In April the new look NHS emerged. The UK’s public health budget will be ring fenced and devolved to local authority. A certain amount of its cash and the responsibility for how it is spent nationally will be retained by Whitehall but the bulk of the money – and financial incentives for those who show how it improves local health – will pass to the local Clinical Commissioning Groups [CCGs] and Health & Wellbeing Boards.
As far as obesity is concerned, only time will tell if 2013 will be the year when a totally preventable epidemic begins to become a thing of the past. The people in Whitehall are hoping that it will: others – and count me amongst their number – are not betting on it. In my view, success will ultimately depend on local authorities developing a new strategy – or strategies – to accomplish what Whitehall was completely unable to do in the past 13 years. What is needed more than anything else is to stop children from getting fat in the first place. Background Too many children are born fat and too many become fat in the first two years of their lives. The simple statistic, that on average 25 per cent of UK children are overweight or obese by the time they enter primary school, is an horrific figure. Somewhere along the line, and certainly within the 1000 days between conception to the child’s 2nd birthday, the chance for hundreds of children in your local authority’s area to look forward to a healthy lifestyle has evaporated. Certainly from their first signs of life - and probably for some time before - we are failing them. Something must be done about it – and soon.
Something must be done since the consequences of childhood obesity may be worse than the simple obesity itself. Type II diabetes, which used to be an adult onset condition, is increasingly appearing in young people. Cardiovascular problems and some cancers are two further co-morbidities threatening the lives of adolescents. In fact, early death itself is a possibility and it is truly appalling to consider that children may now be at risk of dying before their parents. It is arguably even more appalling that the parents themselves are blissfully aware of the dangers because successive national governments have not got this message across. It is difficult to believe that with this knowledge any parent would feed their children on junk food and allow them to drink highly-sugared energy drinks in an effort to be ‘cool’.
There are several national weight loss programmes which are on offer in many UK towns and cities – MINI‑MEND, The Carnegie Weight Loss Programme, Trim Tots etc – and they do the best that they can. They do not however reach every locality and can’t cater for the tens of thousands of children who need them. When family efforts at weight loss have broken down these programmes are the only alternative since pre-pubertal children, unlike adults, can’t be given drug or bariatric surgical solutions. Even if they could the cost to the NHS would be prohibitive. It is imperative therefore that new, low cost local strategies are implemented which are aimed at getting all children born at an average weight, fed correctly from the start and pointed in the direction of a healthy lifestyle which, hopefully, will stay with them for life. What might the strategies be? Here are some priority pointers.
Start at the beginning Start at the beginning actually means starting well before birth when the would-be mother is still at school. Because women are increasingly entering pregnancy either overweight or obese, and courting the real dangers that such fatness might lead to, every female of childbearing age should be taught from as early as is reasonable just how important it is to stay trim for conception. Recently the Royal Society of Medicine heard a presentation flippantly entitled ‘get in shape for serious sex’ but the message was serious enough. The speaker emphasised that the opportunity to deliver it was when girls gathered en masse for their rubella and human papillomavirus immunisations in secondary school.
Even if 50 per cent forgot the message the moment the school nurse left the building, 50 per cent just might remember it and 50 per cent is, co-incidentally, the approximate percentage of unplanned pregnancies. There is little chance of getting the very overweight woman at booking-in back to size since dieting in pregnancy is not recommended: it’s a no brainer therefore that she should do everything possible enter pregnancy at a reasonable weight.
Body mass index If she is overweight at booking-in, calculating her body mass index [BMI] and then doing something meaningful with it should be another priority. It would be ideal, too, if at some early stage of the pregnancy the father’s BMI could be calculated since the risk factor for the baby to develop overweight in childhood increases dramatically if both parents are fat. Knowing if either or both parents have high BMIs should direct both midwifery and health visitor teams to anticipate a rapid weight gain after delivery, plan intervention programme to mitigate it and deliver appropriate dietary advice. At booking-in midwifery teams in particular should also hammer home the message that pregnancy is not the time for the would-be mother to “eat for two” and that the midwife should routinely monitor pregnancy weight gain over the ensuing months. It is quite disturbing that in 2006 NICE dismissed the need routinely to check this with the result that to-day far too many women are being wheeled into the labour ward at a quite unhealthy size.
