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Obesity in childhood Report of an expert committee Convened by the World Health Organization, Kobe, June 2005.

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Contents .................................................................................................................................................................1 1. Introduction......................................................................................................................................................9
The need for action on child obesity................................................................................................................ 10 The Kobe meeting conclusions........................................................................................................................ 11 Child obesity in the 21 st Century ................................................................................................................. 11 Identifying the risk factors .......................................................................................................................... 11 Growth and malnutrition............................................................................................................................. 11 Monitoring and assessment......................................................................................................................... 12 Interventions to prevent child obesity......................................................................................................... 13 Evidence and research ................................................................................................................................. 14

WHO nutrition programme.............................................................................................................................. 16 WHO Global Strategy on Diet, Physical Activity and Health ................................................................... 17 2. Child obesity in 21st Century...................................................................................................................... 18
2.1 The size of the problem.............................................................................................................................. 18 2.2 The double burden of disease..................................................................................................................... 23 2.3 Health consequences and costs.................................................................................................................. 25 Psycho-social consequences........................................................................................................................ 26 Sleep- disordered breathing and asthma....................................................................................................... 27 Fatty liver disease........................................................................................................................................ 28 Menstrual problems and early menarche..................................................................................................... 28 Glucose intolerance and Type 2 diabetes .................................................................................................... 29 Cardiovascular risk factors.......................................................................................................................... 30 Metabolic syndrome and paediatric obesity................................................................................................ 31 Tracking of obesity into adulthood.................................................................................................................. 32 Financial costs of child obesity................................................................................................................... 32 2.4 The need for a WHO consultation............................................................................................................. 35

3. Risk factors for child obesity....................................................................................................................... 37


3.1 Patterns of growth and weight gain ............................................................................................................ 37 Early growth ................................................................................................................................................ 37 Weight gain in infancy and childhood........................................................................................................ 38 Weight gain in adolescence......................................................................................................................... 40 Geneticenvironment interactions............................................................................................................... 40 3.2 Social and environmental risk factors linked to obesity............................................................................ 42 Ethnicity ...................................................................................................................................................... 42 Maternal diabetes........................................................................................................................................ 42 Smoking in pregnancy ................................................................................................................................. 43 Early malnutrition..................................................................................................................................... 43 Social deprivation........................................................................................................................................ 45 Family and school functioning.................................................................................................................... 46 Environmental risk factors............................................................................................................................... 46 Infant feeding.............................................................................................................................................. 47 Macronutrients and energy density............................................................................................................. 48 Soft drinks................................................................................................................................................... 49 Eating patterns............................................................................................................................................. 49 Portion size.................................................................................................................................................. 50 Fast food restaurants and school canteens................................................................................................... 50 Food marketing............................................................................................................................................ 52 Physical activity and sedentary behaviour .................................................................................................. 52 Television viewing ...................................................................................................................................... 53 Ethnic interactions with obesogenic risk factors......................................................................................... 54 3.3 Nutrition and sedentary transitions ............................................................................................................ 55

Nutrition insecurity...................................................................................................................................... 57 Sedentary transition ..................................................................................................................................... 60 Commercial targeting of children ................................................................................................................ 60

4 Growth and malnutrition.............................................................................................................................. 63


4.1 The life-course approach ............................................................................................................................ 63

Foetal development and the maternal envi onment .................................................................................... 63 r


Infancy......................................................................................................................................................... 64 Childhood and adolescence......................................................................................................................... 65 Adulthood.................................................................................................................................................... 65 Ageing and older people.............................................................................................................................. 66 Intergenerational effects.............................................................................................................................. 66 Intervening throughout life.......................................................................................................................... 66 4.2 Malnutrition, stunting and obesity............................................................................................................. 67 Overweight and stunted children ................................................................................................................. 69 Consequences of rapid weight gain in infancy ............................................................................................ 70 Supplementary feeding programmes........................................................................................................... 71 Recommended energy requirements........................................................................................................... 73

5 Monitoring and assessment.......................................................................................................................... 76


Body fat assessment .................................................................................................................................... 76 Definitions of overweight and obesity in young people ...................................................................... 76 Review of reference charts.......................................................................................................................... 81 The MGRS gold standard growth charts.................................................................................................. 83 Reference data for older children ................................................................................................................ 85 Uses of charts and cut -offs .......................................................................................................................... 88 Methodological caveats for surveys............................................................................................................ 90 Further recommendations............................................................................................................................ 91

6. Interventions .................................................................................................................................................. 93
6.1 Prevention and population health............................................................................................................... 93 Evidence base for child obesity prevention ................................................................................................. 95 The wider environment ............................................................................................................................... 98 Involvement of other sectors ..................................................................................................................... 100 Cultural resistance to change ..................................................................................................................... 101 Health promotion....................................................................................................................................... 102 Concerns and caveats................................................................................................................................ 104 Screening for obesity risk .......................................................................................................................... 106 Policy framework ...................................................................................................................................... 107 National action plans................................................................................................................................. 108 Global Strategy recommendations............................................................................................................ 109 Recommendations from the Kobe expert meeting .................................................................................... 112

7 Evidence and research ................................................................................................................................ 119


7.1 Identifying evidence needs....................................................................................................................... 119 Alternatives to control trials...................................................................................................................... 120 Broadening the definition of evidence ...................................................................................................... 122 7.2 Investing in child health........................................................................................................................... 124 7.3 Gaps in the evidence ................................................................................................................................ 126 Contextual concerns .................................................................................................................................. 129 Upstream analyses ..................................................................................................................................... 129 Recommendations on evidence and research............................................................................................ 131

Appendix: Table of evidence from the Cochrane review of obesity prevention .................................... 132 Referencess....................................................................................................................................................... 148

WHO Expert Meeting on Childhood Obesity 2024 June 2005


WHO Centre for Health Development (WHO Kobe Centre WKC) I.H.D. Centre Building, 9th Floor 5-1, 1-chome, Wakinohama-Kaigandori Chuo-ku, Kobe 651-0073 Japan Tel: +81 78 230 3100 Fax: +81 78 230 3178 URL: http://www.who.or.jp/
Chairs: Professor Reynaldo Martorell and Professor Shiriki Kumanyika Rapporteurs: Dr Tim Lobstein and Dr Ladda Mo-suwan

Provisional List of Participants


THIS LIST NEEDS CHECKING AGAINST FINAL
AFRO Dr Kagnassy Dado Sy Division of Nutrition Ministry of Health BP 232 Bamako Mali Tel: 223-2203697 / 2206497 Email: kagnassy.dado@caramail.com Dr Anna Lartey Department of Nutrition and Food Science Faculty of Science University of Ghana P.O. Box 25 Legon, Ghana Tel: 233-21-767278 Fax: 233-21-500389 Email: aalartey@hotmail.com Dr Francis Ofei University of Ghana Medical School Department of Medicine P.O. Box GP 753 Accra, Ghana Tel: 233-21668219 Email: fofei@africaonline.com.gh Dr Simone French Division of Epidemiology and Community Health University of Minnesota Westbank Office Building 1300 South Second Street, Suite 300 Minneapolis, MN 55454 USA 1-612-626-8594 1-612-624-0315 French@epi.umn.edu Professor Shiriki Kumanyika (Cochair) Center for Clinical Epidemiology Dr Emmanuel Yehouessi Specialist of Chronic Disease Control 02 BP 376 Cotonou Benin Tel: 229-309368 Fax: 229-957349 / 229-487431 Email: cardsey@intnet.bj

Dr Izaak Odongo Ministry of Health Division of Non-communicable Diseases P.O. Box 30016 Nairobi, Kenya Tel: 254-27170117 Email: izago@yahoo.com AMRO Ms Carmen Aldinger Education Develoment Center Health and Human Development Programmes 55 Chapel Street Newton, MA 02458 USA Tel: 1-617-969-7100 Email: caldinger@edc.gov

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Dr Edward Frongillo Division of Nutritional Sciences B17 Savage Hall

Professor Reynaldo Martorell (Co-chair) Department of Global Health Rollins School of Public Health Emory University Grace Crum Rollins Building - 754 1518 Clifton Road Atlanta, Georgia 30322 USA Tel: 1-404-727-9854 Fax: 1-404-727-1278 Email: rmart77@sph.emory.edu Professor Ricardo Uauy Instituto de Nutricin y Tecnologa de los Alimentos

Cornell University Ithaca New York 14853-6301 USA Tel: 1-607-255-3153 Fax: 1-607-255-1033 Email: eaf1@cornell.edu

and Biostatistics University of Pennsylvania School of Medicine 8th Floor Blockley Hall 423 Guardian Drive Philadelphia PA 19104-6021 USA Tel: 1-215-898-2629 Fax: 1-215-573-5311 Email: skumanyi@cceb.med.upenn.edu Ms. Parvin Mirmiran Endocrine Research Center Shaheed Beheshti University P.O. Box 19395-4763 Teheran Islamic Republic of Iran Tel: 98-21-2409309 Fax: 98-21-2402463 Email: mirmiran@erc.ac.ir

University of Chile Casilla 138-11 Santiago Chile Tel: 56-2-678-1536 Fax: 56-2-678-1497 Email: uauy@uchile.cl +++????????????

EMRO Professor Mahmoud Bozo Pediatrics Department, Damascus Hospital and General Coordinator of Pediatrics, Ministry of Health Damascus Syria Tel: 963-11-3334585 Fax: 963-11-3316023 Email: mahbozo@scs-net.org

Dr Sahar Abdul-Aziz Mohammed Khairy Department of Growth and Development National Nutrition Institute 16 Kasr El Aini Street, Cairo Mailing Address: 42 Ali Amin Street Nasr City, 1 st zone, zip code 11371 Cairo, Egypt Tel: 20-2-3646413 Fax: 20-2-3647476 Email: m2s2r@hotmail.com dr_ms_mrs@yahoo.com +++????????????

EURO Professor Colin Boreham Department of Sport and Exercise Science Room 15J01 School of Health Sciences University of Ulster Jordanstown Campus Shore Road, Newtownabbey Co. Antrim BT37 0QB United Kingdom Tel: 44-28-9036-6665 Email: ca.boreham@ulster.ac.uk Dr Jaap Seidell Department of Nutrition and Health Faculty of Earth and Life Sciences Free University of Amsterdam Van der Boechorststraat 7 De Boelelaan 1085 1081 HV Amsterdam The Netherlands Tel: 31-20-598-6995 Fax: 31-20-598-6940 Email: seidell@bio.vu.nl S EARO Dr Anoop Misra Department of Medicine All India Institute of Medical Science Asarinagar New Delhi 110029, India Tel: 91-11-26588297 Fax: 91-11-26588663 Email: anoopmisra@hotmail.com anoopmisra11@yahoo.com WPRO

Dr Tim Lobstein (Rapporteur) Childhood Obesity Programme International Obesity Task Force 231 North Gower Street London NW1 2NS United Kingdom Tel: 44-20-7691-1911 Fax: 44-20-7387-6033 Email: childhood@iotf.org

Dr Jana Vignerov National Insitute of Public Health Srobarova 48 100 42 Praha 10 Czech Republic Tel: 420-267-082-304 Fax: 420-267-102-121 Email: jvig@szu.cz

Professor Carolyn Summerbell Department of Human Nutrition School of Health and Social Care University of Teesside Parkside West Offices Middlesbrough TS1 3BA United Kingdom Tel: 44-1642-342769 Fax: 44-1642-342961 Email: carolyn.summerbell@tees.ac.uk Dr Ladda Mo-suwan (Rapporteur) Department of Pediatrics Faculty of Medicine Prince of Songkla University Hat Yai Songkhla 90110, Thailand Tel: 66-74-429618 / 212070 Fax: 66-74-212912 Email: ladda.m@psu.ac.th

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Professor Louise Baur Clinical School The Children's Hospital at Westmead Locked Bag 4001 Westmead NSW 2145 Australia Tel: 61-2-9845-3393 Fax: 61-2-9845-3389 Email: louiseb3@chw.edu.au Professor Andrew Hills School of Human Movement Studies Queensland University of Technology Kelvin Grove Campus, KG-OA422 Victoria Park Road Kelvin Grove Queensland 4059 Australia Tel: 61-7-3864-3286 Fax: 61-7-3864-3980 Email: a.hills@qut.edu.au

Professor Chengye Ji Institute of Child and Adolescent Health Peking University 38 Yi Xue Yuan Road Haidan District Beijing 100083 China Tel: 86-10-82801524 Email: hjzhuang@263.net Professor Ma Guansheng Instiutute of Nutrition and Food Safety Chinese Center for Disease Control and Prevention 29 Nan Wei Road Beijing 100050 China Tel: 86-10-83132572 Fax: 86-10-83132021 Email: mags@chinacdc.net.cn

Dr Boyd Swinburn School of Health Sciences Deakin University 221 Burwood Highway Burwood, Melbourne 3125 Australia Tel: 61-3-9251-7096 Fax: 61-3-9244-6017 Email: boyd.swinburn@deakin.edu.au Professor Elizabeth Waters School of Health and Social Development Deakin University 221 Burwood Highway Burwood, Victoria 3125 Melbourne Australia Tel: 61-3-9251-7265 Mobile: 61-408-573-966 Fax: 61-3-9244-6261/6017 Fax: elizabeth.waters@deakin.edu.au

Dr Mabel Yap Research and Information +++???????????? Management Division Health Promotion Board 3 Second Hospital Avenue Singapore 168937 Tel: 65-64353531 Fax: 65-65368532 Email: Mabel_Yap@hpb.gov.sg UN AGENCIES AND OTHER INTER -GOVERNMENTAL ORGANIZATIONS Dr Laurence Grummer- Strawn Peter Glasauer Maternal Child Nutrition Branch Food and Nutrition Division Division of Nutrition and Physical Food and Agricultural Organization Activity of the United Nations (FAO) National Center for Chronic Disease Viale delle Terme di Caracalla Control and Prevention 00100 Rome Centers for Disease Control Italy and Prevention Tel: 4770 Buford Highway, NE, MS/K-24 Fax: Atlanta, Georgia 30341-3717 Email: USA Tel: 1-770-4885820 Fax: 1-770-488-5473 Email: lxg8@cdc.gov Dr Jacques Baudouy Professor Nancy Butte Health, Nutrition and Population Food and Nutrition Program Human Development Network United Nations University (UNU) World Bank C/o Bayler College of Medicine 1818 H Street, NW Children's Nutrition Research Center Washington D.C., 20433 Department of Pediatrics USA 1100 Bates Street Tel: 1-202-473-2256 Houston, TX77030 Fax: 1-202-614-0657 USA Email: Tel: 1-713-798-7179 Fax: 1-713-798-7187 Email: nbutte@bcm.tmc.edu Dr Yvonne Maddox Dr Roger Shrimpton National Institute of Child Health and United Nations System Standing Human Development (NICHD), Committee on Nutrition (SCN) National Institutes of Health (NIH), Office 477 - WCC U.S. Department of Health and Human C/o World Health Organization

Dr Rainer Gross Nutrition Section Programme Division United Nations Children's Fund (UNICEF) 3, United Nations Plaza New York, NY 10017 USA Tel: 1-212-824-6368 Fax: 1-212-824-6465 Email: rgross@unicef.org

Dr Marie Ruel Food Consumption and Nutrition International Food Policy and Research Institute (IFPRI) 2033 K Street, NW Washington, D.C., 20006-1002 USA Tel: 1-202-862-5600 Fax: 1-202-467-4439 Email: M.Ruel@cgiar.org Ms Wendy Snowdon Lifestyle Health Section Secretariat of the Pacific Community (SPC) BP D5, Noumea Cedex

Services (DHHS) Building 31, Room 2A03, MSC 2425 Bethesda, MD 20892-2425 USA Tel: 1-301-496-1848 Fax: 1-301Email: maddoxy@exchange.nih.gov Dr Pedro Andreo Division of Human Health Department of Nuclear Sciences and Applications International Atomic Energy Agency (IAEA) Wagramer Strasse 5 P.O. Box 100 A-1400 Vienna Austria Tel: 43-1-2600-21650 or 21658 Fax: 43-1-26007-21658 Email: p.andreo@iaea.org SE CRETARIAT WHO/HQ Dr Denise Costa Coitinho Nutrition for Health and Development Noncommunicable Diseases and Mental Health World Health Organization Avenue Appia, 20 1211 Geneva 27, Switzerland Tel: 41-22-791-2809 / 3321 Fax: 41-22-791-4156 Email: coitinhod@who.int Dr Colin Tukuitonga Primary Prevention of Chronic Diseases Noncommunicable Diseases and Mental Health World Health Organization Avenue Appia, 20 1211 Geneva 27, Switzerland Tel: 41-22-791-1437 / 3903 Fax: 41-22-791Email: tukuitongac@who.int WHO/WKC Dr Wilfried Kreisel WHO Centre for Health Development I.H.D. Centre Building, 9th Floor 5-1, 1-chome, Wakinohama-Kaigandori Chuo-k u Kobe 651-0073, Japan Tel: 81-78-231-3102 Fax: 81-78-230-3178 Email: kreiselw@who.or.jp

20 Avenue Appia CH-1211 Geneva 27 Tel: 41-22-791-3323 Fax: 41-22-791 Email: shrimptonr@who.int

New Caledonia Tel: 687-262-000 Fax: 687-263-818 Email: WendyS@spc.int

Dr Shaw Watanabe National Institute of Health and Nutrition 1-23-1 Toyama Shinjuku-ku Tokyo 152-8636 Japan Tel: 81-3-3203-5721 Fax: 81-3-3202-3278 Email:

Van Hubbard ++ ++

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Dr Chizuru Nishida Nutrition for Health and Development Noncommunicable Diseases and Mental Health World Health Organization Avenue Appia, 20 1211 Geneva 27, Switzerland Tel: 41-22-791-3317 / 3455 Fax: 41-22-791-4156 Email: nishidac@who.int Dr Jack Jones Health Promotion/ Chronic Diseases and Health Promotion Noncommunicable Diseases and Mental Health World Health Organization Avenue Appia, 20 1211 Geneva 27, Switzerland Tel: 41-22-791-2582 Tel: 41-22-791Email: jonesj@who.int Dr Guojun Cai Ageing and Health Programme WHO Centre for Health Development I.H.D. Centre Building, 9 th Floor 5-1, 1-chome, WakinohamaKaigandori Chuo -ku Kobe 651-0073, Japan Tel: 81-78-230-3112 Fax: 81-78-230-3178 Email: gcai@who.or.jp

Dr Mercedes de Onis Nutrition for Health and Development Noncommunicable Diseases and Mental Health World Health Organization Avenue Appia, 20 1211 Geneva 27, Switzerland 41-22-791-3320 / 4727 41-22-791-4156 deonism@who.int +++????????????

Dr Tomo Kanda Ageing and Health Programme WHO Centre for Health Development I.H.D. Centre Building, 9 th Floor 5-1, 1-chome, WakinohamaKaigandori Chuo -ku Kobe 651-0073, Japan Tel: 81-78-230-3116 Fax: 81-78-230-3178 Email: kandat@who.or.jp Dr Kunal Bagchi EMRO Dr Tommaso Cavalli- Sforza WPRO EMRO????????????

REGIONAL ADVISERS (Nutrition) Dr Aristide Sagbohan Dr Enrique Jacoby AFRO AMRO Dr Francesco Branca Dr Rukhsana Haider EURO SEARO REGIONAL ADVISERS (Noncommunicable Diseases) AFRO ???????????? AMRO????????????

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Background papers commissioned for the consultation Potential impact of PEM intervention programmes on overweight and obesity in children Professor Ricardo Uauy and Professor Juliana Kain, Instituto de Nutricin y Tecnologa de los Alimentos, University of Chile, Santiago, Chile Assessment of overweight and obesity for school-age children and adolescents Dr Edward Frongillo Division of Nutritional Sciences, Cornell University, Ithaca, N.Y., USA and Dr Kathleen Merchant, Maternal Child Health Initiative, Institute of Public Health, Graduate School of Public Health, San Diego St ate University, San Diego, C.A., USA Cochrane Library Systematic Review of the interventions for preventing obesity in children, Professor Elizabeth Waters, School of Health and Social Development, Deakin University, Melbourne, Australia and Professor Carolyn Summerbell, School of Health and Social Care, University of Teesside, Middlesbrough, United Kingdom Prevention of child obesity: practical issues Dr Tim Lobstein, International Obesity TaskForce, London, United Kingdom Acknowledgements Reviewers: Mary Flynn, Food Safety Authority of Ireland, Dublin, Ireland Michael Goran, University of Southern California, Los Angeles, California, USA Simone Franch , University of Minnesota, Minneapolis, Minnesota, USA Kim Raine, University of Alberta, Edmonton, Alberta, Canada Boyd Swinburn , Deakin University, Melbourne, Australia. (Colin Tukuitonga, Noncommunicable Diseases and Mental Health, WHO, Geneva) Nancy Butte , Baylor College of Medicine, Houston, Texas, USA Martin Neovius, Karolinska Institute, Stockholm, Sweden Scott Going, University of Arizona , Tucson, Arizona, USA Cynthia Ogden, Centers for Disease Control and Prevention, Hyattsville, Maryland, USA Mark Tremblay, Statistics Canada, Ottawa, Canada Babette Zemel, University of Pennsylvania, Philadelphia, Pennsylvania, USA Benjamin Caballero, Johns Hopkins University, Baltimore, MD, USA Terrence Forrester, University of the West Indies , Kingston, Jamaica Phillip James, London School of Hygiene and Tropical Medicine, London, UK Geok Lin Khor, Universiti Pu tra Malaysia, Serdang, Malaysia Harshpal Singh Sachdev, Maulana Azad Medical College, New Delhi, India And reviewers of the Cochrane review ??? Kobe Centre staff, and other support staff: Patricial Robertson, WHO Geneva ++ + +++

1. Introduction The WHO Consultation on Childhood Obesity met in Kobe, Japan, from 20 to 24 June 2005. Dr Wilfred Kreisel, Director of the WHO Centre for Health Development, Kobe, opened the meeting on behalf of WHO. The principle aims of the consultation were (a) to review the need for growth standards and references to assist in the assessment of child and adolescent obesity, and (b) to make recommendations for policies to improve the prevention of child and adolescent obesity. Specifically, the objectives were:

to review progress towards the generation of reliable statistical data on child growth patterns which could be used to set growth standards and to create reference charts for growth assessment;

to consider the links between traditional malnutrition and later obesity risk, and the need to consider energy and nutrient requirements for children in families experiencing food insecurity;

to make recommendations for interventions in childhood to promote optimum growth and wellbeing;

to make recommendations on strategies and policies to prevent child and adolescent obesity, taking into account the WHOs Global Strategy on Diet, Physical Activity and Health;

to identify areas requiring further research in relation to these issues.

In order to achieve these objectives, peer-reviewed background documents were prepared by experts in relevant fields. WHO is pleased to draw attention to these contributions which contributed significantly to the discussions. The individuals and institutions are mentioned in the Acknowledgements sections (page X). Additional documents were provided at the meeting, and presentations were made by the participants. The present report draws from these sources and from the discussions held during the meeting.

The need for action on child obesity The Kobe expert meeting was called in response to the dramatically rising trends in the prevalence of child and adolescent obesity and the serious health problems that are emerging as a result. In many developed economies child obesity levels have doubled in the last two decades, and are set to double again, probably over a shorter period. The impending disease burden has been described as a public health disaster waiting to happen (1), a massive tsunami (2), and a health time-bomb ( 3), and politicians are aware that the amount of time they have left to make policy decisions is rapidly declining. The great majority of children are at risk, especially if the environmental factors that encourage obesity are present as they are in most industrialised countries and urbanised populations. The Kobe expert meeting noted the difficulty treating obesity once it has become established. Many reviews have indicated that the prevention of obesity is not only possible but is the most realistic and cost effective appro for ach 4 5 6 7 dealing with childhood obesity ( , , ) as it is for adult obesity ( ). One of the measures needed for an effective intervention is a reliable set of data establishing the extent of the problem, the trends over time and the identification of groups particularly at risk. This requires agreed criteria for assessing child growth and agreed definitions of what constitutes excessive adiposity. Following an earlier WHO expert report which identified the need for new reference curves which took account of breastfeeding and weaning practices (8), a programme of work has been undertaken (the Multicentre Growth Reference Study) to compile a new dataset which can be used as the gold standard for child growth patterns. These developments were discussed and reviewed at the Kobe expert meeting. The meeting was held in the context of two WHO programmes of work relating to child obesity. The first is the long-standing WHO nutrition programme. The original focus of this programme was on malnourishment and nutrie nt deficiency and in recent years this has been extended to consider issues relating to obesity and other aspects of diet, including the intake of energy-dense, nutrient poor foods that have been highlighted as being linked to obesity risk (9). The two aspects of nutrition can affect the same populations, and indeed the same individual, and have been dubbed the double burden which can be characterised by undernourished infants failing to develop their full height while receiving energy-dense, micronutrient-poor diets that encourage weight gain. This results in a high risk of central adiposity, bringing a likelihood of adult diseases such as diabetes, heart disease, hypertension and other disorders referred to collectively as the metabolic syndrome. The double burden and the specific issue of feeding stunted children were considered at the Kobe expert meeting. The second WHO programme is the WHO Global Strategy on Diet, Physical Activity and Health, referred to above. This was developed by WHO in response to the World Health Assemblys call for action to tackle the rise in non-communicable disease through policies at international as well as national and local level (10) and was followed by a series of consultations held with member states, UN agencies and other

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international bodies, civil society organisations and private sector representatives. The resulting strategy document ( 11) was adopted by the World Health Assembly at its meeting in May 2004. The Strategy makes a number of proposals which have a s pecific bearing on child obesity, including policies to ensure that the cultural and physical environments are conducive to health, that schools are supporting the adoption of healthy diets and plentiful physical activity, that food and agriculture production policies are consistent with healthy diets, and that food marketing, especially to children, does not encourage unhealthy dietary practices or physical inactivity. The Kobe meeting conclusions On the basis of these programmes and activities, and on the basis of the background documents and the presentations at the meeting, the participants discussed a wide range of issues described in the present report and reached conclusions which are summarised here. Child obesity in the 21st Century There has been a rapid rise in the numbers of children affected by excess bodyweight, in economically developed countries and in countries in economic transition. Some groups of children may be at particular risk of obesity due to their social, economic or ethnic status. In some countries the epidemic of obesity among children sits alongside continuing problems of undernour ishment, creating a double burden of nutritionrelated ill health. The costs of this escalating problem are considered, both in terms of the health burden experienced by the obese child during childhood and subsequently, and in terms of the financial costs which have yet to be fully appreciated . Identifying the risk factors In order to make interventions, either as treatment of an obese child or through prevention strategies, it is necessary to understand how a child becomes obese. This section considered the mechanisms for weight gain and the various physical and environmental risk factors that increase the likelihood that a child will accumulate excess weight. It also looked at the wider context in which the risk factors are set: namely the changing pattern of diets and the reduced need for physical activity (the nutrition and sedentary transitions) which many children are experiencing as members of newly urbanised, industrialised populations. Growth and malnutrition Opportunities for intervention can be explored through a life course approach, which considers the influences on a childs nutritional status as a result of current diet and physical activity, earlier experiences of breastfeeding and weaning, foetal exposure to mis-nourishment, and influence of parents and grandparents through direct and indirect risk factors. A lthough this approach focuses specifically on the individual, it has implications for population-based approaches. Recent evidence suggests that stunted children may not benefit from generalised food assistance programmes if this leads to

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weight gain without commensurate gain in height. Alternative approaches are needed to prevent central obesity and consequential disease risks. The Kobe expert meetings recommendations included:

Well baby clinics should record obesity indices as well as growth indices and aim to improve childrens length in preference to increasing their weight. Food-based interventions for infants should be based on promoting a healthy, varied diet with an emphasis on the upper limits of energy and fat intakes. Supplements for mothers should be reviewed for their impact on child growth. The new standards for energy requirements were noted, but there is a need for equivalent recommendations for energy expenditure, and for standardised methods for measuring physical activity and sedentary behaviour.

Monitoring and assessment Interventions are predicated on adequate monitoring and classification systems. The Kobe expert consultation discussed the need for agreement on methods for assessing an individual childs growth, and for defining the prevalence of overweight and obesity in populations. In particular, the meeting recognised that the MGRS programme to define a gold standard for the growth of children was reaching fruition, and that the issue of population-based definitions was being discussed at further expert consultations during 2006. The participants at the Kobe meeting agreed that the new growth curves should be referred to as WHO child growth standards. The meeting noted that the new standards could lead to new, lower figures for the prevalence of under-nutrition and higher figures for the prevalenc e of stunting and overweight compared to previous references. The Kobe expert meeting recommended:

The collection of survey data should be continued and extended, especially in developing and poorly developed economies. Governments should be encouraged to undertake sample surveys of childrens weight and height (and other anthropometric measures if appropriate) annually. Until better reference data are available, prevalence data intended for international comparison may best be reported in terms of the WHO 1995 criteria and/or the IOTF criteria, in addition to any locally -used criteria. Ideally (to provide compatibility with future standards) reports should also include mean, standard deviation and skewness. The development of a broader range of IOTF-style cut-offs should be investigated. Additional technical work should be done to evaluate the implications of ethnic differences in child growth patterns. When used in children and particularly adolescents, BMI should be interpreted according to age, gender, and when possible stage of maturation and fitness level. Waist circumference may be able to indicate central, truncal, or upper body fat better than BMI in adults and possibly in children. Waist circumference should be included in routine surveying, and cut-off criteria developed for identifying children at high risk. The Kobe expert meeting noted that there is a need for low-cost length-measuring equipment with minimal need for training. Similarly there is a need for low-cost skin-fold measuring equipment.

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Interventions to prevent child obesity A series of reviews of interventions designed to prevent child obesity have found only modest effects for preventive activities undertaken at community level, for example in schools. It was concluded that such initiatives will be more successful if they are supported by environments that encourage healthy behaviour. The Kobe expert meeting made a number of recommendations concerning the most appropriate forms of intervention at school and community level and the types of intervention that are needed at national and international level to ensure that community-level interventions are supported. Besides fully endorsing the Global Strategy and its recommendations, the Kobe expert meeting made a number of other broad-reaching suggestions see pages XX below. Key among them are the following:
Early years Health services should be routinely monitoring and advising women, starting with health advice in schools and community settings.

Preventive services should ensure that the needs of nutritionally-at-risk infants and children are met, giving special attention to linear growth of preterm and/or low birth weight infants, and that interventions should prevent excess weight gain in order to decrease risk of obesity in later life. Parents should be encouraged to interact with their children, and especially infants in their earliest years, to promote active play and developmental growth.

Nurseries and kindergartens should ensure that they do not unnecessarily restrict physical activity during the growing years. Schools

Schools are positioned to be community leaders and their practices should set an example. A coherent, comprehensive whole school approach (including children, parents and all staff, and coving taught lessons, physical activities and food services) is desirable, and may have potential benefits to the wider community.

