The European Journal of Public Health Advance Access originally published online on August 10, 2005
The European Journal of Public Health 2005 15(6):576-579; doi:10.1093/eurpub/cki068
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Obesity |
Policies to prevent childhood obesity in the European Union
T. Lobstein1 and L. A. Baur2
1 Childhood Obesity Working Group of the International Obesity TaskForce (IOTF), London, UK
2 Childhood Obesity Working Group of IOTF, University of Sydney Discipline of Paediatrics & Child Health, The Children's Hospital at Westmead, NSW, Australia
Correspondence: Tim Lobstein, Coordinator, Childhood Obesity Working Group of the International Obesity TaskForce (IOTF), 231 North Gower Street, London NW1 2NS, UK, tel: +44 20 7691 1900, e-mail: childhood{at}iotf.org
Received July 5, 2004, accepted November 3, 2004
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Abstract |
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The increasing prevalence of childhood obesity needs to be addressed. Without clear evidence to show which preventive interventions are most likely to work, a series of precautionary measures can be suggested. At a meeting of scientific experts organised by the International Obesity TaskForce and held at the European Congress on Obesity in May, 2004, a number of measures were proposed which follow the precautionary principle of promoting health while being unlikely to increase the risk of harm. The proposals are reported in the present paper.
Keywords: child, obesity, prevention, policies, expert opinion
Adramatic increase in the prevalence of overweight and obesity among children and adolescents in the European Union (EU) has occurred in the last 20 years, particularly the last 10 years. Recent surveys,1 indicate that an estimated 18% of European school children (i.e. some 14 million children out of 77 million school children in the 25 EU member states) are overweight, with an annual rise in prevalence of between 0.55% and 1.65%, i.e. more than 400 000 new cases every year. Among the overweight children, at least 3 million are estimated to be obese, and their number is rising by more than 85 000 each year. [Overweight and obesity are defined according to the criteria for children recommended by the International Obesity TaskForce (IOTF),2 based on age- and gender-specific body mass index (BMI) cut-off points equivalent to adult BMIs of 25 kg/m2 and 30 kg/m2, respectively.]
Overweight and obese children are at a raised risk of co-morbidities including type 2 diabetes, fatty liver disease, and endocrine and orthopaedic disorders.1 Overweight children enter adulthood with a raised risk of adult obesity of up to 17-fold (after adjusting for parental obesity),3 and adult obesity in turn carries an increased likelihood of metabolic and cardiovascular diseases, certain cancers and a range of other disorders including psychiatric problems.4 Even if subsequent weight loss is achieved and maintained, there is evidence that mortality rates are higher among those adults who had been obese as adolescents.5
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Prevention approaches |
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If obesity could be effectively treated in childhood this might reduce subsequent disease risk and health service costs. However, effective treatment for the majority of obese children and adolescents remains elusive. Management protocols, involving behaviour modification, family support, and lifestyle change are difficult to put into practice and may require the input of multi-disciplinary professional teams.6 Lifestyle modification requires motivation and active participation by the family and young person and is a particular challenge as the child grows into adolescence. Yet obesity in adolescence is a major risk factor for adult obesity and its co-morbidities. There is an urgent need, therefore, to focus on obesity prevention.
The evidence base for effective prevention of child obesity is poor. A Cochrane systematic review conducted in 2001 found only 10 trials that were sufficiently large and of sufficient duration and quality to be included in the review,7 all of which involved children who were already overweight. Three out of the four long-term studies that combined dietary education and physical activity interventions resulted in no difference in their effect on overweight. In two studies of dietary education alone, a multimedia action strategy appeared to be effective but other strategies did not. The one long-term study that focussed on physical activity resulted in a slightly greater reduction in overweight in favour of the intervention group, as did two short-term studies of physical activity. The reviewers acknowledged the difficulties researchers face when attempting to control the relevant variables and to introduce the necessary preventive measures in a consistent, uniform manner in school or family settings.
Other literature reviews8–10 of European and North American papers have suggested that the chances of successful prevention at the community level are increased if measures are broad-based and well integrated into children's lives, such as:
- healthy school policies involving school cafeterias, vending machines and snack bars, plentiful school-based physical activity classes and recess activities;
- classroom health education linked to the school's food and activity practices;
- links between school practice and home and community activities;
- prolonged interventions rather than short-term ones, involving adults and children, at school and at home;
- the involvement of all children, not just some, using techniques sensitive to the cultural, ethnic and gender characteristics of the children.
Other investigators have suggested that hours spent watching television may be strongly associated with weight gain in childhood,1 although whether this is due to the concomitant sedentary behaviour, or a tendency to consume snack foods while watching television, or the effects of advertising of energy-dense foods during television programmes, is not clear.
Furthermore, television watching may be symptomatic of other factors which encourage weight gain but which are even harder to study in controlled trials. Interventions are needed which can manipulate, for example, the relative availability of different food products in local retailers, or the level of safety in streets or parks, which might affect play activities. There have been no trials of the effects of removing local fast food outlets, or the provision of safe cycling schemes for children, in terms of reducing the prevalence or risk of obesity. Environmental risk factors, or ‘obesogens’,12 and the societal forces that underpin them, such as growth in road traffic, urbanisation of populations or globalisation of food supplies,13 are not easily controlled for research purposes, although some natural variations can be exploited. These potential obesogens are widely distributed in the community, and affect the population at large. Policies concerning their appearance, modulation or removal are shaped at city, national or international level and involve interested parties, such as car users, fast food companies and advertising agencies.
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Interested parties |
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The differing views of the interested parties, or stakeholders, may lead to challenges to the scientific basis and strength of evidence underlying policy proposals. The absence of strong evidence for obesity and overweight prevention will undermine the political will to make changes in local or national policy to alter a child's environment. Policy-makers may find it hard to support policies which limit, for example, commercial freedom or personal choice, without having compelling evidence for the benefit of these policies. Until such evidence becomes available, precautionary activities need to be undertaken based on the best available evidence supported by a consensus of scientific opinion. In this respect, professional practitioners with expertise in child obesity and related health problems have a significant role to play.
An opportunity for the expression of expert opinion in a scientific context arose at the 13th European Congress on Obesity, held in Prague, Czech Republic (26–29 May 2004). In a workshop on childhood obesity prevention conducted by the International Obesity TaskForce and attended by 60 specialists from 17 countries and several international organisations, a series of proposals were made for action at various levels of government and by relevant non-governmental organizations (see table 1). These recommendations can be viewed as options for consideration, and reflect a precautionary approach to the problem of childhood overweight and obesity: namely, the recommendations are unlikely to raise the risk of further ill-health and are consistent with the promotion of health and well-being in the population.
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Conflict of interest |
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The workshop was open to any person attending the Congress, without entrance charge, and was not sponsored by any commercial interest. The costs of the workshop were met from core funds of the IOTF, a section of the International Association for the Study of Obesity (IASO) and a recognised collaborating agency of the World Health Organization. IOTF and IASO operate an ethical policy which restricts donations from corporate sponsors. Authors' conflicting interests: none declared.
Key points
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