raport oms - obezitate infantilă

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ENDINGCHILDHOODOBESITY

REPORT OF THE COMMISSION ON


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ENDINGCHILDHOODOBESITY

REPORT OF THE COMMISSION ON


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WHO Library Cataloguing-in-Publication Data

Report of the commission on ending childhood obesity.

1.Pediatric Obesity prevention and control. 2.Child. 3.Feeding Behavior. 4.Food Habits. 5.Exercise. 6.Diet. 7.Health Promotion.8.National Health Programs. I.World Health Organization.

ISBN 978 92 4 151006 6 (NLM classication: WS 130)

World Health Organization 2016

All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchasedfrom WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22791 4857; e-mail: [email protected]).

Requests for permission to reproduce or translate WHO publications whether for sale or for non-commercial distribution should beaddressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html).

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoeveron the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, orconcerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for whichthere may not yet be full agreement.

The mention of specic companies or of certain manufacturers products does not imply that they are endorsed or recommended by theWorld Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names ofproprietary products are distinguished by initial capital letters.

All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication.However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for theinterpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arisingfrom its use.

Printed by the WHO Document Production Services, Geneva, Switzerland

Layout design: blossoming.it


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CONTENTS

Glossary and denitions

Executive summary

Introduction

Guiding principles

Strategic objectives

Recommendations

Actions and responsibilitiesfor implementing the recommendations

Monitoring and accountability

Conclusions

References

ANNEX 1: The Commission on Ending Childhood Obesity

ANNEX 2: Commissioners

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GLOSSARY ANDDEFINITIONS

BMI Body mass index = weight (kg)/height (m2).

BMI-FOR-AGE BMI adjusted for age, standardized for children.

CHILDREN Those less than 18 years of age.1

INFANTS Those less than 12 months of age.

HEALTHY FOODS Foods that contribute to healthy diets if consumed in appropriateamounts.2

OBESITY From birth to less than 5 years of age: weight-for-height morethan 3 Standard Deviation (SD) above the WHO Child GrowthStandards median.3

From age 5 to less than 19 years: BMI-for-age more than 2 SDabove the WHO growth reference median.4

OBESOGENICENVIRONMENT

An environment that promotes high energy intake and sedentarybehaviour.

This includes the foods that are available, affordable, accessibleand promoted; physical activity opportunities; and the socialnorms in relation to food and physical activity.

OVERWEIGHT From birth to less than 5 years of age: weight-for-height morethan 2 SD above WHO Child Growth Standards median.3

From age 5 to less than 19 years: BMI-for-age more than 1 SDabove WHO growth reference median.4

UNHEALTHY FOODS Foods high in saturated fats, trans-fatty acids, free sugars or salt

(i.e. energy-dense, nutrient-poor foods).

YOUNG CHILDREN Those less than 5 years of age.

1 Convention on the rights of the child, Treaty Series, 1577:3(1989): PART I, Article 1 denes a child as every human being below the age of eighteen years unless, under the lawapplicable to the child, majority is attained earlier. The World Health Organization (WHO) denes adolescents as those between 10 and 19 years of age. The majority of adolescentsare, therefore, included in the age-based denition of child, adopted by the Convention on the Rights of the Child, as a person under the age of 18 years.2 http://www.who.int/mediacentre/factsheets/fs394/en/.

3 http://www.who.int/childgrowth/standards/technical_report/en/.4 http://www.who.int/nutrition/publications/growthref_who_bulletin/en/. The new curves are closely aligned with the WHO Child Growth Standards at 5 years, and therecommended adult cut-offs for overweight and obesity at 19 years. They ll the gap in growth curves and provide an appropriate reference for the 519-year age group.


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EXECUTIVESUMMARY

Childhood obesity is reachingalarming proportions in manycountries and poses an urgentand serious challenge. TheSustainable Development Goals,set by the United Nations in2015, identify prevention andcontrol of noncommunicablediseases as core priorities. Amongthe noncommunicable diseaserisk factors, obesity is particularlyconcerning and has the potentialto negate many of the healthbenets that have contributed toincreased life expectancy.

The prevalence of infant,childhood and adolescent obesityis rising around the world.Although rates may be plateauing

in some settings, in absolutenumbers there are more childrenwho are overweight and obese inlow- and middle-income countriesthan in high-income countries.Obesity can affect a childsimmediate health, educationalattainment and quality of life.Children with obesity are verylikely to remain obese as adultsand are at risk of chronic illness.

Progress in tackling childhoodobesity has been slow andinconsistent. The Commission

on Ending Childhood Obesitywas established in 2014 toreview, build upon and addressgaps in existing mandates andstrategies. Having consultedwith over 100 WHO MemberStates and reviewed nearly 180online comments (see Annex 1),the Commission has developeda set of recommendations tosuccessfully tackle childhood andadolescent obesity in differentcontexts around the world.

Many children today aregrowing up in an obesogenicenvironment that encouragesweight gain and obesity.Energy imbalance has resultedfrom the changes in food type,

availability, affordability andmarketing, as well as a declinein physical activity, with moretime being spent on screen-based and sedentary leisureactivities. The behavioural andbiological responses of a childto the obesogenic environmentcan be shaped by processeseven before birth, placing aneven greater number of childrenon the pathway to becoming

obese when faced with anunhealthy diet and low physicalactivity.

No single intervention can haltthe rise of the growing obesityepidemic. Addressing childhoodand adolescent obesity requiresconsideration of the environmentalcontext and of three criticaltime periods in the life-course:preconception and pregnancy;infancy and early childhood; andolder childhood and adolescence.In addition, it is important to treatchildren who are already obese,for their own well-being and that oftheir children.

Obesity prevention and treatmentrequires a whole-of-governmentapproach in which policies acrossall sectors systematically takehealth into account, avoid harmful

health impacts, and thus improvepopulation health and healthequity.

The Commission has developeda comprehensive, integratedpackage of recommendations toaddress childhood obesity. It callsfor governments to take leadershipand for all stakeholders torecognize their moral responsibilityin acting on behalf of the child

to reduce the risk of obesity. Therecommendations are presentedunder the following areas.

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VII VII

PROMOTEPHYSICAL ACTIVITY

HEALTH, NUTRITION AND PHYSICAL

ACTIVITY FOR SCHOOL- AGE CHILDREN

PROMOTE INTAKE OFHEALTHY FOODS

WEIGHTMANAGEMENT

PRECONCEPTION ANDPREGNANCY CARE

EARLY CHILDHOODDIET AND PHYSICAL

ACTIVITY

ENDINGCHILDHOOD

OBESITY

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RECOMMENDATIONS

Ensure that appropriate and context-specicnutrition information and guidelines forboth adults and children are developed anddisseminated in a simple, understandable andaccessible manner to all groups in society.

Implement an effective tax on sugar-sweetenedbeverages.

Implement the Set of Recommendations on theMarketing of Foods and Non-alcoholic Beveragesto Children to reduce the exposure of children andadolescents to, and the power of, the marketingof unhealthy foods.

Develop nutrient-proles to identify unhealthyfoods and beverages.

Establish cooperation between Member States toreduce the impact of cross-border marketing ofunhealthy foods and beverages.

Implement a standardized global nutrient labellingsystem.

Implement interpretive front-of-pack labelling,supported by public education of both adults andchildren for nutrition literacy.

Require settings such as schools, child-caresettings, childrens sports facilities and events tocreate healthy food environments.

Increase access to healthy foods in disadvantagedcommunities.

IMPLEMENT COMPREHENSIVE PROGRAMMESTHAT PROMOTE THE INTAKE OF HEALTHY FOODS

AND REDUCE THE INTAKE OF UNHEALTHYFOODS AND SUGAR-SWEETENED BEVERAGES BYCHILDREN AND ADOLESCENTS.

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1.2

1.3

1.4

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Provide guidance to children and adolescents,their parents, caregivers, teachers and healthprofessionals on healthy body size, physical activity,sleep behaviours and appropriate use of screen-based entertainment.

Ensure that adequate facilities are available onschool premises and in public spaces for physicalactivity during recreational time for all children(including those with disabilities), with the provisionof gender-friendly spaces where appropriate.

Diagnose and manage hyperglycaemia andgestational hypertension.

Monitor and manage appropriate gestational weight gain.

Include an additional focus on appropriate nutritionin guidance and advice for both prospectivemothers and fathers before conception and duringpregnancy.

Develop clear guidance and support for thepromotion of good nutrition, healthy diets andphysical activity, and for avoiding the use of andexposure to tobacco, alcohol, drugs and othertoxins.

IMPLEMENT COMPREHENSIVE PROGRAMMESTHAT PROMOTE PHYSICAL ACTIVITY ANDREDUCE SEDENTARY BEHAVIOURS IN CHILDREN

AND ADOLESCENTS.