Schools need to be fully funded so they are not put in the position of having to raise funds for school programmes, which renders them vulnerable to p ressure from commercial interests. Teachers may need additional training in health promotion, including training to ensure obese children are not stigmatised or bullied by others in the school. Set high standards. Develop standards for foods made available in schools. Consistent policies are needed to ensure a health promoting food environment. Require daily PE in all grades, and make sure the programs are appealing to children. Clinics Health care facilities need to provide a range of preventive services and health promoting activities, and should liaise with schools and community services to ensure their messages are given prominence. Health care staff also have a role in monitoring childrens growth to recognise early signs of mis -nourishment, including stunting and overweight, and provide appropriate responses. Government In addition to the Global Strategy recommendations, the Kobe expert meeting identified

the need to centralise government action into one office in order to ensure cross-departmental, cross-sectoral polices can be implemented. This should be monitored by a separate agency, such as a parliamentary scrutiny committee or an obesity observatory.

The need to build capacity at national and at local levels, to support the recommendations for interventions made in this report

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State support for commerce (e.g. food enterprises, agricultural enterprises) should include health criteria. Political donations from food companies should be restricted or banned. Access to and affordability of fruits and vegetables should be improved, especially for low income and disadvantaged population groups National governments should support WHO moves to ensure that all UN agencies have policies that are consistent with the Global Strategy. Marketing and food promotion

The Kobe expert meeting strongly supported the Global Strategys call to ensure that the promotion of food products is consistent with a healthy diet. In addition it recommended: Continued support for the full implementation of the WHO-UNICEF Code of Marketing of Breast Milk Substitutes in all countries. The creation of an international marketing monitoring body, which should include health and consumer advocacy organizations, to report to WHO and other UN agencies on compliance issues and on the development of new marketing methods.

An International Code on Marketing of Food and Beverage Products.

Ensure that marketing controls extend to printed media, electronic media, cross-branding, product positioning (e.g. by checkouts) and product formulation (e.g. use of non-nutritional food additives designed to attract children to energy dense, micronutrient poor foods). Support moves to develop a global alliance of non-governmental organizations concerned with health issues, and encourage such an alliance to consider food production and marketing policies as part of their range of concerns.

Evidence and research The final section of this report considers the difficulties in obtaining relevant evidence for policy-making. Health promotion policies may need to be based on an investment approach rather than a clinical intervention approach. Investments require different types of information including costs, likely effectiveness, likely depth and reach of impact, sustainability and acceptability. Attention needs to be paid to the effects of upstream policy decisions on population health. Research is needed on the effects of, for example, food pricing on purchasing and consumption patterns. The Kobe expert meeting made the following recommendations:

All interventions should include process evaluation measures, and provide resource and cost estimates . Evaluation can include impact on other parties, such as parents and siblings. Interventions using control groups should be explicit about what the control group experiences. Phrases like normal care or normal curriculum or standard school PE classes are not helpful, especially if normal practices have been changing over the years. In schools a one -year intervention may mean one school year which amounts to less than eight months of school attendance. There is a need for more interventions looking into the needs of specific sub-populations, including immigrant groups, low income groups, and specific ethnic and cultural groups.

There is a shortage of long-term programmes monitoring interventions. Long-term outcomes could include changes in knowledge and attitudes, behaviours (diet and physical activity) and adiposity outcomes. New approaches to interventions, including prospective meta-analyses, should be considered.

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Community-based demonstration programmes can be used to generate evidence, gain experience, develop capacity and maintain momentum. There is a need for an international agency to encourage networking of community -based interventions, support methods of evaluation and assist in the analysis of the cost-effectiveness of initiatives. The Kobe meeting also exp ressed concern at the role of interested parties in the funding and evaluation of research. The meeting recommended that research reviews should not be funded by commercial interests. The meeting identified a need to evaluate the impact of programs funded by industry and other sources of potential bias, in order to examine their contribution to the evidence base.

The Kobe expert group concluded by expressing its thanks to the hosts for facilitating the discussions and ensuring that the meeting was a success. The group appointed one of the rapporteurs, Dr Tim Lobstein, to prepare a draft report.

15

WHO nutrition programme


WHO has a major responsibility for promoting healthy nutrition for all the worlds people, through collaborative support to Member States, particularly in their national nutrition programmes, in partnership with other intergovernmental and nongovernmental organizations, and their related sectoral approaches. The aim of WHO's work in nutrition, led by the Department of Nutrition for Health and Development (NHD), is to prevent, reduce and eliminate malnutrition worldwide, (especially protein-energy malnutrition; iodine, vitamin A, and ir on deficiencies; obesity and dietrelated diseases; other specific deficiency diseases), and promote sustainable health and nutritional well-being of all people, thereby reinforcing and accelerating human and national development. Objective 1. To strengthen and support the capabilities and effectiveness of Member States for assessing and addressing nutrition, malnutrition, and diet-related problems, primarily through the development and implementation of national nutrition policies, programmes and plans of action. Objective 2. To develop through consultation, research and collaboration, the scientific knowledge base, methodologies, authoritative standards, norms and criteria, and guidelines and strategies for detecting, preventing and managing all major forms of malnutrition, whether of deficiency or excess, for application by Member States. Objective 3. To promote optimal sustainable health and nutrition benefits of food-assisted development projects targeted to the vulnerable food -insecure, particularly by ensuring the relevance and effectiveness of WFP food aid policies and programmes, in both emergency and development contexts. Objective 4. To maintain global databases for monitoring, evaluating, and reporting on the world's major forms of malnutrition, the effectiveness of nutrition programmes, and progress towards achieving targets at national, regional and global levels. The WHO Nutrition Programme currently maintains databases on obesity and on childhood nutrition, including WHO Global Database on Child Growth and Malnutrition, which includes data on approximately 31 million children younger than 5 years who participated in 419 national nutritional surveys in 139 countries from 1965 through 2002. The Nutrition Programme is also sponsoring the development of new child growth reference data. A Working Group on infant growth, established by the World Health Organization in 1990, recommended an approach that described how children should grow, setting standards across diverse ethnic groups. Internation al growth references should then be upgraded to reflect the standards more closely, to assist in monitoring and attaining international goals related to health and other aspects of social equity. These new standards, based on a global sample of children whose health needs are met, will also provide a useful advocacy tool to health-care providers 1 2 and others with interests in promoting child health. The resulting Multicentre Growth Reference Study (MGRS) is a community-based, multicountry project to develop new growth references for infants and young children. The details of the MGRS project were considered at the expert meeting, and are referred to in more detail in section 5 below.

16

WHO Global Strategy on Diet, Physical Activity and Health


A few largely preventable risk factors account for most of the world's disease burden. NCDs including cardiovascular disease, diabetes, cancers and obesity-related conditions now account for some 60% of global deaths and almost half (47%) of the global burden of disease. A Global Strategy on Diet, Physical Activity and Health was requested by WHO Member States in a 2002 World Health Assembly Resolution on integrated prevention of noncommunicable Diseases (WHA55.23). The Strategy was formally adopted by the 57th WHA in May 2004. The Strategy text 13 describes population-wide, prevention-based policy options to address two of the major risks responsible for the heavy and growing burden of noncommunicable diseases (NCDs): unhealthy diet and physical inactivity. The Strategy explains the global burden of NCDs and how healthier diet, nutrition and physical activity can help to prevent and control them. The document specifies roles for WHO Member States, UN agencies, civil society and the private sector in helping to reduc e the occurrence of NCDs. It also addresses the role of NCD prevention in health services; food and agriculture policies; fiscal policies; surveillance systems; regulatory policies; consumer education and communication including marketing, health claims an d nutrition labelling; and school policies as they affect food and physical activity choices. It suggests limiting intake of sugars, fats and salt in foods, and increasing the consumption of fruits, vegetables, legumes, whole grains and nuts. The Strategy emphasizes the need for countries to develop national strategies with a long-term, sustainable perspective to make the healthy choices the preferred alternatives at both the individual and community level. The Strategy aims to provide Member States and other interested stakeholders with a range of recommendations and policy options to promote healthier diets and more physical activity. It will be up to Member States to decide how these should be further developed and implemented at the country level: Member States then have the responsibility for determining which specific policy options are appropriate to their circumstances at the national level. WHO will then provide technical support for the implementation of programmes, as requested by Member States. Among its recommendations concerning children, the Strategy urges governments to ensure that consumers are given accurate and balanced information, and in particular that food and beverage advertising should not exploit childrens inexperience or credulity. Messages that encourage unhealthy dietary practices or physical inactivity should be discouraged, and positive, healthy messages encouraged. (p7) Governments are encouraged to adopt policies that support healthy diets at school and limit the availability of products high in salt, sugar and fats. Nutrition and physical activity education and acquisition of media literacy should start in primary schools, the Strategy suggests. The Strategy also considers the need to review food assistance programmes, which are often aimed at children in families experiencing economic difficulties. It states: Special attention should be given to the quality of the food items and to nutrition education as a main component of these programmes, so that food distributed to , or purchased by, the families not only provides energy, but also contributes to a healthy diet.(p8) The Strategy was one of the key documents considered at the expert meeting, and is referred to again in sectio n 6 below.

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2. Child obesity in 21st Century This section describes the remarkable recent escalation in the numbers of children affected by excess bodyweight, even in countries in economic transition. Some groups of children may be at particular risk of obesity due to their social, economic or ethnic status. Economic conditions play a significant role, and in some countries the epidemic of obesity among children sits alongside continuing problems of undernourishment, creating a double burden of potential ill health. Furthermore, there may be a link between under-nutrition, especially prior to birth and subsequent risk of obesity and obesity-related ill health in later childhood or adulthood. These considerations were set in the context of the WHOs current nutrition programme and its recently-launched Global Strategy on Diet, Physical Activity and Health, and led the participants in the Expert Meeting to discuss the issues of assessment and prevention described in subsequent sections. 2.1 The size of the problem During the past two decades the prevalence of overweight and obesity in children has increased in virtually every country of the world . Representative data have been collected in many industrialised countries as well as in a number of developing countries, although for most developin g countries the data are more limited, with few figures for older children (>5 years) and adolescents. Among children under the age of 5 years , the global prevalence of obesity (defined as >2SDs, weight for height) was estimated at 3.3%, based on figures collected during the 1990s (14). Among young people aged 5 years, data collated for the WHO Global -17 Burden of Disease report ( 15) and extrapolated to countries where no data are available indicate the prevalence of overweight (including obesity) worldwide to be approximately 10%, and the prevalence of obesity alone to be 2-3%, based on relatively conservative (IOTF) definitions ( 16). These global figures reflect a wide range of prevalence levels, with the prevalence of overweight in Africa and Asia averaging significantly below the global average and in the Americas and Europe significantly above it.

18

Figure 1 Prevalence of obesity among children under 5 years


Algeria Egypt Argentina Chile Morocco South Africa Bolivia Peru Uruguay Jamaica Jordan Australia Brazil USA China Zimbabwe Indonesia Paraguay Azerbaijan Kenya Iran Pakistan Venezuela Turkey Uganda Colombia Tanzania Romania Ghana India Mali Bangladesh Central Afric Philippines Vietnam

10

Source: De Onis and Blossner, 2000

Figure 2 Prevalence of overweig ht and obesity among children aged 5 -18 years
Overweight and obesity in children aged 5-18 years according to IOTF cut-offs. Based on surveys in different years.
35 30 Prevalence (%) 25 20 15 10 5 0
W orl dw ide Am eri ca s Ne ar/ m Euro idd p leE e as t As Su b-S ia-P a ah ara cific Af ric a

overweight obese

Source: Lobstein, Baur and Uauy, 2004

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The prevalence of excess weight among children is increasing in both developed and developing countries. Among children aged under 5, indic es of overweight (prevalence of BMI (CHECK) greater than +2 SD (CHECK)) show a rapid increase in the numbers of children affected in many de veloping economies (see figure below) within a decade.. Fig Changes in the prevelance of overweight among children under 5 years in selected countries
% overweight
12 10 8 6 4 2 0
1994-1999 1991-1998 1988-1995 1987-1992 1998-2000 1991-2002 1986-1996 1982-1996 1988-1998 1989-1998 1991-2000

Costa Rica

Zimbabwe

Armenia

Egypt

Mexico

Dominican Republic

Cameroon

Morocco

Source: Uauy presentation at Kobe, derived from de Onis 2004 (ref?)

Similar patterns are found for older children. North America and some European countries have shown high year-on-year increases in prevalence : for example in the USA and Brazil an additional 0.5% of the entire school-age population is joining those already overweight each year, while figures for Canada show nearly 1.0 of all children are becoming overweight each year. Figure 3 Trends in the prevalence of overweight 1970-2000
Trends in childhood overweight 1970-2000

35 30
Prevalence % Australia Brazil Canada China

25 20 15 10 5 0
1970 1980 1990 2000

Romania

Spain UK USA

Bolivia

Peru

20

Overweight defined by IOTF criteria. Childrens ages (in years) Australia: 2-18, Brazil: 6 -18, Canada: 7-13, China: 6-18, Spain: 6 -14, UK: 7-11, USA: .6-18.
Sources: Lobstein et al (17), Magarey et al (18), Moreno et al (19),Tremblay et al (20), Wang et al (21)

Overweight is especially high among poorer families in developed economies and among better-off families in developing economies. In industrialised countries it is children in lower socio-economic groups who are at greatest risk. In contrast, developing countries show obesity to be more prevalent among higher income sectors of the population, and among urban populations rather than rural ones Developing countries undergoing rapid socio-economic and nutrition transitions are experiencing both under- and over-nutrition problems, creating a double burden of malnutrition and obesity. For example, in Brazil in 1997, the prevalence of overweight and obesity (IOTF definitions) among young people aged 6-17 rose to 13.9%, while the prevalence of underweight (<5th centile NHANES-I) remained high at 8.6%. Similarly, among urban children in China the prevalence of overweight and obesity in 1997 was 12.4%, while the prevalence of underweight was 10.0%. In rural areas the 1997 figures showed the prevalence of overweight to be 6 .4%, and underweight 13.9% , having changed little during the decade. The role of economic development is highlighted by trends in Eastern Europe during a period of severe economic recession in the 1990s. Several countries in the region reported a fall in obesity rates: in Russia, the prevalence of overweight and obesity declined from 15.6% to 9.0% between 1992 and 1998, a period when the country suffered severe socio-economic difficulties. In Poland in 1994, during a period of economic crisis, a survey of over 2m young people found 8% to be overweight compared with the national reference figure of 10% (22). Among younger children, and among children in rural areas, the figure was even lower at 7% overweight. Some socio-economic status groups are disproportionately affected. US data for overweight prevalence among children according to household income are shown earlier in this section. Racial background is also a highly relevant factor in the US: the most recent figures for 1999-2000 (using obesity defined as >95th centile, CDC 2000 reference) show that black and Hispanic children are around twice as likely to be obese as white, non-Hispanic children, their prevalence rates having risen rapidly within the previous decade (23). Figure 4 Obesity among children according to racial group USA

21

25
Age 6-11 Age 12-19

20

Prevalence %

15

10

0 White, non-hispanic Black, non-hispanic Mexican American

Obesity according to 95th centile, CDC 2000 reference. Survey (NHANES) 1999-2000. Source: Ogden et al 2002.

Data from South Africa indicates a different pattern (24). Among young people aged 13-19 years the highest prevalence levels for overweight were found among white (23%) and Indian (25%) populations compared with Africans (17%) (IOTF definitions). That income level interacts with ethnicity can be seen in earlier US data which differentiates between social groupings by both income and ethnic origin, and shows a strong income effect among white population groups but a less marked and possibly reverse pattern among non-white groups (both black and Hispanic). Fig 5.

22

Percent o verweight* among 12-17 year olds by ethnicity and family income: NHANES 1988-1994

25

Poor

Near Poor

Middle or High Income

20

15

10

0 N-H the sex N-H percentile BMI cutoff points in 1966-70 Mexican American *BMI at or aboveWhite and age -specific 95thBlack **age-adjusted Source: Health United States, 1998
Source: Kumanyika slides at Kobe

2.2 The double burden of disease Successful programmes to counter communicable diseases and malnutrition have led to a fall in deaths from these sources, while deaths from chronic non-communicable diseases, such as cardiovascular disease, cancers and diabetes have risen. In all regions except Africa, deaths from non-communicable disease outnumber those from communicable and nutrition-deficiency diseases combined. Communicable diseases , Noncommunic able maternal and perinatal diseases conditions and nutritional deficiencies Africa 7.78m 2.25m The Americas 0.88m 4.54m Eastern Mediterranean 1.75m 2.03m Europe 0.57m 8.11m S-E Asia 5.73m 7.42m W. Pacific 1.70m 9.00m
Source: WHO, WHR, 2003

Deaths for non-communicable diseases occur in younger age groups in de veloping economies, possibly due to more severe forms of these diseases or to the lack of

23

adequate treatment services available to sufferers. The burden of these diseases on health services is rising rapidly in countries such as India, and the loss to the economy from early deaths is also severe. Fig: In India a third of CVD deaths occur under age 65.
80% 70% 60% 50% 40% 30% 20% 10% 0% 35-44 45-54 55-64 65-74 75+ USA India

Source: http://www.unsystem.org/scn/Publications/AnnualMeeting/SCN31/impact.pdf While infectious diseases and undernutrition continue to be significant causes of ill health and death among children in underdeveloped and developing economies, obesity and a rise in associated diseases such as diabetes and heart disease are increasingly being seen in the same developing world populations. Several authors have noted the co-existence, sometimes even within the same household, of undernutrition and overweight (25). This has led to increased concern for children at risk of poor linear growth stunting and their risk of developing excess body weight for height. Stunting (short height for age) affects one third of all children aged under five globally (some 222 million children), most of them in less developed or transitional economies (26). Evidence from several surveys has shown the co-existence of stunting and overweight or obesity in the same child and/or among other members of the same household, in urban areas in developing countries ( 27, 28, 29, 30) and poorer communities in developed countries ( 31,32). Stunting may increase susceptibility to weight gain especially in children consuming diets relatively high in fat (33,34) or where extra food is available opportunistically ( 35). Physiological mechanisms that are triggered by famine and chronic undernutrition might encourage excess weight gain when exposed to environments where high energy foods are plentiful (36). These issues are discussed in greater detail in sections 3.2 and 4.2 below.

24

Probability of obesity in 6-year old children, Chile 1987 and 2003


0.25 2003
probability of obesity

0.2 0.15 1987 0.1 0.05 0 <-2 -2 to -1 -1 to 0 0 to +1 +1 to +2 >+2


height category (z score CDC 2000 reference)

ref Uauy and Kain paper, Kobe 2005 2.3 Health consequences and costs The rise in childhood obesity has been accompanied by higher rates of the correlates of obesity and the emergence of new, or newly identified, health conditions. Once considered rare in children, cardiovascular risk factors, type 2 diabetes and menstrual abnormalities began to be reported in paediatric literature in the 1980s and 1990s. Their occurrence in some populations is now routinely observed. As Pinhas-Hamiel has suggested (37), life-style-related diseases are no longer the exclusive domain of adult medicine (p704). The health effects of the rise in prevalence in childhood obesity are made more serious by the increased severity of the condition. Not only is a greater proportion of the population overweight, but those that are overweight are more overweight than typically observed before, with the most extreme levels in particular appearing more frequently. The delineation of the full range of health consequences linked to excess bodyweight among children and adolescents may help to direct resources to their prevention. As shown in the table below there are few organ systems which severe obesity does not affect, and which have life time consequences for health and wellbeing .
Table: Consequences of childhood and adolescent obesity

Psycho-social Reduced self-esteem Stigmatization and discrimination Depression and suicidal thoughts Pulmonary:

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Sleep apnoea Asthma Pickwickian syndrome Orthopaedic: Slipped capital epiphyses Blounts disease (tibia vara) Tibial torsion Flat feet Ankle sprains Increased risk of fractures Neurological: Idiopathic intracranial hypertension (e.g. pseudotumour cerebri) Gastroenterological: Cholelithiasis Liver steatosis / non-alcoholic fatty liver Gastro-oesophageal reflux Endocrine: Insulin resistance/impaired glucose tolerance Type 2 diabetes Menstrual abnormalities Polycystic ovary syndrome Hypercorticism Cardiovascular Hypertension Dyslipidaemia Fatty streaks Left ventricular hypertrophy Other Systemic inflammation/raised C-reactive protein
Source: Lobstein, Baur and Uauy 2004

Psycho-social consequences Obesity in children and adolescents may have its most immediate consequences in the psychological and social realms. Stigmatisation of obese children and adolescents has long been recognised in westernised cultures, and is well documented among the childrens peers. A 1967 study showed that young boys (aged 6-10) described obese body types as being indicative of negative personality characteristics cheating, lazy, sloppy, lying, naughty, mean, ugly, dirty or stupid (38). Similar observations have been made among Australian boys and girls (aged 8-12) (39). In younger children the degree of negative stereotyping increased with age (40). Among a dolescents, girls may be more affected than boys although both genders report some negative experiences (41). Few studies have assessed the association of obesity with concurrent or subsequent psychiatric pathology, such as depression or anxiety states. Braet et al (42) compared obese children from clinical and non-clinical settings with normal weight controls and found that while self-esteem was reduced in both obese groups, increased psychiatric pathology was only present among obese children in the clinical group suggesting that the factors which led the parents to bring their child to seek treatment may be more

26

responsible for the psychological effects than the obesity per se. Among Californian elementary school children a modest but statistically significant association between increasing symptomatology of depression and higher BMI has been observed for girls although not for boys (43). Eisenberg et al (44) have reported increased suicidal ideas, and suicidal attempts, among overweight adolescents who reported being teased by peers or family members. The social consequences of obesity in childhood and adolescence are pervasive in western societies. American women who were obese as adolescents became adults with lower educational attainment, earning less money, experiencing higher rates of poverty and having a lower likelihood of marriage, compared with thinner women (45). Similar results have been observed in a British cohort (46). Obese youths have experienced greater discrimination in attempting to rent apartments (47) and in gaining admission to colleges, although there is no evidence that obesity is related to lower academic aptitude or to a lesser desire to attend college (48, 49). Not all cultures view excess weight as a negative attribute. For example, a study in Mexico noted that food treats for children are a cultural index of parental caring, and that parents value child fatness as a sign of health ( 50). The study found that obese Mexican children have no greater social problems (peer rejection or stigma) or psychological problems (anxiety, depression, or low self esteem) than their non-obese peers. Such studies emphasise the importance of family and peer attitudes in the generation of psychological distress in the obese child. Several studies have shown a correspondence between a mothers attitudes to food and her childs self-perceptions (51). Similarly, children who have been teased by peers about their body shape are more likely to be dissatisfied with their appearance when older, to the extent of d eveloping eating disorders (52). Sleep-disordered breathing and asthma A well-established pulmonary consequence of childhood obesity is sleep-associated breathing disorder, most clearly seen in severe obesity. The term refers to a broad spectrum of slee p-related conditions including increased resistance to airflow through the upper airway, heavy snoring, reduction in airflow (hypopnoea) and cessation of breathing (apnoea). Obesity-linked hypoventilation syndrome, sometimes referred to as Pickwickian syndrome, is a serious condition associated with pulmonary embolism and sudden death in children ( 53). In one small study, a third of subjects with severe obesity had symptoms consistent with sleep apnoea, and 5% had severe obstructive sleep apnoea (54). Another study found abnormal sleep patterns in 94% of obese children (55), with oxygen saturation below 90% for approximately half of total sleep time and with 40% of severely obese children showing central hypoventilation. Secondary metabolic correlates of obstructive sleep apnoea include hyperinsulinaemia, after accounting for obesity severity (56). Clinically significant effects on learning and memory function in obese children with obstructive sleep apnoea represent a troubling consequence of severe obesity (57).

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Several cross-sectional studies have suggested an association between childhood overweight and asthma (58, 59, 60). In a representative survey of US children aged 2 months to 18 years, BMI above the 85th centile was linked to increased asthma prevalence, independent of age, sex and ethnicity ( 61), although socio-economic status and smoking were associated predictors. A representative survey in the UK showed asthma and obesity linked among girls in an inner city area but not among boys ( 62). The observation that weight loss can improve lung function in obese adults (63) suggests that obesity prevention may decrease the impact of asthma, if not its occurrence. Fatty liver disease Non-alcoholic fatty liver disease (NAFLD) is increasingly recognized as a major health burden in obese children. NAFLD is a spectrum, ranging from fatty infiltration of the liver alone (steatosis) that is relatively benign to fatty infiltration with inflammation known as steatohepatitis or non-alcoholic steatohepatitis (NASH) and chara cterized by the potential to progress to fibrosis, cirrhosis, and end-stage liver disease (64). Current prevalence estimates indicate that NAFLD affects approximately 3% of all children in various countries and from 23% to 53% of children who are obese, wit h up to 70% of these having steatohepatitis, severe fibrosis, or cirrhosis (65, 66). NAFLD therefore appears to be a common form of liver disease in many children, especially in developed countries where the obesity epidemic is most advanced. Childhood NAFLD is typically a silent disease detected as asymptomatic elevation of the hepatic transaminases. Certain children complain of malaise, fatigue, or a sensation of fullness or discomfort in the right upper abdomen and some may have acanthosis nigricans on physical examination. The natural history of NASH is generally one of slow progression with manifestation of clinical disease in adulthood, although advanced liver disease including cirrhosis is known to occur in association with childhood obesity. Menstrual problems and early menarche Abnormalities in menstruation and early menarche represent part of the endocrine response to excess body weight in girls. Previous studies have established a relationship between obesity and lowered fertility (67, 68) but the impact of excess weight on menstrual problems in adolescence is less well established. Oligomenorrhoea or amenorrhoea associated with obesity, insulin resistance, hirsutism, acne and acanthosis nigricans comprise a polycystic ovary syndrome. The prevale nce of polycystic ovary syndrome in youth is unknown, and it is often undiagnosed. However, hormonal patterns typical of polycystic ovary syndrome are increasingly described in obese children (69, 70). In a case-control study, increased BMI at age 18 (based on recalled weight and height) was associated with elevated risk of ovulatoryrelated infertility in young women ( 71). This study, of the US Nurses II cohort, also indicated a positive association between BMI at age 18 and irregular menstrual cycling.

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Menarcheal timing is influenced by weight status, with higher relative weights associated with earlier menarche (72, 73). Evidence from the US NHANES II study shows that the frequency of early menarche is closely linked to obesity status: 33% of higher-weight girls attained menarche before age 11 compared with less than half that proportion among lower-weight girls, and the difference is even more marked when looking at the proportions of girls attaining menarche below the age of ten years. The possible health consequences of early menarche are both immediate and delayed. Early menarche is an established risk factor for breast cancer and has been linked to other cancers of the female reproductive system (74, 75). Delayed maturation linked to obesity in adolescent boys Overweight boys tend to show later maturation than their non-overweight counterparts. The differences are also reflected in the changing body composition that occur during puberty, when girls tends to increase fat mass as a result of maturation while boys tend to increase muscle and other non-fat body mass. Glucose intolerance and Type 2 diabetes Previously only seen in adults, the emergence of type 2 diabetes in youth represents a particularly alarming consequence of the obesity epidemic in childre n. The onset of diabetes in youth will increase the risk in early adulthood of the advanced complications of the disorder cardiovascular disease, kidney failure, visual impairment and limb amputations. A review by the American Diabetes Association suggests that as many as 45% of paediatric diabetes is the type 2 non-insulin dependent form (76). Although other factors are associated with type 2 diabetes in children (including family history, ethnicity and the presence of acanthosis nigricans), the most important risk factor is obesity. In a study of childhood diabetes, Scott (77) found excess bodyweight among over 90% of adolescents with type 2 diabetes while among children with type 1 diabetes excess bodyweight was found in about 25% of cases. There is also evidence that obesity affects the development of type 1 diabetes by accelerating its onset ( 78). The prevalence of type 2 diabetes among children is difficult to establish. In a multiethnic study of a clinical population of 167 obese children and adolescents in the US, impaired glucose tolerance was present in a 25% of younger obese children and 21% of obese adolescents by two-hour tolerance test (79). Undiagnosed diabetes was detected in 4% of the adolescents. Similar findings had been noted 30 years earlier, when 17% of a group of 66 obese children showed impaired glucose tolerance, and 6% met the criteria for type 2 diabetes (80). As the prevalence of obesity rises, the prevalence of diabetes type 2 can be expected to follow: in Cincinnati the prevalenc e of adolescent diabetes type 2 increased ten-fold from 0.7 to 7.2 cases per 100,000 population in the period 1982 to 1994 ( 81). Ethnic minority groups are at high risk of adult diabetes and may also show increased risk among adolescents. Prevalence rates for type 2 diabetes as high as 5% of the

29

adolescent population have been found among some native American populations (82) and among indigenous Australians living in urban areas (83). In Japan, the prevalence of type 2 diabetes is reported to have nearly doubled in the period from the late 1970s to the early 1990s, from 7.3 to 13.9 cases per 100,000 adolescents ( 84). A study in Tokyo of 1400 children attending a diabetes clinic during the 1980s found that none under the age of 9 had type 2 diabetes, but by the age of 1314 the proportions where roughly equal between type 1 and type 2 diabetes, with the proportion of type 2 diabetes rising further into young adulthood (85). Japanese children with type 2 diabetes were both taller and heavier than the national average, and about 80% of these children were obese (86). As a progressive condition for which treatment relies heavily on self -management, type 2 diabetes in youth will require particular attention from health care providers and carers. Physical activity improves insulin resistance in both obese and non-obese youth (87) and weight loss improves insulin sensitivity and decreases hyperinsulinaemia although obese children who maintain weight loss continue to show elevated insulin levels in spite of improved gluc ose tolerance (88). Cardiovascular risk factors More than 60% of overweight children have at least one additional risk factor for cardiovascular disease, such as raised blood pressure, hyperlipidaemia or hyperinsulinaemia, and more than 20% have two or more risk factors.89 Hypertension Obesity is frequently associated with hypertension in adults and the same appears true in children. Up to 30% of obese children suffer from hypertension (90), and among adolescents one survey found 56% of those with persisten elevated blood pressure were t also significantly overweight ( 91). A second study has shown that measures of resting blood pressure are correlated with waist circumference and skinfold measurements in children (92). Measures of blood pressure during exercise may provide further evidence of the links between obesity and hypertension in children (93) Figure 21 Proportion of children with raised systolic and diastolic blood pressure by BMI centiles

30

25%

Systolic
20%

15%

Diastolic
10%

5%

0% <25 25-49 50-74 75-84 85-94 95-97 >97

BMI centiles

Children aged 5 -10 years old. Percentage with blood pressure measures above 95th centiles. Source: Freedman et al ( 94)

Serum lipids and lipoproteins Increased levels of LDL cholesterol, decreased levels of HDL cholesterol and raised serum triglyceride levels are highly correlated with increased triceps skinfold thickness among adolescents (95) and with centile scores of BMI (96). The relationship may be non-linear, however, with no significant increases in these measures in children with BMIs below the 85th BMI centile, but with dramatic increases found among children above the 97th BMI centile Prospective studies show that the serum lipid and lipoprotein levels can track from childhood into young adulthood and are predictive of adult levels. A longitudinal study over 15 years of 1,169 children aged 5 to 14 years at the beginning of the study found that their lipoprotein levels in childhood were associated with their levels when they became adults ( 97). The best predictor for adult dyslipidaemia was childhood LDL level. Metabolic syndrome and paediatric obesity Data from Finland suggest that the cluster of cardiovascular risk factors in adulthood including hypertension, hypertriglyceridaemia, low HDL cholesterol and hyperinsulinaemia (now commonly referred to as the metabolic syndrome) is especially common among obese adults who were also obese as children (table below). Table Prevalence of metabolic syndrome among adults according to obesity status
Not obese as adults (n=293) Obese as adults, not obese in childhood (n=71) Obese as adults, obese in childhood (n=75)
Source: Vanhala et al ( 98)

Prevalence 1% 10% 28%

Odds ratio 1 16 56

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The prevalence of a metabolic syndrome among adolescents aged 12 to 19 years has been investigated in the NHANES 1988-1994 cohort (99). The overall prevalence of the syndrome was 4.2% (6.1% among males and 2.1% among females). The prevalence was significantly related to weight status, being found among less than 0.1% of adolescents of normal weight (BMI below 85th centile), rising to 6.8% among overweight adolescents (BMI 85th 95th centiles) and an extraordinary 28.7% among obese adolescents (BMI 95th centile and above). Trackin g of obesity into adulthood Child obesity is a risk factor for adult obesity indeed the only greater risk factor for adult obesity is having parents who were also obese. Child obesity shows an increasing link to later obesity as the child grows older: work by Whitaker et al 100 shows that at the age of eight years, the risk for subsequent adult obesity is ten-fold for children above the 85th BMI centile compared with those below, rising to nearly 20-fold for those children above the 95th BMI centile. At age 12 these relative risks have increased considerably (see figure). Fig: R isk (odds ratio) of being obese as an adult aged 21-29 according to obesity status in childhood
50 40 odds ratio 30 20 10 0 age 4 not obese age 8 obese age 12 very obese

Source: Whitaker et al 1997.

