The latest National Diet and Nutrition Survey published by Public Health England today has found that young children are still consuming far too much sugar. This follows the recent launch of the Government's Childhood Obesity Strategy, which was criticised by many for not going far enough to tackle the root causes of obesity in children. As public health leaders prepare to meet for their annual conference next week, Nora Cooke O'Dowd examines some of the proposals in the Government strategy and offers her verdict.
The long-awaited Childhood Obesity Strategy was published on 18 August, while half the country was on holiday. The 'plan for action' turned out to be a short read at only 13 pages, including the cover page and references. There's a lot to be said for brevity, and short does not necessarily mean inadequate. However, the reaction to the strategy has been one of disbelief, pointing to gaping holes where tight regulation of junk food marketing and advertising should be, and an overall sense of disappointment that the opportunity to tackle childhood obesity has been missed.
The scale of the problem is well known, but worth reiterating: in 2014/15, 22 per cent of reception-year children were overweight or obese. That’s one in five 4–5 year-olds – and this increases to 33 per cent in year six: that's one in three 10–11 year-olds. Excess weight in childhood typically persists into adulthood and is associated with co-morbidities and lower achievement in school and later life. Early intervention is key to preventing adverse adult outcomes.
Here, rather than echoing what is missing from the strategy, I examine what actions have been included for industry, schools and other stakeholders.
Introducing a soft drinks industry levy
The so-called 'sugar tax' is the linchpin of the childhood obesity plan and the only proposed measure resulting in penalties. The Government estimates that the levy will raise £520 million in 2018–19, £500 million in 2019–20 and £455 million in 2020–21, and this money will fund other elements of the strategy. The Treasury notes a medium-high level of uncertainty around these estimates, due predominantly to uncertainties in the size of the tax base and the behavioural response of both consumers and suppliers. Unsurprising opponents to the sugar levy include the British Soft Drinks Association, who estimated that such a tax would actually result in a loss to the exchequer once job losses were accounted for. Though this is a supply-side tax, the Office for Budgetary Responsibility anticipates that it will be entirely passed onto the consumer and, as with all 'sin taxes', is likely to have a disproportionate impact on lower-income groups.
Though not without its critics, the potential benefits of the introduction of the sugar tax include the reduced consumption of sugary drinks, and decreased BMI. But arguably the biggest draw of a sugar tax is the clear signal it sends on the Government's commitment to tackling obesity. However, reports that an earlier version of the strategy was watered down following industry lobbying seem to send the opposite message entirely.
Taking out 20 per cent of sugar in products
The proposal to reduce, by 20 per cent, the sugar levels in a range of foods eaten by children is a laudable aim. However, given that the food and drinks industry are being “challenged” rather than forced to do this could limit its success, and the proposal has been criticised by major retailers for not going far enough. Public Health England has been charged with monitoring and assessing this target, but has no powers to address poor performance. If sufficient progress is not made by 2020, “other levers” will be used to achieve the same aims. Surely it would be more sensible to adopt these measures concurrently?
A number of recommendations have been made for schools. These include the introduction of a voluntary healthy rating scheme in primary schools, to be taken into account during Ofsted inspections as evidence that healthy eating and physical activity are being promoted. The strategy touts the scheme as a means for “schools to demonstrate to parents that they are taking evidence-based actions to improve the pupils’ health”. This sounds more like a marketing tool for schools with sufficient resources at their disposal than an objective in a comprehensive strategy. If the scheme is successful in improving health outcomes in the exemplar schools that volunteer to run with it, it has the potential to widen health inequalities between schools that do not.
The plan recommends that children partake in an hour of physical activity every day, 30 minutes of which should happen in school and 30 minutes at home. Suggestions are made as to how this requirement can be met in schools, and additional money for school sports is due to come from the sugar tax if it yields revenue.
If 30 minutes of physical activity is successfully introduced across all schools, the big unknown relates to the remaining 30 minutes that is supposed to happen at home. Analysis of the Millennium Cohort Study showed that physical activity and diet are associated with inequalities in levels of obesity across income groups: five-year-old children in the bottom income quintile were twice as likely to be obese as those in the top income quartile, and 11 year-olds were three times more likely. Sport England's strategy for getting the population more active – published earlier this year – fails to address this and, if not given careful consideration, could exacerbate these inequalities.
Baseline figures show the sheer scale of trying to implement the 60-minutes-a-day target: in 2012, it was estimated that only one quarter of 5–7 year-old children met the recommended daily activity level, and this fell to 11 per cent for 13–15 year-olds. Overall, the proportion of children getting enough exercise dropped from 24 per cent in 2008 to 18 per cent in 2012.
Food standards have improved diets in schools, but the 3,896 academies and free schools that were founded between September 2010 and June 2014 are not obliged to comply with these regulations. By the end of March 2016, 1,420 academies and free schools had voluntarily signed up to follow the standards, leaving over two thirds who did not. I would hazard a guess that the majority of schools yet to sign up are in less affluent areas. School breakfast clubs are also to be supported with £10 million a year from the sugar-tax levy, if revenue occurs.
Further voluntary guidelines are to be prepared on dietary requirements for early-years settings.
Parental BMI is related to children’s BMI and families may need support and guidance to help them raise children with a healthy weight. Proposed initiatives in the strategy to deliver this include: continuing to provide vouchers to eligible families for healthy food through the Healthy Start scheme; clearer food labelling to encourage healthy decisions; and an upgrade of the nutrient profile model that provides Ofcom with guidance to identify 'less healthy' foods to appropriately moderate advertising. Health professionals are encouraged to initiate conversations and provide support and advice to families on weight issues through the Making Every Contact Count initiative and refer to local weight management services where necessary.
Will it be enough?
A sugar tax is the focus of the Childhood Obesity Action Plan, supplemented by voluntary initiatives without agreed targets for schools, and other stakeholders. Some of these initiatives are to be financed by the sugar tax, but there is considerable uncertainty surrounding the total tax revenue accruing. Socioeconomic status plays a pivotal role in childhood obesity levels and due consideration has not been given to potential inequalities. The strategy claims: “The actions in this plan will significantly reduce England’s rate of childhood obesity within the next ten years”. There is nothing that I have observed in it to make me believe this plan will even make a dent.
Cooke O'Dowd N (2016) ‘Is reducing childhood obesity still a slim prospect?’. Nuffield Trust comment, 9 September 2016. https://www.nuffieldtrust.org.uk/news-item/is-reducing-childhood-obesity-still-a-slim-prospect