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2.1

2.2

3.1

3.2

3.3

3.4

3 INTEGRATE AND STRENGTHEN GUIDANCE FORNONCOMMUNICABLE DISEASE PREVENTIONWITH CURRENT GUIDANCE FOR PRECONCEPTION

AND ANTENATAL CARE, TO REDUCE THE RISK OFCHILDHOOD OBESITY.


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Enforce regulatory measures such as The InternationalCode of Marketing of Breast-milk Substitutes andsubsequent World Health Assembly resolutions.

Ensure all maternity facilities fully practice the TenSteps to Successful Breastfeeding.

Promote the benets of breastfeeding for both motherand child through broad-based education to parentsand the community at large.

Support mothers to breastfeed, through regulatorymeasures such as maternity leave, facilities and timefor breastfeeding in the work place.

Develop regulations on the marketing ofcomplementary foods and beverages, in line with

WHO recommendations, to limit the consumption offoods and beverages high in fat, sugar and salt byinfants and young children.

Provide clear guidance and support to caregiversto avoid specic categories of foods (e.g. sugar-

sweetened milks and fruit juices or energy-dense,nutrient-poor foods) for the prevention of excess weight gain.

Provide clear guidance and support to caregiversto encourage the consumption of a wide variety ofhealthy foods.

Provide guidance to caregivers on appropriatenutrition, diet and portion size for this age group.

Ensure only healthy foods, beverages and snacks areserved in formal child care settings or institutions.

Ensure food education and understanding areincorporated into the curriculum in formal child-caresettings or institutions.

Ensure physical activity is incorporated into the dailyroutine and curriculum in formal child care settings orinstitutions.

Provide guidance on appropriate sleep time, sedentaryor screen-time, and physical activity or active play forthe 25 years of age group.

Engage whole-of-community support for caregiversand child care settings to promote healthy lifestyles for

young children.

PROVIDE GUIDANCE ON, AND SUPPORT FOR,HEALTHY DIET, SLEEP AND PHYSICAL ACTIVITY INEARLY CHILDHOOD TO ENSURE CHILDREN GROW

APPROPRIATELY AND DEVELOP HEALTHY HABITS.

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Establish standards for meals provided in schools,or foods and beverages sold in schools, that meethealthy nutrition guidelines.

Eliminate the provision or sale of unhealthyfoods, such as sugar-sweetened beverages andenergy-dense, nutrient-poor foods, in the schoolenvironment.

Ensure access to potable water in schools and sportsfacilities.

Require inclusion of nutrition and health education within the core curriculum of schools.

Improve the nutrition literacy and skills of parentsand caregivers.

Make food preparation classes available to children,their parents and caregivers.

Include Quality Physical Education in the schoolcurriculum and provide adequate and appropriatestafng and facilities to support this.

Develop and support appropriate weightmanagement services for children and adolescents

who are overweight or obese that are family-based, multicomponent (including nutrition, physicalactivity and psychosocial support) and deliveredby multi-professional teams with appropriatetraining and resources, as part of Universal HealthCoverage.

IMPLEMENT COMPREHENSIVE PROGRAMMESTHAT PROMOTE HEALTHY SCHOOLENVIRONMENTS, HEALTH AND NUTRITIONLITERACY AND PHYSICAL ACTIVITY AMONGSCHOOL-AGE CHILDREN AND ADOLESCENTS.

PROVIDE FAMILY-BASED, MULTICOMPONENT,LIFESTYLE WEIGHT MANAGEMENT SERVICES FORCHILDREN AND YOUNG PEOPLE WHO ARE OBESE.

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ACTIONS AND RESPONSIBILITIESFOR IMPLEMENTING THE RECOMMENDATIONS

ACTIONS AND RESPONSIBILITIES FOR:

MembersStates

Internationalorganizations

Take ownership, provide leadership and engagepolitical commitment to tackle childhood obesityover the long term.

Coordinate contributions of all government sectorsand institutions responsible for policies, including,but not limited to: education; food, agriculture;commerce and industry; development; nance andrevenue; sport and recreation; communication;environmental and urban planning; transport andsocial affairs; and trade.

Ensure data collection on BMI-for-age of children including for ages not currently monitored andset national targets for childhood obesity.

Develop guidelines, recommendations or policy

measures that appropriately engage relevantsectors including the private sector, whereapplicable to implement actions, aimed atreducing childhood obesity, as set out in this report.

Cooperate to build capacity and support MemberStates in addressing childhood obesity.

A

A

B

C

D

WHO Institutionalize a cross-cutting and life-courseapproach to ending childhood obesity across allrelevant technical areas in WHO headquarters,regional and country ofces.

Develop, in consultation with Member States, aframework to implement the recommendations ofthe Commission.

Strengthen capacity to provide technical support foraction to end childhood obesity at global, regionaland national levels.

Support international agencies, nationalgovernments and relevant stakeholders in buildingupon existing commitments to ensure that relevantactions to end childhood obesity are implemented atglobal, regional and national levels.

Promote collaborative research on ending childhoodobesity with a focus on the life-course approach.

Report on progress made on ending childhood obesity.

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B

C

D

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Nongovernmentalorganizations

The private sector

Philanthropicfoundations

Academic institutions

Raise the prole of childhood obesity preventionthrough advocacy efforts and the dissemination ofinformation.

Motivate consumers to demand that governmentssupport healthy lifestyles and that the food andnon-alcoholic beverage industry provide healthyproducts, and do not market unhealthy foodsand sugar-sweetened beverages to children.

Contribute to the development andimplementation of a monitoring andaccountability mechanism.

Support the production of, and facilitate access to,foods and non-alcoholic beverages that contribute to ahealthy diet.

Facilitate access to, and participation in, physical activity.

Recognize childhood obesity as endangering childhealth and educational attainment and addressthis important issue.

Mobilize funds to support research, capacity- building and service delivery.

Raise the prole of childhood obesity preventionthrough the dissemination of information andincorporation into appropriate curricula.

Address knowledge gaps with evidence tosupport policy implementation.

Support monitoring and accountability activities.

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A

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B

B

B

B

C

C

The greatest obstacle to effectiveprogress on reducing childhoodobesity is a lack of politicalcommitment and a failure ofgovernments and other actors totake ownership, leadership andnecessary actions.

Governments must invest in robustmonitoring and accountability

systems to track the prevalenceof childhood obesity. Thesesystems are vital in providingdata for policy development andin offering evidence of the impactand effectiveness of interventions.

The Commission would like

to stress the importance andnecessity of tackling the

complex issue of childhoodobesity. WHO, internationalorganizations and their MemberStates, as well as non-Stateactors, all have a critical role toplay in harnessing momentumand ensuring that all sectorsremain committed to working

together to reach a positiveconclusion.


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GOALS OF THECOMMISSION

The overarching goals of the Commission onEnding Childhood Obesity are to provide policyrecommendations to governments to prevent infants,children and adolescents from developing obesity,and to identify and treat pre existing obesity inchildren and adolescents.

The aims are to reduce the risk of morbidity andmortality due to noncommunicable diseases, lessen

the negative psychosocial effects of obesity both inchildhood and adulthood and reduce the risk of thenext generation developing obesity.

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INTRODUCTION

The obesity epidemic has thepotential to negate many ofthe health benets that havecontributed to the increasedlongevity observed in the world.

In 2014, an estimated 41 millionchildren under 5 years of agewere affected by overweightor obesity (1) (dened as theproportion of children withweight-for-height z-score valuesmore than 2 SDs and morethan 3 SDs, respectively, fromthe WHO growth standardmedian (2)). Figure 1 showsthe prevalence of overweightchildren under 5 years of ageworldwide. In Africa, the numberof children who are overweightor obese has nearly doubledsince 1990, increasing from5.4 million to 10.3 million. In2014, of children under 5 yearsof age who were overweight,48% lived in Asia and 25% inAfrica (1). The prevalence ofinfant, childhood and adolescentobesity may be plateauing insome settings, but in absolutenumbers more overweight and

obese children live in low- and

middle-income countries thanin high-income countries(3).Figure 2 shows the prevalenceof overweight by WHO regionand World Bank income group.

Prevalence data available forolder children and adolescentsare currently being veried andare due to be released by WHOin 2016. To date, progress intackling childhood obesity hasbeen slow and inconsistent (4).

An even greater number ofchildren are, even from beforebirth, on the pathway todeveloping obesity. Childrenwho are not yet at the body-mass-index (BMI)-for-agethreshold for the currentdenition of childhood obesityor overweight may be at anincreased risk of developingobesity. The recommendationsin this report also addressthe needs of these children.Undernutrition in early childhoodplaces children at an especiallyhigh risk of developing obesitywhen food and physical activity

patterns change.

