Chief Medical Officer’s report on childhood obesity published today

The report Time to Solve Childhood Obesity: an independent report by the Chief Medical Officer, 2019, Professor Dame Sally Davies has been published today. The report highlights the serious impact that obesity is having on children’s health and the need for bold action in order to achieve the Government’s ambition to halve childhood obesity by 2030.

The report stresses that the current obesity crisis is primarily due to children growing up in an obesogenic environment and that, in order to tackle childhood obesity, changes must be made to create a healthier environment across many different sectors.

The key outcomes the report states must be achieved are that children:

• have access to healthy and affordable food,
• are protected from marketing of unhealthy foods, and
• have the opportunity to run, bike and play safely.

A number of wide-ranging recommendations are set out in the report that include:

• Fiscal measures to favour healthier options, e.g. changes to how VAT is applied to foods and drinks and calorie caps on food sold outside the home;
• Controls on marketing of less healthy food and drink products, e.g. phasing out marketing of such products at public events;
• Investing in the built environment to make it easier to be active, e.g. introducing car-free zones around schools;
• Actions to address excess weight in pregnancy, encourage breastfeeding and support healthy eating in infancy, e.g. updating national guidelines on healthy weight in pregnancy and developing nutritional standards for infant foods;
• Ensuring nurseries and schools play a role in supporting healthy eating, e.g. developing early years national food standards;
• Enhancing NHS support in managing obesity, e.g. ensuring health professionals understand weight stigma and are empowered to initiate conversations about weight with children and families;
• Making better use of data and technology, e.g. to track children’s weight more effectively allowing earlier intervention.

Professor Davies highlights that children have the right to live healthy, active lives and that Government has a responsibility to act in order to protect and improve children’s health. The report states that policies such as making healthier foods cheaper than unhealthier ones, reducing children’s exposure to unhealthy food and drink advertising and reducing the concentration of fast food outlets near schools have high levels of public support.

The scale of the problem of childhood obesity is clearly extremely challenging.  In the last year of primary school, on average, six children out of a class of thirty are obese and a further four are overweight, twice as many as thirty years ago. Furthermore, obesity disproportionately affects children living in deprived areas and the gap between the most and the least deprived groups has widened over the past ten years. According to the report, projections suggest that if this trend continues as many as 1 in 3 children in the most deprived areas will be obese by 2030. As the report outlines, bold action on a number of fronts will be needed in order to tackle childhood obesity. As such, the report has rightly taken a broad view, looking at the food supply, marketing and promotions, the built environment, pregnancy, early years settings and schools.

It’s clear that getting the best start in life begins with the health of mothers and that a woman’s diet both before and during pregnancy can affect the long-term health of her child. As such, it is important that women are supported with information that is evidence-based, relevant and actionable to help ensure they have a healthy diet, weight and lifestyle before, during and after pregnancy, as reflected in the report’s recommendations. It is also important to bear in mind that many pregnancies in the UK are unplanned and so the nutritional health of all women of childbearing age is a concern, and national surveys show that teenage girls in particular have low intakes of a number of essential vitamins and minerals. Good nutrition is as much about eating more of some things as it is about cutting back on others. The integrated message of variety, balance and nutrient density – making every calorie count – needs to be reflected in food production right through to what we teach children in school.

Following on from pregnancy, the early years are a key window of opportunity for improving health and reducing risk of childhood obesity. With nearly 1 in 4 children entering reception overweight or obese, it’s vital that efforts to promote a healthy diet and lifestyle start early, before children get to school. While voluntary guidance is available for nurseries and early years settings, there are currently no regulated standards that they have to adhere to. Setting food standards for early years settings is one of the recommendations of the report.

However, ensuring menus for nurseries are healthy is not always straightforward and settings may need support from nutrition experts to implement guidance/standards effectively. It is also important that any standards introduced are adequately monitored as part of Ofsted inspections and that appropriate guidance on doing so is provided for inspectors. This might be through additional responsibility given to Ofsted or another body.  

There is very little reference to food provision or education on nutrition within the current Early Years Foundation Stage framework, meaning that it is unlikely that this will be a key component of Ofsted inspections and consequentially may not be prioritised by settings. Whilst there was a commitment to undertake research into what a curriculum that supports good physical development in the early years looks like by Ofsted in the Childhood Obesity Strategy, chapter 2, we have not so far seen significant progress on this. BNF is a partner in the social enterprise the Early Years Nutrition Partnership (EYNP), which offers a Quality Mark, training and tailored support in food and nutrition for nurseries. Resources and checklists developed within EYNP might be a useful starting point for integrating food provision/education into Ofsted inspections.