As previous WHO reports have indicated, adult obesity especially that starting in young adulthood, is associated with a poor prognosis for many chronic conditions. A study by Must et al ( 101) showed that even if adult weight status was normal, a history of childhood obesity gave a significantly increased likelihood of heart disease and overall higher mortality rates in later adulthood. Prevention of obesity in childhood can thus bring both immediate and long term benefits. Financial costs of child obesity There are clearly high health costs associated with adult obesity, estimated at between 3% and 7% of the national health care budget (102) plus an even greater amount for the

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indirect costs to the workplace, the family and social services (103). There are also direct costs associated with childhood obesity which occur during childhood, although these may not appear so high when compared to other disorders in that age group for several reasons. Firstly, few treatments are provided for most overweight children so the health care costs may be low. This might in turn be a result of health professionals not appreciating the seriousness of the problem, or of discrimination against overweight children within the health services. As a result, associated disorders may remain undiagnosed and hence under-reported. Furthermore, there is a failure to record bodyweight measures when diagnosing childhood disorders, leading to a lack of information that could relate a range of possible disorders to a childs excess weight. Calculation of the true costs of child obesity will need a methodology that takes into consideration the associated disorders and their treatment costs. One study which attempted to establish the costs for hospital treatment of obesityrelated disorders in children has been published by Wang and Dietz (104). Using US hospital discharge diagnoses during 1997-1999, they listed the most frequent principal diagnoses where obesity was listed as a secondary diagnosis. The most common comorbidities, accounting for over 40% of principle diagnoses observed in obese children, included asthma, diabetes, gall bladder disease and a range of psychological and behavioural problems. The cost to hospital services was over US$127m, which amounted to 1.7% of annual total US hospital costs. The costs to the health services of failing to intervene in childhood obesity should be considered. If childhood obesity is a risk factor for adult diseases, then rising rates of childhood obesity, especially among the heaviest children, can be predicted to lead to earlier onset of adult obesity-associated disorders. Earlier onset in adulthood will then lead to a longer subsequent lifetime of disability and treatment, creating a significant extra financial burden on national health services. Indirect costs The indirect costs of obesity are those relating to a reduction in the level of economic activity following illness or premature death attributable to obesity, both for the individual and for those who care for that individual It is difficult to calculate . equivalent costs for childhood obesity as the contribution of children to a nations economy is highly variable. Alt hough the standard measures for indirect costs e.g. premature death, loss of productivity, absenteeism, sick leave and disability pensions, may be applied to older adolescents, other more innovative factors will need to be considered, especially for younger children. These might include the need to take time off work for parents caring for ill obese children, time off school, specific costs to the education system, as well as for adolescents entering employment. It may be possible in the future to consider more specifically the costs to the education system, for example, of absenteeism of obese children and the effect this has on the school, and on the costs of providing special equipment and teaching, especially in the physical education sphere.

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Childhood obesity may also have effects on the provision of other services and goods: school transport, leisure facilities, fuel, clothing and even food supplies. Lastly, the costs of premature death produced by obesity in childhood will need to be studied specifically. Intangible costs The intangible costs of obesity are the social and personal costs or losses associated with obesity. The costs spent by families on commercial weight loss programs would be one intangible cost that might be relatively easy to collect. However other intangible costs are far more difficult to define, are more variable and might be subject to the interests and biases of the individual researcher. For example, it is agreed that obesity reduces the quality of life of individuals: they tend to have lower self-esteem. There is no standard approach either to the measurement of these psycho-social factors or to the costs or losses they may produce. In a paper for the IOTF, Segal and co-workers estimated that the intangible costs of adult obesity in Australia were of the order AU$13 18 billion, ten times the direct costs of obesity (105). The same is likely to be true of other developed economies. These intangible costs of obesity probably have the most impact on the individual, and particularly on the child, who is overweight or obese. It is important to design studies to estimate the intangible costs of obesity which children bear and not to assume that the costs and effects are similar or smaller compared to those found in studies on adults. In one study of severely obese children in the USA the quality of life scores were substantially lower than those of non-obese children, and were similar to the scores of children diagnosed as having cancer (106). Studies are needed which investigate the consequences of psycho-social factors on school performance, job prospects and employment. Such intangible costs will have a major impact for the child and for society. A systematic analysis of the quality of life needs to be undertaken so that an assessment of the intangible costs of obesity in childhood can be made.

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2.4 The need for a WHO consultation This section of the report has shown that the numbers of children suffering obesity has rapidly risen in the last two decades. The consequences can be seen in a range of childhood diseases and indicators of risk of subsequent disease, and a high likelihood that obesity in later childhood will track through to adult obesity. The financial costs are high and rising in developed economies. It can be anticipated that the costs will also be high for developing economies either through treatment costs or in lost years of productive life. In response to these trends, the WHO commissioned a series of papers on child obesity and followed this with an expert meeting in Kobe, Japan, during June 2005. Previous exert consultations had already identified the need to tackle obesity in childhood and adolescence. In 2000, WHO published the report of an expert consultation on obesity (107) which noted that the management of obesity in childhood should involve only small reductions in energy intake in order to avoid compromising normal growth and development, and that research on the value of exercise in treating childhood obesity was very limited. It also noted that evidence for the efficacy of childhood obesity treatment was largely based on a series of trials undertaken by Epstein and colleagues,(108 109) which showed long term benefits for comprehensive programmes involving children from white, middle class American families with two parents, and included family participation in the treatment programme. The report stated that introduction of obesity prevention programmes in schools was justified for a number of practical reasons, and the evidence to date was modestly encouraging but that the maintenance of such programmes suffered from competition for school resources in terms of time, staff input and finances. The report added that care should be taken to avoid risking malnutrition, the encouragement of easting disorders or stigmatization of the overweight child. In its summary, the report urged that priority be given to establishing a standard model for defining childhood and adolescent obesity, the need to develop and validate measures for excess weight across different societies and ethnic groups, and the need to increase understanding of the relationship between BMI and adiposity in stinted children, especially in countries undergoing rapid nutrition transition. It called for prevention of overweight and obesity to begin early in life, and it should involve the development and maintenance of lifelong healthy eating and physical activity patterns. Prevention, it added, is not just the responsibility of individuals but also requires structural changes in societies, and that Communities, governments, the media and the food industry need to work together to modify the environment so that it is less conducive to weight gain. A second WHO consultation also noted the need to tackle child obesity. Based on a review of risk factors for diet, physical activity and chronic disease in 2002,( 110) a WHO Expert Committee gave the following advice for obesity avoidance in infants and young children:

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The promotion of exclusive breastfeeding Avoiding the use of added sugars and refined starches when feeding formula Instructing mothers to accept the childs ability to regulate energy intake rather than feeding until the plate is empty Assuring the appropriate micronutrient intake needed to promote optimal linear growth. Education provided to mothers, especially those who have experienced food insecurity, should emphasise that overweight and obesity in children do not represent good health.

In later childhood, the report advised obesity avoidance through the following:
Promote an active lifestyle Limit television viewing Promote the intake of fruit and vegetables Restrict the intake of energy-dense, micronutrient-poor foods Restrict the intake of sugar -sweetened soft drinks Ensure opportunities for family meals Limiting the exposure of young children to marketing practices which promote ener gydense, micronutrient-poor foods Providing the information and skills to make healthy food choices

The report noted the importance of prevention in preference to treatment, not only because the manifestations of chronic disease are occurring earlier and earlier, but that once they have developed they track in the individual through life, and that overweight and obesity are notoriously difficult to correct after becoming established. Following the publication of the two expert reports, the WHO has proceeded to develop its nutrition programme on child growth reference standards (see later in this report) and has developed a Global Strategy on Diet Physical Activity and Health. In calling an expert meeting, the WHO recognised the need for advice on:

reliable statistical data on child growth patterns which could be used to set growth standards and to create reference charts for growth assessment; the links between traditional malnutrition and later obesity risk, and the need to consider energy and nutrient requirements for children in families experiencing food insecurity; interventions in childhood to promote optimum growth and wellbeing; strategies and policies to prevent child and adolescent obesity, taking into account the WHOs Global Strategy on Diet, Physical Activity and Health; and the need to identify areas requiring further research in relation to these issues. These issues were considered at the Kobe expert meeting and their conclusions are described in the sections below.

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3. Risk factors for child obesity The previous section of this report noted the extent of childhood obesity and the health consequences, both in childhood and adulthood, as well as the financial costs. In order to make interventions through treatment of obese children and adolescents or through prevention of the problem in populations at risk it is necessary to understand how a child becomes obese. The present section considers the various physical and environmental risk factors that increase the likelihood that a child will accumulate excess weight. It also looks at the wider context in which the risk factors are set: the changing pattern of diets and the reduced need for physical activity which many children are experiencing as members of newly urbanised, industrialised populations. 3.1 Patterns of growth and weight gain Early growth A number of studies have shown that birth weight, a crude summary of growth in utero, is positively related to subsequent fatness (111, 112), suggesting that the foetal environment plays a role in the development of obesity. Several studies report a J- or Ushaped relationship, with a higher prevalence of obesity seen for both the lowest and highest birth weights (113, 114), suggesting a more complex association between growth in utero and obesity. Just such a U-shaped relationship between birthweight and subsequent age-adjusted adult BMI was found in the US Nurses Health Study 1 (115) (see figure xx). Figure xx Birthweight and age-adjusted adult BMI

27.5 27 26.5 26 25.5 25 24.5

<5

5-5.5

5.6-7.0

7.1-8.5

8.6 -10

>10

Birth Weight (lb)

Source: Martorell et al (2001) citing Curhan et al (1996)

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Studies of famine or maternal smoking during pregnancy also suggest the picture is complicated, and that an adverse foetal environment may promote obesity independent of any effect on foetal growth (116, 117). Maternal diabetes during pregnancy results in offspring with higher birth weight, and higher risk of obesity in children, although only after 4 5 y (118). The latter association seems to be independent of birth weight and maternal weight, suggesting that the effect is due to alterations to the intrauterine environment. Further work is required to determine whether different types of diabetes, insulin and non-insulin dependent, and gestational diabetes have different effects. Another possibility is that postnatal weight gain is important: a recent study reported that rapid weight gain during the first 4 months of life increased risk of obesity at 7 years of age, independently of birth weight and gestational age, weight at 1 year, maternal BMI and education (119). Other studies suggest that it is the combination of foetal growth and subsequent growth that is relevant, and that light babies who show postnatal catch up growth or rapid childhood growth are at increased risk of obesity ( 120, 121). Weight gain in infancy and childhood It is normal for young infants to put on a high percentage of body fat but the rate of fat deposition slows from around the age of weaning onwards. Plotted over time, the body mass index shows an initial fall during the second to fifth year of life and then a gradual rise from the sixth year through adolescence and most of adulthood. The age at which this second increase starts has been termed the adiposity rebound. If children are becoming progressively and excessively fat at ages when other children are tending to show a fall in fatness and in BMI (i.e. between around six months and five years old), this is probably a warning sign for significant and perhaps, since it is developing when other children are tending to reduce fat, persistent obesity. A study of children aged eight years showed that both weight at birth and relative weight at age eight years have a significant effect on abdominal fat levels: those children with the lowest birthweights combined with the highest relative weight at eight years showed the greatest level of abdominal fat some 50% higher than those children who had been heaviest at birth but relatively lighter at age eight. Thus low birthweight and high weight gain in infancy are both predictive of abdominal fat levels.

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Abdominal fat %

6.5 6.0 5.5 5.0 4.5 4.0 <3 '3 - 4 >4


Weight at Birth (Kg)

> +0.67 intermediate < -0.67


Weight at Age 8 yr SDS

Source: Baur (Kobe meeting powerpoint)

Adiposity rebound A child's BMI normally falls from around the age of one year, only to rise again around the fifth year. Several studies have shown that the earlier this rise (or rebound) occurs the greater the risk of subsequent obesity (122). One study has suggested that earlier adiposity rebound is induced by thinness at around the age of one to two years, and this is linked to later risk of diabetes ( 123). At this age it appears to be the thin infant who is likely to become overweight and diabetic in later life rather than the fat one, an important finding for public health policy w hich might otherwise assume that fat two year-olds are at greater risk of later ill-health than thin ones ( 124). It is not clear whether the importance of the early adiposity rebound lies in a biological mechanism for enhanced weight gain during childhood as a causative factor, or whether it is merely indicative of a tendency to gain weight more rapidly than other children due to prevailing genetic or environmental conditions. Dietary variables do not appear to predict adiposity rebound (125), although this requires confirmation in other studies. The link between an early adiposity rebound on later adult obesity appears to be independent of BMI at rebound or parental obesity (126). However, the age of rebound may add little to the prediction of adult obesity if BMI at age 7 years, (i.e. after rebound), and height in childhood are known for a given BMI in childhood the taller child is more likely to be an obese adult (127 128). Cole has suggested that a growth pattern crossing the centiles upwards is more closelyt related to later obesity than the timing of the rebound. 129

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Weight gain in adolescence Adolescence is one of the most vulnerable periods for the development of overweight/obesity. Risk factors for cardiovascular disease, insulin resistance, hepatic steatosis, polycystic ovary syndrome, and orthopaedic complications associated with obesity increase and the probability of becoming an obese adult also increases in adolescence. Adolescence seems to be a period for entrainment of obesity-related morbidity (130).While correlations between adiposity in earlier childhood and in adulthood are poor to moderate, correlations between adiposity at ages 13-14 years and at age 25-36 years range up to 0.91 for boys and 0.78 for girls. As the prevalence and degree of childhood obesity increases in populations, the strength of the correlations may also increase. Furthermore, adolescent obesity may have a direct effect on adult morbidity and mortality, independently of adult weight status ( 131). Although the mechanism is unclear, it is possible that fat distribution patterns established during adolescence play a role: boys tend to deposit fat centrally and lose fat peripherally as they mature, showing a pattern predictive of diabetes, heart disease, hypertension and hyperlipidaemia in adults. During the early pubertal period, growth is associated with significant changes in body composition ( 132). Girls tend to accumulate more fat than boys. Fat gain occurs in boys and girls early in adolescence, but then ceases and even reverses temporarily in boys, and continues throughout adolescence in girls. Menarche usually occurs shortly after the peak in height velocity. As height velocity decelerates there is an acceleration in fat gain (133). Lean body mass increases rapidly during adolescence to reach a maximum at 20 years. For more discussion of assessment of adiposity during this period see section 5 below. Genetic environment interactions The risk of a child becoming overweight increases with parental overweight and obesity (134,135). It is likely that the family association is due partly to genetic factors and partly to shared patterns of diet and physical activity. Some data suggest that the parent -child fatness relationship may be stronger between mothers and their offspring than fathers and offspring, and that the mother-offspring correlation strengthens as the child gets older ( 136). Other data shows that parental obesity is a more important predictor of offspring obesity and its tracking into adulthood if expressed in early childhood: by adolescence, a childs own weight status is a far stronger predictor of adult obesity than the weight status of the parents (137). A series of elegant analyses conducted by Bouchard and colleagues have looked at twin pairs exposed to under- and overfeeding, and indicate a substantial genetic component in weight gain in response to food intake (138) accounting for up to 50% of the variability. The authors suggest that the genetic components are complex and that amount and rate of weight gain are unlikely to be related to a single gene in the majority of cases of obesity (139). A review of the field by Allison et al ( 140) noted that

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monozygotic twin studies have found the heritability of BMI to be as high as 85% while adoption and family studies have found heritability in the range 25%-50%. The authors suggest that the true figure is likely to be around 70%. That genes should account for so much of the variation in BMI might lead to the conclusion that the environment has little impact, but this would be erroneous. Genes are best expressed in appropriate environments and with the rise in obesity prevalence being noted in so many countries, it is clear that the environmental conditions for obesity expression are being created in several parts of the world, especially in urban, industrialised regions. As the reviews authors conclude: If we are to be responsive to the obesity problem that the population has as a whole, the environment must be changed to become less obesegenic [sic] and more promoting of healthy diets and activity patterns (p160). The argument can be posited differently: what proportion of the rise in obesity seen in the population can be attributed to a purely genetic factor, virtually unaffected by environmental stimuli? The review by Allison et al (op cit) suggests that some 10% of population may become overweight even in environments that militate against weight gain, and a similar proportion of the population might have a strong genetic predisposition to remain thin in obesogenic environments. The majority of the population carry combinations of genes which may have evolved to cope with food scarcity, a genetic predisposition which is maladaptive in an environment of ready availability of calorie-dense food where low energy expenditure is the norm. The influence of the environment is clearly illustrated in a comparison of weight status of Pima Indians living in the mountain state of Sonora in Mexico and genetically similar Pima Indians living on the Gila River Indian reservation in Arizona. The Pimas who reside in Mexico have an average BMI of 25, whereas Pima men and women living in Arizona have average BMIs of 31 and 36, respectively (141). Similarly, studies of immigrants into the United States from countries with lower obesity rates, such as China and Japan, show that the US immigrants develop higher obesity rates than the population they left, and the immigrants offspring continuing to live in the US develop even higher rates of obesity than their parents (142). Genetic risk factors This document will not deal extensively with individual children at risk as these children are not normally the targets of health promotion or disease prevention programmes of the sort being discussed here. In brief there are a number of cases of obesity in children which may be due to specific genetic factors (Down syndrome, Prader-Willi syndrome, Duchenne muscular dystrophy and others) or to the side effects of treatment for other disorders (such as epilepsy and behaviour disorders) or to other aspects of ill health (such as physical disability or poor control over type 1 diabetes). Further discussion can be found in Lobstein, Baur and Uauy 2004 (143). Health screening programmes to identify children with excess bodyweight in community populations may need to be aware of these complications.

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3.2 Social and environmental risk factors linked to obesity There are several identifiable risk factors within the population of normal children which affects their risk of becoming obese. These are summarised in this section. Ethnicity It is a common impression that schoolchildren from non-Caucasian backgrounds living in westernised societies have a greater propensity for developing obesity than white Caucasian children but, when socio-economic circumstances and parental education are taken into account, the differences may not be great. In the USA, for example, African Americans and Hispanic Americans appear to contribute more to the obesity epidemic, with more rapid rates of change in their populations, than in the white America n population (144). Furthermore, overweight among white families appears to be inversely associated with income status, whereas this is not apparent among Hispanic and nonHispanic Black American groups (see figure X in section 2). In the UK, children from South East Asian backgrounds tended to have a lower ponderal index than white children, but showed higher insulin levels and a stronger relationship between adiposity and raised insulin concentration (145) but now adolescent children from Asia and the Afro-Caribbean are more prone to overweight (146) A survey in the Netherlands of Turkish and Moroccan immigrant groups found the children to be more at risk of overweight than Dutch children ( 147). These racial/ethnic disparities may be partially but not fully explained by family income and other social inequalities ( 148). A study in Germany of some 2000 children aged 6 years old has shown that the prevalence of overweight was twice as high among families from southern and eastern European backgrounds compared to children in families of German descent, but that most of the differences could be explained by known risk factors, especially mothers lower educational level and childrens greater television viewing. 149 The prevalence of complications of obesity such as Type 2 diabetes mellitus and hypertension amongst populations from the Indian subcontinent, together with the lower BMI levels for risk of complications in adults, have implications for the development of obesity in children from the Indian subcontinent. The re is need for more research on body composition in ethnic minorities in different countries and on the outcomes for childhood obesity in these groups. Maternal diabetes The offspring of women who had diabetes during pregnancy are more likely to become obese later in childhood and to have a higher prevalence of impaired glucose tolerance than the offspring of women who were non-diabetic.( 150) By age 15 years, children of diabetic mothers showed greater body fatness, higher blood pressure, and raised fasting levels of blood glucose, insulin, glucagon and triglycerides than children of non-diabetic mothers (151).

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Although maternal diabetes during pregnancy results in offspring with higher birth weights, Silverman et al found that heavier babies tend to revert to normal weights by one year of age but then show increases in BMI after about age four years compared with national reference standards, i.e. the children showed an early adiposity rebound (see above). This normalisation followed by departure from normal implies that these childrens obesity is metabolically imprinted or programmed during their intrauterine experience, rather than reflecting a persistence of obesity acquired before birth. Smoking in pregnancy Maternal smoking has been linked to subseque nt adiposity in children ( 152, 153). Although several confounders may limit the interpretation of the results, von Kreis et al have shown a dose -dependent relationship between maternal smoking during pregnancy and prevalence of overweight and obesity in children aged 5-7 years, which could not be explained by social class, mothers weight or childs birthweight ( 154). In this study, smoking after pregnancy appeared unrelated to child obesity, suggesting that intrauterine exposure to the products of smoking, rather than family lifestyle factors, were instrumental in raising the risk of childhood obesity. Early malnutrition As noted above, a u-shaped relationship exists between birth weight and subsequent risk of obesity. A higher risk of obesity has been observed in young Dutch adults who had been born to mothers who had faced famine conditions in early pregnancy ( 155) and several reviews have noted an association between poor intrauterine growth and later obesity (156, 157). Considerable evidence now exists that obese children and obese adults who had low birth weights are more vulnerable to both coronary heart disease and type 2 diabetes than similarly obese people who had higher birthweights ( 158). In addition, stunting at birth appears closely linked to insulin resista nce in pre-pubertal children, with the highest insulin resistance among those children who have become the heaviest by this age. 159 The relationship between birthweight and risk of subsequent heart disease or diabetes among adults has been demonstrated among populations in the Indian sub-continent, where it has been found more pronounced among urban populations than among rural ones, even though lower birthweights are more common among rural populations. Yajnik and co-workers have demonstrated that a combination of low birthweight followed by subsequent weight gain in childhood led to the highest risk of developing insulin resistance and cardiovascular risk factors (160, 161). Low birthweight babies in Indian populations appear to have depleted muscle mass and visceral mass, but preserved subcutaneous fat, and are prone to gain weight by increasing their central obesity. This high-risk pattern was associated with a lack of fruit and vegetables in the mothers diet during pregnancy and to indications of malnutrition in the mothers own early life growth, such as shortness of stature and small head circumference (162). The risk factors for developing obesity, diabetes and coronary heart disease seem therefore evident in the previous generations nutritional status. Supplemental feeding

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programmes for low birthweight babies may e ncourage rapid weight gain and exacerbate their risk of subsequent chronic disease. These factors are considered in more detail in section 4 below. Special risks in communities with HIV-AIDS Nutrition can be a major concern in communities where a significant number of families are affected by HIV-AIDS. Although obesity prevention may not appear to be a high priority for children in these circumstances, there are risks that a child being cared for may be inadvertently put at greater risk of chronic diseases such as obesity through well-intentioned measures to provide supplemental feeding. Several points need attention: 1. HIV women have a higher incidence of pre-term and low birthweight deliveries ( 163, 164 ). As low birthweight is a risk factor for later chronic disease and central obesity, as well as for immediate risk of undernourishment, interventions to raise the nutritional status of the mother before and during pregnancy are desirable. A well-nourished mother is also less likely to transmit HIV through breastfeeding (165), so maternal nutrition continues to be an important means of protecting both mother and child. 2. The fear of a risk of HIV infection through breastfeeding, or the inability of an infected mother to offer breastfeeding, may result in children being put on formula feeds and/or weaned early, which may raise the risk of weight gain and early adiposity rebound (see below). Breastfeeding policies for HIV-AIDS infected mothers need to be kept under review in the light of research into the risk of disease transmission, and weighed against the risks of feeding from alternative sources. Breastmilk supplied by non-infected mothers might be the option of choice. 3. HIV -exposed infants may start life with impaired nutrition and shower slower growth.( 166) Attempts to introduce high energy feeds for these children may raise the risk of rapid weight gain without the necessary gain in length/height, leading to obesity combined with stunting, as discussed above. Equally, offering a limited range of micronutrient supplements will not compensate for a poor diet with restricted quantities and range of foods. A diverse diet, adequate in quantity and quality is recommended, preferably based on local foods and crops that are nutrient rich and culturally acceptable (167). 4. There is some evidence that HIV-infected children treated with anti-retrovirals are likely to show central obesity and insulin resistance in addition to malnutrition (168). Data on the aetiology of malnutrition in such children, the nutritional effects of highly active anti-retroviral therapies, and the effects of nutritional intervention strategies for HIV-infected children need further assessment. Most HIV-AIDS cases are in poorer communities in developing countries, where food and nutrition security issues need to be addressed for all the population and particularly for people living with HIV -AIDS. However, it should also be recognised that food insecurity is also found among HIV-AIDS high risk groups in developed countries:

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research among HIV-positive individuals in Canada found food insecurity to be highest among women, native Canadians, households with children, those with lower educational attainment, a history of recreational injection drug and/or alcohol abuse, and an unstable housing situation.( 169) Household food security, micronutrient supplementation and fortification, maternal nutrition, infant feeding, school nutrition programmes, food safety and communitybased feeding programmes need to be reviewed. Sustainable nutrition interventions should aim towards ensuring children in these circumstances have access to a fully balanced and varied diet of culturally appropriate foods. The provision of nutrition care and support has not been a priority in HIV programmes, despite the observation that the people themselves often request food and nutrition before medication ( 170).

Social deprivation In most western societies children from socio-economically deprived environments have a greater risk of obesity than those from more affluent groups ( 171). Adult obesity in advanced economies also appears related to relative deprivation, with higher obesity prevalence found in countries with the greatest income disparity, after adjusting for absolute average per capita income ( 172). Low self esteem and feelings of disempowerment may be relevant to how deprived families cope with children who are overweight. However conditions such as a depressed environment with nowhere safe for children to play; a lack of opportunity for away -from-home activities so television watching becomes the main leisure activity; and distance from shops where fruit, vegetables and low energy density foods are affordable and readily available, may all contribute to obesity prevalence, and may act from an early age . Socio-economic status and educational level appear to be independently related to adult BMI, suggesting that socio-economic circumstances in early life have an enduring and important effect ( 173). In countries with less industrialised diets, the patterns of obesity related to socioeconomic status of the family are more complex, with a tendency for urban children and children in high earning families to be more at risk of excessive weight gain. In China, for example, children from advantaged backgrounds tend to have higher BMIs than those from disadvantaged backgrounds ( 174). In both industrial and developing countries, the ease of access to an energy-rich, nutrient-poor diet and to sedentary activities such as television watching appear to be most closely linked to weight gain. Obesogenic lifestyle are determined by many factors, including family income, access to transport, the distribution and marketing practices of the producer companies, and lack of access to healthie r alternatives. In developing countries underweight may co-exist with overweight within the same household: one estimate (for households in Asia) suggests that the coexistence of both forms of mis-nutrition is up to 15% of all households, and that between 30% and 60% of all households where one member is underweight will have another member who is overweight (175). Public health policies aiming to reduce underweight may inadvertently serve to encourage excess weight (see section 4) (176).

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Family and school functioning Family size, position of the obese child in the family, lone- or both-parent families have all been found relevant to the prevalence of childhood obesity in some studies but the results are inconsistent ( 177). Family functioning may be linked to behavioural and psychological factors : a Danish study reported that parental neglect and lack of parental support of children were both risk factors for developing obesity in early adulthood (178). In the Danish context, the quality of the home, the local environment and the level of caring within a family appeared to be more relevant to the development of obesity than the familys size or specific economic status. Children with parents who show high levels of dietary disinhibition (abandonment of control of dietary intake in presence of certain external food cues), especially with concurrent dietary restraint (conscious restriction of diet to control weight) show greater increases in fatness ( 179). In infancy, a vigorous feeding style (180) and distress in response to food limitations (181) were related to increased subsequent fatness, while the readiness with which a child could be soothed was linked to decreased fatness. In childhood, predictors of fatness included behavioural features such as decreased adaptabilit y, increased intensity and withdrawal (182), various aspects of self-esteem and family functioning (183, 184), and feelings of inadequacy (185). At school, a higher percentage of overweight children are found among low -achievers, and this association between overweight and under -achievement persists into adulthood (186). A study in Thailand found that being or becoming overweight in adolescence was associated with poor school performance, although this was not the case for younger children (187). In young adults, intelligence test scores and educational levels are lower among those with BMIs above the median (188). Environmental risk factors In modern industrialised societies, processed foods and beverages are widely available, few people have jobs requiring hard physical labour, car ownership has increased rapidly and homes have labour saving devices. Yet human metabolism evolved under very different conditions with a sparse and erratic food supply and huge physical demands for survival, which has selected individuals with a thrifty genotype. This genotype is ill-suited for the modern world. Excessive fat storage, leading to obesity, is the default situation and can be considered a natural response to prevailing environmental conditions unless specific action is taken. The 2002 WHO/FAO expert consultation on diet, nutrition and the prevention of chronic diseases recognised this link between the wider environment and the increasing prevalence of obesity in adults (189). It is probable that similar factors are linked to the rise of overweight in children: for example, a decline in walking to school and a rise in snack food and soft drink consumption and in the popularity of fast-food outlets. Within this obesogenic environment there are a number of factors which warrant specific consideration with respect to the risk of overweight in children and adolescents.

