Children's nutrition: Children's nutrition: a global emergencya global emergency

Philip JamesPhilip James

IPAIDFIOTF

IUNS WHF

LSHTM and Chair of IOTF and thePresidential Council of the Global Prevention Alliance

Malnutrition: a continuing outrageMalnutrition: a continuing outrage

TMRU, Kingston, Jamaica, Christmas 1966

Elimination malnutrition: a global deficit in policies and priorities

UN Millennium report. James et al. Food & Nut Bulletin 2000, 21:Supplment 3

Prevalence (%) of underweight preschool children

Millions of underweight preschool children

30

0

20

10

0

20

40

60

80

100

120

140

160

180

200

1990 1995 2000 2005 2010 2015 2020

World Food Summit Goal

Potential response on the

basis of Thai experience

Desired UN response with

ampli fied effort

Opportunity lost with current policies

Current IFPRI economic and social policy projections

based on existing mechanisms

Potential response on the basis of Thailand's

achievements

%

World Food

Summit goal

Desired UN response with major change in policies

% underweight children in the world

IFPRI Projections with free market

mechanisms

Millions of underweight & stunted schoolchildren

WHERE IS THE PRIORITY ?WHERE IS THE PRIORITY ?

Lifecycle: the proposed causal links

Higher maternal mortality

Reduced mental

capacity

Reduced capacity to

care for baby

Inadequate foetal

nutrition

Higher mortality

rate Impaired mental development

Untimely / inadequate WeaningFrequent

infections

Inadequate food, health & care

Inadequate growth

WomanMalnourished

PregnancyLow Weight

Gain AdolescentStunted

ChildStunted

Elderly Malnourished

BabyLow Birth

Weight

Inadequate food, health & care

Inadequate food, health & care

Reduced mental

capacity

Inadequate food, health

& care

Epigenetic susceptibility to

chronic diseases if diet becomes inappropriate

Adapted from James et al. SCN Millennium Rep. Food & Nutrition Bulletin, 2000, 21, 3S.

British wartime feeding based on novel nutritional conceptsBritish wartime feeding based on novel nutritional concepts

Milk

Cod liver oil

Orange juice

The transformation of agriculture: an issue of The transformation of agriculture: an issue of fundamental national securityfundamental national security

A quarter-pound cheeseburger, A quarter-pound cheeseburger, large fries and a 16 oz. soda large fries and a 16 oz. soda provide:provide:

1,166 calories 1,166 calories 51 g fat 51 g fat 95 mg cholesterol95 mg cholesterol 1,450 mg sodium1,450 mg sodium

1900 – 2000: Prevalence of overweight and obesity 1900 – 2000: Prevalence of overweight and obesity for 5 - 15 yr old Australian children for 5 - 15 yr old Australian children

Norton K et al, Int J Pediatr Obes 2006

20001980196019401920190019000

10

20

30

40

Year

% o

verw

eig

ht

or

ob

ese

Raw data

All data

Excess bodyweight is increasinglyprevalent in children and adolescents

IOTF/EASO Obesity in Europe Report 2002; IOTF 2004

30

25

20

15

10

5

0

Prevalence (%)

1960 65 70 75 80 85Year

90 95 2000

Spain

NetherlandsSwitzerland

UK

Czech Republic

France

Poland

2005

More than 80 million European childrenand adolescents are now overweight or

obese

Projected overweight (incl. obesity) rates for Projected overweight (incl. obesity) rates for school age children school age children

Wang and Lobstein, IOTF, 2006.

e.g. China

e.g. India

%%

PrevalencePrevalence

e.g. US

S.Arabia

e.g. UK

Global totalGlobal totalObese 74 mil.Obese 74 mil.O/wt 287 mil.O/wt 287 mil.

Global totalGlobal totalObese 74 mil.Obese 74 mil.O/wt 287 mil.O/wt 287 mil.