Many countries now face theburden of malnutrition in all itsforms, with rising rates of childhoodobesity as well as high rates ofchild undernutrition and stunting.

Childhood obesity is often under-recognized as a public health issuein these settings, where, culturally,an overweight child is oftenconsidered to be healthy.

In high-income countries, the risksof childhood obesity are greatestin lower socioeconomic groups.Although currently the converseis true in most low- and middle-income countries, a changingpattern is emerging. Withincountries, certain populationsubgroups, such as migrantand indigenous children, areat a particularly high risk ofbecoming obese (5), due to rapidacculturation and poor accessto public health information.As countries undergo rapidsocioeconomic and/or nutritiontransitions, they face a doubleburden in which inadequatenutrition and excess weight gain

co-exist(6).


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The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organizationconcerning the legal status of any country, territory, city or area, or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps representapproximate border lines for which there may not yet be full agreement. All rights reserved. Copyright WHO 2015.

Source: Tracking tool (http://www.who.int/nutrition/trackingtool)

AFR=African Region, AMR=Region of Americas, SEAR=South-East Asia Region, EUR=European Region, EMR=Eastern Mediterranean Region, WPR=Western Pacic Region.

Source: UNICEF, WHO, The World Bank. Joint Child Malnutrition Estimates. (UNICEF, New York; WHO, Geneva; The World Bank, Washington, DC; 2015).

FIGURE1: AGE-STANDARDIZED PREVALENCE OF OVERWEIGHT IN CHILDREN UNDER 5 YEARS OF AGE,COMPARABLE ESTIMATES, 2014

FIGURE2:PREVALENCE OF OVERWEIGHT IN CHILDREN UNDER 5 YEARS OF AGE, BY WHO REGION AND

WORLD BANK INCOME GROUP, COMPARABLE ESTIMATES, 2014

(0) No dataLatest Prevalence

(1) < 5.0%(2) 5.0 - 9.9%(3) 10.0 - 14.9%(4) 15.0 - 19.9%(5) 20%

AFR

O v e r w e i g h t

( % )

0

2

4

6

8

10

12

14

AMR EMR EUR SEAR WPR Highincome

Uppermiddleincome

Lowermiddleincome

Lowincome


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Obesity arises from acombination of exposure of thechild to an unhealthy environment(often called the obesogenicenvironment(7)) and inadequatebehavioural and biologicalresponses to that environment.

These responses vary amongindividuals and are stronglyinuenced by developmental orlife-course factors.

Many children today aregrowing up in environmentsthat encourage weight gainand obesity. With globalizationand urbanization, exposure tothe obesogenic environment isincreasing in both high-incomecountries and low- and middle-income countries and across allsocioeconomic groups. Changesin food availability and type, and

a decline in physical activity fortransport or play, have resultedin energy imbalance. Childrenare exposed to ultra-processed,energy-dense, nutrient-poorfoods, which are cheap andreadily available. Opportunities

for physical activity, both in andout of school, have been reducedand more time is spent on screen-based and sedentary leisureactivities.

Cultural values and normsinuence the perception ofhealthy or desirable body weight,especially for infants, youngchildren and women. In somesettings, overweight and obesityare becoming social normsand thus contributing to theperpetuation of the obesogenicenvironment.

In Africa, the number of childrenwho are overweight or obesehas nearly doubled since 1990,increasing from 5.4 million to

10.3 million.

10.3 MILLION


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The risk of obesity can be passedfrom one generation to the next,as a result of behavioural and/or biological factors. Behaviouralinuences continue throughgenerations as children inheritsocioeconomic status, cultural

norms and behaviours, andfamily eating and physical activitybehaviours.

Biological factors can lead toan increase in the risk of obesityin children through two generaldevelopmental pathways:

(i) The mismatch pathway.This results from malnutrition sometimes subtle duringfetal and early childhooddevelopment, due, for example,to poor maternal nutrition or

placental insufciency. Theunderlying processes involveenvironmental effects on genefunction (epigenetic effects) thatdo not necessarily have obviouseffects on measures such as birthweight (8). Children who have

suffered from undernutrition andwere born with low birth weightor are short-for-age (stunted), areat far greater risk of developingoverweight and obesity whenfaced with energy-dense dietsand a sedentary lifestyle laterin life. Attempts to deal withundernutrition and stunting duringchildhood may have led to theunintended consequences ofobesity risk for these children.

(ii) The developmental pathway.This is characterized by the

mother entering pregnancy withobesity or pre-existing diabetes,or developing gestationaldiabetes. This predisposes thechild to increased fat depositsassociated with metabolic diseaseand obesity. This pathway

may also involve epigeneticprocesses. Recent researchindicates that paternal obesitycan also contribute to a greaterrisk of obesity in the child(9),probably through epigeneticmechanisms. Inappropriate earlyinfant feeding also impacts onthe childs developing biology.Appropriate interventions beforeconception, during pregnancyand in infancy may prevent someof these effects, but these maynot easily be reversed once acritical period of development

In absolutenumbers moreoverweight andobese childrenlive in low- andmiddle-incomecountries thanin high-income

countries.


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has passed. Since many womendo not consult a healthcareprofessional until the end ofthe rst trimester, it is essentialto promote knowledge of theimportance of healthy behavioursin adolescents, young women and

men before conception and inearly pregnancy.

Overweight and obesity arenot absolute cut-offs and manychildren are on the pathway toobesity when they are withinthe normal range for BMI-for-age. The health consequencesof overweight and obesity arealso continuous and can affecta childs quality of life beforeBMI-for-age cut-offs are reached.Across the distribution of BMIthere is a trend for individualsto have more body fat andless lean muscle mass than inprevious generations (10). Thepattern of fat deposit in thebody is also important in termsof health outcomes(11). Somepopulation groups have morefat deposits and less lean musclemass than others at the sameBMI. Although BMI is the simplest

means to identify children whoare overweight and obese, itdoes not necessarily identifychildren with abdominal fatdeposits that put them at greaterrisk of health complications.While new methodologies areavailable, such as dual-energyX-ray absorptiometry, magneticresonance imaging or bodyimpedance to measure body fatand lean mass, these are currently

beyond the scope of population-based surveys.

None of these upstream causalfactors are in the control ofthe child. Therefore, childhoodobesity should not be seen as aresult of voluntary lifestyle choices,particularly by the younger child.Given that childhood obesityis inuenced by biological andcontextual factors, governmentsmust address these issues byproviding public health guidance,

education and establishingregulatory frameworks to addressdevelopmental and environmentalrisks, in order to support familiesefforts to change behaviours.Parents, families, caregivers andeducators also play a critical

role in encouraging healthybehaviours.

Obesity has physicaland psychological healthconsequences during childhood,adolescence and into adulthood.Obesity itself is a direct causeof morbidities in childhoodincluding gastrointestinal,musculoskeletal and orthopaediccomplications, sleep apnoea,and the accelerated onset ofcardiovascular disease andtype-2 diabetes, as well as thecomorbidities of the latter twononcommunicable diseases(12). Obesity in childhoodcan contribute to behaviouraland emotional difculties, suchas depression, and can alsolead to stigmatization andpoor socialization and reduceeducational attainment(13, 14) .

Critically, childhood obesity is astrong predictor of adult obesity,which has well known health andeconomic consequences, bothfor the individual and societyas a whole (15, 16) . Althoughlongitudinal studies suggest thatimproving BMI in adulthood canreduce the risk of morbidity andmortality(17), childhood obesitywill leave a permanent imprint onadult health (18).

Evidence on the lifetime cost ofchildhood obesity is developing,but is scarce compared withthat on the economic burden ofadult obesity. To date, studieshave concentrated primarily onhealthcare expenditure, ignoringother costs, including the cost ofthe accelerated onset of adultdiseases and the tendency forchildhood obesity to continueinto adulthood with attendanteconomic costs(19). Early onset

of noncommunicable diseasesimpair the individuals lifetimeeducational attainment and labourmarket outcomes and place asignicant burden on health-caresystems, family, employers andsociety as a whole (20).

Prevention of childhood obesitywill result in signicant economicand intergenerational benets thatcurrently cannot be accuratelyestimated or quantied. Spill-overbenets also include improvedmaternal and reproductive healthand a reduction in obesogenicexposure for all members ofthe population, thus furtherstrengthening the case for urgentaction.

Childhood obesityis a strongpredictor of adultobesity, which haswell known healthand economicconsequences,both for theindividual andsociety as a whole.


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GUIDINGPRINCIPLES

The childs right to health:Government and society havea moral responsibility to act onbehalf of the child to reduce therisk of obesity. Tackling childhood

obesity resonates with theuniversal acceptance of the rightsof the child to a healthy life aswell as the obligations assumedby State Parties to the Conventionof the Rights of the Child.1

Government commitmentand leadership: Rates ofchildhood obesity are reachingalarming proportions in manycountries, posing an urgentand serious challenge. Theseincreasing rates cannot beignored and governments needto accept primary responsibilityin addressing this issue on behalfof the children they are ethicallybound to protect. A failure to actwill have major medical, socialand economic consequences.