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However, it is also important to consider the micro-environment created in the home. For younger children in particular the family environment plays an important role in determining their risk of obesity, for example parental physical activity levels, the familys eating behaviours, and television viewing habits ( 190,191,192,193). Infant feeding Several studies have suggested a protective effect of breast feeding on obesity (194, 195, 196 ), and on the risk of type 2 diabetes during childhood and adolescence among high risk groups (197), but others argue that the apparent effect may be due to confounding factors such as social class, maternal fatness, maternal diabetic status, maternal reluctance to breastfeed, or infant birthweight (198, 199, 200, 201). Koletzko and von Kreiss study of 10,000 children in Bavaria found significantly greater proportions of those children who had been formula -fed as infants were overweight at the age of school entry (5 or 6 years old) compared with those who had been breastfed ( 202). The protective effect of breastfeeding was dose-dependent, with better protection against excess weight gain among those children with the longest duration of breastfeeding as infants. However, the authors acknowledge the potential role of confounding factors, including social class, smoking during pregnancy and general family dietary habits. A study of 32,000 children aged around 3.5 years by Armstrong and Reilly found obesity to be lower in breastfed children, after adjusting for socio-economic status, birthweight and gender (203). A longitudinal study by Bergmann of a cohort of nearly 1000 infants found no difference in BMI at birth, a raised BMI among breastfed babies at 1 month, but after 2 months a raised BMI and increased skinfold thickness among bottlefed babies compared with those that had been breastfed for two months or more (204). Fig: Effect of breast-feeding vs formula feeding on childhood obesity: covariate adjusted odds ratios of nine studies and pooled odds ratio

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Source: Arenz et al 2004 ( 205) (from Baur Kobe powerpoint) Risk factors in infancy have been reviewed in a large-scale longitudinal study being conducted in the UK (the Avon study) and initial results suggest that several factors independently increase the risk of obesity by the age of 7 years, including birthweight, maternal smoking, parental obesity, time spent watching television, short duration of night time sleep, catch-up growth and early adiposity rebound, lack of breastfeeding, early weaning onto solid foods, and a diet of energy-dense junk foods although these last three are accounted for by family social class and the childs total food energy intake.(206) Macronutrients and energy density Energy density reflects the energy content of foods, usually expressed per unit weight, and is generally highest in foods containing high levels of fat, although there are exceptions in some processed foods.(207) Foods containing high levels of added sugars and refined starches may add energy but few micro-nutrients, thereby reducing the overall nutrient -density of the diet. In the 2003 WHO technical report on diet and chronic disease it is suggested that there is convincing evidence that a high dietary intake of energy-dense, micronutrient-poor foods would increase the risk of obesity (208). The report notes that such foods tend to be processed foods that are high in fat and/or sugars while low energy-dense (or energy-dilute) foods, such as fruit, legumes, vegetables and whole grain cereals, are high in dietary fibre and water. (page 63) In an analysis of typical foods served at fast food outlets in the UK, Prentice and Jebb (209) found the food to have greater energy density (by weight) than that found typically in UK diets, and to be more than twice the energy density of foods recommended for

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healthful diets. A study by Bowman et al in the USA found that on those days when children consumed fast food products their diet was likely to be less healthful than on other days: the energy levels were higher, the energy density per gram was higher, the fat intake was higher and the fruit and vegetable intake lower (210). Figures show the consumption of fast food by children has increased by 300% in two decades (211). Soft drinks Energy consumed as drinks should be considered separately from solid food since experimental studies suggest that the post-ingestive effects on appetite may differ. Soft drinks make a growing contribution to the diet of young people, even young children (212). The quantity of soft drinks consumed increases with age and can account for the largest single source of non-milk-extrinsic sugar intakes among young people (213). A prospective study by Ludwig et al (214) reported a positive association between consumption of sugar-sweetened drinks and obesity in children aged 11-12 years, monitored over a 19 month period. However, those children consuming more soft drinks had other dietary differences compared with those consuming less soft drinks, and the association may not be related to soft drink intake per se but to broader dietary or lifestyle habits associated with soft drink consumption. In the Ludwig et al study, increased diet (low calorie) soft drink consumption was negatively related to obesity incidence, but this association may be confounded as these drinks may be preferred by individuals trying to control weight. There is no comparable medium- or long-term study in children. In a study of children given a single meal accompanied eit her by a sugar-sweetened drink or an aspartamesweetened drink, there was no significant difference in energy consumed from the other foods at the meal, but the children consumed more energy in total when the sugar sweetened drink was served ( 215). A study by James et al found that a year -long school intervention designed to decrease consumption of soft drinks amongst children aged 711 years was successful in reducing intake by a little over half a portion per day ( 216). Furthermore, the proportion of children who were overweight at the end of the period had slightly reduced while the proportion had significantly increased in a matched control group. Eating patterns Babies and young children characteristically have frequent eating episodes. In most westernised societies, this behaviour is generally replaced with a three-meals-a-day culture as children get older. However, there is an increasing tendency in these industrial societies for more frequent and less well-defined eating occasions in both adults and young people ( 217) with increases in grazing , i.e. the consumption of snacks and beverages at more frequent or irregular intervals. Few studies have examined the association between eating frequency and body weight in young people, although irregular snacking was found to be correlated with a raised risk of obesity among 3 year-old children in Japan (218).

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The types of foods commonly consumed as snacks are often high in fat or high in carbohydrates (sugar and/or starch). In a study by Marmonier et al (219) in adult subjects, isocaloric snacks of 1 MJ delayed the request for a subsequent meal differentially according to the principal macronutrient in the snack: those snacks with a high fat and high carbohydrate content delayed meal requests by an average of 25 a nd 34 minutes respectively while high protein snacks delayed meal requests by an average of 60 minutes. The authors comment that a 1 MJ snack might have been expected to delay meal requests by 200 minutes according to the subjects average basal energy expenditure, implying that all snacks had poor satiating efficiency. Children who skip breakfast may be at increased risk of weight gain (220, 221). There is clearer evidence for this among adults (222) although the exact mechanism remains unclear: eating breakfast may be associated with decreased fat intake and decreased snacking later in the day, or eating breakfast may be a marker of more organised family routines that are indicative of better health behaviour generally. Portion size In North America, and to some extent in other countries with well-established industrialised food supplies, increases in standard portion sizes have occurred across a range of foods eaten in and outside the home ( 223). Academic research suggests that while very young children have innate control of appetite and are able to match intake to energy needs, in older children this biological mechanism can more easily be overridden by environmental and social factors. A study of the effect of portion size on food intake at a given meal showed no change in energy intake among 3 year-old children but a positive association in 5 y -old children (224). A second study showed that in very young children, aged 12 to 18 months, body weight was positively related to energy intake and to portion size but not to the number of eating occasions ( 225). More research is needed, particularly in relation to the effect of portion size on subsequent energy intake in older children and the contextual factors that may influence this. Nevertheless, it is immediately apparent that a kingsize snack or beverage can provide a disproportionately large contribution to a childs energy needs in a single food item. Fast food restaurants and school canteens Several studies have noted the possible role of fast food restaurants as a possible environmental risk factor for obesity: as noted, the menu items tend to be particularly energy dense226 and branded fast food chains are heavily marketed through television, collectable toys, cartoon characters, sponsorships and interne t sites. Few studies have examined the effects of fast-food consumption on specific nutrition or health-related outcome, however, although a popular report of an individual whose diet for a month consisted of food from one fast food chain indicated substantial ill-effects on cardiovascular function, liver function and obesity. 227 One study of fast food restaurant

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use by adolescents found that more frequent use was associated with greater total daily food energy intake, higher percent energy from fat and fewer daily servings of fruit, vegetables and milk. Frequent use was also linked to television viewing and to home availability of unhealthy foods, but was not associated with overweight status. 228 A link between fast food consumption and obesity among urban children in China has also been suggested (229, 230). A study by Bowman et al 231 on over 6,000 children and adolescents found that 30% of the subjects consumed fast food on any typical day, and that on the days when fast food was eaten the children consumed more total energy and had a poorer overall diet than on days when they did not eat fast food. Compared with children who routinely ate fast food, those who did not routinely eat fast food consumed nearly 200kcal less total energy per day, less total energy per gram of food, less total fat, less sugar, fewer soft drinks, and more dietary fibre, more milk and more fruit and non-starchy vegetables. An Australian report on the location of fast food outlets showed that families living in areas of lowest socio -economic status had 2.5 times the exposure to fast food outlets than people in the wealthiest category. 232 More recently, a US study has shown that the differences in obesity rates between different US states may be in part to the density of fast food outlets in each state: the number of square miles per fast food restaurants and the number of residents per restaurant accounted for 6% of the variance in state obesity rates after controlling for population density, ethnicity, age, gender, physical inactivity, and fruit and vegetable intake. 233 Studies of school canteen choices suggest that these, too, may encourage poor dietary choices. A survey of over 100 junior schools in New Zealand found that twice as many less healthy food items were chosen than more healthy items.234 There were nearly six times as many less healthy main dishes on the school menu than more healthy dishes, and over nine times as many less healthy snack items than more healthy snack items. A comparison of the diets of students who had access to a snack bar selling less healthy foods compared with students who did not have access to a snack bar found that accessibility led to greater consumption of less healthy foods. 235 The presence and availability of poor dietary items encourages their consumption. In an attempt to reverse this pattern, trials by researchers at the University of Minnesota (236, 237, 238) have shown that healthful behaviour, such as the selection of healthier food items at a school canteen or from a vending machine, can be influenced by changes in the price of the products being purchased. In trials of vending machine price manipulation of more and less healthful foods undertaken in secondary schools (children aged 12-16) price differentials of 10%, 25% and 50% in favour of healthful foods led to 9%, 39%, and 93% increases in purchases respectively (239), indicating that switches from less healthful to more healthful choices appear strongly influenced by pricing factors. When the price advantages are removed the purchase preferences for healthier foods disappear. The use of health promotion material (such as displays at the point of purchase) was less effective at influencing choice. Further discussion of schoolbased prevention initiatives can be found in section 6 below.

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Food marketing There has been some debate about the role of advertising especially that directed towards children in the promotion of poor dietary patterns and excess consumption of foods encouraging weight gain. The foods most frequently promoted on television advertising are energy dense, nutrient poor foods ( 240), the consumption of which is convincingly linked to an increased risk of weight gain ( 241). The numbers of such advertisements can be as high as 12 per hour during childrens television programmes (242) and a recent UK review suggested that there is adequate evidence to show that advertising leads to increased category sales, not just brand switching ( 243). Furthermore, there is evidence that the frequency with which such advertisements are shown on childrens television correlates with the prevailing prevalence of child overweight, while in contrast the showing of advertisements for healthier foods was linked to lower prevalence of child overweight ( 244). Other forms of marketing to children also merit atten tion. Consumer groups have noted a rise in the promotion of energy-dense foods to children through the internet, through messaging to mobile telephones, through cross-branded toys and household goods, and through food-branded story books and educational books ( 245,246). The novel marketing methods largely bypass the current, largely voluntary controls in place to regulate marketing to children ( 247). Physical activity and sedentary behaviour Direct evidence of decreasing energy expenditure among children in rece nt years is lacking. Some data suggest reduced walking and cycling behaviour between the 1980s and 1990s, among children in the UK and USA, along with increasing use of cars (e.g. to travel to school) (248, 249). In the UK, children appear to become less activ e as they get older, and show decreases in activity levels during adolescence, starting earlier in girls than in boys (250). A systematic review identified a number of longitudinal studies estimating the effect of physical activity measured in childhood, usually by questionnaire, on subsequent fatness: the studies were generally small, and roughly divided between finding no effect, or a protective effect of increased physical activity (251). In a review of available data in the USA over 50 years, Brownson identified long-term trends related to (a) physical activity, (b) employment and occupation, (c) travel behavior, (d) land use, and (e) related behaviors (e.g., television watching), together giving an overall trend of declining total physical activity. 252 These trends have put the majority of the American population at high risk of physical inactivity. Overweight and obese children may be less proficient in motor skills and health-related fitness activities, they are less likely to experience success in phys ical activity and sport, and they are less likely to choose active in favour of inactive behaviours. Their poor perceived competence, lack of motivation, increase d fatness, less activity and predisposition to sedentary behaviours can form a self -perpetuating vicious cycle .

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Television viewing Multivariate studies have found that television viewing and playing video games for longer periods of time, or not participating in sports outside of school, promotes obesity, whilst physical activity shows protective effects or no relationship (253, 254, 255). Several studies have specifically examined the links between television viewing and childrens risk of overweight. Although some find only weak relationships ( 256, 257), several others have found that hours of television viewing were closely associated with increased levels of obesity in cross sectional and prospective studies, among children in the USA (258), China (259), Australia (260), Mexico ( 261), Thailand ( 262), Greece (263) and Native Canadian groups ( 264). A prospective study by Gortmaker et al ( 265) monitored a cohort of over 700 children aged 10-15 during a four-year period. The results showed a strong dose-response relationship between hours of television viewing and the prevalence of overweight at the end of the period, even after adjusting for previous overweight (in 1986), baseline maternal overweight, socioeconomic status, household structure, ethnicity, and maternal and child aptitude test scores. Those children watching television the most (over five hours per day) were five times as likely to be overweight than those watching fewer than two hours per day. They were also the most likely to gain weight during the period, and least likely to cease to be overweight if they had been overweight at the start. Various factors are likely to be important in determining the amount of time spent viewing television. A study by Wiecha et al (266) showed that the presence of a television in a childs bedroom increases the time spent watching television by an average of 38 minutes per day. Recent surveys indicate that US families provide televisions in childrens bedrooms at a young age: 30% of children aged 0-3 years had a TV in their bedroom, and this figure rose to 43% among children aged 4-6 years.(267) This study also showed that other significant factors include: the presence of additional televisions outside the youth's bedroom (7 minute more viewing per additional set in the household), the child never or seldom has family dinners (33 minutes more viewing) and the child experiences no parental limits on television viewing time (29 minutes more viewing). The presence of parental limits on television viewing time was associated with 13 minutes more reading per day. An Australian study showed that after adjusting for differences in food intake and for general activity level, television ceased to be independently significantly related to child BMI, implying that the effect of television viewing on obesity is mediated through one or both of these influences ( 268). Television viewing may be associated with changes in eating behaviour, for example by encouraging casual snacking, or may modulate eating habits through greater exposure to advertisements for foods high in added sugars and/or fat ( 269). Exposure to 30-second television food commercials can influence the subsequent food choices made by pre-school children (270). A French-Canadian study of children aged 10 years found that a fifth of girls and a quarter of boys consumed food in front of the television daily, and that among boys there was a strong positive link between the frequency of eating in front of the TV and the childrens requests to parents for advertised foods. 271 Eating while watching television may psychologically reinforce

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the messages being absorbed. These messages may not encourage healthy eating practices , and some may specifically confuse viewers about appropriate lifestyle and health choices ( 272, 273). The links between television viewing and weight gain may also be affected by other social factors: for example the use of television as a child-care substitute, especially in larger families. In one study the time spent watching television correlated positively with fatness in children from poorer socio-economic communities, but not in children from better-off communities (274). Ethnic interactions with obesogenic risk factors This document has already noted the specific risk factors linked to socio-economic status and the potential interaction between socio-economic status and specific ethnic groups. Educational status and TV watching were noted as intermediate variables in explaining the higher levels of obesity found among children in immigrant families in Germany, and may also explain the raised levels of obesit y found among children of North African origin living in Paris, France (275). Higher levels of obesity are also found among children of Asian Indian origin living in the UK. An analysis of possible physical, economic and social factors which influence the risk of obesity among non-white ethnic groups has been undertaken by the US Centers for Disease Control, and the summary table is shown below. Reviewers noted that there were more food commercials on prime time television programmes directed towards black audiences compared with general prime time programming (5 versus 3 adverts per 30 minutes) and that more commercials featured candy and soft drinks (276). In addition, US surveys show that children in non-white families watch more television, and watch more videos and play video games, compared with children in white families ( 277). Examples of excess environmental risks in non-white population groups, USA.
Physical Environment Food Targeted marketing Excess fast food outlets Few supermarkets Lim ited shelf choices in groceries Widely available high-fat food (home, church) Less private transportation Poorer public transportation Low neighbourhood demand for low calorie/low fat foods Low family incomes and cash flow Other household expenses Little home grown food Financial incentives offered to under-resourced schools by commercial cafeteria vendors Activity Distance to private fitness facilities Few worksite fitness opportunities Few or deteriorating neighbourhood recreation facilities High neighbourhood crime rates Less private transportation Poorer public transportation Limited investment in parks/recreation facilities Fees at fitness facilities Cost of exercise equipment Less stable employment patterns Fewer trained school physical education instructors / larger classes Poorly equipped school facilities / fewer exercise options Less availability of volunteers to assist school staff in after school sports/recreation programs

Economic Environment

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Socio-cultural Environment

Traditional cuisine Fasting-feas ting Extant food insecurity Prevalent obesity Body image Female roles Context responsiveness

Cultural attitudes about physical activity and importance of rest Activity lifestyles Fears about safety Cultural reverence for cars, particularly among males Over reliance on TV for engaging children after school hours

Source: CDC 2004 278 3.3 Nutrition and sedentary transitions Several previous reports ( 279, 280, 281, 282, 283) have drawn attention to the underlying social changes which have led to rising levels of obesity in both the adult and child populations. These underlying factors such as those listed below are often a part of general trend of economic development and urbanisation. Such trends, based on financial investment to enhance production, income and consumption, are generally regarded in a positive light and may form part of a lifestyle to which significant sections of the population aspire. Examples of social trends which may raise obesity risk Greater quantities and variety of energy dense foods available Rising levels of promotion and marketing of energy-dense foods More frequent and widespread food purchasing opportunities More use of restaurants and fast food stores Larger portions of food offering better value for money Increased frequency of eating occasions Rising use of soft drinks to replace water, e.g. in schools Reduced rates of breastfeeding, early weaning Increase in use of motorised transport (e.g. to school) Increase in traffic hazards for walkers and cyclists Fall in opportunities for recreational physical activity Increased sedentary recreation Multiple TV channels around the clock

As household income rises a familys pattern of diet is likely to change , with reduced quantities of staple cereals and vegetables a nd increased quantities of meat and of fatty and sugary processed foods.(284) This can be shown in the per capita supply figures for fats and sugars over the last few decades for the developing regions of the world (see figure below). In families experiencing change, those children at highest risk of developing obesity are likely be those most exposed to energy-dense, micro-nutrient poor diets and sedentary activity patterns , including sophisticated marketing for massproduced foods (e.g. snacks, candy and soft drinks) and products encouraging sedentary behaviour (e.g. TV shows, screen games and videos).

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Figure. Rising per capita supplies of fats and sugars in China, India and Latin America, but not in Africa.

Source: Dalmeny et al ( 285) using data from FAO Food Balance Sheets In countries undergoing economic transition it might be expected that obesity prevalence would be higher in areas that are newly industrialised and urbanised, offering greater access to obesogenic products. In Brazil, urbanisation is closely linked to a raised prevalence of childhood overweight, and a similar trend can be shown in China, although the levels are lower in both urban and rural areas (see figure below). Figure 2: Different rates of child obesity according to urban or rural location, in the USA (1988-1994), China (1997) and Brazil (1997).

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30 25 Prevalence % 20 15 10 5 0 USA China Brazil

Urban Rural

Source: Wang et al ( 286) When household incomes have risen beyond the point at which families can afford, and have available, a range of processed foods e.g. fast foods, soft drinks, snack foods etc further rises income may then allow some protection from exposure to obesogenic influences. Better off families can choose to adopt a healthy lifestyle, with more food choices, better nutrition education, and better access to safe recreational facilities in residential areas. Thus the highest risk for child obesity is likely to be found among the newly-urbanised, middle- and lower-income groups in countries in transition. That countries will differ in their response to nutritional changes has been documented by Popkin et al, specifically in the Asia-Pacific region ( 287). Obesity, diabetes and cardiovascular disease are prevalent at high rates in urban India (288, 289). In Pakistan a survey of boys aged 2-18 years in Karachi found the prevalence of overweight to be lower among both the poorest and richest sections of the community (290), indicating that the most vulnerable members of that community were those who could afford to buy the highly processed foods offered by westernised mass production, but do not choose (or cannot afford) the healthiest versions of these foods, such as fresh or chilled products. It should be noted that there are complex associations between genetic predispositions, early nutrition and subsequent environmental exposures that need further exploration: Reddy and Yusuf note a marked ethnic diversity in the manifestations of cardiovascular disease, citing the high rates of stroke coupled with low rates of coronary heart disease in Chinese (despite high smoking rates) and African populations, and the lack of association between the high prevalence of diabetes and coronary heart disease in groups such as the Afro-Caribbeans (291). Nutrition insecurity When household income is low and food insecurity high, some members of the household (e.g. male wage earners, favoured children) may have priority access to food while other members (e.g. women, elderly people, less favoured children) may be

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deprived. The simultaneous presence of overweight and underweight individuals within one household has been explored in a series of surveys conducted in Brazil, China, Indonesia, the Kyrgystan, Russia, Vietnam and the United States ( 292). In six of the countries studied, 22-66% of households with an underweight person also had an overweight person. Countries with the highest prevalence of dual burden households were those in the middle range of gross national product, although all countries were affected to some degree. The study authors recommend that where dual bur den households share sociodemographic profiles with overweight households, obesity prevention efforts should focus on messages that are beneficial to the good health of all, such as increasing fruit and vegetable intake, improving overall diet quality and increasing physical activity. The FAO has noted that some of the same nutrient deficiencies in the underfed also afflict the overfed.( 293) These problems apply not only to countries in economic transition but to lower-income households in developed economie s. Attempts to improve maternal and child nutrition in the USA through the WIC program (supplemental food program for women, infants and children) which targets low income groups have found that the children in the program frequently suffer from iron deficiency and other forms of inadequate nutrient intake, and that these nutritional problems are especially common among the overweight children in the programme (294). The American Dietetic Association now recognises that Malnutrition has been linked to delaye d physical, psychosocial, and cognitive development and is now recognized as a major contributor to the growing problem of overweight and obesity in the child and adolescent population. ( 295) Malnutrition in this context refers to dietary patterns dominated by high energy, low micronutrient foods. There are several reasons why lower income households may have poor diets which, while containing enough food energy are deficient in micronutrients. Processed foods tend to have higher energy levels and lower micr onutrient levels than fresh, perishable foods, and are also more heavily advertised and marketed and made available in a wide range of food outlets. Households with low incomes may not possess food preparation and food storage appliances: a lack of equipment such as a fridge or cooker may lead to the purchase of processed foods with a long shelf life, rather than fresh, perishable foods for home preparation. Besides these factors, a compelling reason why lower income families eat diets high in energy and low in micronutrients is likely to be cost. In countries with high levels of supply of mass-produced foods, the cost per unit of food energy ($/MJ) is lowest for fats and oils, white bread and sugary foods, compared with fresh fruit and vegetables, fresh meat or fish, and wholegrain products. Low-income householders in developed countries tend to spend less of their money on protective foods such as fruit and vegetables and relatively more on energy-dense foods (296). In contrast, higher-income families eat more fruit and vegetables, and spend a smaller share of their total income on food as shown in the UK (see figure 3) (297).

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Figure 3. Relationship of income to consumption of fresh fruit and vegetables and the share of income spent on food in UK households.

400 300 grams 200 100 0 1 2 3 4 5 6 7 8 9 10 Deciles of net family income (per head) 1 - lowest incomes, 10 - highest incomes fruit and vegetables: grams/person/day percent income spent on food

30 25 20 15 10 5 0

Source: Defra 2001

298

Although the cost per unit of food energy may not be foremost in the mind of a consumer when making food choices, the relationship between prices and the energy density of foods can be shown to affect purchasing patterns. In a study of French adults purchasing patterns by Drenowski and colleagues ( 299, 300, 301), foods high in fat, sugar, and grains were associated with lower costs after adjustment for energy intakes, gender, and age. For most levels of energy intake, each additional 100 g of fats and sugars was associated with a small percentage reduction in diet costs, whereas each additional 100 g of fruit and vegetables was associated with a small percentage increase in diet costs. Similar findings have been demonstrated in the UK, showing the higher per calorie costs of fresh fruit and vegetables compared with snacks and soft drinks.( 302) Modern food supplies show an inverse relationship between energy density of foods (MJ/kg) and energy cost ($/MJ) so that diets based on refined grains, added sugars, and added fats are more affordable than the recommended diets based on lean meats, fish, fresh vegetables, and fruit. The use of processing techniques to enhance appearance, taste and convenience of processed foods can also skew food choices in the direction of energy dense, micronutrient poor foods.( 303) In respect of child nutrition, the WHO has observed that rapid social and economic change intensifies the difficulties that families face in properly feeding and caring for young children.(304) Expanding urbanization results in more families becoming dependent on informal or intermittent employment with uncertain incomes and few or no maternity benefits, which in turn threatens sustained breastfeeding and increases the risk of early weaning, possibly onto unsuitable diets. Both self-employed and nominally employed rural women face heavy workloads, usually with no maternity protection. Meanwhile, economic transition may lead to traditional family and community support

percent

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structures being eroded, with resources devoted to supporting health- and, especially, nutrition-related, services dwindling and accurate information on optimal feeding practices not available all at a time when the number of food-insecure rural and urban households may be rising. Further consideration of obesity risk under conditions of nutrition insecurity are considered in the discussion of stunting and malnutrition below (section 4.2). Sedentary transition The links between increasing household income and rising patterns of sedentary behaviour match those for changing food consumption patterns. Access to television and video entertainments, increasing use of motorised transport reduced opportunities for outdoor recreational activities are linked to urbanisation in developing economies. Higher income families may live in residential areas with safe streets and parks, cycle routes and sports facilities, but these may not be available for lower income urbanised populations. The changing nature of physical activity and sedentary behaviour in emerging economies can be shown in statistics for sales of the relevant goods and services. For example, car sales in India are predicted to rise at around 10% per year over the period 2002-2007, while car sales in China have increased 40% year-on-year 2001 to 2002. 305 In India, video games and gaming consoles sales are predicted to rise almost 70% per annum between 2003 and 2008. 306 China is the world's second largest Internet user, with online game-playing by over 20 million young people, and with revenues from game playing rising by 25% annually 2003-2004. 307 In Malaysia, 30% of children watch an average of 8 hours of television per day during school holidays. 308 Commercial targeting of children Specific trends in the nutrition and sedentary transition may be relevant to child obesity even for the youngest children. Trends towards reduced prevalence of breastfeeding and earlier weaning can be seen when communities in less developed regions are exposed to commercial influences and the opportunities to purchase formula feeds, combined with marketing methods that may encourage them to make these purchases. The World Health Organization has long recognised the need to defend breastfeeding and to ensure that substitutes are not aggressively marketed, although the agreed Marketing Code does not have regulatory effect in all countries of the world, and evidence that the Code is being broken is frequently reported.( 309) Changes in the opportunities to purchase soft drinks, to visit fast food stores, to consume confectionery and snack foods all potentially affect the exposure of children to obesogenic influences in many parts of the world. In Africa, for example, the soft drinks company Coca Cola invested nearly $500m during the decade 1993-2003. At the end of that period, the company reported sales worth over $800m in 2003, with revenue grow ing by over 20% per annum ( 310).

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Fast food stores have also seen rapid growth in the developing world. In the ten years 1991-2001, the number of McDonalds outlets increased from around 200 to over 1,500 in Latin America, and from 1,400 to over 6,700 in the Asia -Pacific region.(311) (See figure below) Figure 4. The rise of fast food outlets in developing markets shown by the brand leader McDonalds 1991 -2001.

Source: McDonalds Corporation annual reports (312) Advertising of processed foods and soft drinks is also widespread throughout the developed world and the urbanized developing world. A 1996 survey of 13 industrialised countries identif ied the fast-food restaurant McDonald s as the most prolific advertiser on childrens commercial television channels. Other widely advertised brand names were Nestl, Mars and Cadbury s, and the most widely advertised products were sweetened breakfast cereals, fast food stores, confectionery, soft drinks, snack foods and biscuits.(313) In 2001, the global advertising budget for food products was estimated to be around $40 billion, 314 a figure that exceeds the national economies of more than half the worlds nations (69% of nations had a Gross Domestic Product under $40bn in 2003. 315). Children are a prime target of the food companies marketing strategies.( 316) The marketing methods do not rely solely on television, as many households may not have TVs or have a culture of watching them for hours on end. Instead a range of alternative approaches are used, such as in-store singing contests (KFC, Thailand), community sports sponsorship (McDonalds, Scotland), organized zoo trips (KFC, Singapore),

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music band tie -ins (Coca-Cola, India), sponsored school books (Pepsi, UK) and downloadable animations from the internet (KFC, Japan).( 317) In each of the following countries, Coca-Cola, the worlds largest beverage company, spent between $10-30m advertising its products in 2000: Venezuela, Turkey, China, South Africa, Hungary, Poland, India, Columbia, Chile and Argentina, and it spent over $50m advertising in Russia and even more in Mexico (318). That children may need protection from commercial exploitation through advertising is recognised in many countries, and various levels of regulation and voluntary marketing codes are in place (319). Consumer advocacy organisation are concerned that these controls are insufficient to prevent children from being unduly influenced towards desiring the advertised items, and pestering their parents to buy them.( 320) Reports from consumer organisations indicate that 68% of Filipino children love to watch televised advertisements, as do 73% of Pakistani children (321). In these countries the proportion of childrens advertising which is for food products varies between 50% and 75%.

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4 Growth and malnutrition This section considers the opportunities for intervention, and bases these primarily on the well-established life course approach, which considers the influences on a childs nutritional status as a result of current diet and physical activity, earlier experiences of breastfeeding and weaning, foetal exposure to mis-nourishment, and influence of parents and grandparents through direct and indirect risk factors. Although the life course approach focuses specifically on the individual, it has implications for population-based approaches. Its value in tackling malnourishment and the problems of poor growth have helped to identify the specific needs of children experiencing stunting. Recent evidence suggests that stunted children may not benefit from generalised food assistance programmes if this leads to weight gain without commensurate gain in height. Alternative approaches are needed to prev central ent obesity and consequential disease risks. 4.1 The life-course approach With the increasing evidence that chronic disease risks begin in foetal life and accumulates throughout childhood, adulthood and older age, a life-course approach that captures both the cumulative risk and the many opportunities to intervene that this affords has been recommended in previous UN and WHO expert reports.( 322,323) The life -course approach considers the opportunities for improving health at each stage in life, both f or the individual and for their offspring. Good nutrition in early life pays clear social and economic dividends in later childhood and adult life. Furthermore, the impact of early nutrition on a young woman may, in turn, have an impact on the health of the children she bears. Improved life expectancy increases the numbers of older people which brings further intergenerational advantages: through better opportunities for child -caring, stable family structures and the transfer of culture and skills. Although progression from one life stage to the next is gradual, five stages have been identified for convenience: foetal development and the maternal environment; infancy; childhood and adolescence; adulthood; and ageing and older people. Foetal development and the maternal environment In respect of the later development of chronic disease, the four relevant factors in foetal life are: (i) intrauterine growth and growth retardation, (ii) premature delivery of a normal growth for gestational age foetus , (iii) overnutrition in utero, and (iv) intergenerational factors. There is considerable evidence, mostly from developed countries, that intrauterine growth retardation is associated with an increased risk of central adiposity, especially if followed by rapid catch-up growth. Central adiposity in childhood and early adulthood raises the risk of coronary heart disease, stroke, diabetes and hypertension. Excessive intrauterine growth leading to a large size at birth (macrosomia) is also associated with an increased risk of obesity, diabetes and cardiovascular disease in adulthood.