It is brilliant that more women than ever are making the decision to exclusively breastfeed – and subconsciously follow nature’s way of slimming children down after the first weeks of life. It is tragic however that their aspirations to continue to do so for the next six months are being are being stymied by the failure to provide proper support for them in their ambition. Only 1 per cent achieve it. Successful breastfeeding is for many an acquired skill and it can be some time before mother and baby have an acceptable modus operandi. Patience from whoever is delegated to the support task should be mandatory since without it mothers will turn to formula preparations and a real benefit to the health of both parent and infant will be lost. If this lack of support is also compounded by your local environment – workplaces, shops, offices, restaurants and public buildings – not tolerating breastfeeding, a priority should be to sort them out, too. It is disgraceful that years after a law was passed stating that mothers should not be prevented from breastfeeding in public – and should be offered a quiet room in which they could breastfeed in private – mothers are still being shown to the toilet or nappy‑changing room to feed their infants.
Routine weight checking Implementing the routine monitoring of 1st yr weight routinely to check that it is not significantly shifting upwards towards obesity has to be another priority. A substantial number of the 25 per cent of pre-schoolers who are overweight at age four didn’t suddenly put on that weight overnight: they will have begun to pile on the pounds as early as two weeks following delivery. Currently, routine weighing is frequently not adhered to because the Department of Health’s own child health manual, The Healthy Child Programme, fails to recommend any routine that will identify the early stages of obesity as recommended by the Chief Medical Officer for England in 2003.
Indeed, over the last generation, the UK has ignored the value of charting any growth monitoring throughout the early years of life and that is a fact that must have contributed to the current epidemic. The popular conception that to have a big, bonny, bouncing baby is the epitome of success in childrearing is misplaced. To curb inappropriate early weaning doesn’t escape the priority list either. Early weaning is a risk factor for obesity since it is likely to instil an unwarranted dependence on solids and over‑consumption. No infant should be fed solids prior to 17 weeks but stories abound of mothers having no qualms in offering their babies pureed chips and remnants of their previous night’s takeaways at 12 weeks! Such food – or indeed any food - will be injurious to the gut and kidney at this age.
A final priority should be that health visitors are enabled to continue to undertake a role that the educational system abandoned twenty years ago and teach mothers to cook. It is an indictment on society that there are UK mothers who left school finding that even boiling an egg is a challenge and are quite incapable of producing the kind of meal which you and I would call ‘healthy’.
It is a relief that cookery as a classroom subject is starting to re-emerge in primary and secondary schools but it will be a decade or longer before many very young children get the nutrition that a healthy lifestyle calls for.
Activity Footnote: If nutritious food is important for an infant to learn this lifestyle, learning to physically exercise is equally so. Contrary to popular belief, research has shown that being overweight leads to inactivity and not the other way round. New guidelines have recently been published recommending movement from the earliest age. ‘Tummy time’ or scrabbling around the floor is emphasised for infants who are not yet walking with 3hrs of daily activity for those who are. Floor-based and water-based play, such as ’parent and baby’ swim sessions encourages infants to use their muscles, develop motor skills and finish up with a trim tot. Play also provides valuable opportunities to build social skills and emotional bonds.
About the author Tam Fry, 73, honorary chairman of the Child Growth Foundation, has spoken for children with growth problems since 1977, has championed childhood obesity since 1994 and became a Forum Trustee in 2005. For further information of the work of the National Obesity Forum, visit www.nationalobesityforum.org.uk
Transport for London (TfL) has announced a new programme that will see 'Healthy Streets officers' work across London’s boroughs to reduce school-run traffic and encourage greater walking, cycling and public transport use.