A whole-of-governmentapproach: Obesity preventionand treatment requires a whole-of-government approach inwhich policies across all sectors

systematically take healthinto account, avoid harmfulhealth impacts and so improvepopulation health and healthequity. The education sectorplays a critical role in providingnutrition and health education,increasing the opportunities forphysical activity and promotinghealthy school environments.Agriculture and trade policiesand the globalization of thefood system impact on foodaffordability, availability andquality at national and locallevels. In 2013, WHO MemberStates adopted a resolution toconsider the interplay betweeninternational trade and healththrough multistakeholderdialogue.2 Urban planning

THE COMMISSION AFFIRMS THEFOLLOWINGPRINCIPLES AND

STRATEGIES:

1

Committee on the Rights of the Child: General comment No. 15 (2013) on the right of the child to the enjoyment of the highest attainable standard of health (art. 24), para 47;CRC/C/GC/15.2 Resolution WHA59.26 on international trade and health.


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and design, and transportplanning, all impact directlyon opportunities for physicalactivity and access to healthyfoods. Intersectoral governmentstructures can facilitatecoordination, identify mutual

interest, collaboration andexchange of information throughcoordinating mechanisms.

A whole-of-societyapproach: The complexity ofobesity calls for a comprehensiveapproach involving all actors,including governments, parents,caregivers, civil society,academic institutions and theprivate sector. Moving frompolicy to action to addresschildhood obesity demandsa concerted effort and an

engagement of all sectors ofsociety at the national, regionaland global levels. Withoutjoint ownership and sharedresponsibility, well-meaning andcost-effective interventions havelimited reach and impact.

Equity: Governments shouldensure equitable coverage ofinterventions, particularly forexcluded, marginalized orotherwise vulnerable populationgroups, who are at high risk bothof malnutrition in all its formsand of developing obesity. Thesepopulation groups often havepoor access to healthy foods, safeplaces for physical activity andpreventative health services andsupport. Obesity and its associatedmorbidities erode the potential

improvements in social and healthcapital, and increase inequity.

Aligning with the globaldevelopment agenda:The Sustainable DevelopmentGoals (SDG) call for an end to

malnutrition in all its forms (SDGtarget 2.2) and a reductionin premature mortality fromnoncommunicable diseases (SDGtarget 3.4). Childhood obesityundermines the physical, socialand psychological well-beingof children and is a known riskfactor for adult obesity andnoncommunicable diseases.Progress will be made in achievingthese goals by tackling this issue.

Accountability: Political andnancial commitment is imperative


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Without joint ownership and sharedresponsibility, well-meaning and cost- effective interventions have limited

reach and impact.

in combatting childhoodobesity. A robust mechanismand framework is needed tomonitor policy development andimplementation, thus facilitatingthe accountability of governments,civil society and the private sector

on commitments made.Integration into a life-course approach: Integratinginterventions to address childhoodobesity with existing WHO andother initiatives, using a life-courseapproach, will offer additionalbenets for longer-term health.These initiatives include the UnitedNations Secretary GeneralsGlobal Strategy for Womens,Childrens and AdolescentsHealth,1 the Every Woman, EveryChild initiative,2 the Political

Declaration of the High-levelMeeting of the General Assemblyon the Prevention and Control ofNon-communicable diseases,3 and the Rome Declaration of theSecond International Conferenceon Nutrition.4 There are a number

of current WHO and other UnitedNations agencies strategies andimplementation plans related tooptimizing maternal, infant andchild nutrition and adolescenthealth that are highly relevant tokey elements of a comprehensiveapproach to obesity prevention.Relevant principles andrecommendations can be foundin documents providing guidancethroughout the life-course.5 Initiatives to address childhoodobesity should build upon theseto help children realize their

fundamental right to health, whilereducing the burden on the healthsystem.

Universal Health Coverage 6 and treatment of obesity: Sustainable Development Goal

target 3.8 calls for the achievementof Universal Health Coveragethrough integrated health servicesthat enable people to receive acontinuum of health promotion,disease prevention, diagnosis,treatment and management,over the course of a lifetime.7 Assuch, prevention of overweightand obesity and the treatment ofchildren already obese, and thosewith overweight who are on thepathway to obesity, should beconsidered an element of UniversalHealth Coverage.

1 http://www.who.int/life-course/partners/global-strategy/global-strategy-2016-2030/en/.2 http://www.everywomaneverychild.org.3 http://www.who.int/nmh/events/un_ncd_summit2011/political_declaration_en.pdf.4 http://www.fao.org/3/a-ml542e.pdf.5 WHA Resolutions: WHA53.17 on Prevention and Control of Noncommunicable Diseases; WHA57.17 on the GlobalStrategy on Diet, Physical Activity and Health; WHA61.14 on Prevention and Control of Noncommunicable Diseases:Implementation of the Global Strategy; WHA63.14 on Marketing of Food and Non-alcoholic Beverages to Children;WHA65.6 on the Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition; and WHA66.10on the follow-up to the Political Declaration of the High-level Meeting of the General Assembly on the Prevention andControl of Non-communicable diseases; WHA68.19 Outcome of the Second International Conference on Nutrition.Meeting to Develop a Global Consensus on Preconception Care to Reduce Maternal and Childhood Mortality andMorbidity, WHO, 2013; The optimal duration of exclusive breastfeeding. Report of an expert consultation, WHO,2001; Complementary feeding. Report of global consultation: summary of guiding principles, WHO, 2002; Globalrecommendations on physical activity for health, WHO, 2012; Population-based approaches to childhood obesityprevention, WHO, 2010; PAHO/AMRO Plan of Action for the Prevention of Obesity in Children and Adolescents, 53rdDirecting Council, 66th Session of the Regional Committee of WHO for the Americas, October 2014; Resolution EUR/RC63/R4 Vienna Declaration on Nutrition and Noncommunicable Diseases in the Context of Health 2020; WPR/RC63.R2 Scaling up Nutrition in the Western Pacic Region.

6 http://www.who.int/universal_health_coverage/en/.

7 United Nations General Assembly Resolution A/67/L36 Global Health and Foreign Policy.


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STRATEGICOBJECTIVESNo single intervention can halt the rise of thegrowing obesity epidemic. To successfullychallenge childhood obesity requiresaddressing the obesogenic environment aswell as critical elements in the life-course.

TACKLE THEOBESOGENICENVIRONMENTAND NORMS

The major goals of addressingthe environmental componentsinclude improving healthy eatingand physical activity behavioursof children. A number of factorsinuence the obesogenicenvironment, including political

and commercial factors (trade

agreements, scal and agriculturalpolicies and food systems); thebuilt environment (availability ofhealthy foods, infrastructure andopportunities for physical activityin the neighbourhood); socialnorms (body weight and image

norms, cultural norms regarding

the feeding of children and thestatus associated with higher bodymass in some population groups,social restrictions on physicalactivity) and family environment(parental nutrition knowledge andbehaviours, family economics,

family eating behaviours).

1 2


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REDUCE THE RISK OFOBESITY BY ADDRESSINGCRITICAL ELEMENTSIN THE LIFE-COURSE

It is the primary responsibilityof governments to ensure thatpolicies and actions addressthe obesogenic environmentand to provide guidance andsupport for optimal development

at each stage of the life-course.By focusing attention on thesesensitive periods of the life-course,interventions can address specicrisk factors, both individuallyand in combination. Such an

approach can be integrated intoother components of the maternal-neonatal-child health agenda,and to the broader effort to tacklenoncommunicable diseases acrossthe whole population.

Developmental factors change both the biology and behaviour of individuals frombefore birth and through infancy, such that they develop with a greater or lesserrisk of developing obesity. The Commission considers it essential to address both the

environmental context and three critical time periods in the life-course: preconception andpregnancy, infancy and early childhood and older childhood and adolescence.

543


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TREAT CHILDRENWHO ARE OBESETO IMPROVE THEIRCURRENT ANDFUTURE HEALTH

ROLES ANDRESPONSIBILITIES

When children are already

overweight or obese, additionalgoals include reduction inthe level of overweight,improvement in obesity-relatedcomorbidities and improvementin risk factors for excess weightgain. The health sector in eachcountry varies considerably and

will face different challenges

in responding to the need fortreatment services for thosewith obesity. However, themanagement of children withoverweight and obesity shouldbe included in effective servicesextended under Universal HealthCoverage.

The Commission recognizes thatthe scope of potential policyrecommendations to addresschildhood obesity is broad andcontains a number of novelelements, including a focus on thelife-course dimension and on theeducation sector. A multisectoralapproach will be essential forsustained progress.