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Infancy Retarded growth in infancy can be a reflected in a failure to gain weight and a failure to gain height. Short stature, a reflection of socioeconomic deprivation in childhood, is a lso associated with an increased risk of CHD and stroke, and to some extent, diabetes, especially if associated with increased central adiposity. In a study of 11-12 year-old Jamaican children, blood pressure levels were found to be highest in those with retarded foetal growth and greater weight gain between the ages of 7 and 11 years, and similar results were found in India ( 324, 325) Low birth weight Indian babies have been described as having a characteristic poor muscle but high fat preservation, so-called thin-fat babies. This phenotype persists throughout the postnatal period and is associated with an increased central adiposity in childhood that is linked to the highest risk of raised blood pressure and disease. In most studies, the association between low birth weight and high blood pressure has been found to be particularly strong if adjusted to current BMI, suggesting the importance of weight gain after birth. Further research is needed to define optimal growth in infancy in terms of prevention of chronic disease. As noted in the discussion of risk factors, early weaning and bottle-feeding appear to increase the risk of later childhood obesity, and the protective effects of breast-feeding appear to extend to reduced risk of diabetes as well as obesity in adulthood. Fig: Life -course risk factors for obesity
Reduced capacity to care for children

Bottle-feeding, early weaning Energy-dense diets


Rapid weight gain

Elderly
Obese

Baby
Low birth weight Stunted growth

Sedentary behaviour

Lower social status

foetal mis-nutrition

Visceral obesity

Child Mother
Overweight Diabetic Overweight

Adults
Overweight

Adolescent
Overweight Lower income, poor access to healthy diets and safe environments Energy-dense diets, sedentary behaviour

Energy-dense diets, sedentary behaviour

Lower social status, psychiatric problems

Source: adapted from ACC/SCN326

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Childhood and adolescence Impaired glucose tolerance and an adverse lipid profile are seen in childhood and adolescence, where they typically appear clustered together with higher blood pressure and relate strongly to obesity, in particular central obesity. Raised blood pressure, impaired glucose tolerance and dyslipidaemia also tend to be clustered in children and adolescents with unhealthy lifestyles and diets characterised by energy-dense, micronuitrient-poor foods.(327) Lack of exercise and increased television viewing add to the risk. In older children and adolescents, habitual alcohol and tobacco use may also contribute to raised blood pressure and to the development of other risk factors in early adulthood. Many of the same factors continue to act throughout the life course. Such clustering represents an opportunity to address more than one risk at a time: measures taken to prevent obesity will have beneficial effects on the prevention of many linked chronic diseases in later adulthood, improve the psycho-social functioning of the child and improve its subsequent educational and economic capacity. Disease that develops during adolescence may be hardest to reverse. Three critical aspects have an impact on chronic diseases: (i) the development of risk factors during this period; (ii) the tracking of risk factors throughout life; and, in terms of prevention, (iii) the development of healthy or unhealthy habits that te nd to stay throughout life, for example physical inactivity because of television viewing. Not only are early manifestations of chronic disease occurring earlier and earlier, but once they have developed they tend to track in that individual throughout life. Overweight and obesity are notoriously difficult to correct after becoming established, and there is an established risk of overweight during childhood persisting into adolescence and adulthood. Adulthood The most firmly established lifestyle risk factors for chronic non-communicable diseases during adulthood are tobacco use, diet, physical activity and alcohol consumption ( 328). Most of the studies are from developed countries, but supporting evidence from developing countries is beginning to emerge, for example, from India. In developed countries, low socioeconomic status is associated with higher risk of obesity, cardiovascular disease and diabetes, although in these developed economies social inequalities may be a stronger predictor of obesity and diabetes risk than absolute levels of income. 329 The combined effects of energy-dense diets, low intake of fruit and vegetables, specific dietary risk factors such as saturated fat and salt, along with low levels of physical activity and habitual sedentary behaviour, together account for about one third of the burden of disease in developed economies and increasing proportions of the total disease burden in developing economies. As with adolescents, this clustering of risk factors helps direct resources towards t he best opportunity for prevention by focussing on, for example, obesity prevention through improved diets and greater activity levels.

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Ageing and older people Three critical aspects relate to chronic diseases in the later part of the life-cycle: (i) most chronic diseases will be manifested in this later stage of life; (ii) there is an absolute benefit for ageing individuals and populations in changing risk factors and adopting health-promoting behaviours such as exercise and healthy diets; and (iii) the n to eed maximize health by avoiding or delaying preventable disability. Furthermore, interventions aimed at supporting the individual and promoting healthier environments will often lead to increased independence in older age , as well as greater ability to help care for new generations of children and to pass on their cultural and practical skills, thereby enhancing community development. Intergenerational effects Young girls who grow poorly become stunted women and are more likely to give birth to low -birth-weight babies who are then likely to continue the cycle by being stunted in childhood and adulthood. Maternal birth size is a significant predictor of a childs birth size after controlling for gestational age, sex of the child, socioeconomic status, and maternal age, height and pre-pregnant weight. There are clear indications of intergenerational factors in obesity, such as parental obesity, maternal gestational diabetes and maternal birth weight. Low maternal birth weight is associated with higher blood pressure levels in the offspring, independent of the relation between the offsprings own birth weight and blood pressure. Intervening throughout life It is clear from the discussion above that the major biological and behavioural risk factors emerge and act in early life, and continue to have a negative impact throughout the life course, and that their impact can continue to influence the health of the next generation. Globally, trends in the prevalence of many risk factors are upwards, especially those for obesity and physical inactivity. Interventions are needed that can extend beyond individual risk factors and continue throughout the life course , and that interventions early in the life course offer lifelong benefits. As well as preventing chronic diseases, there are clearly many other reasons to improve the quality of life of people throughout their lifespan. The intention of primary prevention interventions is to move the profile of the whole population in a healthier direction. Small changes in risk factors in the majority who are at moderate risk can have an enormous impact in terms of population-attributable risk of death and disability. For example, increased physical activity and improved diets has been shown in one study to reduce the risk of progression to diabetes by a striking 58% in just 4 years ( 330) while other studies have shown that up to 80% of cases of coronary heart disease, and up to 90% of cases of type 2 diabetes, could potentially be avoided through changing lifestyle factors, and about one -third of cancers could be avoided by eating healthily, maintaining normal weight and exercising throughout life ( 331,332,333).

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For interventions to have a lasting effect it is essential to change or modify the environment in which disease develops. Changes in dietary patterns, the influence of advertising and the globalization of diets, and widespread reduction in physical activity have generally had negative impacts in terms of risk factors. P opulation nutrient goals have been recommended by the Joint WHO/FAO Expert Consultation on Diet, Nutrition and the Prevention of Chronic Diseases (334), and are intended to be adapted and tailored to local or national diets and populations, where diet has evolved to be appropriate for the culture and local environment. The goals are intended to reverse or reduce the impact of unfavourable dietary changes that have occurred over the past century in the industrialized world and more recently in many developing countries. The implications of the recommendations would be to increase the consumption of fruits and vegetables, to increase the consumption of fish, and to alter the types of fats and oils, as well as the amount of sugars and starch consumed, especially in developed countries. We shall return to these themes in section 6, concerning interventions aimed to prevent childhood obesity. In the next section we look specifically at interventions related to stunting and the risk of central obesity. 4.2 Malnutrition, stunting and obesity As noted already, poor nutrit ion starts in utero and can extend throughout the lifecycle and can have an impact on the health of subsequent generations through further fetal growth retardation. Undernourished children fall ill recurrently and fail to develop optimally - both physically and mentally. The prevention of stunting in utero requires urgent attention. The ACC/SCN report recommends population-wide interventions in countries where intra-uterine growth retardation (IUGR) exceeds 20%, or in the absence of information on gestation age, where low birthweight is more than 15%. Interventions likely to be beneficial include a balanced protein/energy supplement where diets are deficient, as well as smoking cessation and anti-malarial chemoprophylaxis in primigravidae. Pregnant women at risk with a low body weight show particular benefit. Field research in the Gambia has shown that low birth weight can be reduced by about 40% and infant mortality by 50% through improved food intake during pregnancy (335). The public health community needs to develop a consensus on best practices to prevent foetalgrowth retardation, and for countries to develop programmes with broad coverage. The battle against poor maternal nutrition, and the directly-related underweight and stunting in childhood, requires novel approaches, taking full account of societal organisation, women's rights and well-being, sanitation and nutrition. These issues lie beyond the scope of the present report, but the public health implications are closely linked to those which need to be considered when intervening among stunted children to prevent child obesity. Infants who are born small are at greatest risk of stunting: thus stunting is very common in countries with a high prevalence of low birth weights , such as the less developed regions of Asia (see figs below). With the prevalence of stunting at over 50% in several countries, millions of children will grow up at risk of central adiposity and related

67

chronic diseases. For these children, interventions are needed to promote catch-up growth without increasing the risk of central obesity.

Source: http://www.unsystem.org/scn/Publications/AnnualMeeting/SCN31/improve_survival.pdf

Source: ACC/SCN report

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The high levels of underweight babies and stunted infants in Southern Asia deserve comment. Babies may be born too small if their mothers are short and begin pregnancy underweight or if they gain only small amounts of weight in pregnancy, e.g. <5 kg. All three factors have been shown to be relatively common in South Asia . Surveys in the early 1990s found half of all women in India are undernourished before pregnancy ( 336), and the fact t hat South Asian women are deprived of sufficient food and health care has been well documented ( 337). The limited capacity for catch up growth amongst low birthweight South Asian children also reflects the susceptibility of both mothers and babies to infections in an environment where sanitation and hygiene practices are particularly poor. A significant feature of South Asian nutrition is a vegetarian diet containing surprisingly small amounts of raw ingredients. Cooked vegetables are likely to have fewer nutrients and other valuable bioactive compounds than those consumed raw. The absence of meat and fish, with their dense micronutrient content, is also important. It is reasonable to conclude that South Asian stunting relates to the absence of high-quality protein such as meat in the diet as well as the impact of recurrent intestinal infections. Overweight and stunted children Evidence from several surveys has shown the co-existence of stunting and overweight or obesity in the same child and/or among other members of the same household, in urban areas in developing countries (338, 339, 340, 341) and poorer communities in developed countries (342,343). The prevalence of overweight among stunted children h as been estimated as 45% in the Russian Longitudinal Monitoring Survey (1994-5) of children aged 3 to 9 years, and around 20% in the China Health and Nutrition Survey (1991-3) (344). The incidence was lower in surveys of stunted children in South Africa (13% overweight) and Brazil (4% overweight). In Chile, a careful analysis of the relative risk of obesity in relation to childrens height status showed a U-shaped or Jshaped curve, with obesity prevalence lowest among children between 1 and 2 SD below the mean. Over the period 1987-2003 the curve effect increased, with obesity prevalence rising among both the shortest and the tallest children (see figure XX in section 2.2, above). Longitudinal studies suggest that stunting increases the risk of central obesity (e.g. as measured by waist-hip ratios) but does not raise the risk of overweight (assessed by BMI) in later childhood (345) or adulthood ( 346). A longitudinal study in Guatemala found that although stunting in childhood was not linked to BMI some 15 to 20 years later, children with severe stunting had significantly greater abdominal fatness (waisthip ratios) when they were adults, and the effect was most pronounced among women who had migrated to urban areas (347). There is also some evidence that stunting during early childhood increases the strong link between overweight and high blood pressure in later childhood (348). The suggestion that stunted children may be less likely to undertake physical activity, and that obesity is a corollary, does not appear to be supported by evidence: a study of energy expenditure among stunted and matched control children in Brazil using doubly labelled water showed no association between stunting and resting energy expenditure

69

or total energy expenditure ( 349). The study noted that girls had a lower total energy expenditure than boys, which the authors suggest may help to explain the higher ris k of obesity in stunted adolescent girls and women in urban areas of developing countries. An alternative suggestion is that stunting may increase susceptibility to weight gain especially in children consuming diets relatively high in fat ( 350,351) or where extra food is available opportunistically (352). Physiological mechanisms that are triggered by famine and chronic undernutrition might encourage excess weight gain when exposed to environments where energy-dense foods are plentiful (353). The Kobe expert meeting recommended that well baby clinics should record obesity indices
as well as growth indices. Their targets should involve improving childrens length in preference to increasing their weight. The meeting also noted that there is a need for low-cost length -measuring equipment with minimal need for training. Similarly there is a need for low-cost skin -fold measuring equipment.

Consequences of rapid weight gain in infancy Depending on the outcome under study, there are differences in whether linear growth or growth in weight, particularly weight relative to height matters. Most often, rapid weight gain is the most significant indicator , leading to excess adiposity which is an important risk factor for many chronic diseases of adulthood. It is generally accepted that excess body fat, especially when stored in the abdominal region is a major determinant of insulin resistance. However, individuals with similar amounts of fat mass may have different levels of insulin resistance. Boul et al (354) examined the effect of early postnatal malnutrition on the relation between insulin sensitivity and abdominal adiposity in adulthood. Results showed that when the previously malnourished group of adults was matched for low abdominal fat with the group with normal growth, there was no difference in insulin sensitivity between them, however when these two groups were matched for high abdominal fat, those previously malnourished, had significantly lower insulin sensitivity. Thus higher levels of abdominal fat are more detrimental to insulin sensitivity in previously malnourished individuals. Several studies now indicate that the highest risk for cardiovascular outcomes is associated with lower birth weight and higher attained BMI during childhood. A study which included n born children from Avon, England showed that those with catch-up ew growth in the first two years were fatter and had more central fat distribution at 5 y ears than other children. Longitudinal data from the US National Perinatal Collaborative study show that, independent of birth weight, one third of obesity at age 20 is attributable to rapid weight gain in the first 4 months of life. Although, most of the studies which have shown the association between foetal undernutrition, nutritional abundance and increased chronic diseases during adulthood have been carried out in developed countries, this combination is more prevalent in the developing world undergoing the nutrition transition. Data from the Cebu Longitudinal Health and Nutrition Survey (355) including over 2000 Filipino adolescents showed that

70

boys who were thin at birth and had rapid child growth were more likely to be obese at ages 14-16 y and also to have higher blood pressure . In addition, girls who showed a rise in BMI before age 5 years (early adiposity rebound) gain fat at a faster rate compared to those who showed a late rise (after age 5 years), and that by age 9, girls with an early rise were significantly heavier.(356) Annual velocity of fat mass gain was over 2 -fold higher in early compare d to late weight-gainers. There remains controversy about the age at which higher growth rates pose risk of later disease. Some studies show elevated blood pressure in association with rapid weight gain in infancy, while other studies show no effect, or a protective effect (infants with larger weight increments have lower blood pressure as adults). The degree to which rapid infant growth represents risk may depend on whether it occurs in the context of recovery from foetal growth restriction and results in normalization of body weight or whether it leads to early obesity. The combination of poor linear growth in association with more rapid weight gain appears to lead to the greatest risk of central adiposity, high BMI in adolescence and later adulthood, and the related indications of disease linked to the metabolic syndrome. Bhargava el al ( 357), in a prospective population-based study on 1492 Indian men and women 26 to 32 years of age followed from infancy, demonstrated that individuals with impaired glucose tolerance or diabetes were more likely to have had a low BMI up to 2 years of age, followed by an early adiposity rebound and an accelerated increase in BMI until adulthood. The most vulnerable young adults were those who were thin at infancy and became overweight in early childhood. This leads to the possibility of defining overweight and obesity at different stages of development not on statistical normality based on population distributions but on context specific criteria based on the biologic consequences of adiposity at early and later stages of the life course. For example, in the Indian cohort referred to above , of the 219 subjects who developed impaired glucose tolerance or diabetes mellitus as young adults, despite an increase in body mass index between the ages of 2 and 12 years, none of these subjects could be categorized as obese by the international (IOTF) classification. Supplementary feeding programmes Stunted children may be of low weight for age, but could have a near normal weight for le ngth (height). Early interventions are desirable, s ince recovery in length for age is likely to be incomplete if nutrition improvement occurs after 24 to 36 months of age (358). Above this age, little or no gain in length for age is observed (359) and stunted children given additional food may gain significantly more weight for age than length for age, raising the risk of overweight. Feeding programmes focussing on protein-energy supplementation may not be appropriate for stunted children as it may encourage weight gain without height gain, leading to obesity. In areas of the world, such as Latin America and South East Asia where populations are progressively becoming urban and sedentary and energy availability is not a limiting factor, definitions of undernourishment may misguide

71

policy, since they may assume that the problem is solved by providing food energy to the poor. Under these conditions, poverty is related to adequate or even excess energy relative to physical activity levels and diet is of poor quality in terms of healthy foods, rather than amount of energy ( 360).Unless underweight (wasting) is universal, supplemental feeding programmes should use target d strategies to avoid providing e excess food energy to children within the normal range of weight for length/height. As the figure below shows, during treatment for malnutrition, recovery of weight and length/height for age lag significantly behind recovery of weight for length/height and an indicator of fat deposition (triceps skinfold) indicating that pr ogrammes need to monitor their impact on adiposity, not just age -related growth. Fig: Growth measures taken during protein-energy supplementation (CHECK Ricardo) The impact of a supplementation programme shows accumulated fat (triceps skinfold) and above average adiposity occurring within three months of the programme, while weight and length for age remain below reference values.

20 10 % of Standard 0 -10 -20 -30 -40 -50 0 1 2 Weight for Age Length for age Weight for length Triceps fatfold 3 4 5

Months of treatment
Source: Uauy 2005 Kobe presentation

The quality of the foods provided is crucial in pre-school and school feeding programs: food supplements focussing on protein-energy content may be deficient in specific micronutrients needed for linear growth. Fruits and vegetables should be included in the diet of children to secure micronutrients and prevent energy excess, while zinc and iron

72

fortification of fat-reduced milk or the provision of modest amounts of animal protein e.g. meat or eggs may also be valuable where stunting and obesity co-exist (361) as stunting was shown in the early part of the last century to respond selectively to meat or milk supplementation. Cereal and dairy foods are poor in zinc, vitamin A and iron, and the fibre content of cereals may inhibit micronutrient bioavailability, while energy intakes may exceed energy needs. Dietary variety is advisable, and in the case of malnourished children some case-by-case monitoring may be needed. Child feeding programmes in Chile have been presented as a paradigm of the success of supplementary feeding, and indeed there is an association between the presence of these large-scale interventions and the decline in malnutrition in all age groups. But close examination of the data has shown that for infants, preschool and school children, undernutrition based on weight for age was virtually eradicated by the late 1980s while stunting rates remained low but significant until the mid 1990s. It is exactly at this stage of the transition that obesity needs to be considered in the implementation of programmes and necessary changes need to be incorporated. In fact, data from Chile in the last two decades has shown that the impact of the programmes in reducing malnutrition was progressively lost while the association with rising obesity prevalence had become notable ( 362). In the light of the Chilean experience, calls have been made to re-evaluate the cost effectiveness and utility of food supplementation programmes, apart from those targeting extremely deprived populations, and to ensure that food-based interventions are based on promoting a healthy diet with an emphasis on the upper limits of energy and fat intakes.(363) The Kobe expert meeting supported these recommendations. The Kobe expert meeting also noted that supplements for mothers can affect child nutrition, either directly (for exam ple when the mother shares her supplement with a child) or indirectly (e.g. when a pregnant womans dietary supplementation has effects on the foetus) and supplemental feeding programs for mothers should review their impact on child growth. The meeting also noted that the ntroduction of nutrition interventions should be discussed with the family and community, including the men, or else they may reject a supplemental food from the household . Recommended energy requirements Considerable attention has been f ocussed on energy balance and the need to define the energy required for healthy growth. Energy requirements for growth have two components: 1) the energy used to synthesise growing tissues; and, 2) the energy deposited in those tissues, basically as fat and protein, since carbohydrate storage is negligible. A recent analysis of energy balance in healthy children and adolescents (364) has led to a re-appraisal of the recommendations for food supply used by international bodies such as the WHO. The revised proposals for energy intake, based on doubly labelled water methods for monitoring energy intake and expenditure, are shown in figure (below) with the previous recommendations.

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The proposed new energy requirements are 18-20% lower for boys and girls under 7 years of age, and 12% lower for boys 710 years old. From age 12 onwards, the proposed requirements are 12% higher for both boys and girls, assuming moderate levels of physical activity. Interventions such as child feeding programmes, if based upon the previous recommendations, could have led to excess energy intake among target populations, with a potential problem of encouraging the consumption of nutrientpoor, energy-rich diets, and of encouraging excessive weight gain among these children. Figure 29 Comparison of proposed energy requirements with 1985 figure s. A) BOYS
A. Boys
460 440 420 400 380 360

FAO/WHO/UNU 1985 estimates

ER (kJ/kg/d)

340 320 300 280 260 240 220 200 180 160 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

PROPOSED 2001 estimates

Age (years)

B)

GIRLS
B. Girls
460 440 420 400 380 360

FAO/WHO/UNU 1985 estimates

ER (kJ/kg/d)

340 320 300 280 260 240 220 200 180 160 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

PROPOSED 2001 estimates

Age (years)

74

Source: Torun 2001

In respect of physical activity, the Kobe expert meeting noted there were no equivalent recommendations for energy expenditure, and indeed that there were no standardised methods for measuring physical activity and sedentary behaviour.

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5 Monitoring and assessment This section discusses the need to define criteria against which individual children and groups and populations of children can be assessed and monitored in terms of their adiposity. Methods of estimating body fat are described in the literature and are referred to only briefly here. (More detail can be found in Lobstein et al. (365)) The Kobe expert consultation discussed the the need for agreement on methods for assessing an individual childs growth, and for defining the prevalence of overweight and obesity in populations. In particular, the meeting recognised that a long-standing programme to define a gold standard for the growth of children (the Multicentre Growth Reference Study) was reaching fruition, and that the issue of population-based definitions was being discussed at further expert consultations during 2006. Body fat assessment In a review by Power et al (366), the authors state an ideal measure of body fat should be accurate in its estimate of body fat; precise, with small measurement error; accessible, in terms of simplicity, cost and ease of use; acceptable to the subject; and well-documented, with published reference values. They comment that no existing measure satisfies all these criteria. Direct measures of body composition provide an estimation of total body fat mass and various components of fat-free mass. Such techniques include underwater weighing, magnetic resonance imaging (MRI), computerised axial tomography (CT or CAT) and dual energy X-ray absorptiometry (DEXA). The use of radio isotopes can assist studies into metabolic processes (and some research s upport may be available for this from the International Atomic Energy Agency). The methods are used predominantly for research and in tertiary care settings, but may be used as a standard to validate indirect, anthropometric measures of body fatness. Among the anthropometric measures of relative adiposity or fatness are waist, hip and other girth measurements, skin fold thickness and indices derived from measured height and weight such as Quetelets index (BMI or W/H2), the ponderal index (W/H3 ) and similar formulae. All anthropometric measurements rely to some extent on the skill of the measurer, and their relative accuracy as a measure of adiposity should be validated against a direct measurement of body fat content. Definitions of overweight and obesity in young people In clinical practice, the variations found in body fat mass and non-fat mass for a given bodyweight may make any judgement based on weight (adjusted for height and/or for age) unreliable as an estimate of an individuals actual body fat. At higher levels, BMI and the BMI cut -offs may be helpful in informing a clinical judgement, but at levels near the norm additional criteria may be needed. For clinical assessment, more direct measures, such as bio-impedance, as well as indirect measures such as waist

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circumference, are sometimes used. In contrast, assessments of populations for survey purposes, and the ability to monitor secular trends and to predict from these the likelihood of health risks and health burdens, can benefit greatly from defining and agreeing classifications. (For further discussion of the uses of reference charts and classifications at individual and population levels see section 5.x below). Faced with a continuous distribution, criteria need to be created which define cut-off points (or cut-points) that best fulfil their purpose. For practical reasons, the definitions have usually been based on anthropometry, with waist circumference and BMI being the most widely used both clinically and in population studies. Weight for height Although not validated against health criteria, weight for height measurements have become a common means of assessing populations of children, especially those aged under five years, and are used to define both under - and over nutrition. Low weight for height is termed thinness, and very low weight for height is termed wasting, usually found as a consequence of acute starvation and/or disease. A high weight for height is termed overweight and very high weight for height is termed obese. The use of weight for height has the advantage of not requiring knowledge of the childs age, which may be hard to assess in less developed areas, but it should not be used as a substitute for height for age, or weight for age, as all three measures reflect different biological processes ( 367). In 1995, the use of weight for height was recommended by WHO for children below the age of 10 years but a WHO review found that use of the US-based National Center for Health Statistics should be reconsidered as it did not take account of differences between breastfed and non-breastfed children. New reference standards based on multinational studies of breastfed children showing healthy growth are currently being developed (see below). Waist circumference In a large -scale epidemiological study of young people aged 5 to 17 years, Freedman et al showed that central fat distribution (particularly as assessed by waist circumference) was associated with an adverse lipid profile and hyperinsulinaemia ( 368). A high waist circumference has also been shown to track well into adulthood (369). Waist circumference percentile charts have been described (e.g. for the UK (370) and USA (371)), although appropriate cut -off points for defining high or low health risks have not been identified. A five -year longitudinal syudy of children in western Sydney, Australia, found waist circumference a more sensitive indicator of change in overweight and obesity during the period (see figure below) using IOTF cut off criteria for BMI compared with 91st and 98th centile cut-offs for waist circumference. Waist circumference and skinfold measures amy be more sensitive to interventions than BMI: an eight-month schoolbased intervention to prevent weight gain showed significant improvements in both

77

these measures, and in aerobic fitness, but no significant change in BMI (Singh, Chin A Paw, Brug, van Mechelen, cited by Seidell, Kobe presentation). Waist circumference may be useful in clinical practice as a means of determining a child or adolescents response to weight control measures. In epidemiological studies, it may be used to characterise a population in terms of abdominal fat distribution and to determine the prevalence of risk factors. However, at present waist circumference cannot be used to categorise a child as being at a high or low risk, and its diagnostic ability remains to be clarified.

% of children overweight or obese in a 5 year follow-up of children in western Sydney


Central adiposity
50

Waist 91st centile/ 98 th centile Total adiposity BMI IOTF criteria

40

30

obese overwt

20

10

GIRLS

7y

12 y

7y

12 y

Garnett et al, Int J Obesity 2005, in press

Source: Baur presentation at Kobe, from Garnett et al 2005 372

Body mass index Although not a perfect reflection of adiposity, BMI is significantly associated with relative fatness in childhood and adolescence, and is the most convenient way of measuring relative adiposity (373 ). BMI varies with age and gender. It typically rises during the first months after birth, falls after the first yea r and rises again around the sixth year of life: this second rise is sometimes referred to as the adiposity rebound. A given value of BMI therefore needs to be evaluated against age- and gender -specific reference values. Several countries, including the USA, France, the United Kingdom, Singapore, Sweden, Denmark and the Netherlands, have developed their own BMI-for -

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age gender-specific reference charts using local data. In the United States, reference values published by Must et al ( 374) derived from US sur vey data in the early 1970s, have been widely used and were recommended for older children (aged 9 years or more) by a WHO expert committee in 1995. More recently, the US National Center for Health Statistics (NCHS) has produced reference charts based on d from five national health ata examinations from 1963-1994 ( 375), although to avoid an upward shift of the weight and BMI curves, data from the most recent survey were excluded for children over the age of six. The advantage of using BMI-for-age charts is that a child can be described as being above or below certain centile lines (for example the 85th, 90th or 95th centile). The NCHS documentation recommends that those children with a BMI greater than or equal to the 95th percentile be classified as overweight and those children with a BMI between the 85th and 95th percentile be classified as at risk of overweight. In some papers, US children at or above the 95th centile are referred to as obese and in others obesity refers to US children above the 85th centile. BMI for age Z-scores An alternative to the use of centiles is to reflect the distribution in terms of Z -scores (deviation from the median expressed in units of standard deviation). Thus a Z-score of 0 is equivalent to the median or 50th centile value, a Z-score of +1.00 is approximately equivalent to the 84th centile, a Z-score of +2.00 is approximately equivalent to the 98th centile and a Z-score of +2.85 is >99th centile. As with other measures, BMI Z -scores can be used to compare an individual or specified population against a reference population. They have the advantage over centiles in that they can better differentiate data describing the high centile levels. However, BMI for age Z-scores require suitable statistical skills or software programmes, there is difficulty in choosing an appropriate reference population, and there are only arbitrary cut-off points for categorising into non-overweight, overweight and obese. BMI based on adult cut -off points An expert committee convened by the International Obesity TaskForce in 1999 determined that although BMI was not ideal as a measure of adiposity, it had been validated against other, more direct measures of body fatness and may therefore be used to define overweight and obesity in children and adolescents (376). As it is not clear at which BMI level adverse health risk factors increase in children, the group recommended cut -offs based on age specific values that project to the adult cut-offs of 25 kg/m2 for overweight and 30 kg/m2 for obesity. Using data from six different reference populations Great Britain, Brazil, the Netherlands, Hong Kong, Singapore and the United States Cole et al derived centile curves that passed through the points of 25 kg/m2 and 30 kg/m2 at age 18 years.( 377) These provide age and gender specific BMI cut offs to define overweight and obesity, from age 2 years to 18 years , corresponding to the adult cut off points for overweight and obesity recommended by

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the WHO expert committee in 1997 (378). These IOTF-recommended cut-off points have been used widely in epidemiological surveys and have been applied retrospectively to reveal secular trends in child obesity. Some criticisms of the IOTF cut-offs have been made, however, on the grounds that there are differences in body composition across adult ethnic groups, with one study in whites and Asians showing differences of 2-3 BMI units in adults with the same body fat composition. This implies that the adult cut-offs of BMI 25 and 30 may not be universally applicable, and hence the use of those cut-offs to define the range of childhood BMIs that correspond to them, may also be inappropriate for some child populations. In respect of adults, a WHO-sponsored seminar on Asian obesity risks suggested that overweight and obesity might be defined at BMI 23+ and 25+ respectively ( 379), while a study of Malaysians has shown that body fat levels are higher than those found in Caucasians, and that overweight and obesity should be defined at BMI 23+ and 27+, respectively (380). For Pacific Islanders, overweight and obesity may be better defined at 26+ and 32+ respectively ( 381). Other criticisms of the IOTF cut-off methodology concern its application during adolescence because of differential timing of puberty across different populations, although these concerns represent a challenge for any international reference. In addition, the IOTF reference assumes that the prevalence of overweight and obesity is constant with age, which may not be true. Furthermore, the IOTF reference was anchored at 18 years as the commencement of adulthood, whereas the normal postpubertal increase in BMI may not have stabilised by this age. Comparisons of BMI Several studies have compared the US NHANES criteria for defining overweight or obesity using age- and gender-specific 85th and 95th centile cut-offs with those of the more recent US Centres for Disease Control (CDC) using similar percentile cut-offs, and the IOTF alternative set of cut-offs based on centiles passing through the BMI 25 and BMI 30 at age 18. Using the NHANES III data, Flegal et al (382) show that the different methods give approximately similar results, but with some significant discrepancies especially among younger girls.
Comparison of prevalence rates of overweight and obesity using different criteria Age 6 -8 Age 12 -14 Boys Girls Boys Girls overweight NHANES/WHO >85th 25% 31% 30% 30% CDC >85 th 23% 23% 29% 31% IOTF >BMI 25 equivalent 18% 23% 29% 31% obese th NHANES/WHO >95 13% 17% 11% 12% th CDC >95 11% 11% 12% 12% IOTF >BMI 30 equivalent 8% 8% 9% 10%
Source: Flegal et al 2001.

