The childhood obesity strategy, Chapter 2: Roll on Chapter 3!

June saw the launch of an update to Theresa May’s 2016 childhood obesity strategy (HM Government, 2016; 2018) – and not a lot has happened to the plan in the intervening two years. In fact, with Brexit taking centre stage, one might believe that Whitehall has almost forgotten an obesity problem exists. Cutely titled Chapter 2 to signify the continuation of a “conversation” that Government is keen to pursue with us about the issue, it escaped the mauling that her first attempt at a strategy received – but only just.

The update, intended to make up for the “brave and bold” document with game-changing and draconian measures that its predecessor lacked, did little of the sort. It merely listed the actions that ought to be taken, while putting off any real dates for implementation. With a few exceptions, every proposal it made was tied to a “consultation” that would have to precede it, and in general the plan was a hotch-potch of good intentions but nothing in concrete.

What was particularly juvenile was May’s assertion that the Government’s plan was “world-leading”, completely glossing over the fact that truckloads of people from Whitehall have been flocking to Amsterdam to find out how the Dutch were dramatically lowering their obesity figures whilst the UK patently wasn’t (Sheldon, 2018). Looking at the data, even a child would be able to figure out that, whatever measures Britain was taking, it was clearly not leading the world anywhere.

Except for the sugar “tax”, of course. However, the Soft Drinks Industry Levy, to give it its full name, was a success even by the time the original strategy was published, and it is unacceptable that she should claim credit for it. The levy was the brainchild of George Osborne, the Chancellor that May got rid of when becoming Prime Minister, and it might not have materialised even under David Cameron’s government without Osborne fighting tooth and nail in Cabinet for its introduction. Tories don’t like imposing taxes but, knowing that obesity and its comorbidities were costing the nation some £24 billion per annum, the Chancellor realised that some kind of fiscal action had to be in his grasp. The levy’s brilliance was that it penalised industry rather than the consumer, and offered the soda barons the opportunity not to pay any surcharge if they reformulated their products to acceptable sugar levels. Almost to a man, they took it. By the time May entered Number 10, they were already on the job of ensuring that trillions of calories disappeared from fizzy drinks. By not paying any levy, their endeavours ensured that the Treasury received only half of the money that Osborne calculated he would raise, but nobody is unhappy. The sugar has gone. Job done.
 
Missed opportunities – again
The measures that remain to be done in May’s mind are summarised in just four pages of Chapter 2, and they are not enough. She is mistaken if she thinks that simply reducing sugar and calories in foodstuffs, capping some advertising and encouraging local government to do a bit more in its areas will be enough to halve childhood obesity by 2030. It won’t. The gold-standard plan to tackle obesity was published in the McKinsey Institute’s global review of obesity in 2014 (Dobbs et al, 2014). This listed a total of 44 measures which, if implemented in concert under the direction of a dynamic, Cabinet-level minister, might have a chance of successfully denting the obesity problem. Even then, McKinsey estimated that it would only reduce obesity levels by 20% in 5–10 years.

Two omissions in particular in Chapter 2 should be noted in this commentary. The first error was to omit any reference to helping families not raise unhealthily fat children in the first two years of life – the so-called 1000 days (Pietrobelli and Agosti, 2017). The second was to squander the opportunity to monitor all children’s growth regularly in their early years: an opportunity to identify any signs of excess weight gain as early as practicable and refer the child to one of the many weight management courses that now exist, before the weight becomes a real problem. Paediatricians were warned thirty years ago that if children were allowed to put on weight unchecked, obesity would be an inevitable consequence. No-one listened and we are now reaping the results of their negligence.

The first 1000 days of a child’s life are now generally regarded as the time to instil healthy eating and exercise habits. Catch children before they have the chance to begin eating badly and not exercise, and the likelihood is that they will retain a good lifestyle throughout childhood. Though this strategy was missing when Chapter 2 was released, Andrea Leadsom’s recent appointment to head up a cross-government working group to look at the early years could yet save the chapter from complete ignominy. Leadsom is passionate about the early years and, as a prominent MP, was considered a candidate for the Prime Ministerial post. Although, as I write, nothing further has been published to tell us exactly what is expected of the group – or, crucially, the budget it will be working to – we should wish it success. On the down side, Westminster watchers have suggested that Leadsom’s appointment was a merely a “reward” for backing May in all her Brexit wranglings over the summer, and that the announcement was merely headline-grabbing rather than being substantive. Since Leadsom’s main interest is in mental rather than public health, it is also possible that anti-obesity measures will sink down her list of things to discuss. We will find out.

Monitoring infant growth is a different kettle of fish. Although health professionals’ duty to weigh every child “by default” was included in the 2016 childhood obesity plan, the only reference to measuring or monitoring in Chapter 2 is a pledge to retain the two National Child Measurement Programme (NCMP) height and weight checks at primary school entry and exit. Given that 25% of children are already overweight or obese by age 5 years, and that the NCMP is a statistical rather than clinical exercise, failure to announce that preschool children would also be monitored is a fundamental error. It is particularly so given that the Royal College of Paediatrics and Child Health, cognisant of its previous lapse of judgment, now demands that the growth of all children be monitored from birth to adolescence. Scotland is halfway there by including in its Diet and Healthy Weight Delivery Plan the need to weigh children 11 times by the time they first go to school (Scottish Government, 2018), but the Holyrood government should quickly come to realise that omitting to measure BMI at half of these contacts is not at all what the doctors ordered.

As for the childhood obesity strategy, roll on Chapter 3, for it must surely come!

Childhood obesity: a plan for action, Chapter 2 is available to download from: https://bit.ly/2K7e2zW