Countries should measure BMI-for-age to establish the prevalenceand trends in childhood obesityat national, regional and

local levels. They should alsogather data on nutrition, eatingbehaviours and physical activityof children and adolescentsacross different socioeconomicgroups and settings. Althoughsome data are collected (21),there remains a signicant gapfor children over 5 years of agethat needs addressing. This datawill guide the development ofappropriate policy priorities andprovide a baseline against whichto measure the success of policiesand programmes.

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RECOMMENDATIONS

The recommendations and accompanying rationales,presented below, were developed by the Commissionfollowing the review of the scientic evidence, thereports of the ad hoc working groups to the WHODirector-General, and feedback from the regionaland online consultations. The effectiveness, cost- effectiveness, affordability and applicability ofpolicies and interventions were also considered.


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RECOMMENDATIONS RATIONALE

Ensure that appropriateand context specicnutrition information andguidelines for both adultsand children are developedand disseminated in asimple, understandable andaccessible manner to allgroups in society.

It is not sufcient to rely on nutrient labelling or simple codes such as

trafc light labels or health star ratings. All governments must lead indeveloping and disseminating appropriate and context-specic food- based dietary guidelines for both adults and children. The necessaryinformation should be provided through media and educational outletsand public health messaging in ways that reach all segments of thepopulation, such that all of society is empowered to make healthierchoices.

As children enter school, health and nutrition literacy should beincluded in the core curriculum and supported by a health-promotingschool environment (see recommendations for early childhood, school- age children and adolescents).

1.1

IMPLEMENT COMPREHENSIVE PROGRAMMESTHAT PROMOTE THE INTAKE OF HEALTHY FOODS

AND REDUCE THE INTAKE OF UNHEALTHYFOODS AND SUGAR-SWEETENED BEVERAGES BYCHILDREN AND ADOLESCENTS.

Nutrition information can beconfusing and thus poorlyunderstood by many people.Given that individuals andfamilies choose their diets,the population needs to beempowered to make healthierchoices about what to eatand provide their infants andchildren. This is not possibleunless nutrition literacy isuniversal and provided in

a manner that is useful,understandable and accessibleto all members of society.

Recent trends in foodproduction, processing, trade,marketing and retailing havecontributed to the rise in diet-related noncommunicablediseases. The potential impact

of trade reform can affect dietand nutrition transition. Thehealth and equity impacts ofnational and internationaleconomic agreements andpolicies need to be considered(22). Processed, energy-dense, nutrient-poor foods andsugar-sweetened beverages,in increasing portion size,at affordable prices havereplaced minimally-processed

fresh foods and water in manysettings at school and familymeals. The easy access toenergy-dense foods and sugar-sweetened beverages andthe tacit encouragement tosize-up through commercialpromotions have contributed tothe rising caloric intake in manypopulations.

1


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Implement an effectivetax on sugar-sweetenedbeverages.

The adoption of scal measures for obesity prevention has receiveda great deal of attention (23) and is being implemented in anumber of countries.1 Overall, the rationale for taxation measuresto inuence purchasing behaviours is strong and supported by the

available evidence (24, 25). Further evidence will become availableas countries that implement taxes on unhealthy foods and/or sugar- sweetened beverages monitor their progress.2 The Commissionbelieves there is sufcient rationale to warrant the introduction of aneffective tax on sugar-sweetened beverages.

It is well established that the consumption of sugar-sweetenedbeverages is associated with an increased risk of obesity (26, 27).Consumption patterns may vary in different settings (28) and moredetail is needed about the patterns of intake in children in differentsettings. Low-income consumers and their children have the greatestrisk of obesity in many societies and are most inuenced by price.Fiscal policies may encourage this group of consumers to makehealthier choices (provided healthier alternatives are made available)as well as providing an indirect educational and public health signalto the whole population.

Available evidence indicates that taxes on products such as sugar- sweetened beverages are the most feasible to implement with dataindicating an impact on consumption.

Some countries may consider taxes on other unhealthy foods, such asthose high in fats and sugar. Taxing energy-dense, nutrient-poor foodswould require the development of nutrient proles (29) and modellingsuggests this may reduce consumption.

Implement the Set ofRecommendations on theMarketing of Foods andNon-alcoholic Beveragesto Children to reduce theexposure of children andadolescents to, and thepower of, the marketing of

unhealthy foods.

There is unequivocal evidence that the marketing of unhealthy foodsand sugar-sweetened beverages is related to childhood obesity (30,31). Despite the increasing number of voluntary efforts by industry,exposure to the marketing of unhealthy foods remains a major issuedemanding change that will protect all children equally. Any attemptto tackle childhood obesity should, therefore, include a reduction inexposure of children to, and the power of, marketing.

Settings where children and adolescents gather (such as schools andsports facilities or events) and the screen-based offerings they watch

or participate in, should be free of marketing of unhealthy foods andsugar-sweetened beverages. The Commission notes with concern thefailure of Member States to give signicant attention to ResolutionWHA 63.14 endorsed by the World Health Assembly in 2010 3 and requests that they address this issue. Parents and caregivers areincreasingly the target of marketing for foods and beverages high infats and sugar, aimed at their children (32).

1.2

1.3

1 http://www.wcrf.org/int/policy/nourishing-framework/use-economic-tools.2 See preliminary data on Mexico tax on sugar-sweetened beverages which has been submitted for publication (http://www.insp.mx/epppo/blog/3666-reduccion-consumo-bebidas.html).3 WHA63.14 on the Marketing of Food and Non-alcoholic Beverages to Children.


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Develop nutrient-proles toidentify unhealthy foods andbeverages.

Establish cooperationbetween Member Statesto reduce the impact ofcross-border marketingof unhealthy foods andbeverages.

There is wide variation in the types of business, attitudes andbehaviour within the food and non-alcoholic beverage, retailand marketing industries. Even voluntary initiatives must conformto guidelines determined by government and must be subject to

independent audit. Governments must dene clear parameters,enforcement and monitoring mechanisms and, if necessary, considerregulatory and statutory approaches. Regulation would provide equalprotection to all children regardless of socioeconomic group andensure equal responsibility by large, regional, multinational and smalllocal producers and retailers.

Clarity on the range of healthy products that can be marketed withoutrestriction is needed, as is consideration of both direct and indirectmarketing strategies, including pricing, promotion (including portionsize promotion) and placement. Such approaches require identifyinghealthy and unhealthy foods using independent nutrient proling.These considerations must also take into account issues of foodsecurity, where this is relevant, either at a national, sub-national orsub-population level.

The WHO Framework for implementing the set of recommendationson the marketing of foods and non-alcoholic beverages to children(33) provides practical guidance to Member States on thedevelopment and implementation of policy and monitoring andevaluation frameworks.

The Commission recognizes that in certain settings adolescentsconsume alcohol, and that alcohol is particularly obesogenic.Although this is beyond their scope of work, the Commission notesthat it is very difcult to market alcoholic products targeted at youngadult consumers, in particular, without exposing cohorts of adolescentsunder the legal age to the same marketing. The exposure of childrenand young people to appealing marketing is of particular concern.A precautionary approach to protecting young people against themarketing of such products is needed.

Implement a standardizedglobal nutrient labelling

system.

A standardized system of food labelling, as recommended by theCodex Alimentarius Commission1 can support nutrition and healthliteracy education efforts, if mandatory for all packaged foods andbeverages.

1.4

1.5

1 WHA56.23 Joint FAO/WHO evaluation of the work of the Codex Alimentarius Commission.

1.6


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Implement interpretive front-of-pack labelling supportedby public education of bothadults and children fornutrition literacy.

Healthy eating habits can be nurtured from infancy and have bothbiological and behavioural dimensions. This requires caregiverunderstanding of the relationship between diet and health, andbehaviours to encourage and support the development of such healthy

habits. Simple, easy to understand food labelling systems can supportnutrition education and help caregivers and children to make healthierchoices.

Require settings such asschools, child-care settings,childrens sports facilities andevents to create healthy foodenvironments.

Nutrition and food literacy and knowledge will be undermined ifthere are conicting messages in the settings where children gather.Schools, child-care and sports facilities should support efforts toimprove childrens nutrition by making the healthy choice the easychoice and not providing or selling unhealthy foods and beverages.

Increase access to healthyfoods in disadvantagedcommunities.

Nutrition literacy and knowledge of healthy food choices also cannotbe acted upon if such foods are not readily available or affordable.Inuencing the food environment requires a collaborative approachto food production, processing, accessibility, availability andaffordability. Where access to healthy foods is limited, ultra-processedfoods are often the only available and affordable alternatives. Anumber of public and private sector initiatives to promote healthierfood behaviours have been developed and the limited evidenceavailable indicates the potential to promote healthier choices amongconsumers (34). Such initiatives, where they are supported by

evidence, are to be encouraged.