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In a study which examined data from children in national surveys in the USA, Russia and China, a comparison of three different methods for defining cut-offs found that the methods produced similar estimates for the prevalence of overweight (>85th centile US references and > BMI 25 equivalent for the IOTF method), but that estimates of obesity (>95th centile US references and > BMI 30 equivalent IOTF method) showed some differences ( 383). For adolescents the IOTF method tended to give slightly lower estimates for the prevalence of obesity, while for younger children the IOTF method gave more significantly lower estimates for the prevalence of obesity. The IOTF method also gave significantly lower estimates of obesity prevalence compared with figures based on weight-for-height Z score > 2, for children aged 6-9 (older children were not assessed on this score). In general, the IOTF method appears to give a more conservative view of the extent of overweight and obesity among paediatric populations compared with methods based on the 85th and 95th centiles of US-based reference populations or based on the use of weight-for-height Z scores. BMI cut-offs based on alternative criteria The IOTF BMI cut-offs discussed above are based on adult BMI cut-offs extrapolated back into childhood. Alternative approaches can be suggested, for example that child BMI cut-offs can be defined in relation to health in childhood. This approach has been developed in Taiwan, wh cut-offs have been estimated using definitions of fit or unfit ere according to a set of physical fitness criteria ( 384). Using data from nearly a million young people recorded in a nation-wide fitness survey, those individuals deemed physically fit (i.e. excluding those in the bottom quartile on the fitness tests) at age 18 showed 85th and 95th centile points at around 23 kg/m2 and 25 kg/m2 respectively. These values tie in with adult recommendations for Asian populations of BMI 23 and 25, reflecting overweight and obesity cut -off points respectively. Review of reference c harts There is a clear need for agreement on the classification methods for overweight for children. There is also need for agreement on the reference population that should be used to define expected growth patterns. The definition of normal growth is of paramount importance to secure normal health and nutrition. Normative gender and age specific data of weight, height and body mass index are needed if public health programmes are to define who is undernourished, who is normal, and who is obese. Present growth charts have been planned to describe normal population growth, rather than recommended growth based on health outcomes throughout the life course. The most commonly used growth c harts are based on the USA National Centre for Health Statistics (NCHS), and, since they are based on children growing in an affluent society, they have been considered as the standard of healthy growth and have been the basis for earlier WHO recommended standards.

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However, the charts are derived from a non-representative sample of the population and are drawn from a group of infants who was predominantly formula fed. Infants fed according to present WHO recommendations and living in conditions that favour the achievement of genetic growth potential have been shown to grow less rapidly than the present WHO/NCHS reference, particularly after 46 months. The negative deviations are large enough to lead health workers to make faulty decisions regarding the adequate growth of breastfed infants, and thus to mistakenly advise mothers to supplement unnecessarily or to stop breastfeeding altogether. Given the health and nutritional benefits of breastfeeding, this potential misinterpretation of the growth pattern of healthy breastfed infants has great public health significance. The premature introduction of complementary foods can have life-threatening consequences for young infants in many settings, especially where breastfeeding's role in preventing severe infectious morbidity is crucial to child survival. According to data collected in the early 1990s for WHO, by age 1 year breastfed babies tend to be thinner shorter and significantly lighter than the WHO references then recommended (see figure, below). On the understanding that the WHO charts of normal growth might be skewed towards higher values relative to those observed in predominantly breast fed infants, a WHO Expert Committee in 1995 supported the development of a new growth reference. The multi-country (Brazil, Norway, India, Ghana, USA and Oman) growth reference study (MGRS) is specifically designed for this purpose Fig; Mean zscores from a survey of breast-fed infants relative to the NCHS/WHO reference.

Source: WHO 1995 385

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The MGRS gold standard g rowth charts The multicentre growth reference study (MGRS) has been undertaken in diverse geographical areas, using samples of infants and children whose care-givers follow the established WHO recommendations. Data collection was started in 1997 and was completed by 2003. The research design combined a longitudinal study from birth to 24 months of age of 300 newborns per country, with a cross-sectional study of 1,400 children aged 1871 months per site. More than 13,000 healthy infants and children were involved in the study. The resulting new international growth reference will provide a scientifically reliable descriptor of healthy physiologic growth for advocacy in support of good health and nutrition. It will also support the concept that human growth during the first years of life is very similar across groups of children of different ethnic backgrounds, indicating that existing differences are predominantly environmentally derived and can be subject to improvement. Prevalence estimates of under nutrition and obesity in children will clearly be affected to the extent that the new reference differs from the current WHO norms presently being used. Most importantly, the reference will set the growth of the breast fed infant as the normative standard. Optimal infant feeding for now as presently defined by WHO is exclusive breastfeeding for the first six months of life, followed by continued breastfeeding with adequate complementary foods for up to two years and beyond. Existing national and international s tandards have defined normal growth based on the weight and length gain observed in apparently healthy children but, given that these may overweight compared with the optimally-fed children participating in the MGRS programme, the older reference data may be misleading, especially where the concern is the prevention of obesity and related burden of chronic disease in adult life. An important characteristic of the new reference is that it makes breastfeeding the biological norm and establishes the breastfed infant as the normative model. Health policies and public support for breastfeeding will be strengthened when breastfed infants become the reference for normal growth and development. By prescribing the nature of the sample, the recommended approach will provide a single international reference that represents the best description possible of growth for all children less than five years of age and approximates the closest attainable standard of physiologic growth for young children. MGRS methodology The design of the MGRS combines a longitudinal study from birth to 24 months with a cross-sectional study of children aged 18 to 71 months. The pooled sample from the six participating countries (Brazil, Ghana, India, Norway, Oman, and the United States) consists of about 8,500 children. The individual inclusion criteria were absence of health or environmental constraints on growth, adherence to MGRS feeding recommendations, absence of maternal smoking, single term birth, and absence of significant morbidity. In the longitudinal study, mothers and newborns were screened

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and enrolled at birth and visited at home 21 times: at weeks 1, 2, 4, and 6, and monthly from 2 to 12 months then every 2 months in their second year. In addition to the data collected on anthropometry and motor development, information was gathered on socioeconomic, demographic, and environmental characteristics, perinatal factors, morbidity, and feeding practices. The wealth of collected data will allow the replacement of the current international references on attained growth (weight and length for age, and weight for length) and allow the development of new references for triceps and subscapular skinfolds, head and arm circumferences, and BMI. The longitudinal nature of the study will also allow the development of growth velocity curves. Health-care providers will not have to wait until children cross an attained growth threshold to make the diagnosis of under- or over-nutrition, because velocity references will enable the early identification of children in the process of becoming under- or over-nourished. Tools and materials to be developed The MGRS programme includes the development of computer software for use in surveys for assessing and monitoring growth at the population level, based on the new reference charts. Tools for individual management at the clinical level may be more complicated, depending on which indicator is used. Clear guidelines on breastfeeding and complementary feeding will accompany the growth charts. When the new charts are published, each country will need to decide whether or not to adopt them and determine specifically how to include the information in its health cards. While some countries have their own national growth references, most developing countries use the NCHS reference and it is anticipated they will readily adopt the new standards. Reference versus standard The terms reference and standard hold different meanings, the first term applying to the function of charts for the purposes of comparison, and the second referring to the use of charts in terms of targets and goals. The MGRS was originally conceived to develop an international reference, but the resulting growth curves will be a standard given their prescriptive nature. The participants at the Kobe meeting agreed that the new growth curves should be referred to as WHO child growth standards.

An important exercise will be to compare the new standards with other available references, particularly the NCHS reference. This is still in the process of being done, and the variability is expected to be distinct. Data from the MGRS concerning the first 2 years of life was gathered from the same children over time, whereas the other references are based on groups of differently aged children. In general, the MGRS sample of children was thinner and taller than those of the NCHS and CDC references. Therefore, the new standards may lead to a lower prevalence of

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under -nutrition and a higher prevalence of stunting and overweight compared to previous references. It is still not clear how the new standards will affect the prevalence figures for severe malnutrition, but apart from a few countries in Asia , lower prevalence is expected to be observed. Reference data for older children The main drawback of the MGRS growth curves is that they cover children only up to five years of age. In an attempt to devise a set of charts, at least in respect of BMI, which could be used as a prescriptive gold standard for older children, Frongillo conducted an analysis of available large-scale data sets specifically for the Kobe meeting (see Background papers commissioned for the consultation, listed on page XX). The aim was to capture the BMI distribution of a population of children that had not been affected by the obesity epidemic, based on comparisons among available data sets by age and sex. The results showed that data sets from 1980 for both France and the Netherlands did not show a characteristic increase in the right tail of the distribution (i.e., at the higher centiles, indicating a rise in obesity prevalence), even at older ages. All data sets tended to be similar at lower centiles. Since the Netherlands 1980 data set is larger than the France data set, the proposed prescriptive reference would be based essentially on the Netherlands 1980 data. Fig: Body mass index values at percentiles 3, 5, 25, 50, 75, 95, and 97 from selected data sets for (a) boys and (b) girls at 10 years of age. The data sets with the least extreme values at the 75th , 95th and 97th centiles were from France and the Netherlands in 1980. (a) BOYS

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28 26

Body mass index

24 22 20 18 16 14 12
00 20 C st CD Mu US ck st Bla Mu er US hite amm W H US hite 95 W 19 US hite W UK 990 0 1 00 UK en 2 5 ed 99 Sw en 1 ed e Sw por ga 7 Sin ia 199 ss ds 0 Ru rlan 198 the ds Ne erlan th Ne n pa Ja e c an Fr ers nd g) Fla h Kon ec ong Cz a (H in Ch il az Br

Data set

(b) GIRLS
28 26

Body mass index

24 22 20 18 16 14 12
00 20 C st CD Mu US lack ust r B M e US hite amm W H US hite 95 W 19 US hite W UK 990 0 1 00 UK en 2 5 ed 99 Sw en 1 ed Sw pore ga Sin ia 1997 ss s Ru rland 1980 the s Ne rland the Ne n pa Ja ce an Fr ers ) nd ng Fla h Ko ec ng Cz a (Ho in Ch il az Br

Data set
Source: Frangillo 2005 (Commissioned paper for Kobe expert meeting)

Although the Netherlands data indicates a lack of right-skewing, at the time it was published it was considered as indicating that Dutch children were showing signs of being at risk of obesity compared with previous generations, casting doubt on their value as a gold standard. Furthermore, the Dutch are among the tallest people in the world, which may or may not make these data desirable for height and weight

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references. The Dutch data set may therefore have some limitations in providing a true prescriptive reference for international use. In order to assess the value of the Dutch data set, or any ot her possible data set, such as that from the Czech Republic, which could be considered as a possible standard, they will need to be matched at the young end with the data collected in the MGRS programme. If the proposed figures are a close match to those published by the MGRS then that provides some hope that the data can be used as a reference for older children. This comparative work is planned for 2005-2006. If a prescriptive standard can be found from the current cross-sectional data sets then this can be analysed to provide centile charts, and cut -offs according to Z-scores, notional centiles or adult BMI-linked centiles. The two cut-offs proposed in the IOTF model of adult BMI-linked centiles, at BMI 25 and BMI 30 can be expanded to take account of populations where adult BMIs of 23 or 27 are deemed appropriate healthrelated cut-offs, so that cut-offs under different definitions, but all referring to a standard population base, are used. Work examining this possibility is also planned for 2005-2006. However, if a standard data set for older children is not forthcoming from these analyses, then there is an argument for undertaking a full longitudinal study of children, defining their optimal growth according to prescribed patterns of diet, physical activity, exposure to infectious disease and other familial, social and environmental criteria. The WHO meeting agreed that the ideal position would be to have reference data which (a) could be used to define the gold standard for growth, preferably in all populations, and (b) could be used by clinicians to monitor a childs progress towards or away from optimum health, and (c) could define degrees of overweight and obesity for survey, monitoring and population comparisons, preferably linked to health outcomes. Desirable attributes of a reference data set Several countries from different geographical regions should be included, among them less-developed ones Data should be based on healthy populations (without obesity) Sample sizes and should be adequate Raw data should be available The age range from birth to adolescence should be covered (overlap in age with MGRS) Good quality control and measurements For adolescents, measures of sexual maturity should be available Secular trends in obesity should be small or absent Sensitive to intervention and treatment effects Desirable attributes of cut-off criteria Can be applied to all countries Includes age groups from infancy to adulthood

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Linked to health outcomes in childhood and adulthood Sensitive to intervention effects

Uses of charts and cut-offs Obesity assessment is carried out for many purposes. A family doctor may want to check a child in the clinic, a school nurse may want to screen the new student intake, a health ministry may want to survey the child population, and all three of these interested parties may want to see if their interventions are having an effect. All of them are faced with a range of possible assessment methods for measuring adiposity directly or indirectly, and then making judgements on the basis of how their data compare with some form of reference of standard. As discussed earlier, the reference population recommended by WHO has been criticised for being based on US children who were largely formula fed, and hence probably showing different growth curves to those that might be shown by healthy children following WHO guidelines for breastfeeding and weaning. A new set of charts is being prepared to account for this. The new charts will not settle the issue of cut-off criteria for defining overweight. Ideal cut-off criteria are based on health outcomes: children above a certain cut-off will be at high risk of specific disease factors while children below the cut-off will not. In practice the relation between risk and adiposity is a continuous one, and the disease outcome may not be apparent until later in childhood or well into adulthood. Severalapproaches can be taken to deal with this. The first is to choose statistically convenient cut-offs, for example based on centiles (e.g. 95th) or Z-scores (e.g. +2.0) , which serve the purposes of monitoring and assessment well, but which do not link to health risk. A second is to set cut-offs by comparison with more exact measures of body composition. A third is to use health-related criteria, such as biochemical markers, or distal outcomes such as health risk, morbidity, or mortality. This third approach has been developed using cut-offs relating to adult health risk defined as BMI 25 and BMI 30 (which are themselves somewhat arbitrary a nd disputed for some population groups) and translate d backwards through childhood to create gender- and age -specific cut-offs for childrens BMI equivalent to the adult ones. This is the approach taken by Cole et al (386) and adopted as a recommendation for epidemiological surveys by the International Obesity TaskForce. Table: Comparison of data sets NCHS/WHO Multiple countries No Infants, children and Yes adolescents? Unaffected by No obesity epidemic

CDC 2000 No Yes No

IOTF 2000 Yes From age 2 Requires broad database

MGRS 2006 Yes No Yes?

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Distribution of BMI available Weight and height distributions available Health-related cut-off criteria

Yes Yes

Yes Yes

Cut-offs only No

Yes Yes

No

No

Yes

No?

Different applications may require different approaches. The individual clinician examining a single child may not need to use cut-offs if the child is making progress across the centile charts the charts alone will suffice. Furthermore, the clinical judgement does not depend on whether the chart is base d on local, US or international reference sets only the trend in time in the childs measurements are significant, relative to the points on the chart. For research and survey work, however, the choice of reference curves and cut-off criteria becomes more significant. Public health policy decisions are needed, and resources allocated, on the basis of absolute criteria rather than relative ones: and for this the reference groups and the cut-offs need to be appropriate and acceptable. Researchers may want to compare their data with those from other sources, and an agreed reference base that is used widely in the research community and acceptable internationally is desirable.
Table: Examples of uses of centile curves and cut-off criteria Purpose Assessment Criteria for judgement Individual children Clinical Several measures of Crossing centiles assessment of adiposity, repeated over upwards individual child time Screening Single measure of Exceeding cut-off individuals for adiposity criteria interventions

Notes

Local charts acceptable Public Health decision on whether local criteria preferable to international ones Public Health decision on whether local charts preferable to international ones (absolute measure acceptab le, because should not be shrinking naturally) Local charts and criteria acceptable but reporting to wider community may benefit from use of international ones

Monitoring individuals for interventions Assessing individual response to intervention

Repeated measures of adiposity (longitudinal)

Crossing centiles upwards

Before-after measure of adiposity

Downward change in measure or in Zscore, crosses cut-off downwards, crosses centiles downwards.

Population groups

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Prevalence surveys

Simplest indicators of adiposity (e.g. weight for length or BMI, waist circumference) Repeated surveys, based as above

Prevalence monitoring for trends

Mean and variance compared to reference group: proportion exceeding cut-off criteria Change in mean or variance; change in proportion exceeding cut-off criteria Mean and variance of measures; proportion exceeding cut-off criteria

Target groups (defined by risk factors, e.g. maternal obesity)

Several measures of adiposity

Evaluation of group interventions

Repeated measures of adiposity

Changes in mean or variance, change in proportion exceeding cut-off criteria

International references/cut-offs preferred if data are to be compared to other countries/regions International references/cut-offs preferred if data are to be compared to other countries/regions Local criteria acceptable but reporting to wider community may benefit from use of international criteria Local criteria acceptable but reporting to wider community may benefit from use of international criteria

Methodological caveats for surveys In a review of child obesity issues, the International Obesity TaskForce (387) noted several constraints on the use of survey data for interpreting regional prevalence and trends in obesity in children and adolescents: Sampling issues: Some published surveys are based on national representative surveys while others are based on smaller surveys which do not represent national populations. Sexual maturation: Sexual maturation influences body fatness: fat gain occurs in both boys and girls early in adolescence, then ceases and may even temporarily reverse in boys but continues throughout adolescence in girls. There are large intra and inter-population variations in the patterns of sexual maturation. Secular trends in growth and development: Over recent decades, children worldwide have become taller, they mature earlier, and in some cases, become heavier for a given age. These trends have affected some populations more than others, and at different rates of change. Comparisons between populations may need to take these secular trends into account. Stunting: Stunted children are more likely to be become overweight in countries undergoing a rapid nutrition transition (see earlier in this report). This is of particular significance when examining the trends in obesity in developing countries, where the secular trends in linear growth continue and the prevalence of stunting has declined.

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Adiposity rebound: Considerable differences may exist in the timing and patterns of adiposity rebound between populations in particular, between populations in industrialised and in non-industrialised communities. This may affect the estimate of obesity prevalence for children from developing countries at around the age of adiposity rebound when using cut-off criteria obtained in industrialised economies, and it may affect differences between rural and urban populations. Measurement errors: Data collected in different studies and countries and over time may not have the same quality. The potential influence of measurement errors should not be ignored. All these factors may influence the observed secular trends.

Despite these caveats, the continued collection of survey data is essential. Until better reference data are available, prevalence data intended for comparison with other international pre valence surveys may best be reported in terms of the WHO 1995 criteria and/or the IOTF/Cole criteria, in addition to any locally -accepted criteria. Ideally (to provide compatibility with future standards) reports should also include mean, standard deviatio n and skewness. Governments should be encouraged to undertake sample surveys of childrens weight and height (and other anthropometric measures if appropriate) annually.
Further research is recommended to investigate childrens growth in developing countries.

Nationally representative data in developing countries are particularly needed, especially for older children (>5 years old) and adolescents, and these data will be valuable for monitoring trends in obesity during periods of economic change and urbanisation. In addition, collection of longitudinal data to track the development of obesity and evaluate interventions needs to be encouraged. Longitudinal studies may prove particularly valuable for examining the social, environmental, behavioural, and biological factors that may contribute to the secular trends in childhood obesity. Further recommendations As noted above, several research developments are currently underway, including the finalisation of the MGRS reference charts, and the work to validate cross-sectional surveys of older children (e.g. the Netherlands 1980 data) against the MGRS data. The Kobe meeting of experts noted that this should include validating the health-related links by charting the proposed dataset for older children against the Mercedes data at age 5, to show that the optimum 5-year-old BMI corresponds to an optimum adult BMI (which may be assumed to be a BMI of 22). Furthermore the dataset for older children could provide a wide range of cut-offs for different needs, providing age- and gender-specific BMI cut-offs relating to BMIs in adulthood of 19, 22, 23, 25, 27, 28, 30, 40 etc. However, providing cut-offs for these higher levels needs data with a broad range of outcomes (adult BMIs) to get robust back-tracking of the higher cut -offs, whereas the Dutch childrens dataset will have very few datapoints at the higher levels, if the children are truly health. Populations with unhealthy outcomes are needed to provide robust cut -offs back-tracked into childhood.

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Recognising that these issues require further development work, and that several papers are being prepared for discussion in 2006, the expert group made no specific recommendations to change current practices concerning the measurement and assessment of overweight and obesity in paediatric populations. The expert group also noted that

The International Atomic Energy Agency (IAEA) is able to support research into child growth using radio isotopes in various settings: for example in the study of energy expenditure or breast feeding patterns. The IAEA is conducting a co-ordinated research project for 2005-2207 Assessing body adiposity and its relationship with risks for non communicable diseases. Potential collaborators are recommended to form research networks within a region to share the equipment and training overheads.

When used in children and particularly adolescents, BMI must be interpreted based on age, gender, and when possible stage of maturation. Fitness level should also be considered when interpreting the BMI value relative to health risk of an individual.

There may be important ethnic differences in patterns of BMI, in the relationship of BMI to body fatness, and in the relationship of BMI to functional outcomes. Full consideration of these differences and the implications for a proposed reference will have to be given. Some additional technical work should be done to evaluate the implications of these differences.

Waist circumference may be able to indicate central, truncal, or upper body fat better than BMI in adults and possibly in children. As levels of central, truncal, or upper body fat appear to be more closely linked with certain chronic disease risk (metabolic syndrome, cardiovascular disease, diabetes) than total body fat in children it may provide better health-linked cut-off criteria.

As indicated earlier, the Kobe expert meeting noted that there is a need for low -cost length-measuring equipment with minimal need for training. Similarly there is a need for low-cost skin-fold measuring equipment.

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6. Interventions The following section describes the context for child obesity prevention, and summarises the evidence for effective prevention strategies. This leads to the conclusion that small-scale preventive activities , for example in schools, have only modest effects, and that such initiatives will need to be supported by environments that encourage healthier choices and do not encourage unhealthy ones. The Kobe expert meeting made a number of recommendations concerning the most appropriate forms of intervention at school and community level and the types of intervention that are needed at national and international level to ensure that localised interventions are supported. 6.1 Prevention and population health As shown earlier, child obesity is increasing rapidly in the majority of countries of the world. This is a relatively recent phenomenon, with little evidence of any change in the prevalence of childhood obesity before the early 1980s, and signs of a rapid increase in prevalence during the 1990s and early 2000s. An obese child faces a life-time of increased risk of various diseases, including cardiovascular disease, diabetes, liver disease and certain forms of cancer. Even during childhood, obesity increases the risk of these diseases, and is a significant cause of psychological distress. At present, paediatric services have few treatment options available. Once a child is substantially overweight, successful weight loss is difficult to achieve, as it is for adults, and requires intensive hea lth care resources. Prevention of obesity is to be preferred, for the childs sake as much as for the health and social costs that otherwise ensue.
Many people believe that dealing with overweight and obesity is a personal responsibility. To some degree they are right, but it is also a community responsibility. When there are no safe, accessible places for children to play or adults to walk, jog or ride a bike, that is a community responsibility. When school lunchrooms or office cafeterias do not provide healthy and appealing food choices, that is a community responsibility. When new or expectant mothers are not educated about the benefits of breast-feeding, that is a community responsibility. When we do not require daily physical education in our schools, that is also a community responsibility ... The challenge is to create a multi-faceted public health approach capable of delivering long-term reductions in the prevalence of overweight and obesity. This approach should focus on health rather than appearance, and empower both individuals and communities to address barriers, reduce stigmatization and move forward in addressing overweight and obesity in a positive and proactive fashion. - Dr D Satcher, US Surgeon General, 2001 (foreword) (388)

Preventive activities cover a broad spectrum from individual and local group-based initiatives which tend to be the ones most closely researched through to organisational, national and international policies. This can be visualised with the diagram below, showing how each level of intervention is set within a wider context.

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Figure Opportunities for influencing a childs environment

The diagram is drawn to indicate how children are vulnerable to the social and environmental pressures that raise the risk of obesity. Although they can be encouraged to increase their self-control in the face of temptation, and although they can be given knowledge and skills to help understand the context of their choices, children cannot be expected to bear the full burden of responsibility for preventing excess weight gain. The prevention of childhood obesity requires: Improving the familys ability to support a child in making changes, which in turn needs support from school and community, for example... Ensuring the school has health-promoting policies on diet and physical activity, and that peer group beliefs are helping the child, which in turn requires that The cultural norms, skills and traditional practices transmitted by the school are conducive to health promotion, and that the community provides a supportive environment, such as Neighbourhood policies for safe and secure streets and recreation facilities, and ensuring universal access to health-enhancing food supplies, which in turn requires that authorities at municipal, and regional level are supporting such policies, e.g. for safe streets and improved food access through appropriate infrastructure, which in turn may require that National and international bodies which set standards a nd provide services are supporting better public health, and that commercial practices consistently promote healthy choices, which in turn may require

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Legislative and regulatory support is in place to ensure that strategies for obesity reduction are fully resourced and implemented, and appropriate control measures are enforced, and that these are not contradicted by other government policies , for example in the realm of trade and investment policies. It can be seen from this that government and inter-governmental activities in all departments, including education, agriculture, transport, trade, the environment and social welfare policies need to be monitored for their health impact and their consistency and compliance with health and nutrition policies. It follows from this approach that, although actions to improve individual childrens lifestyles are needed and are perhaps the only recourse for limiting obesity development in the short-term, actions undertaken from a broader public health and policy perspective will be needed to have a significant impact on the problem in the medium and long term. The evidence for individually-oriented approaches is discussed below, but in summary they appear to have limited success when undertaken without supporting social and environmental changes. An over-reliance on individual approaches with insufficient public health actions may allow the situation to worsen and, particularly, to become concentrated in socially disadvantaged populations (389). Evidence base for child obesity prevention The evidence base for effective prevention of child obesity is poor. A Cochrane systematic review conducted in 2001 found only ten trials that were sufficiently large and of sufficient duration and sufficient quality to be included in the review, all of which involved children who were already overweight.390 An updated Cochrane review was conducted in time for submission to the Kobe expert meeting, and this found 22 studies that tested a variety of intervention programmes, all of which focused directly on children and which involved increased physical activity and dietary changes, singly or in combination. The summary of these 22 interventions is included as an appendix (see Appendix X). The updated Cochrane review came to the conclusion that there was not enough evidence from trials to prove that any one particular programme can prevent obesity in children, although comprehensive strategies to address dietary and physical activity change, together with psycho-social support and environmental change may help. It noted that the current evidence suggests that many diet and exercise interventions to prevent obesity in children are not effective in preventing weight gain, but can be effective in promoting a healthy diet and increased physical activity levels. Of the 22 studies analysed in the Cochrane systematic review, ten were considered long-term with follow-up data a year after commencement of the intervention. Of these ten studies, two focused on dietary intervention and showed no impact on measures of adiposity, two focused on physical activity and showed small, nonsignificant reductions in the prevalence of overweight children in the intervention group, and six studies focused on combining dietary change with physical activity: and of these only one showed an improvement in weight status following the intervention,

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with the girls showing a significant fall in the prevalence of obesity. This one successful program (Planet Health) focused on increasing physical activity and fruit and vegetable consumption and reducing fat consumption and television watching. This last factor was the most closely linked to the reduction in the prevalence of obesity: for each hour of reduction in television-viewing time per day the study found a 15 percent reduction in the risk of obesity.( 391) Four of the twelve short-term studies focused on interventions to increase physical activity levels, and two of these studies resulted in minor reductions in overweight status in favour of the intervention. The other eight studies combined diet and physical activity, but none had a significant impact. The reviewers note that t he studies were mixed in terms of their design, their quality, the target populations, the theoretical underpinning, and the outcome measures, making it impossible to combine study findings using statistical methods. The reviewers also noted there were no data given on the costs of interventions, with the result that cost-effectiveness relationships could not be calculated. The Kobe expert meeting also had access to two broader reviews of the literature on childhood obesity prevention. The first, undertaken by the Cochrane review team, had been prepared for the UK National Institute for Health and Clinical Excellence. 392 It concluded there was good evidence that a whole school approach can influence dietary intake through small but important changes in food choices made by children, such as increasing the consumption of fruit and vegetables. A whole school approach is one which integrates the various opportunities for health promotion in the school, including classroom teaching, physical activity sessions, canteen food choices and vending machine sales. It involves children, staff and parents, and can extend health promotion through school-family and school-community links. The review also found good evidence fo a small but important beneficial effect of r breakfast clubs (providing food when children arrive early at school) on behaviour, dietary intake, health, social interaction, concentration and learning, attendance and punctuality. This positive impact is reaching many families whose members are at risk of, or are actually experiencing, social exclusion. The review noted that school based interventions that deliver an intense dietary educatio n programme using multimedia did appear to help children them from becoming overweight, but that these required significant additional resources. Other points raised in the review were:

School-based physical activity interventions that appear interesting and innovative to children (such as dance clubs), and interventions that aim to reduce television, videotape and video game use, are most effective.

School-based interventions can help children to eat a healthier diet, with the most successful interventions focusing on promoting one aspect of a healthy diet, such as fruit and vegetables. Introducing nutrition standards for school foods needs to be

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supported by measures to ensure the healthy options are selected. Restricting the choices of food available to children is associated with healthier eating.

Within schools, a comprehensive school policy on snacks brought to school, supplemented by a school fruit tuck shop (and, in England, by free fruit provided to younger infants), may achieve a more substantia l impact.