Nutritional Contrasts

Childhood overweight & obesityChildhood overweight & obesity

0

5

10

15

20

25

30

35

Wor

ldwide

Amer

icas

Europ

e

Near/m

iddle

Eas

t

Asia-P

acific

Sub-S

ahar

a Afri

ca

35

30

25

20

15

10

5

0

World

Americas

Near & Middle East

Europe

Asia-Pacific

Sub-Sahara

Prevalence %

OverweightObese

OverweightObese

Lobstein et al., Obesity in Young Children. 2004, Obesity Reviews 5 (Suppl. 1), 4–85

The impact of inappropriate Western diets on most of the world's susceptible populations: health systems already overwhelmed

Adapted from James et al. SCN Millennium Rep. Food & Nutrition Bulletin, 2000, 21, 3S.

Early onset Type 2

Diabetes

Reduced play and

social isolation

Reduced capacity to

care for baby

Disordered foetal

nutrition

Untimely / inadequate Early Weaning

Frequent fast foods

Inadequate physical activity

Normal/high growth

Womano/w or obese Pregnancy

Glucose intolerance/diabetes Adolescent

O/W-obese

Child overweight

Elderly

Diabetes, strokes,

heart disease, cancersarthritis

Fat BabyHigh Birth

Weight

Poor school conditions

Inadequate obstetric care

Reduced job opportunities

Inadequate health care

system

Abdominalobesity

RapidRapid weight gainweight gain

Reduced fertility; CVD, HT Cancers

The increasing risk of adult coronary heart The increasing risk of adult coronary heart disease if adults in childhood ( 7-13 yrs) disease if adults in childhood ( 7-13 yrs)

had modest weight increaseshad modest weight increases

Copenhagen school children's study of 276,835 children measured from 1955 - 1960 with National Death and Hospital Discharge Registries. Hazard relates to one BMI Z score: linearly related to events at all ages but hazard ratio progressively increases with age during childhood.

Baker, Olsen & Sorensen. NEJM 2007, 357: 2329-32

The keys to success in the food The keys to success in the food business and in obesity and chronic business and in obesity and chronic

disease preventiondisease prevention

• PricePrice

• AvailabilityAvailability

• MarketingMarketing

Fundamental changes in physical activity: Fundamental changes in physical activity: inevitable and optional changesinevitable and optional changes

Inevitable: Rural to urban transition Labour changes; Mechanisation/computerisation of standard work; also home

duties e.g. cooking, washing, cleaning

Optional: Urban building policies: high intensity or US style sprawl? Road and community design Office & supermarket location policies Car policies versus preference for cyclists/pedestrians Policies on free spaces for children's play; lighting for safety

e.g. for older people Park/leisure/sports facilities/school PA lessons Ease of transport of perishable foods into towns/cities

Obesity: time watching TV overwhelms leisure activity in Australia

Adapted from Salmon, Bauman et al IJO 2000;Adapted from Salmon, Bauman et al IJO 2000; 24:600-60624:600-606

TV time

Increasing TV time Leisure time sport & activity

Average BMI for

each group

28

27

26

25

24

23

22

21

Total daily physical activity

High Moderate Low Inactive

e.g. Focus on Health Education; campaigns selectively help upper socio-economic groups

Individual responsibility

Changes to the "toxic" environment

Adapted from Puska P, 2001

Progressively adapt all towns/cities to favour pedestrian/cycling as norm with car restrictions

Nutritional standards for food in all government facilities/schools; eliminate trans fats; catering on Finnish scale: fruit + veg. within meal costs

Limit/abolish all marketing to children

Selectively increase costs of high fat/sugary products; soft drinks

Social/employment/medical policies for breast feeding as the norm

Complementary Complementary approaches to approaches to obesity & obesity & chronic disease chronic disease preventionprevention

Complementary Complementary approaches to approaches to obesity & obesity & chronic disease chronic disease preventionprevention