1.8

1.9

1.7


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IMPLEMENT COMPREHENSIVE PROGRAMMESTHAT PROMOTE PHYSICAL ACTIVITY AND REDUCESEDENTARY BEHAVIOURS IN CHILDREN AND

ADOLESCENTS.

Recent evidence shows that

physical activity declines fromthe age of school entry (35).Globally, in 2010, 81% ofadolescents aged 1117 yearswere insufficiently physicallyactive. Adolescent girls wereless active than adolescentboys, with 84% of girls and78%1 of boys not attainingthe 60 minutes of moderate tovigorous physical activity dailyas recommended by WHO(36). Low physical activity israpidly becoming the socialnorm in most countries, andis an important factor in theobesity epidemic. Physicalactivity can reduce the riskof diabetes, cardiovasculardisease and cancers (37), andimprove childrens ability tolearn, their mental health andwell-being. Recent evidencesuggests that obesity, in turn,reduces physical activity,creating a vicious cycle ofincreasing body fat levels anddeclining physical activity.

Urban planning and design has

the potential to both contributeto the problem and offer theopportunity to form part of thesolution. Increased recreationalspace and safe walking-and cycling-paths for activetransport, help make physicalactivity functions of daily life.

Physical activity behavioursacross the life-course can beheavily influenced by childhoodexperience. Creating safe,physical activity-friendlycommunities, which enable,and encourage the use of activetransport (walking, cycling etc.)and participation in an activelifestyle and physical activities,will benefit all communities.Particular attention needs tobe given to improving accessto, and participation in,physical activity for childrenalready affected by overweightand obesity, disadvantagedchildren, girls and children withdisabilities.

2

1 http://apps.who.int/gho/data/view.main.2482ADO?lang=en.

of adolescents do not achievethe recommended 60 minutesof physical activity each day.81%


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Provide guidance tochildren and adolescents,their parents, caregivers,teachers and healthprofessionals on healthybody size, physical activity,sleep behaviours andappropriate use of screen-based entertainment.

All members of society, including parents, need to appreciate theimportance of both adequate growth and the consequences ofexcess body fat deposition to the short-term and long-term healthand well-being of the child. The Commission recognizes that in

some cultures this may be in conict with traditional perceptions andpractice.

Physical activity provides fundamental health benets for childrenand adolescents, including increased cardiorespiratory and musculartness, reduced body fatness and enhanced bone health.

Ensure that adequate

facilities are availableon school premises andin public spaces forphysical activity duringrecreational time for allchildren (including those

with disabilities), with theprovision of gender-friendlyspaces where appropriate.

Context-specic guidance on how to achieve physical activityrecommendations and the appropriate number of hours thatchildren should sleep or watch television (3840), for example,

should be a component of any healthy-living education provided tochildren or caregivers.

Increasing the opportunities for safe, appropriate and gender- friendly structured and unstructured physical activity, both in andout of school, including active transport (walking and cycling), willhave positive health, behavioural and educational spill-over effectsfor all children and adolescents.

2.1

2.2

Physical activity can reducethe risk of diabetes,cardiovascular disease andcancers, and improve childrensability to learn, their mentalhealth and well-being.


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INTEGRATE AND STRENGTHEN GUIDANCE FORNONCOMMUNICABLE DISEASE PREVENTIONWITH CURRENT GUIDANCE FOR PRECONCEPTION

AND ANTENATAL CARE, TO REDUCE THE RISK OFCHILDHOOD OBESITY.

The care that women receivebefore, during and afterpregnancy has profoundimplications for the later healthand development of theirchildren. Timely and good-qualitycare throughout these periodsprovides important opportunitiesto prevent the intergenerationaltransmission of risk and has ahigh impact on the health ofthe child throughout the life-

course.1

Evidence shows thatmaternal undernutrition (whetherglobal or nutrient-specic),maternal overweight or obesity,excess pregnancy weight gain,maternal hyperglycaemia(including gestational diabetes),smoking or exposure to toxinscan increase the likelihoodof obesity during infancy andchildhood (4146). Evidenceis emerging that the health offathers at the time of conceptioncan inuence the risk of obesityin their children (9). Healthylifestyle guidance thus needs

to include advice to would-befathers.

Current guidance forpreconception and antenatalcare focuses on the preventionof fetal undernutrition. Givenchanging obesogenic exposures,guidelines are needed thataddress malnutrition in allits forms (including caloricexcess) and later obesity risk in

the offspring. Interventions toaddress childhood obesity riskfactors also prevent other adversepregnancy outcomes (47) and socontribute to improving maternaland newborn health. Maternaloverweight and obesity increasethe risk of complications duringpregnancy, labour and delivery(including stillbirth), and maternalundernutrition increases the riskof low birth weight. These factorscan put the child at greater risk ofinfant mortality, childhood obesityand adult noncommunicablediseases.

3

1 Committee on the Rights of the Child: General comment No. 15 (2013) on the right of the child to the enjoyment of the highest attainable standard of health (art. 24), para 53;CRC/C/GC/15.

The care that a woman

receives before, during andafter pregnancy has profoundimplications for the later healthand development of her child.


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Diagnose and managehyperglycaemia andgestational hypertension.

Monitor and manageappropriate gestational

weight gain.

There is a need for screening and appropriate management of pre- existing diabetes mellitus and hypertension in pregnant women; earlydiagnosis and effective management of gestational diabetes andpregnancy-induced hypertension, depression and mental health issues;

gestational weight gain pattern (48); and ensuring dietary quality andappropriate physical activity.

Include an additional focuson appropriate nutritionin guidance and advicefor both prospectivemothers and fathers beforeconception and duringpregnancy.

Develop clear guidance andsupport for the promotion ofgood nutrition, healthy dietsand physical activity, andfor avoiding the use of andexposure to tobacco, alcohol,drugs and other toxins.

Interventions that integrate guidance related to all forms of malnutritionshould address undernutrition and unbalanced diets, including excessnutrition and specic nutrition deciencies (49). Young people areoften unaware of what constitutes a healthy diet. This highlights theneed for governments to take leadership in ensuring nutrition and foodliteracy.

There is evidence for the benecial effects of appropriate exerciseprogrammes in pregnancy on maternal BMI, gestational weight gainand birth outcomes, which are linked to a later risk of childhoodobesity (50).

There is limited, but growing, evidence that paternal health prior toconception has some impact on offspring health (9). There are, thus,direct reasons to also target paternal behaviour and health.

3.1

3.2

3.3

3.4


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PROVIDE GUIDANCE ON AND SUPPORT FORHEALTHY DIET, SLEEP AND PHYSICAL ACTIVITY INEARLY CHILDHOOD TO ENSURE CHILDREN GROW

APPROPRIATELY AND DEVELOP HEALTHY HABITS.

The rst years of life are criticalin establishing good nutritionand physical activity behavioursthat reduce the risk of developingobesity. Exclusive breastfeedingfor the rst six months of life,followed by the introduction ofappropriate complementary foods,is a signicant factor in reducingthe risk of obesity(51). Appropriatecomplementary feeding withcontinued breastfeeding can reducethe risk of undernutrition and excess

body fat deposition in infants, both

risk factors for childhood obesity.Encouraging the intake of a varietyof healthy foods, rather thanunhealthy, energy-dense, nutrient-poor foods and sugar-sweetenedbeverages, during this criticalperiod supports optimal growth anddevelopment. Health-care providerscan use routine growth monitoringopportunities to track childrensBMI-for-age and give appropriateadvice to caregivers to help preventchildren developing overweight

and obesity.

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Enforce regulatorymeasures such as TheInternational Code ofMarketing of Breast-milk Substitutes 1 andsubsequent World Health

Assembly resolutions. 2

Ensure all maternityfacilities fully practice theTen Steps to SuccessfulBreastfeeding. 3

Promote the benets ofbreastfeeding for motherand child through broad-based education to parentsand the community atlarge.

Support mothers tobreastfeed, throughregulatory measuressuch as maternity leave,facilities and time forbreastfeeding in the workplace. 4

Breastfeeding is core to optimizing infant development, growth andnutrition and may also be benecial for postnatal weight managementin women.

Given the changes in womens lifestyles and roles, the ability tobreastfeed outside of the home, and to sustain breastfeeding when amother returns to work, are critical to achieving the recommendations.

Policies that establish the rights of women and the responsibilities ofemployers are needed and some are in place. However, to protectall mothers and infants, regardless of social or economic status, theseshould be universal.