Children will choose healthier options from vending machines, such as mineral water, pure fruit juice and skimmed milk, even when healthy drinks vending machines are set alongside the schools usual vending machine. The key to successful healthy drinks vending is pupil involvement, appropriate location of the vending machine close to the dining area, and ensuring continuity of provision (that the machine is full and in working order)

Walking to school and cycling to school schemes may be effective, but there is no good evidence available on which to base a recommendation. The second review of child obesity prevention available to the Kobe expert meeting was based on the work of a team supported by Health Canada and the Calgary Health Region 393. In addition to the usual selection criteria based on methodological quality, outcome measures, robustness and generalisability, the review also considered the degree to which the research programmes included the principles of population health, i.e. the importance of the upstream determinants of health, and the need for multiple levels of intervention, multiple areas of action and participant involvement, as outlined in the Ottawa Charter for Health Promotion (394). The review also took a broader perspective than most by including in its search strategy a wide range of grey literature sources, internet searches, hand searches of leading journals and foreign language reports, resulting in over 13,000 reports which described programmes to promote healthy weights in children. The review indicated that a large number of potentially useful interventions are taking place which are not providing sufficient material to be properly evaluated. Further, there are many childrens health promotion efforts which may be havin g an impact on obesity but which do not have a measure of childrens adiposity as an outcome. They may fail to appear in systematic reviews because they cannot provide strict evidence-based guidance on best practice on obesity, even though they may provide legitimate indicators for healthy body weight. After excluding overlapping reports, notices of projects still underway or being proposed, projects conducted more than 20 years earlier, and projects for children with specific medical problems (such as children of diabetic mothers or children with respiratory dysfunction) the Calgary reviewers identified 500 reports that gave sufficient information about their operation to identify good practices and which could be assessed using the chosen criteria. Of the se, 145 scored highly on programme quality, 20 scored highly on methodological rigour, 4 scored highly on immigrant health aspects and just one scored highly on principles of population health promotion, prescribed by the Ottawa Charter. An editorial com mentary on the Calgary review noted that anti-obesity programmes may show high levels of methodological rigour but still fail to identify the best practices

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that can form the basis of a health policy. 395 The quality of evidence may be unrelated to its practical usefulness, especially when the forms of intervention being examined are fail to consider up stream population health questions or deal with population inequalities. For obvious practical reasons, interventions are usually designed around small groups in school, community or clinical settings, face to face with the children being targeted, and do not look at the larger social determinants of obesity and the resulting obesogenic environments. Of the high-quality reports in the Calgary review, none dealt with population-wide policy-related issues such as food marketing, labelling or pricing, play facilities or traffic control. Other literature reviews (396, 397, 398) of European and North American papers have suggested that the chances of successful prevention at the community level are increased if measures are broad-based and well integrated into childrens lives, such as: * healthy school policies involving school cafeterias, vending machines and snack bars, plentiful school-based physical activity classes and recess activities; * classroom health education linked to the schools food and activity practices; * links between school practice and home and community activities; * prolonged interventions rather than short-term ones, involving adults and children, at school and at home; * the involvement of all children, not just some, using techniques sensitive to the cultural, ethnic and gender characteristics of the children. In the promotion of physical activity, Hills has identified a number of factors whic h can improve participation in activities in the school and community settings.399 These are: Immersion learners flooded in, bathed in activity Engagement seeing, hearing, witnessing & experiencing Approximation free to experiment (having a go) Expectation communication of confidence (self-efficacy) Employment time and opportunity to practice Modelling active role played by significant others Response provision of feedback and reinforcement Responsibility personal decision making The wider environment Several authors have urged policy-makers to consider the macro-environmental factors that promote obesity including food pricing policies, agricultural production policies, unregulated marketing to children and patterns of economic development, and these have been reflected in the WHOs Global Strategy on Diet, Physical Activity and Health, noted above. However, the societal factors that predispose populations to obesity are often viewed as desirable, such as greater accessibility of essential goods and services as well as improvements in household income and standard of living. Depending on cultural variations, the changes in lifestyles may include decreased time spent in home food preparation, increased consumption of processed and catered foods, increased mechanisation of work and home activities, increased reliance on motorised

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vehicles and increased access to and use of televisions and computers. These changes inevitably influence social values and cultural norms about eating and physical activity within families, in schools and workplaces and in society at large. Examples of problematic social trends Increase in use of motorised transport, e.g. to school Increase in traffic hazards for walkers and cyclists Fall in opportunities to tak recreational physical activity e Increased playing of sedentary games Multiple TV channels around the clock Greater quantities and variety of food available More frequent and widespread food purchasing opportunities Larger portions of food Rising use of soft drinks to replace water More use of restaurants and fast food stores

Obesity-promoting social and environmental trends are likely to be self-perpetuating unless they can be successfully redirected. In this respect, the trends in child and adolescent obesity and the emergence of obesity-related diseases during childhood and adolescence take on particular importance in motivating social change because the importance of contextual influences on behaviour is more easily recognised where children are concerned. In discussions of adult obesity it is often held that environmental forces are subordinate to personal choices in promoting obesity or preventing weight loss. But the holders of these views will usually acknowledge that the rising prevalence of childhood obesity reflects the potency of environmental influences, including the home environment along with the wider community, and that public health actions may be needed to curtail these influences. A primary goal of public health initiatives to address obesity is to increase awareness within the non-health sectors of the potential adverse effects of their actions on the ability for people to maintain energy balance and to increase their interest in and ability to minimise these adverse effects. Furthermor e, so fundamental to society are the processes that relate to food intake and physical activity that any initiatives undertaken in relation to obesity must be harmonised with programs undertaken to maintain other societal core processes. The need for global co-ordination is also evident from this framework. Many of the economic forces involved are global in nature and any effects of obesity-reducing policies on the relevant industries will undoubtedly have global consequences. Principles underlying genera l obesity prevention initiatives at the population level have been outlined by IOTF and are shown in the table below. Table Ten principles for obesity pre vention at the population level
1. Education alone is not sufficient to change weight-related behaviou rs. Environmental and societal intervention is also required to promote and support behaviour change. 2. Action must be taken to integrate physical activity into daily life, not just to increase leisure time exercise.

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3. Sustainability of programs is crucial to enable positive change in diet, activity and obesity levels over time. 4. Political support, intersectoral collaboration and community participation are essential for success. 5. Acting locally, even in national initiatives, allows programmes to be tailored to meet real needs, expectations and opportunities. 6. All parts of the community must be reached not just the motivated healthy. 7. Programs must be adequately resourced. 8. Where appropriate, programs should be integrated into existing initiatives (Box 4.1). 9. Programs should build on existing theory and evidence. 10. Programs should be properly monitored, evaluated and documented. This is important for dissemination and transfer of experiences.
Source: Kumanyika et al 2002 ( 400)

Targets for action focus on changes in the nature of the food supply and in the mechanisation of physical activity. Strategies can be modelled partly after successful campaigns for tobacco control, automotive safety, and recycling all of which have involved a successful combination of consumer education and advocacy, legislative and policy changes, and community-based programs (401). Approaches that specifically target children include changes in the food and activity options in schools, to improving infrastructure for walking and access to safe and affordable outdoor play areas, and regulating food advertising on television, particularly advertising that is aimed at children. However, t he goal is not to find a single programme that works, as this is unlikely to be found, but to stimulate regional, national and local initiatives that are suitable for their context. Initiatives to meet the rising problem must be proportional to their target, for example: school curriculum development for health education may need to be set as a national policy sports promotion may need to be centred on school and community programmes food marketing controls may need to be introduced at national, regional or even global level reduced car use and increased walking or bicycle use may be the responsibility of municipal planners working under national guidelines.

Involvement of other sectors It is clear from this approach that some influential stakeholders outside of the health sector may have interests complementary to health sector obesity prevention objectives. Policy development can identify and capitalise upon partnerships with such interested agencies and stakeholders. Within the health sector itself, nutritional objectives for obesity prevention are highly compatible with those for the promotion of cardiovascular health as well as cancer prevention. Similarly, efforts to improve breastfeeding adoption and to increase consumption of fruits and vegetables are consistent with general guidelines for infant and child nutrition.

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Outside of the health sector, allies in efforts to increase childrens physical activity may be found among those working to increase the sustainability of the environment, including proponents of sustainable transport and of safer streets or of the development of parks and recreational facilities. In addition, teachers and school administrators, when convinced that healthful eating and physical activity are favourable to academic performance, can also become powerful allies for implementing changes in school environments and extend school sports facilities for local community use. (See for example, the transcripts from the U.S. Healthy Schools Summit at http: //www.actionforhealthykids.org/hss/presentations.htm). School boards may also be encouraged to review their school nutrition policies by direct exhortation from health care professionals. A recent Policy Statement from the American Academy of Pediatrics (402) identifies soft drinks in schools as a risk factor for obesity and is intended for school superintendents, school board members and parents as well as health professionals. It calls on paediatricians to assist in educating school authorities about their responsibilities for the nutritional health of their student body. Barriers to obesity prevention are economic, cultural, and practical. It is welldocumented within the field of tobacco control and also reported with respect to the promotion of healthy eating (403) that initiatives to curtail the advertising and sale of food elicit strong opposition from commercial interests. For example, in the United States and some European countries, exclusive marketing contracts to sell food and beverage products to school children have been negotiated with some schools, with incentives to school administrators who use the associated revenues to increase resources for school programs (403). Such policies need to be reviewed and assessed for their potential health impact. Cultural resistance to change To find economically viable strategies that can prevent a continuing escalation of the absolute amount of food and calories marketed within countries and across national boundaries is extremely challenging. Restrictions on marketing and advertising are opposed on the grounds of strong and legally-protected cultural values such as the right to free speech, although marketing and advertising that is aimed at children has come under criticism from consumer organisations. Professional bodies for paediatrics and psychology have also taken positions against the marketing of products which could undermine the health of children. In addition, consumer demand is a barrier to obesity prevention. Once consumers have become accustomed to and relatively dependent upon the modern food environment for example, abundant quantities of conveniently packaged foods at low cost efforts to alter this environment in the name of obesity prevention may encounter strong cultural resistance. There are major economic and cultural implications associated with initiatives to decrease physical inactivity or to increase activity. Small-scale programs to reduce the

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time spent in sedentary activities such as television viewing or use of computers or computer games can be effective and tolerated, but large scale initiatives of the same type may encounter substantial economic and cultural barriers. Sedentary lifestyles are culturally normative and defended as such. In summary, long-term obesity prevention strategies must be economically viable, culturally acceptable, and futuristic. Obesity prevention cannot be accomplished by turning back the clock to reverse development and economic advancement. Rather, the challenge is to create environmental incentives and opportunities that will prevent excess weight gain that are compatible with other aspects of the desired aggregate lifestyles. Health promotion Interventions to prevent obesity are the latest of a long history of health promotion activities. There has accumulated a large body of evidence relating to health promotion and the best practices, some of it summarised in the collection of papers produced by the WHO for the Jakarta Declaration.( 404). The health promotion approach recognises that targets of an intervention must also be the active players. The Ottawa Charter for Health promotion states Health promotion is the process of enabling people to exert control over the determinants of health and thereby improve their health ( 405) not only individually through, for example, education and economic advancement and the development of social capital to create healthsupportive environments. On this basis, obesity prevention would be seen as only one benefit from a larger social gain, and that any evaluation of an intervention should include the gains made in the ability of a community to protect and promote its own health. Social and political empowerment becomes one of the indicators of health gain. ( 406) The Ottawa Charter set the challenge for a move towards the new public health by reaffirming social justice and equity as prerequisite s for health, and advocacy and mediation as the processes for their achievement (quote from Adelaide page). Under the Charter, healthy public policy is the fundamental goal, by which four other goals can be achieved: supportive environments, personal skill development, community action and prevention-oriented health services. This was reflected in the follow-up conference after Ottawa, held in Adelaide in 1988: Healthy public policy is characterised by an explicit concern for health and equity in all areas of policy and by an accountability for health impact. The main aim of healthy public policy is to create a supportive environment to enable people to lead healthy lives. Such a policy makes health choices possible or easier for citizens. It makes social and physical environments health -enhancing. In the pursuit of healthy public policy, government sectors concerned with agriculture, trade, education, industry, and communications need to take into account health as an essential factor when formulating policy. These sectors should be accountable for the health consequences of

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their policy decisions. They should pay as much attention to health as to economic considerations. (407) The Adelaide statement acknowledged that government plays an important role in health, but that health is also influenced by corporate and business interests, nongovernmental bodies and community organizations. Their potential for preserving and promoting people's health should be encouraged. Trade unions, commerce and industry, academic associations and religious leaders have many opportunities to act in the health interests of the whole community. New alliances must be forged to provide the impetus for health action. The conference added that food was a fundamental priority area. Food and nutrition policies need to integrate methods of food production and distribution, both private and public, to achieve equitable prices. A food and nutrition policy that integrates agricultural, economic, and environmental factors to ensure a positive national and international health impact should be a priority for all governments. The first stage of such a policy would be the establishment of goals for nutrition and diet. Taxation and subsidies should discriminate in favour of easy access for all to healthy food and an improved diet. The Conference recommends that governments take immediate and direct action at all levels to use their purchasing power in the food market to ensure that the food -supply under their specific control (such as catering in hospitals, schools, day-care centres, welfare services and workplaces) gives consumers ready access to nutritious food. The need to involve stakeholders in the process of developing and implementing public health policies has been echoed in many documents. The US Centers for Disease Control urges any programme undertaking a public health intervention to engage stakeholders in the process, as they will be crucial to the interpretation of the results. In their document (408) they state The evaluation cycle begins by engaging stakeholders (i.e., the persons or organizations having an investment in what will be learned from an evaluation and what will be done with the knowledge). Public health work involves partnerships; therefore, any assessment of a pub lic health program requires considering the value systems of the partners. Stakeholders must be engaged in the inquiry to ensure that their perspectives are understood. When stakeholders are not engaged, an evaluation might not address important elements o f a program's objectives, operations, and outcomes. Therefore, evaluation findings might be ignored, criticized, or resisted because the evaluation did not address the stakeholders' concerns or values (12). After becoming involved, stakeholders help to execute the other steps. Identifying and engaging the following three principal groups of stakeholders are critical: those involved in program operations (e.g., sponsors, collaborators, coalition partners, funding officials, administrators, managers, and staff); those served or affected by the program (e.g., clients, family members, neighborhood organizations, academic institutions, elected officials, advocacy groups, professional associations, skeptics, opponents, and staff of related or competing organizations); and

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primary users of the evaluation.

Sharing power and resolving conflicts helps avoid overemphasis of values held by any specific stakeholder (15). Occasionally, stakeholders might be inclined to use their involvement in an evaluation to sabotage, distort, or discredit the program. Trust among stakeholders is essential; therefore, caution is required for preventing misuse of the evaluation process. Concerns and caveats The Kobe expert meeting raised several concerns over the introduction of pr eventive actions, including actions for the individual, in the community and among the population generally. Specifically, interventions among individuals need to be carefully managed. For infants and young children especially, moves to reduce the intake of energy-dense foods must ensure that this does not jeopardise normal growth. In children that are overweight, there is some evidence that e nergy restriction can, even in supervised weight reduction diets, lead to reductions in height velocity ( 409). Nonetheless, Epstein et al (410) have shown that individual treatment with frequent monitoring, can be effective at stabilising weight w ithout compromising growth. Secondly, in some cultures, high levels of obesity are acceptable, or even considered desirable, while in other cultures there is strong prejudice against overweight people, which many children are clearly aware of ( 411) including those as young as four years of age (412). Measures to reduce the prevalence of obesity need to be introduced which emphasise healthy behaviours and activities rather than idealised weight or appearance. Thirdly, care must be taken to ensure that obesity prevention programs do not induce unhealthy slimming practices, which may lead to the development of clinical eating disorders ( 413), or risky behaviour such as smoking to control weight (414). Although there appears to be little evidence suggesting that treatments of obesity can lead to eating disorders, there is a possible risk that preventive programmes which focus on dietary restrictions may induce anxiety and disrupted eating patterns in vulnerable children, which may in turn trigger a disorder. Again, the better approach is to encourage healthy eating patterns, following national dietary recommendations and food-based guidelines for population health, combined with the promotion of physical activity. The goals of promoting healthy eating, active living and positive body image can be used as a sensitivity check when formulating anti-obesity interventions. Care may also need to be taken when encouraging increased physical activity. There may be many reasons why children are resistant to participation in sports activities, including embarrassment in changing facilities, fear of ridicule or fear of failure, and discomfort from sweating or breathlessness. Schools may also need to consider their responsibilities for safety and the prevention of accidental injury. Training for staff may also be valuable: helping staff to promote and provide physical activities and to recognise and prevent discriminatory behaviour.

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The solution to some of these problems is to ensure that the targets for the interventions are involved in the planning of the interventions. A change in school practices will be best implemented if all the relevant stakeholders children, staff, parents, etc participate in the planning stages; and this is especially important if their co-operation is needed for implementing the proposals.( 415). Evaluation is a vital part of any proposed intervention, especially if it is to be part of a phased programme of actions. Evaluation measures should be considered in advance so indicators can be taken at baseline, before the intervention, and even before widespread discussion of the proposals. Evaluation should also consider the resource inputs required, so that the outcome can be reported alongside an estimate of the costs of achieving that outcome. This allows estimates of overall cost-effectiveness to be made. Measures of success in interventions should be broad-ranging. Outcome measures which rely on average BMI of a group of children are likely to be insensitive to change, and may affected by childrens growth over the period, affected by increases in lean body mass resulting form increased physical activity, and possibly obscured if children leave the group. Other measures of adiposity in individuals (e.g. BMI-Z scores, skinfold thikness, waist circumference, or percent fat using biometric impedance) may be more sensitive to intervention effects, as may measures of adiposity distribution within the intervention group (e.g. prevalence of overweight and obesity using cut-off criteria). Self-reported data for body measurements and for dietary intake are not reliable and may be particularly biased among those that are more overweight. The meeting also raised concerns about the cultural context for interventions and the need for funding agencies to consider a range of issues when financing interventions to prevent child obesity. Funding agencies should ensure that they commission research which: Considers population groups that have not been well studied such as children aged 0-5, immigrant groups, ethnic minority groups, adolescent boys. Considers the life-cycle, so that interventions involving maternal nutrition, foetal nutrition and breastfeeding are more adequately researched. Allows sustainable interventions beyond the initial study, and allows longer-term follow-up to monitor effectiveness. Considers the impact on chronic disease indicators in addition to obesity. Reports the costs and resource implications of the intervention. Is directed towards population-based initiatives to complement the current emphasis on localised and individual-based programmes.

Further discussion of evidence and research needs can be found in section 6 below.

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Screening for obesity risk The expert meeting also considered the advantages and problems that occur when groups of children are screened for overweight and obesity risk. Experience with childhood obesity screening has developed in the last two decades and some guidelines suggested. ( 416, 417, 418). Successful programmes for obesity reduction based on screening and follow-up intervention have been undertaken, most notably in the Trim and Fit programme in Singapore. 419, 420, but may require a high level of commitment from children, schools and families. 421 It is controversial whether childhood obesity screening should be introduced as the early detection of obesity may create expectations without improving the prognosis (422). Childhood obesity screenings might only be of value under the following conditions: the screened obese individuals are ready to have further assessments and make changes to achieve a healthy weight further assessment or other necessary treatment facilities are available in the community effective intervention programmes and follow -up activities for the identified children are accessible and available ( 423).

It is important to consider two further points before embarking on a childhood obesity screening programme. First, apparently healthy children should be willing to present themselves for examination. Second, screening large numbers of children is expensive and can divert both staff and financial resources from other health services activities. It is essential, therefore, to weigh up the potential benefits both for the individuals screened and for the health of the community, against the cost of the resources. In countries where education is compulsory or where the majority of children are in the education system, schools (including pre-schools) are the best place for childhood obesity monitoring and possible screening (424). The screening could be conducted periodically by school personnel during other school functions. For example, in Singapore, weight and height of the students are taken annually by teachers during physical education lessons and the collected information is conveyed to relevant health organisations. The measurements could also be done by a team of doctors and nurses as part of the comprehensive health screening routine in a medical room provided by schools at some or all school levels. In Hong Kong the student health service provides health screening for all school children annually, although not all children utilise the service, with the highest attendance in the earliest years (425, 426). The advantages of school-based screening include feasibility, cost -effectiveness, and good coverage. The disadvantages of such screening are the extra workload for the school personnel, the conduct of screening by teachers without specialised training, and a lack of standardised equipment among schools. All these factors might contribute to inaccurate measurements which are not uniform across schools.

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Policy framework Preventive action to address childhood obesity is complex. As this section has shown, there are significant barriers to change: at the school and community level interventions are easier to implement but have only small effects, largely because the surrounding environments may not be sufficiently health-promoting.(427). At the population level, economic development has encouraged the consumption of energy-dense nutrient poor foods and the adoption of physically inactive behaviour patterns. The conclusion from this analysis is that the changes required to improve child health and prevent obesity will need considerable political will along with investment of resources. It follows that successful policies for child obesity prevention are likely to involve the participation of a wide variety of sectors and stakeholders. This has been the approach taken by the WHO in its consultation process leading up to the Global Strategy on Diet, Physical Activity and Health. 428 Direct methods for consultation with stakeholders have been developed, such as the Delphi technique for consensus building among a panel of stakeholders to reach mutually agreed judgement principles (429). Other approaches have used selected juries as the stakeholder panel who first witness a debate conducted on adversarial lines and then work to reach an agreed verdict.( 430) A range of other consultative techniques (e.g. structured focus groups, group feedback analysis, convergent interviewing) which develop stakeholder views and form a body of qualitative methods under the general umbrella of action-research techniques.431 Multi-criteria mapping is a new technique offering semiquantitative methods for producing descriptive maps of the debate and the framing assumptions that are behind the positions taken by stakeholders.(432). Stakeholder analysis has traditionally been a bus iness management tool. Varvasovszky and Brugha have developed guidance on stakeholder analysis within the public health field,( 433) in part based on findings and experiences from a stakeholder analysis of alcohol policy in Hungary.(434) From recent literature searches, a number of stakeholders concerned with obesity policy and child health can be identified and include the following: Children Parents, carers in loco parentis Health service providers, health professionals Health advocacy bodies, NGOs School staff, including teachers, managers, school boards, catering staff Local and national government departments (e.g. health, education, transport) Retailers Fast food restaurant owners, managers, staff, mobile caterers Fast food suppliers, catering suppliers Vending machine operators Manufacturers of foods, food ingredients, food additives Primary food producers, food transporters and processors Food packaging manufacturers, label designers Advertising and marketing agencies

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TV, telecom and print media providers and regulators Internet service providers and regulators Video and computer games manufacturers Transport authorities, traffic controllers Crime prevention and public safety agencies Building designers, architects Leisure, recreation and parks authorities Sports facility providers, sport events sponsors Rural tourism providers, marketers and authorities Family practitioners, health promotion staff Pharmaceutical and surgical suppliers Health insurers Insurers against liability claims, re-insurers Specialist law firms Investment banks and financial investment advisers

National action plans The purpose of a stakeholder consultation is to ensure an inclusive process for making policy changes that are acceptable and can be implemented by all involved. These policy changes may best be summarised into an agreed action plan, which would normally be implemented under one government department but will require the active participation of many departments, This indicates that a centralised unit, acting from the cabinet or premiers offices, might be most appropriate. National action plans need to be constructed to suit the local political and regulatory context. A WHO-sponsored global conference on health promotion in Mexico City (435) concluded that plans of action are most feasible and effective when: 1. They have clear aims and objectives. 2. The roles and responsibilities between concerned stakeholders have been clarified and accepted. 3. There are transparent mechanisms for accountability. 4. The strategies developed are comprehensive. 5. The plans include mechanisms for monitoring and evaluation. An important element in the implementation of national action plans is the building of capacity to advocate for health measures. For any given programme, technical documents are generated which need assessment by advocates able to represent the interests of those whose voices are less easy to hear, such as parents, members of disadvantaged communities, and children themselves. Capacity-building for advocacy will be needed for national level action plans, but may also be required for specific programmes and intervention initiatives such as school health programmes ( 436, 437) According to the Mexican City declaration on health promotion: The health promotion strategies that are proven to be most effective are those combining complementary actions based in different sectors of society. The most

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common partners in such actions are government agencies, health institutions, NGOs, schools and universities, the mass media, religious groups, and public and private organizations. Health promotion actions often implement an education strategy, e.g. community or popular education, school health education and teaching of life skills, patient education, strengthening family support groups. A social communication strategy including broadcast and print media can also be effective. Social mobilization strategies, including community development, strengthening social support networks, group facilitation, targeted mass communication, and others are also used. Advocacy is an important tool and includes lobbying, political organization and activism, overcoming bureaucratic inertia, identifying a champion for the cause, enabling community leaders and mediating to manage conflicts. Empowerment gives a sense of personal control and the ability to bring about change in the social and health conditions through collective mobilization and counteracts the feelings of powerlessness and despair. Participation in the decision making process is desirable not only from the ethical point of view but also in order to guarantee effectiveness. However, it should be noted that this analysis relates to the issue of how to promote individuals' understanding and their resilience and coping capacity whilst livin g within an obesogenic environment. The quoted statement does not deal directly with the fundamental determinants of the unfavourable environment. Given that many of these determinants are common to developed and developing economies around the world, the World Health Assembly called for advice and assistance from WHO on these global issues. In response, WHO has developed a Global Strategy on Diet, Physical Activity and Health.

Global Strategy recommendations The overall goal of the WHO Global Strategy is to improve public health through healthy eating and physical activity, by promoting environments which can sustain individual, community, national and global actions to reduce death and disease. It is designed to support the UN Millennium Development Goa ls and promote public health worldwide, and should be considered alongside the on-going work carried out by WHO and national governments on related areas, including undernutriton, micronutrient deficiencies and infant feeding. The Global Strategy has four main objectives: to reduce the risk factors for diseases arising from unhealthy diets and physical inactivity, to increase awareness and understanding of the influence of diet and activity on health, to encourage policies and plans that are sustainable, comprehensive, and actively engage all sectors, including civil society, the private sector and the media, and to monitor and support the research and training base for implementing strategies.

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Key recommendations from the Global Strategy The principle recommendations which have a bearing on childhood obesity prevention and changes to the obesogenic environment are as follows: Governments are encouraged to build on existing strategies for disease prevention and health promotion, and consider putting thes e into one national coordinating mechanism. Local authorities should be closely involved. Multi-sectoral and multi-disciplinary expert advisory boards should also be established, and these should ensure that scientific evidence is interpreted without any conflict of interest. Health ministries should ensure the involvement of other ministries and government agencies, including those responsible for policies on food, agriculture, youth, recreation, sports, education, commerce and industry, finance, transportation, media and communication, social affairs and environmental and urban planning. Accurate and balanced information is a pre-requisite for ensuring healthy choices. Governments should support measures to improve information, taking account of literacy levels, communication barriers and local culture, and understood by all segments of the population. Nutrition and physical activity education and acquisition of media literacy, starting in primary school, are important to promote healthier diets, and to counter food fads and misleading dietary advice.

Food advertising affects food choices and influences dietary habits. Food and beverage advertisements should not exploit childrens inexperience or credulity. Messages that encourage unhealthy dietary practices or physical inactivity should be discouraged, and positive, healthy messages encouraged. Governments should work with consumer groups and the private sector to develop appropriate approaches to deal with the marketing of food to children, and to deal with such issues as sponsorship, promotion and advertising.

Labelling can inform consumers on the content of processed foods. Consumers require accurate, standardized and comprehensible information on the content of food items in order to make healthy choices. Governments may require information to be provided on key nutritional aspects, as proposed in the Codex Guidelines on Nutrition Labelling.

Health claims are increasingly used by food producers. As consumers interest in health grows, and increasing attention is paid to the health aspects of food products, but producers messages must not mislead the public about nutritional benefits or risks. National food and agricultural policies should be consistent with the protection and promotion of public health. Governments should be encouraged to examine food and agricultural policies for potential health effects on the food supply. Measures, including market incentives, should be considered to promote the development, production and marketing of food products that contribute to a healthy diet and are consistent with national or international dietary recommendations:

Agricultural production can have a great effect on national diets. Governments can influence agricultural production through many policy measures. As the emphasis on health increases and consumption patterns change, Member States need to take healthy nutrition into account in their agricultural policies.

Prices influence consumer choices. Public policies can influence prices through taxation, subsidies or direct pricing in ways that encourage healthy eating and lifelong physical activity. Several countries use fiscal measures, including taxes, to influence availability of, access to, and consumption of, various foods; and some use public funds and subsidies to promote access among poor communities to recreational and sporting facilities. Evaluation of such measures should include the risk of unintentional effects on vulnerable populations.

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Food programmes often concern children, families with children, poor people, and people with HIV/AIDS and other diseases. Special attention should be given to the quality of the food items and to nutrition education as a main component of these programmes, so that food distributed to, or purchased by, the families contributes to a healthy diet. Food and cash distribution programmes should emphasize empowerment and development, local production and sustainability. Physical activity guidelines should be developed by governments. National and local governments should frame policies and provide incentives to ensure that walking, cycling and other forms of physical activity are accessible and safe; transport policies include non-motorized modes of transportation; labour and workplace policies encourage physical activity; and sport and recreation facilities embody the concept of sports for all. Strategies should be geared to changing social norms and improving community understanding and acceptance of the need to integrate physical activity into everyday life. Environments should be promoted that facilitate physical activity, and supportive infrastructure should be set up to increase access to, and use of, suitable facilities. School policies and programmes should support the adoption of healthy diets and physical activity. Schools influence the lives of most children in all countries. They should protect their health by providing health information, improving health literacy, and promoting healthy diets, physical activity, and other healthy behaviours. Schools should be encour aged to provide students with daily physical education and should be equipped with appropriate facilities and equipment. Governments should adopt policies that support healthy diets at school and limit the availability of products high in salt, sugar and fats. Schools should consider, together with parents and responsible authorities, issuing contracts for school lunches to local food growers in order to ensure a local market for healthy foods. Preventive services should be supported. Governments should consider incentives to encourage preventive services and identify opportunities for prevention within existing clinical services, including an improved financing structure to encourage and enable health professionals to dedicate more time to prevention. Attention should be given to WHOs growth standards for infants and preschool children which expand the definition of health beyond the absence of overt disease, to include the adoption of healthy practices and behaviours. Codex Alimentarius Commission norms and standards can be used to strengthen public health. Areas for further development could include:

labelling to allow consumers to be better informed about the benefits and content of foods; measures to minimize the impact of marketing on unhealthy dietary patterns; fuller information about healthy consumption patterns, including steps to increase the consumption of fruit and vegetables; production and processing standards regarding the nutritional quality and safety of products.

Civil society and nongovernmental organizations can particularly: lead grass-roots mobilization and advocate that healthy diets and physical activity should be placed on the public agenda

support the wide dissemination of information on prevention of noncommunicable diseases through balanced, healthy diets and physical activity form networks and action groups to promote the availability of healthy foods and possibilities for physical activity, and advocate and support health-promoting programmes and health education campaigns

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organize campaigns and events that will stimulate action emphasize the role of governments in promoting public health, healthy diets and physical activity; monitor progress in achieving objectives; and monitor and work with other stakeholders such as private sector entities play an active role in fostering implementation of the global strategy contribute to putting knowledge and evidence into practice.

The food industry, retailers, catering companies, sporting-goods manufacturers, advertising and recreation businesses, insurance and banking groups, pharmaceutical companies and the media all have important parts to play as responsible employers and as advocates for healthy lifestyles. Because many companies operate globally, international collaboration is crucial. Initiatives by the food industry to reduce the fat, sugar and salt content of processed foods and portion sizes, to increase introduction of innovative, healthy, and nutritious choices, and to review current marketing practices, could accelerate health gains worldwide. Specific recommendations to the food industry and sporting-goods manufacturers include the following:

promote healthy diets and physical activity in accordance with national guidelines and international standards and the overall aims of the global strategy limit the levels of saturated fats, trans-fatty acids, free sugars and salt in existing products continue to develop and provide affordable, healthy and nutritious choices to consumers consider introducing new products with better nutritional value provide consumers with adequate and understandable product and nutrition information practice responsible marketing that supports the strategy, particularly with regard to the promotion and marketing of foods high in saturated fats, trans-fatty acids, free sugars, or salt, especially to children issue simple, clear and consistent food labels and evidence-based health claims that will help consumers to make informed and healthy choices with respect to the nutritional value of foods provide information on food composition to national authorities assist in developing and implementing physical activity programmes.