The early years are also a great opportunity for children to learn about where food comes from, preparing foods and drinks and to appreciate the social aspects of eating together. We would suggest that regulations on food in early years settings should look at these aspects as part of a whole-setting approach, as is the case in the EYNP Quality mark, and not at food provision alone.

Schools are also highlighted in the report and a number of recommendations focus on action related to food provision and the opportunity for physical activity. It’s worth noting that, as part of a whole-school approach to health, education around cooking, nutrition and where food comes from is also vital in equipping children to make healthier choices and this does not feature in the report’s recommendations. We would recommend that minimum standards for food education are introduced and monitored, as well as ensuring comprehensive teacher training (see here for further details).

The removal of an A-level in ‘food’ in England and Wales, and the lack of opportunity for progression, may mean that schools are disincentivised to offer ‘food’ at GCSE level, which is unhelpful in promoting the best possible education on nutrition and health for children. There is also a concern that many schools are starting GCSE courses one year early, meaning that a majority of pupils have just two years (around 20-30 hours) of secondary school food education to address the skills needed for a lifetime. We recommend the reintroduction of a modern A-level in food (similar to that offered in Northern Ireland and Scotland). In this sector, as in others, to be successful an obesity strategy has to be integrated across government.

The issue of large portion sizes is highlighted in the report as a contributor to excess calorie intake and weight gain. Portion size has been a key focus for BNF in recent years with the publication of our Find your balance resources on portion size in January 2019. In developing resources, we conducted research with consumers to better understand their views on portion size. In general, the portion size of foods and drinks was not front of mind and the amount consumed tended to be driven more by habits, how the individual felt at the time, value for money or what others served them. Messages directly focussed on restricting portion size were not welcomed. Therefore, encouraging people to eat smaller portions may not be straightforward and strategies to do so need to be tested with consumers to ensure they are effective, particularly as the idea of ‘shrinkflation’ of products (reducing portion size without an equivalent reduction in price) is often very unpopular. There are currently no official UK guidelines on portion size, either for individuals or the food industry. BNF has developed resources for adults and for early years but there are currently very few resources for school-aged children and this is a gap that it would be helpful to address.

The report highlights that we need to restrict calories and nutrients of concern (sugar, salt, saturated fat) in children’s food, but also stresses the need to promote healthier options. While it is clearly very important to tackle excess energy intake, it should not be forgotten that we need a range of essential nutrients from the diet to be healthy. Recent findings from the National Diet and Nutrition Survey (NDNS) show inadequate fibre intakes in all age groups and worsening micronutrient intakes over the past decade, compounding the fact that substantial proportions of some age groups, for example adolescent girls, already have intakes below the lower reference nutrient intake (in other words, intakes regarded as insufficient if consumed routinely by more than a small minority, by definition 2.5%, of a population group). There needs to be consideration of ways to improve intakes of micronutrients and fibre, both in children and adults, as well as restricting foods high in calories (energy dense) but relatively low in essential nutrients. This could be achieved by encouraging higher consumption of fruit, vegetables, wholegrains and oily fish, following the dietary approach already depicted in UK healthy eating advice, the Eatwell Guide. In the consumer research on portion size mentioned above, while portion size itself was not front of mind for participants, the idea of a ‘balanced diet’ was consistently mentioned and positively regarded, and may be a useful lever to engage people.

Healthy eating for children is not just about the calories and nutrients they consume, although this is clearly very important. We also need to make sure that our children learn to understand and apply the principles of healthy eating and this requires a holistic approach that looks at the diet in the context of the meals, drinks and snacks we consume, not just focussed on single nutrients. To achieve this, we need to work together to shift our environment to make it easier to eat well and also to ensure that we provide our children with an understanding of what a healthy diet means and how to achieve it.

The British Nutrition Foundation has a wealth of experience in the food and nutrition issues relevant to many of the areas touched on in Professor Davies’ report – schools, preconception and pregnancy, early years provision, portion size guidance, nutrient intakes, and healthy dietary patterns as well as training in nutrition, and is keen to work with government to help effect the changes needed.