4.1

4.4

4.2

4.3

1 WHA34.22 International Code of Marketing of Breast-milk Substitutes.

2 WHA35.26, WHA37.30, WHA39.28, WHA41.11, WHA43.3, WHA45.34, WHA47.5, WHA49.15, WHA54.2, WHA55.25, WHA58.32, WHA59.21, WHA61.20 and WHA63.23 on

Infant and Young Child Nutrition; WHA65.6 Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition.3 WHO UNICEF Baby-Friendly Hospital Initiative, 1991, updated 2009 (http://www.who.int/nutrition/publications/infantfeeding/bfhi_trainingcourse/en/).4 International Labour Organization, Maternity Protection Convention 183, 2000.


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Develop regulations on themarketing of complementaryfoods and beverages, in line

with WHO recommendations,to limit the consumption offoods and beverages high infat, sugar and salt by infantsand young children.

Provide clear guidance andsupport to caregivers toavoid specic categoriesof foods (e.g. sugar-sweetened milks and fruitjuices or energy-dense,nutrient-poor foods) forthe prevention of excess

weight gain.

Provide clear guidance andsupport to caregivers toencourage the consumptionof a wide variety of healthyfoods.

Established global guidance for infant and young child feedingprimarily targets undernutrition. It is also important to consider therisks created by unhealthy diets in infancy and childhood.

Guidelines that address both undernutrition and obesity risk areclearly needed for countries where there is malnutrition in all itsforms (32).

Current complementary feeding guidelines (52) provide guidanceon the timing of introduction, responsive feeding, quantity andtypes of foods needed.

Family attitudes to eating and perceptions of ideal body weight areimportant determinants of complementary feeding behaviours andneed to be considered.

Recent evidence shows that sensory experiences related to foodbegin in utero and continue during breastfeeding, and that theavours of foods mothers eat are transmitted to their infants. Thisand appropriate complementary feeding can play an importantrole in establishing food preferences and appetite control.Encouraging healthy food variety in children through repeated,positive exposure to new foods (53), seeing caregivers and familymembers enjoy healthy foods, and limiting their exposure tounhealthy foods (that may lead to preferences for very sweet foodsand drinks), all help develop good food habits in children and theirfamilies (54).

4.5

4.6

4.7

Breastfeeding is core tooptimizing infant development,growth and nutrition.


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Provide guidance tocaregivers on appropriatenutrition, diet and portionsize for this age group.

Ensure only healthy foods,beverages and snacks areserved in formal child-caresettings or institutions.

Ensure food educationand understanding areincorporated into thecurriculum in formalchild-care settings orinstitutions.

Ensure physical activity isincorporated into the dailyroutine and curriculum informal child-care settingsor institutions.

Provide guidance onappropriate sleep time,sedentary or screen-time andphysical activity or activeplay for the 25 years of agegroup.

Engage the whole-of-the-community to supportcaregivers and child-caresettings to promote healthylifestyles for young children.

There is evidence that poor sleeping patterns, low physical activityand an excess number of hours spent on screen-based entertainmentare associated with increased risk of obesity in childhood (3840).The evidence to support early interventions to prevent obesity in high-

income countries is still emerging, but looks very promising. Evidencesupports interventions in pre-school and child-care settings for childrenaged 25 years for early child feeding, activity patterns, mediaexposures and sleep that help to promote healthy behaviours andweight trajectories in this period of life (55).

Several strategies in this age group have also supported parentsand caregivers to ensure appropriate television/screen viewing,encourage active play, establish healthy eating behaviours and diets,promote healthy sleep routines and role-model healthy caregiver andfamily lifestyle (55).

The evidence shows that interventions to improve child nutrition, sleepand physical activity are most effective if these are comprehensive andinvolve caregivers and the community at large (55). Societal changesand transitions require a more deliberate and concerted interventions,including support for parents and other caregivers to enable them tocontribute to the recommended behaviour changes.

4.12

4.8

4.9

4.10

4.11

4.13


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IMPLEMENT COMPREHENSIVE PROGRAMMESTHAT PROMOTE HEALTHY SCHOOLENVIRONMENTS, HEALTH AND NUTRITIONLITERACY AND PHYSICAL ACTIVITY AMONGSCHOOL-AGE CHILDREN AND ADOLESCENTS.

School-age children andadolescents, whether in formaleducation or out of school, faceparticular challenges. Theyare highly susceptible to themarketing of unhealthy foodsand sugar-sweetened beverages,peer pressure and perceptions ofideal body image. Adolescents,in particular, may have morefreedom in food and beveragechoices made outside the home.

Physical activity often alsodeclines at this age.

Although a signicant numberof school-age children areunfortunately not in formaleducation, the compulsory school

years provide an easy entrypoint to engage this age groupand embed healthy eating andphysical activity habits for lifetimeobesity prevention. Given thatgovernments in most countriescontrol the education sector,effective collaboration betweenhealth and education can ensurethat school environments arehealthy environments, where bothnutrition literacy and physicalactivity are promoted. To ensureequity, further attention is neededto develop programmes to reachchildren and adolescents outsideformal education.

There is a growing evidencebase to support interventions forchildren and adolescents in schoolsettings and the wider communityas an obesity prevention strategy(23). Qualitative assessmentssuggest that their effectivenesson obesity prevention behavioursand outcomes is related to: a)quality of implementation; b)the educational rigour of theprogramme and its integration

within mainstream curricula

(e.g. reading, science); and c)positioning of school-based effortswithin the context of broadereducational and communityefforts.

To be successful, programmesto improve the nutrition andphysical activity of children andadolescents need to engage witha number of stakeholders. Obesityprevention and health promotion

has traditionally been the remitof ministries of health. Key tosuccess will be the integration ofactivities into a health-promotingschool initiative, with activeengagement of the educationsector. Interventions that will beincorporated into the school dayor curriculum will then be seen aspart of their own remit. The mostfrequently mentioned challengeto implementation is competitionwith the schools primarymission(55). By appropriateengagement with teachers, sucheducation can be integratedeffectively into mainstream topics,rather than requiring separatetime allocation. Collaborationand exchange of information, theuse evidence-based approachesappropriately adapted to context,and resource-sharing betweeneducation and health ministrieswill help to move this agendaforward.

Older children and adolescentsalso need to be engaged in thedevelopment and implementationof interventions to reducechildhood obesity(56). Onlythrough their active contributionin the process will interventionsbe shaped to meet their specicneeds, such that they, and theirpeers, can fully participate and

benet.

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Establish standards formeals provided in schools,or foods and beveragessold in schools, that meethealthy nutrition guidelines.

Eliminate the provision orsale of unhealthy foods,such as sugar-sweetenedbeverages and energy-dense, nutrient-poor foods,in the school environment.

Ensure access to potable waterin schools and sports facilities.

Energy-dense, nutrient-poor foods and sugar-sweetened beveragesare important drivers of the obesity epidemic in school-age childrenand adolescents globally, acting both to induce and maintainoverweight and obesity. It is a paradox to encourage and educate

children on healthy behaviours, while allowing inappropriate foodsand beverages to be sold or marketed within the school environment.To establish healthier behavioural norms and make the environmentless obesogenic it is necessary to reduce access to, or provision of,unhealthy foods and sugar-sweetened beverages in places wherechildren gather.

This strategy must go hand-in-hand with increasing access to,and promotion of, lower energy density foods and to water as analternative to sugar-sweetened beverages.

It may be possible to establish zones around schools where the saleof unhealthy foods and beverages is restricted, but the Commissionrecognizes that this may not be feasible in a number of settings.

Require inclusion of nutritionand health education withinthe core curriculum inschools.

Improve the nutrition literacyand skills of parents andcaregivers.

Make food preparation

classes available to children,their parents and caregivers.

Understanding the role of nutrition in good health is central to thesuccess of interventions to improve diet. As adolescents are the nextgeneration of parents, the importance of health and nutrition literacyduring adolescence cannot be overestimated indeed the schoolyears and the mainstream curricula offer important opportunities forprogress. Life-course education in schools should be co-constructedwith teachers, according to educational criteria and embedded incore curricula subjects.

Effective nutrition literacy goes beyond knowledge to actual behaviourchange. Although there is evidence of the effectiveness of interventionsto improve nutrition knowledge and understanding, the impact of theseinterventions on dietary behaviour is less clear. Combining nutritionliteracy interventions and clear context-specic nutrition advice tochildren and their caregivers and providing additional knowledgeon food preparation in the context of an improved obesogenicenvironment, would enable children, adolescents and their parents/

caregivers to make healthier choices.

Include Quality PhysicalEducation 1 in the schoolcurriculum and provideadequate and appropriatestafng and facilities tosupport this.

Regular participation in quality physical education and other forms ofphysical activity can improve a childs attention span, enhance theircognitive control and processing (57). It can challenge stigma andstereotypes, reduce symptoms of depression and improve psychosocialoutcomes. It is important that school-based physical education isinclusive of all children, of all abilities, rather than focused on thepotential elite sportsperson.

