTEREST Advertising industry Food/drink industry -10 0 5 10 INFLUENCE The interest and influences of different stakeholders Lobstein T : Analyses based on UK Food Commission's experience and new EU policy work.

32. 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 foodin 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 availabilityroutine 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