Childhood obesity: The challenge of policy development in areas of post-normal science

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OFFICE OF THE PRIME MINISTER S CHIEF SCIENCE ADVISOR Childhood obesity: The challenge of policy development in areas of post-normal science Auckland March

1 OFFICE OF THE PRIME MINISTER S CHIEF SCIENCE ADVISOR Childhood obesity: The challenge of policy development in areas of post-normal science Auckland March 2016 Professor Sir Peter Gluckman Chief Science Advisor to the Prime Minister of New Zealand Co-Chair, WHO Commission on Ending Childhood Obesity 1 25 January 2016

2 Obesity: an example of post-normal science Post-normal science The application of science to public issues where facts are uncertain, values in dispute, stakes high and decisions urgent

Childhood Obesity Childhood obesity reaching alarming proportions, with greatest number of overweight and obese children living in low and middle income countries Overweight and obesity are not

3 Childhood Obesity Childhood obesity reaching alarming proportions, with greatest number of overweight and obese children living in low and middle income countries Overweight and obesity are not absolute cut-offs health consequences are continuous Many children who are not yet obese are already on the pathway to later obesity In absolute numbers, there are more overweight and obese children living in low- and middle-income countries As countries undergo rapid socio-economic transition, they face a double burden when inadequate nutrition and excess weight gain coexist

4 Childhood obesity Childhood obesity undermines the physical, social and psychological well-being of children and is a known risk factor for adult obesity and non-communicable diseases. There is an urgent need to act now to improve the health of both this generation and the next.

5 CNN.com

6 Childhood obesity estimates (0-20 years) Boys Obese and o/w % Obese % Girls Obese and o/w % Obese % China India Malaysia New Zealand Samoa Singapore USA Ng et al Lancet 2014

7 Ethnic variation Rate of diabetes South Asian Chinese Black White BMI Chiu et al 2011 Diabetes Care

8 WHO Commission on Ending Childhood Obesity At 67th World Health Assembly the WHO Director- General announced the establishment of high-level Commission on Ending Childhood Obesity (ECHO). Tasked with producing a consensus report specifying approaches and combinations of interventions likely to be most effective in different contexts around the world January 2016

9 Report of the Commission on Ending Childhood Obesity

Members of the Commission Sir George Alleyne (USA, Barbados) Dr Constance Chan Hon Yee (Hong Kong) Helen Clark (UNDP) Sir Peter Gluckman (co-chair) (NZ) Adrian Gore (South Africa) Betty King (USA)

10 Members of the Commission Sir George Alleyne (USA, Barbados) Dr Constance Chan Hon Yee (Hong Kong) Helen Clark (UNDP) Sir Peter Gluckman (co-chair) (NZ) Adrian Gore (South Africa) Betty King (USA) Nana Oye Lithur (Ghana) Dr Sania Nishtar (co-chair) (Pakistan) Paula Radcliffe (UK) Dr Jacques Rogges (IOC) Dr K Srinath Reddy (India) Prof Hoda Rashad (Egypt) Sachita Shrestha (Nepal) Dr Colin Tukuitonga (South Pacific Community) Dr David Nabarro (WHO) January 2016

11 Guiding principles The child s right to health Government commitment and leadership A whole-of-government approach A whole-of-society approach Equity Aligning with the global development agenda Accountability Integration into a life-course approach Universal Health Coverage and treatment of obesity January 2016

12 Commission and Working Groups Commission on Ending Childhood Obesity Co-chairs: Dr Sania Nishtar and Sir Peter Gluckman DG Ad hoc Working Group on Science and Evidence Ad hoc Working Group on Implementation, Monitoring and Accountability January 2016

13 Development of the report Developed an integrated package of recommendations through: Review of the scientific evidence Including extensive inputs from working groups and other academics/experts commissioned to produce subsidiary reports Consultation with 118 Member States and territories at regional meetings Review of online submissions January 2016

and behavioural, environmental and contextual factors and their interaction.