5.1

5.2

5.3

5.4

5.5

5.6

5.7

1 UNESCO Quality physical education (QPE). Guidelines for policy-makers, Paris 2015.


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PROVIDE FAMILY-BASED, MULTICOMPONENTLIFESTYLE WEIGHT MANAGEMENT SERVICES FORCHILDREN AND YOUNG PEOPLE WHO ARE OBESE.

When children are alreadyoverweight or obese additionalgoals include reduction in thelevel of overweight, improvementin obesity-related comorbiditiesand improvement in risk factorsfor excess weight gain. Thehealth sector in each countryvaries considerably and willface different challenges inresponding to the need fortreatment services for thosewith obesity. However, themanagement of children with

overweight and obesity shouldbe included in effective servicesextended under Universal HealthCoverage.

Primary health-care servicesare important for the earlydetection and managementof obesity and its associatedcomplications, such as diabetes.Regular growth monitoring at theprimary health-care facility or atschool provides an opportunity

to identify children at risk ofdeveloping obesity. Low-energydiets can be effective in the shortterm for the management ofobesity, but reducing inactivityand increasing physical activitywill increase the effectivenessof interventions. There is littlewritten on models of healthservice delivery for the provisionof obesity treatment in childrenand adolescents, but it is clearthat these efforts can only beeffective with the involvement

of the whole family or careenvironment.

Health workers and others maydiscriminate against childrenwho are overweight or obese.All such forms of discriminationare unacceptable and must beeliminated(58). The mentalhealth needs of children,including issues of stigmatizationand bullying, need to be givenspecial attention.

6


Develop and supportappropriate weightmanagement services for

children and adolescents who are overweight orobese that are family-based, multicomponent(including nutrition,physical activity andpsychosocial support)and delivered by multi-professional teams withappropriate training andresources, as part ofUniversal Health Coverage.

Evidence reviews of childhood obesity show that family-focusedbehavioural lifestyle interventions can lead to positive outcomes inweight, BMI and other measures of body fatness. This is the casefor both children and adolescents (59). Such an approach is thefoundation for all treatment interventions. However, very few studies

have been undertaken in low- and middle-income countries.For the morbidly obese child, in the face of failure of life-stylemodication, pharmacological and/or surgical options may benecessary (60).

Health professionals and all those providing services to children andadolescents need appropriate training on nutrition and diet, physicalactivity and the risk factors for developing obesity.

6.1


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ACTIONS AND RESPONSIBILITIESFOR IMPLEMENTINGTHE RECOMMENDATIONSThe Commission recognizes that successful implementation of the recommendations requiresthe committed input, focus and support of a number of agencies. Necessary actions andresponsibilities would involve the following:

ACTION RATIONALE

Institutionalize a cross-cutting and life-courseapproach to endingchildhood obesity across allrelevant technical areas inheadquarters, regional andcountry ofces.

Develop, in consultation with Member States, aframework to implementthe recommendations of theCommission.

Strengthen capacity toprovide technical supportfor action to end childhood

obesity at global, regionaland national levels.

Support internationalagencies, nationalgovernments and relevantstakeholders in buildingupon existing commitmentsto ensure that relevantactions to end childhood

obesity are implementedat global, regional andnational level.

It is essential that momentum is maintained to address this complexand critical issue. WHO can lead and convene high-level dialoguewithin the United Nations system and with and between MemberStates, to build upon the commitments made in the SustainableDevelopment Goals, the Political Declaration of the High-level meetingof United Nations General Assembly on the Prevention and Controlof Non-communicable diseases, the Rome Declaration of the SecondInternational Conference on Nutrition and others, to address theactions detailed in this report to end childhood obesity.

Using its normative function, both globally and through its network ofregional and country ofces, WHO can provide technical assistanceby developing or building on guidelines, tools and standards tosupport the recommendations of the Commission and other relevantWHO mandates at country level.

WHO can disseminate guidance for implementation, monitoring andaccountability, and monitor and report on progress to end childhoodobesity.

A

B

C

D

WHO


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ACTION RATIONALE

Cooperate to build capacityand support Member States inaddressing childhood obesity.

Cooperation between international organizations including other UnitedNations agencies can promote the establishment of global and regionalpartners and networks for advocacy, resource mobilization, capacity- building and collaborative research. The United Nations Inter-AgencyTask Force on noncommunicable diseases can support Member States inaddressing childhood obesity.

ACTION RATIONALE

Take ownership, provideleadership and make politicalcommitment to tackle childhoodobesity over the long term.

Coordinate contributions ofall government sectors andinstitutions responsible forpolicies, including, but notlimited to: education; food;agriculture; commerce andindustry; development;nance/revenue; sport andrecreation; communication;environmental and urban

planning; transport and socialaffairs; and trade.

Governments hold the ultimate responsibility in ensuring theircitizens have a healthy start in life. Thus, taking an active role toaddress childhood obesity should not be interpreted as interferencewith individual choice, rather as the state taking ownership ofthe development of their human capital. It is clear that to addresschildhood obesity effectively, the active engagement of multipleagencies of government is needed. There is an understandable

tendency to see obesity as a problem for the health sector. However,preventing childhood obesity requires the coordinated contributionsof all government sectors and institutions responsible for policies.Governments must establish appropriate whole-of-governmentapproaches to address childhood obesity. Further, regional and localgovernments must understand their obligations and harness resourcesand efforts to ensure a coordinated and comprehensive response tothe issue.

A

A

B

International organizations

Members States

ACTION RATIONALE

Promote collaborativeresearch on ending childhoodobesity with a focus on thelife-course approach.

Report on progress made onending childhood obesity.

F

E


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ACTION RATIONALE

Ensure data collection onBMI-for-age of children including for ages notcurrently monitored andset national targets forchildhood obesity.

Develop guidelines,recommendations or policymeasures that appropriatelyengage relevant sectors including the private sector,

where applicable toimplement actions, aimed atreducing childhood obesity,as set out in this report.

Using these data, governments can establish obesitytargets and intermediate milestones, consistent with theglobal nutrition and noncommunicable disease targetsestablished by the World Health Assembly. They should

include in their national monitoring frameworks agreedinternational indicators for obesity outcomes (to trackprogress in achieving national targets), diet and physicalactivity programme implementation (including coverageof interventions) and the obesity policy environment(including institutional arrangements, capacitiesand investments in obesity prevention and control).Monitoring should be conducted, to the fullest possibleextent, through existing monitoring mechanisms.

ACTION RATIONALE

Raise the prole of childhoodobesity prevention throughadvocacy efforts and thedissemination of information.

Motivate consumers to demandthat governments supporthealthy lifestyles and thatthe food and non-alcoholicbeverage industry providehealthy products, and do not

market unhealthy foods andsugar-sweetened beverages tochildren.

Although building the policy framework is undertaken by government,in some countries developing nutrition information and educationcampaigns, implementing programmes, and monitoring and holding

actors to account for commitments made, may be tasks shared betweengovernment and civil society.

Social movements can engage members of the community and providea platform for advocacy and action.

A

B

Nongovernmental organizations

C

D

NON-STATE ACTORSThere are many ways in which non-State actors can play an importantand supportive role in addressing

the challenge of childhood obesity.

As this report shows, the riskof childhood obesity is greatlyinuenced by food, physical activity

and eating behaviours, by the

school and social environment, bycultural attitudes to body image, bythe behaviour of adults and by the

conduct of the private sector.


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ACTION RATIONALE

Contribute to thedevelopment andimplementation ofa monitoring andaccountability mechanism.

ACTION RATIONALE

Support the production of,and facilitate access to,foods and non-alcoholicbeverages that contribute toa healthy diet.

Facilitate access to, andparticipation in, physicalactivity.

The private sector is not a homogeneous entity and includes the

agricultural food production sector, the food and non-alcoholic beverageindustry, retailers, catering companies, sporting-goods manufacturers,advertising and recreation businesses, and the media. It is, therefore,important to consider those entities whose activities are directly orindirectly related to childhood obesity either positively or negatively.Countries need to engage constructively with the private sector toencourage implementation of policies and interventions.

The Commission is aware of a number of private sector initiatives thathave the potential to impact positively on childhood obesity. These needto be encouraged where they are supported by an evidence base. Asmany companies operate globally, international collaboration is vital.However, attention must also be given to local and regional entities andartisans. Cooperative relationships with industry have already led to someencouraging outcomes related to diet and physical activity. Initiatives bythe food manufacturing industry to reduce fat, sugar and salt content,and portion sizes of processed foods, and to increase the production ofinnovative, healthy and nutritious choices, could accelerate health gainsworldwide.

The Commission believes that real progress can be made by constructive,transparent and accountable engagement with the private sector.

A

B

The private sector

C


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ACTION RATIONALE

Recogni

raport oms - obezitate infantilă

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