Prevalence of obesity in schoolchildren in Singapore Prevalence of obesity in schoolchildren in Singapore weight (kg) for height (m) >120%weight (kg) for height (m) >120%

%

16

14

12

10

8

6

4

2

19

7

6 19

7

8 19

8

0

19

8

2 19

8

4 19

8

6 19

8

8 19

9

0 19

9

2 19

9

4 19

9

6 19

9

8 20

0

0

New growth charts used since 1994. Source: Ministry of Health, Singapore

Dramatic response to intense focus on obese children's diet and physical activity

Marketing to ChildrenMarketing to Children

Food industry promotions:Food industry promotions: Can confuse nutritional knowledge, Can confuse nutritional knowledge, e.g. e.g. whether fruit is in productwhether fruit is in product Change food preferencesChange food preferences Change purchasing behaviourChange purchasing behaviour Influence choice and consumption byInfluence choice and consumption by brand brand Alter balance of food categories Alter balance of food categories eateneaten

Manipulating children's behaviour: evidence Manipulating children's behaviour: evidence from the UK government's systematic analysisfrom the UK government's systematic analysis

Hastings Report, UK Food Standards Agency, 25th September, 2003.

The most cost-effective community (not national) The most cost-effective community (not national) interventions in Australiainterventions in Australia

Victoria State Analyses: Sept 2006

Intervention Cost in Australian $ for each DALY saved

Restrict TV advertising 4

Soft drink intervention at school 3,000

Walking buses to school 770,000

Cycling (travel SMART schools) 260,000

After-school community programmes. 90,000

Doctors targeting the overweight children 32,000

School multiple interventions, but no physical education 14,000

AddAdd Physical Education 7,000

School education to reduce TV viewing 3,000

Family-based program for obese child 4,000

School program targeting overweight & obese children 3,000

Medical treatment with drugs, e.g. Orlistat 14,000

Strategies for combating childhood obesityStrategies for combating childhood obesity

Protecting children at least up to 12 yrs:Protecting children at least up to 12 yrs: Breast feedingBreast feeding Proper weaning practicesProper weaning practices Regulated child minders: food and playRegulated child minders: food and play Legislate on all forms of marketing: TV, radio, Legislate on all forms of marketing: TV, radio,

text messages, internet, food product text messages, internet, food product labelling, games etc. labelling, games etc.

School environment : major changes neededSchool environment : major changes needed Supermarket practicesSupermarket practices Pricing policies : affect school aged childrenPricing policies : affect school aged children Policies on density of available fast foods Policies on density of available fast foods

outlets in town centers outlets in town centers

The interest and influences of different stakeholdersThe interest and influences of different stakeholders

INFLUENCEINFLUENCE

-10

-5

0

5

10

INT

ER

ES

TIN

TE

RE

ST

Children

Health professionals

Advocacy orgs.

Scientists

ParentsMinistry of Health

Parliament

Farmers

Media

Church

Ministries of Transport

& Agriculture

Retailers

Treasury

President

Advertising industry

Food/drink industry

Food inspectors

Ministry of Education

Teachers

0 5 10

Ministry of Trade

Lobstein T : Analyses based on UK Food Commission's experience and new EU policy work.

Five Practical PrioritiesFive Practical Priorities• Major drive to increase/ sustain breast feedingMajor drive to increase/ sustain breast feeding: facilities

at work important; maternal leave + cultural change

• Marketing restrictionsMarketing restrictions (not just TV advertising) - statutory for children & adolescents: rights of child extend to 18 yrs

• Control of foodControl of food in nurseries, all school facilities and school environment: avoid choice - all foods of high nutritional quality + facilities to allow spontaneous play - not TV

• Fruit and vegetable availabilityFruit and vegetable availability routine in canteens and restaurants (within main cost)

• Transformation of physical facilities for spontaneous & Transformation of physical facilities for spontaneous & leisure time activityleisure time activity: urban design changes with novel traffic policies; pedestrian only areas immediately adjacent to houses/apartments