14 The causal domains of childhood obesity Biological Behavioural Contextual Childhood obesity risk arises from the combination of biological (developmental) and behavioural, environmental and contextual factors and their interaction. Life course factors affect the later response to an obesogenic environment January 2016

15 Biological factors Biology or behaviour? Evolutionary/ecological considerations and mismatch pathway result from developmental signals such as malnutrition during fetal and early childhood development that effect gene function (epigenetic effects) changing sensitivity to later environment Evolutionarily novel pathway results from mother entering pregnancy with obesity or pre-existing diabetes, or developing gestational diabetes or excessive infant feeding and predisposes child to increased fat deposits These factors create intergenerational influences January 2016

16 Early experience Childhood to adulthood Sensitivity to obesogenic environment Optimal Early life BMI

Changes in metabolism Inflammatory pathways Changes in hormonal

maternal nutrition Multiple pregnancy, primigravida Maternal

17 Early experience Childhood to adulthood Sensitivity to obesogenic environment Optimal Early life Changes in appetite Changes in metabolism Inflammatory pathways Changes in hormonal control Less muscle mass BMI Maternal stunting Unbalanced maternal nutrition Multiple pregnancy, primigravida Maternal ill health, preeclampsia Fetal growth retardation, prematurity Teenage pregnancy

18 Early experience Childhood to adulthood Sensitivity to obesogenic environment Maternal obesity Paternal obesity? Gest diabetes Infant overfeeding Inappropriate weaning More fat cells Inflammatory cells Changed appetite control BMI Optimal Early life

Gest diabetes Infant overfeeding Inappropriate weaning BMI Optimal Early life Maternal

19 Early experience Childhood to adulthood Sensitivity to obesogenic environments Maternal obesity Paternal obesity? Gest diabetes Infant overfeeding Inappropriate weaning BMI Optimal Early life Maternal stunting Unbalanced maternal nutrition Multiple pregnancy, Primigravida Maternal ill health, preeclampsia Fetal growth retardation, prematurity Teenage pregnancy

20 Chronic disease risk Adulthood No intervention Mother and infant Early childhood Childhood and adolescence Late intervention Early intervention Induction reinforcement Life course Plasticity Inadequate response to environment

21 Chronic disease risk Adulthood No intervention Mother and infant Childhood and adolescence Primary prevention is much more effective that secondary intervention; there are compelling biological Early reasons childhood why this is so. Hence the importance of a life course approach. Late intervention Early intervention Induction reinforcement Life course Plasticity Inadequate response to environment

22 Whose responsibility? None of these upstream causal factors are in the control of the child they cannot be seen as a result of voluntary lifestyle choices Therefore governments must accept primary responsibility to address obesity on behalf of the children they are ethically bound to protect Parents and caregivers have an important role to play in encouraging healthy behaviours Will have significant economic and intergenerational benefits January 2016

23 There is a no silver bullet Key conclusions A multivalent approach will be needed Prevention means considering the whole life course Both the priming conditions (early development/life-course approach) and the childhood obesogenic environment must be addressed together Not solely a matter for the health system January 2016

non-alcoholic beverages to children (lack of action by member states) Nutrient profiling, labelling and

24 1. Promote intake of healthy foods and reduce the intake of unhealthy foods Accessible nutrition and food information and guidelines Effective tax on sugar-sweetened beverages Restrict marketing of foods and non-alcoholic beverages to children (lack of action by member states) Nutrient profiling, labelling and front-of-pack labelling Healthy food environment in child-care, school, sports facilities Increase access to healthy foods January 2016

25 2. Promote physical activity Implement comprehensive programmes that promote physical activity and reduce sedentary behaviours in children and adolescents Provide guidance on healthy body size, physical activity, sleep and appropriate use of screen-based entertainment Ensure adequate facilities available in school and public spaces for physical activity during recreational time for all children January 2016

for both parents and maternal nutritional advice and guidance Advice to avoid exposure to tobacco, alcohol, drugs and other

26 3. Preconception and pregnancy care Integrate and strengthen guidance for noncommunicable disease prevention with current guidance for preconception and antenatal care to reduce the risk of childhood obesity Preconceptual nutrition advice and guidance for both parents and maternal nutritional advice and guidance Advice to avoid exposure to tobacco, alcohol, drugs and other toxins Diagnose and manage maternal hyperglycaemia and gestational hypertension, monitor and manage gestational weight gain January 2016

4. Early childhood diet and physical activity Provide guidance on and support for healthy diet, sleep and physical activity in early childhood to ensure children grow

Initiative, maternity leave and facilities for breastfeeding in the workplace) Regulations on marketing of complementary foods Guidance for caregivers and child-care settings

27 4. Early childhood diet and physical activity Provide guidance on and support for healthy diet, sleep and physical activity in early childhood to ensure children grow appropriately and develop healthy habits Protect, promote and support breastfeeding (International Code on Marketing of Breast milk Substitutes, Baby-friendly Hospital Initiative, maternity leave and facilities for breastfeeding in the workplace) Regulations on marketing of complementary foods Guidance for caregivers and child-care settings on nutrition, physical activity and sleep Note: critical window for development of appetite control, food preference and satiety. The importance of appropriate weaning strategies January 2016

5. Health, nutrition and physical activity for school-age children Implement comprehensive programmes that promote healthy school environments, health and nutrition literacy and physical activity

28 5. Health, nutrition and physical activity for school-age children Implement comprehensive programmes that promote healthy school environments, health and nutrition literacy and physical activity among school-age children and adolescents Establish standards for meals provided in school Eliminate provision and sale of unhealthy foods in school Inclusion of nutrition, food and health education in core curriculum (this needs to be pedgogically informed) Quality and adequate Physical Education Improve nutrition literacy of caregivers January 2016

29 6. Weight management Provide family-based, multi-component lifestyle weight management services for children and young people who are obese Develop and support appropriate weight management services that are Family-based Multicomponent (nutrition, physical activity, psychosocial support) Delivered by multi-professional teams As part of Universal Health Coverage January 2016

This is an urgent problem Key messages Governments must take overall responsibility and leadership It requires multiple actions in parallel across multiple domains not just health but education and

30 This is an urgent problem Key messages Governments must take overall responsibility and leadership It requires multiple actions in parallel across multiple domains not just health but education and other agencies Both the life course and the obesogenic environment issues must be addressed together focusing on either in isolation is unlikely to work Non-State actors including the private sector have a critical role to play January 2016

31 Some of the new emphases The urgency and magnitude of the issue both in developed and developing countries The implications to the health and wealth of all countries The recognition of biological, behavioral and contextual factors operating together to lead to childhood obesity and to play many children on the pathway to obesity even if not already obese The central importance of the life course dimension and the recognition that the life course approach and the obesogenic environment must be both addressed for the childhood obesity to be addressed The leadership required by Governments across multiple agencies beyond health The essential role of the compulsory education sector The important role of non-state actors and the importance of constructive relationships with the private sector January 2016

33 Ministry of Health childhood obesity plan

34 Ministry of Health childhood obesity plan There is a need to develop strategies about what accessible and understandable food and nutrition literacy means for different subpopulations and ages

35 Ministry of Health childhood obesity plan The potential of the compulsory education sector

36 Ministry of Health childhood obesity plan The life cycle approach is critical: this means pre-conceptional information and a focus on teenagers

37 Some final points Its complicated and multiple approaches are needed The science is incomplete Assessing the effect of any single intervention is difficult and the intervention science for assessing a suite of interventions even more son Decisions are urgent Values perspectives will always enter into the policy choices by any government Nevertheless clear direction and logic can be applied The NZ plan is compatible with the WHO recommendations; the challenge will be developing appropriate and balanced intervention strategies for different segments of the population

What is the status of child obesity worldwide and in the South East Asia Region?

What is the status of child obesity worldwide and in the South East Asia Region? Implementing the WHO's Recommendations for "Ending Childhood Obesity": Challenges, Barriers and Enabling Factors to Success in the South East Asia Region 16 May 2017 Jessica Blankenship PhD International