Recommendations from the Kobe expert meeting The Kobe participants considered the background papers, presentations and the concerns expressed (see Concerns and caveats, above) and made a series of recommendations relating to the prevention of obesity in childhood and adolescence. In making these recommendations, the participants noted that prevention strategies should be designed to be appropriate for different social and cultural population groups: these should include families on low income, people of colour, other minority ethnic groups, native groups, migrant and transient groups, groups with special dietary needs or other cultural or religious restriction. Depending the context, policies may need to be developed to protect and preserve traditional cultures (traditional lifestyles, cuisines, attitudes, behaviours) where these are health-promoting.

1. Maternal and child health services

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The Kobe expert meeting emphasised the importance of a healthy pregnancy and for parental education about breast feeding and early feeding patterns. Health services should be routinely monitoring and advising women, starting with health advice in schools and community settings. Preventive services should ensure that the needs of nutritionally -at-risk infants and children are met, giving special attention to linear growth of preterm and/or low birth weight infants, and that interventions should p revent excess weight gain in order to decrease risk of obesity in later life. The expert meeting made no other specific comments on complimentary feeding noted the benefits of exclusive breastfeeding and expressed support for the WHO-recommended 6-months exclusive breastfeeding and for the WHO-UNICEF International Code of Marketing of Breastmilk Substitutes. Examples Monitor body weight during pregnancy and provide appropriate advice to women (especially in relation to underweight, overweight and excess weight gain)Aim to reduce the number of women who start pregnancy with a BMI less than 18.5 kg/m2 or greater than 25 kg/m2. Where pregnancy in adolescence is high and low birth weight prevalent, aim to increase the average age at first pregnancy to permit full developmental maturation before the start of childbearing. Monitor growth and avoid rapid weight gain at all stages of life, especially in infancy. Consider food programme support for short -for age children only if this is designed to promote gain in length/height rather than weight. Promote Baby Friendly Hospitals

2. Early childhood settings (kindergartens, child care) It is important in this setting for children and young parents to establish patterns of healthy eating and active play. These early years are a formative period for developing tastes for a wide variety of foods and establishing healthy eating and activity patterns. Parents should be encouraged to interact with their children, and especially infants in their earliest years, to pro mote active play and developmental growth. The kindergarten setting is valuable for educating the mother about good practices, which will benefit her subsequent offspring as well. Policies should be reviewed to ensure that they do not unnecessarily restrict physical activity during the growing years. Parents and child-carers should avoid using television as a pacifier or baby-sitter. Examples Support more evaluations of early learning and pre-school interventions The licensing of premises for pre-school child care can include criteria for healthy diet and activity provision Develop pre -school food and health policy statements, to include meals and snacks, birthday celebrations, taste tables (opportunities to sample foods outside of mealtime), gardening activities and indoor and outdoor play periods. Nurseries and kindergartens should not encourage extended sleeping periods or TV watching.

3 School settings Schools are positioned to be community leaders and their practices should set an example. Schools offer many opportunities to promote healthful eating and physical activity patterns for children

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within and outside the classroom, during the formal timetable and outside of it . Schools are also a potential access point for engaging parents and community members. The universality of school settings for gaining access to children makes them highly relevant to global efforts to combat childhood obesity. However, there is also concern about a potential overreliance on schools settings or overestimation of what can be accomplished with a focus solely on schools. Children spend only a part of their day at school, and thus parental and peer influences, as well as influences in the broader environment, e.g. media and marketing, also have substantial power to affect the environment for obesity prevention, and should be included in any comprehensive strategy. Most childhood obesity prevention studies have been conducted in school settings, and recommendations about the types of programs that may be effective in school settings are, therefore, informed by more evidence than those addressed to some other settings. Most of the available research has been conducted in the United States and the European Community, with a few studies from developing countries primarily in urban areas. Hence, as noted earlier, the organizational, community, and policy contexts need to be considered when assessing the transferability of interventions. For example, most or all school based studies have been conducted in situations where meals (lunch, or both breakfast and lunch) are provided to school children on the premises. Recommendations Nutrition friendly schools Adopt the principles that build on the WHO initiatives to create health promoting schools and reflect the need for common strategies to address prevention of both undernutrition and obesity: improve nutrition knowledge in the school community, promote healthy school meals (school gardens?) promote healthy choices in school canteens promote safe and clean water supply , free and easily accessible promote micronutrient supply (foods + supplements) promote healthier school environment free from food advertisement and food commercial enterprises enhance physical activity and promote safe walking/cycling to school monitor nutritional status promote parental involvement

Whole school approach: This approach implies, ideally, a comprehensive school policy addressing the relevant health and welfare issues, including diet and physical activity, with pupils having been involved in writing policy, parental engagement in supporting policy, and support from staff, including both teachers and catering staff. Components of a whole school policy include meal service standards, snack and vending machine standards, physical activity and play zone policies, health education policies, sponsorships and materials criteria, and curricular guidelines. Teachers may need additional training in health promotion, including training to ensure obese children are not stigmatised or bullied by others in the school. While a comprehensive approach greatly improves the likelihood of influencing weight gain, separate elements of a whole school approach can be expected to have positive benefits in several domains, including improvements in dietary quality and physical fitness, benefits for reduction of other health risks, and improvements in psychosocial status and academic performance Elements of whole school approaches will differ in both relevance and feasibility according to country and local context. Examples Free or subsidized school fruit schemes Canteen pricing policies that favour purchases of healthy foods

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Free or subsidized cooled water, bottled water, allowed into class Vending machine banned (junior high schools) or only healthy options allowed (high schools) Grants to schools in low income areas to teach diet and cooking skills, and create healthy nutrition environments Maximum sugar criteria for juice and soft drinks sold in schools Walking bus schemes to enable more children to walk to school Opening the school physical activity facilities on weekends for community access School gardening schemes (exercise and healthy food) Breakfast provision Adding at least 10 minutes of activity to school day Monitoring school teaching materials and media for commercial bias Ban in-school advertisements and promotions for processed foods Of the specific components, those most clearly supported by available evidence include provision of breakfast, multimedia approaches to delivering dietary education, physical activity interventions designed for interest and innovation (e.g. dance clubs, self-defence clubs), and placement of healthy items in vending machines. Fruit tuck shops which may have added spin -offs related to curriculum, social benefits, community links and litter reduction in addition to increasing fruit intake. Schoolbased interventions that aim to reduce television, videotape and video game use have also been found effective. Walking to school and cycling to school schemes may be effective but there is no good evidence available on which to base a recommendation. Age or developmental differences Not all school-based strategies will be equally applicable or effective for different age groups For example, focus one aspect of a healthy diet, such as fruit and vegetables may be more effective with younger children, while a focus on fitness and physical skills may be more appropriate for older children. School-community links Schools can be the basis for linking to parents and to primary care/ health clinic. Examples o o o o providing parents with information on their child's health, diet and activity needs provide parents with interpretation of their childs health information link BMI parent feedback to primary care provider Provide behavioural and home environment recommendations (limit TV, home food environment, family meals, role modelling)

S chool funding Schools need to be fully funded so they are not put in the position of having to raise funding for school programmes, which renders them vulnerable to pressure from commercial interests. Food availability in schools Develop standards for foods made available in schools. Consistent policies are needed to ensure a health promoting food environment. Examples Eliminate vending machines in schools or restrict foods and beverages sold through vending to healthy foods and beverages Eliminate use of food as reward in class Eliminate food sales for fundraising Eliminate schools as outlet for commodities Fund School meals adequately fund school feeding programs to allow for meeting quality considerations Fund fruit and vegetable programmes in schools

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Price healthy foods affordably Use nutrition labels on foods in cafeteria (for example, red, yellow, green foods) Use school gardens for education and food production Train teachers and food service personnel to verbally encourage fruit and vegetable consumption

Targeted Outcomes of School Programs Link healthy school foods and physical activity to outcomes schools care about, e.g. academic outcomes, behaviour in school. Programs to prevent childhood obesity should be compatible with and have clear benefits for more general goals of schools. Physical Education Require daily PE in all grades, and make sure the programs are appealing to children.

4. Neighbourhoods, local government, local business Communities and their local government have considerable control over the provision of services and the planning of the physical environment, as well as providing the cultural environment which shapes childrens view of themselves and their opportunities through family, church, work-based or youth-based organisations. Regulations at local and neighbourhood levels may also influence the availability of obesogenic products as well as the availability of health-promoting facilities. Examples Support for local shared gardens for fruit and vegetables (including roof-top gardens) Provision of cycleways, paths and parks program Subsidise access to sports and leisure facilities for children Limit densit y of fast food outlets in urban areas Control the licensing of mobile snack and ice-cream vendors Offer awards for health-promoting restaurants Control sales of foods in publicly owned facilities (sports centres, pools etc) and community facilities (churc hes, clubs etc) Provide activity-friendly neighbourhoods, restrict vehicle access to residential areas Set targets for reduced use of cars, reduced accident levels Set targets for low-income neighbourhoods with respect to access to e.g. healthy food outlets, safer streets, supervised play areas.

5. Workplaces Although not directly influencing child health, workplace policies can influence health behaviour in the family and can support parents during early childcare. Examples Provide facilities and support for breastfeeding mothers Advise employees on healthy eating and activity, including measures to prevent obesity

6. Health care settings Health care facilities need to provide a range of preventive services and health promoting activities. This may inc lude liaising with schools and community services to ensure their messages are given

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prominence. Health care staff also have a role in monitoring childrens growth and recognising early signs of mis -nourishment, including stunting and overweight, and providing appropriate responses.

Examples Health services to liaise with schools etc to promote child health Monitor growth using appropriate standards, take necessary actions to prevent stunting in all children and avoid fatness in tall children Implement p rograms for treatment of childhood obesity early to prevent present and future adverse consequences Prevent of underweight adolescents and promote healthy preconceptual weight of reproductive age women

7. Governments, civil society and commerce The re commendations of the Kobe expert meeting echoed those described in the Global Strategy on Diet, Physical Activity and Health, summarised in the section before this. All the Global Strategy recommendations to member governments were endorsed. In addition the meeting drew specific attention to

The need to centralise government action into one office in order to ensure cross-departmental, cross-sectoral polices can be implemented. This should be monitored by a separate agency, such as a parliamentary scrutiny committee or an obesity observatory.

The need to build capacity at national and at local levels, to support the recommendations for interventions made in this report State support for commerce (e.g. food enterprises, agricultural enterprises ) should inc lude health criteria. Political donations from food companies should be restricted or banned. Access to and affordability of fruits and vegetables should be improved, especially for low income and disadvantaged population groups

National governments should support WHO moves to ensure that all UN agencies have policies that are consistent with the Global Strategy.

Marketing and food promotion The Kobe expert meeting felt it was particularly important to challenge the intensive marketing of energy -dense micro-nutrient poor food products and strongly support ed the Global Strategys call to ensure that the promotion of food products is consistent with a healthy diet . The meeting specifically endorsed the need for international action to regulate against the marketing of products to children which are inconsistent with the achievement of healthy diets or with national food based dietary guidelines or national health promotion strategies . The meeting supported calls to encourage the promotion and marketing of foods which are consistent with and promote these guidelines and strategies, especially in relation to the promotion of infant and child health. The Kobe expert meeting also urged continued support for the full implementation of the WHOUNICEF Code of Marketing of Breast Milk Substitutes in all countries.

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The Kobe expert meeting also called for the creation of an international marketing monitoring body, which should include health and consumer advocacy organizations, to report to WHO and other UN agencies on compliance issues and on the development of new marketing methods. Specific steps can be taken at local, national and international level to progress these concerns: Examples Develop an International Code on Marketing of Food and Beverage Products. Consider taxation of advertising of specified food categories Impose a ban on street advertising of specified food categories near schools Regulate against the marketing and promotion of specified food categories in schools (including commercially -provided teaching materials, commercially sponsored activities and equipment). State support for food marketing should include health criteria Ensure that marketing controls extend to printed media, electronic media, cross-branding, product positioning (e.g. by check outs) and product formulation (e.g. use of non-nutritional food additives designed to attract children to energy dense, micronutrient poor foods). Support moves to develop a global alliance of non-governmental organizations concerned with health issues, and encourage such an alliance to consider food production and marketing policies as part of their range of concerns.

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7 Evidence and research The final section of this report considers the problems that were encountered in assessing the evidence for obesity prevention, particularly from the point of view of policy development. Traditional systematic review criteria have proved unsatisfactory in respect of public health interventions and alternative types of evidence are needed. Health promotion policies may need to be based on an investment approach rather than a clinical intervention approach. Investments require different types of information including costs, likely effectiveness, likely depth and reach of impact, sustainability and acceptability. An investor will also want to consider contextual factors and alternative means of achieving results, and this leads to a range of questions concerning the effects of upstream policy decisions on population health. Research is needed on the effects of, for example, food pricing on purchasing and consumption patterns. 7.1 Identifying evidence needs In Section 6 above it was shown systematic reviews of the scientific evidence for implementing childhood prevention strategies such as that required for Cochrane reviews do not reveal clear guidance for best practices, partly because there appears to be no evidence for a highly successful intervention and partly because the requirements for a systematic review are highly restricted and exclude all but a few tightly controlled interventions. The Cochrane review procedure arose from dissatisfaction with the more traditional approach to evaluation of medial treatments, based on clinical experience and expert judgement. There were also concerns that clinical judgements could be affected by commercial interests. Furthermore, clinical outcomes may be affected by expectations and by the "placebo" effect, leading to the development of double -blinded, controlled trials for evaluating clinical effects. Increasingly, medical policies rely on the accumulated evidence from these trials, in which the Cochrane systematic analys is has become the gold standard for evaluating options , and its approach has extended beyond the clinical field into other areas of health policy. For centuries, the majority of public health practices have not been based on strictly controlled trials nor have they been subject to systematic review. From the very local initiative, such as the provision of drinking water in a public park, to the global, such as the Kyoto agreement to reduce greenhouse gas emissions, most actions designed to protect and promote human health and wellbeing are not based on a controlled trials but are based on other forms of evidence of varying quality, quantity and generalisability, and derived from assessments of risk factors, expert opinion and political expediency. The father of public health, Dr John Snow, had only limited, ecological evidence linking the Broad Street well to the local cholera outbreak, but his intervention denying access to the well by removing the pump handle is credited with saving central London from

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a much worse outbreak of cholera than actually happened. The action was taken despite scepticism from the wells Board of Guardians. Although systematic reviews have been used to generate evidence-based recommendations for best practice suitable for public health, there are methodological problems in trying to synthesise and summarise the results of divergent, multi-faceted interventions, using different population groups, different designs and different outcome measures ( 438, 439). It is difficult to use randomisation to control confounding factors in population-based interventions, both ethically and practically. In some circumstances observational study designs may be more appropriate to assess the impact of population interventions. New evaluation techniques are needed in order to formulate public health guidelines for safe and effective interventions. Alternatives to control trials The previous section indicated the pressing need to develop the appropriate measures and study designs to find effective preventive interventions for obesity. The studies need to capture changes in environments and behaviours as well as outcomes such as body mass index. They also need to be administered over long periods of time and across populations. This puts a burden on the resources and on the participants in the studies, and it means that the normal approach, using small-scale control trials may not be appropriate. Some alternative approaches are needed. Design of interventions Recent experience in evaluation has suggested that the controlled trial design can be inappropriate for a number of reasons. The controlled trial approach assumes that there is full control of the intervention, its delivery and the context in which it is implemented. This is certainly not true for most health promotion programs that are complex in nature, delivered in complex contexts over long periods of time, and present difficulties in cont rolling all variables. In reality it is difficult to find matched controls, ensure standardisation of program implementation in all contexts and ensure standardisation of contexts. Furthermore there is a constant threat of contamination of the control gr oup as health promotion relies on the effects of the intervention permeating the target community. It is therefore difficult to control for spill-over to the comparison community, thereby potentially reducing any effect of the intervention. Other problems include: The individuals recruited may not represent the population Randomisation may not be feasible and may not ensure comparability Control conditions are difficult to implement and raise ethical problems The intervention is too disruptive of reality Energy balance cannot be directly assessed Other effect sizes may be too small to detect

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Assessing interventions The assessment of interventions is usually achieved using standard experimental methodologies (randomised controlled trials, cross-over studies, quasi- experimental studies etc). Unless the intervention being tested can deliver a high dose of change in activity levels and/or energy intake, it is unlikely to show an impact on body size. For example, reducing television viewing by to 1 hour/day as achieved by Robinson ( 440) and Gortmaker et al ( 441) appears to achieve a high enough dose to influence body weight, but other school-based interventions, although well implemented, cannot achieve this dose. The effectiveness of real world interventions needs to be assessed in the knowledge that tight control of extraneous variable is very difficult and the use of randomised control groups is usually not possible. An alternative framework is required: an initial formative evaluation to establish cle ar aims and objectives a needs assessment, literature review etc a process evaluation to measure the inputs into an intervention and to describe the processes during the implementation an impact evaluation to measure whether the specific objectives have be en achieved (e.g. changes in physical activity behaviours) an outcome evaluation to measure the longer term effects (e.g. changes in body mass index).

To be rigorous, however, the impact and especially the outcome measures need to be controlled for confounding factors. For example, no change in BMI may represent a successful or a non-successful outcome depending on the background changes in BMI in the rest of the population. Randomisation by individual is the design that is most likely to spread the confounding factors evenly across intervention and control group but this design is usually not feasible for long-term prevention studies where a variety of interventions, including environmental ones, are used. In fact, because the dose of intervention nee ded to prevent unhealthy weight gain is high, it requires a multi-strategy, multi-setting approach and this virtually excludes the individual randomised design. A quasiexperimental design (for example, five intervention schools and five control schools) gives some ability to control for confounding variables, but usually the number of units (e.g. schools) is small and systematic differences may confound the results (e.g. the control schools have a different socio-economic background than the intervention schools). There is the potential for using population monitoring data for not only measuring trends (above) but also for comparative purposes for effectiveness studies. For example, a school-based, region-wide monitoring program may routinely measure BMI (outcomes), school food sales (behaviours), and school food policies (environments). An intervention program in a town within that region may be able to compare changes in these variables against changes across the region. There would still be the potentia l

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for residual confounding factors but at least such a design would allow reasonable confidence on the overall impact of a population-based intervention program on the prevention of obesity. Assessing sustainability, reach and population impact Many intervention studies aimed at influencing long-term behaviours at a population level have a start and finish date. The longer-term sustainability and wider reach and impact across the population are rarely measured, even though this is information that governments and funding agencies need to have. Indeed, such characteristics as reach are usually specifically designed out of studies because it is considered contamination of the control group. For example, in the North Karelia project (442), dietary changes first occurred in this demonstration province but within 5-10 years, the rest of the country had also made the changes. Quite appropriately (from a public health perspective) they had become contaminated. Again the judicious choice of indicators with a comprehensive monitoring program can capture the reach, sustainability and population impact of intervention programs as they move from demonstration areas to the wider region. Broadening the definition of evidence The selection of method depends on the nature of the information required to answer the questions asked. It is therefore advised that both qualitative and quantitative methods be used, and methods for rapid appraisal and health impact assessment may also prove valuable (443, 444). Given the complex nature of health promotion initiatives, traditional evaluation methods are inappropriate for the overall evaluation and therefore a wide range of research methods, both qualitative and quantitative are required. Furthermore, because it is impossible to control for contextual factors due to the impact of interacting factors, new approaches to evaluation need to be developed. While evidence-based public health should incorporate the same rigor and attention to internal validity as clinical trials, it should also maintain contextual and policy relevance, have a realistic chance of implementation, and show potential sustainability.(445) Evidence of effectiveness is not sufficient by itself to guide appropriate decision-making, and true evidence-based policy-making is probably quite rare (446). The evidence needs to be directly linked to the sorts of policy that can be implemented, set in the context of the concerns of those that implement the policy and those destined to benefit from it. Therefore, engaging participants from the start can help to generate practice-based evidence of greater feasibility and relevance than is likely to emerge from the classical evidence-based practice approach. It is also clear from analyses undertaken for the UK Treasury (447) that the interventions needed relating to smoking, obesity and physical inactivity require economic modelling,

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for example by analysing the effects of product prices and marketing practices on consumers purchasing practices. This approach is used in other circumstances where market regulation is required: many countries intervene in the production of cereals, meat, milk, sugar etc by altering subsidy and tariff levels, manipulating minimum prices and shaping markets (e.g. by destroying fish catches or fruit and vegetable crops). These routine economic planning approaches have not often been applied to analyses of options for social policy change. The evidence required to show how policy changes in these areas might affect consumption patterns and subsequent chronic disease rates has not been accumulated. Robinson and Sirard have argued that policy-making for preventing child obesity requires solution-oriented research rather than problem-oriented research. (448) They characterise these as: Problem -oriented research Outcome: understanding causes, mechanisms Past orientation, mainly observational studies Limits hypotheses and action options Solution-oriented research Outcome: understanding what works Future orientation, mainly experimental studies Allows innovative ideas to be tested It is clear from this discussion that the nature of the evidence needed for public health interventions is broader than that currently being considered for child obesity prevention. Evidence in its widest sense is information that can provides a level of certainty about the truth of a proposition ( 449). For the purposes of addressing the questions on obesity prevention, Swinburn has grouped evidence into observational, experimental, extrapolated, and experience-based sources of evide nce and information (450). Each type of evidence has its own strengths and weaknesses. Each can be judged on its ability to contribute to answering the question at hand, which should be phrased in terms of what to do rather than what to blame. Examples of evidence relevant to obesity prevention: Epidemiological studies that may involve comparisons of exposed and nonexposed individuals, e.g. cross-sectional, case -control, or cohort studies; Population-level data that can provide time series information, e.g. trends in obesity prevalence, food supply data, car and TV ownership; Intervention studies where the investigator has control over the allocations and/or timings of interventions, e.g. controlled trials among individuals, groups or whole communities; Expert opinion, e.g. from practitioners and stakeholders with practical experience, e.g. paediatricians, marketing agencies, parents. Critical assessment of programmes, analysing their outcomes, their objectives and their processes;

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Modelling of possible causative pathways to allow identification of potential evidence gaps, or areas for research, e.g. comparing price regulation with consumer education; Modelling methods to make estimates of a programmes efficacy, programme uptake and population reach; Modelling methods that examine costs, e.g. intervention costs, costeffectiveness, or cost-utility; Information allowing an inference, e.g. high levels of food advertising allows an inference that such advertising increases the sales of the advertised products and/or product categories; Information from comparable fields or comparable interventions, e.g. the role of social marketing in changing health-related behaviours such as smoking, speeding, sun exposure, or dietary intake, or information gained from healthpromoting schools programmes; Economic modelling, e.g identifying the impact of farm policies on agricultural production, pricing and the effects of price changes on purchasing and consumption patterns

In practice, there is virtually no evidence concer ning the potential effects on obesity of altering social and economic policies, such as agricultural production policies or food pricing policies, while much more evidence is available on localised attempts to influence the consumer (in this case the child) through various means: education, exhortation, school training, parental training and similar localised approaches. 7.2 Investing in child health In the last decade there has been increasing interest in the suggestion that health promotion should not be described in the usual medical paradigm requiring controlled trials, but instead can be described using a paradigm the investment portfolio borrowed from the world of banking and financial investment. In respect of obesity prevention, Hawe and Shiell (451) suggest that interventions can be described as investments, and just as an investment portfolio should carry a mixture of safe low return reliable savings schemes and risky potentially high-return gambles, so investments in preventing obesity can carry a mixture of low-risk, low -cost approaches, and higher-risk, higher-cost initiatives. In health promotion, a return on investment can be measured in terms of expected health gains and other desired outcomes. The risk can be measured in terms of the consistency of the impact of an intervention and indications of its likely effectiveness. This approach has been developed further by Swinburn and Gill ( 452) and Swinburn, Gill and Kumanyika (453). They have explicitly described a portfolio promise table (see table below ) in which the risk element is displayed in two dimensions: population impact (ranging from low to high) and certainty of having an effect (also ranging from low to high), and the resulting investment promise ranging from least (low certa inty, low impact) to most (high certainty, high impact). Thus intensive interventions within

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small groups or individuals might be low -risk, as they consistently result in changes in behaviour and other outcomes. However, the overall return may only be smal to l moderate as the effect of the intervention may be small and result in only a slight impact on the health status of the community as a whole. Table An analysis grid for determining investment risk and gain Potential population impact Certainty of effectiveness Low Medium High Low Least promising Less promising Promising Medium Less promising Promising Very promising High Promising Very promising Most promising
Source: Swinburn Gill and Kumanyika 2005

The process for assessing and weighing up potential gains and risks permits the adoption of a mix of interventions, or a portfolio, to balance the risks as a way to maintain health promotion momentum without having complete evidence about the effectiveness of interventions ( 454). This approach allows the selection of interventions to be based on the best available evidence whilst not excluding untried but promising strategies. An example of applying this scheme to early childhood interventions is shown in table XX below. As Swinburn et al ( 455) point out, the classification of interventions on their level of promise will require a judgement on the quality of available evidence and an estimation of population impact. For some types of intervention there may already be sufficient data to make estimates of the efficacy of the intervention, its applicability to different settings enabling it to reach the target populations and its uptake by individuals, so that the impact it will have on the population can be assessed. Table 9 The investment model applied to obesity prevention in early child care
Very promising High gain, moderate uncertainty Promising Promising Some promise Moderate gain, high uncertainty

Potential interventions Adapt existing childcare nutrition programs to incorporate specific educational components for childcare staff on maintaining healthy weight and promoting physical activity. Educational programs for parents on issues appropriate to pre-school children including what foods to provide, how to encourage and model increase physical activity. Award and incentive schemes that recognise and ?ncourage adherence to nutrition guidelines e Programs for kindergartens and pre-schools which target both food service and educational curricula

Moderate gain, moderate uncertainty

High gain, high uncertainty

Yes

Yes

Yes

Yes

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on nutrition and physical activity Introduce a specific regime of exercise into childcare and kindergarten settings Work with carers to integrate appropriate physical activity ?nd nutrition policies into after-school care a programs Develop special weight-focused services within the after school care setting to specifically add ress the needs of children with an existing weight problem Develop a vacation care program for young children which requires parental involvement and teaches physical activity and nutrition skills. Work at a national level to ensure the development, implementation and monitoring of comprehensive food service and physical activity policies Enhance the capacity of communities to support families with young children by encouraging and supporting direct community involvement in program development, implementation and evaluation. Source: Gill et al ( 456)

Yes

Yes

Yes

Yes

Yes

Yes

A further step that can be taken to build the investment approach is to analyse the cost effectiveness of interventions. An example of this approach is being undertaken by the government of the state of Victoria, Australia, which has previously supported projects to assess cost -effectiveness in mental health, cardiovascular diseases and cancer ( 457,458) and is now supporting one on obesity interventions (459). This approach analyses the economic aspects of specified interventions with key stakeholders involved in selecting the interventions and making judgements on various aspects of the intervention such as the strength of evidence, the sustainability of the intervention, and its acce ptability to stakeholders. The costs, population impact and health gains, and cost-effectiveness are calculated. Ten interventions are being assessed, with results expected to be published in 2007. A difficulty found in the practical implementation of suc h modelling work is that the adoption by policy-makers is not based on purely scientific or even financial investment criteria. Government agencies and other key stakeholders have additional pressures upon them that lead them to make judgements which will affect the portfolio of options being put into practice. It is therefore essential that the various needs and demands of stakeholders are included in the theoretical model for preventing child obesity. 7.3 Gaps in the evidence Monitoring obesity trends The epidemic of childhood obesity is already present in most high-income countries and emerging in some low -income countries. The first step to evaluating the causative (and preventive) factors is to monitor trends in obesity in a range of populations. Some lowincome countries may already be equipped to monitor trends in childhood obesity if

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they are systematically measur ing the height and weight of infants and children to screen for undernutrition. Routine sampling is preferred, as reliance on occasional, large surveys to determine the trends in overweight and obesity means that available data are usually spasmodic, delayed and used more by universities than health departments. There is an urgent need to establish more formal population monitoring programs. These need to have the following characteristics: Owned and used by governments to assess progress towards targets for childhood obesity, eating and physical activity behaviours and environments Regularly implemented and assured of sustainable funding Measure the key outcomes and determinants of interest: o Height, weight and waist circumference o Eating behaviours and attitudes o Physical activity behaviours and attitudes o Key nutrition-related environmental factors o Key physical activity-related environmental factors Potentially serve as the comparison group for evaluating interventions Monitor the reach, sustainability and population impact of programs

Local benchmarking A further role for monitoring population trends is to allow the communities tha t provided the data to use the results as a stimulus and yardstick for their own efforts. A school-based or local government -based monitoring program that could measure, in a consistent manner, environmental and behavioural factors that are under its control would be very empowering. Schools regularly use benchmarking for literacy and numeracy outcomes whereby their results are fed back to them as trends over time and in comparison with other schools. If nutrition and physical activity data were to be used in a similar manner it could stimulate action in the area and allow schools to measure the impact of their efforts. Cost effectiveness There are many areas in which more evidence is needed if policy-makers are to be convinced that they can, and should, act, and that such action would be worthwhile. If, as has been suggested above, health promotion is to be seen as an investment rather than a form of clinical intervention, then new data will be needed. For example, if an investment approach is to be taken, then much more evidence is needed on the resource requirements and costs of running prevention programmes. Few analyses have been undertaken to show that an intervention is either cost-effective (that it has a reasonable degree of impact for an acceptable level of cost) or that it produces a positive net benefit (that the long-term financial gains are greater the intervention costs). A notable exception is the analysis by Wang et al ( 460) showing a net advantage in both respects gained from the school-based Planet Health intervention, although this was a

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programme which relied considerably on school staff input that was not included in the resource costs. Researchers should report on the projects resource inputs as part of the evaluation of any intervention. Researchers should also indicate the sustainability of a project if the funding for the research component is removed. Problems with controlled prevention trials As suggested above, the controlled trial design is likely to be inappropriate for testing single interventions. Obesity prevention programmes, like other health promotion programs, are complex, often targeted at groups and individuals simultaneously, aiming to influence individual behaviour and lifestyle but also address public health policy in order to change social and environmental factors that affect health. Consequently health promotion evaluation requires multiple approaches in order to assess effectiveness in all these areas. The selection of method depends on the nature of the infor mation required to answer the questions asked. It is therefore advised that both qualitative and quantitative methods be used, and methods for rapid appraisal and health impact assessment may also prove valuable (461, 462). Given this complex nature of health promotion initiatives, traditional evaluation methods are inappropriate for the overall evaluation and therefore a wide range of research methods, both qualitative and quantitative are required. Furthermore, because it is impossible to control for contextual factors due to the impact of interacting factors, new approaches to evaluation are being developed. Multi -site prospective meta-analyses One approach to evaluating interventions is to design a series of interventions to take place simultaneously in different locations. This is the thinking behind the development of the multi-site prospective meta-analysis, which attempts to construct a Cochrane style systematic review based on a planned series of interventions. The interventions would have suitability for comparison with each other and sufficient statistical power built into their design. B y being run concurrently in different locations the interventions may reduce the risks of contamination and could share the construction of a relevant set of control groups. A further advantage of the prospective systematic review is that it avoids some of the biases that can affect retrospective reviews, such as publication bias (only accessing trials that were published in scientific journals) and language bias (only accessing trials published in, say, English). Strategies are needed to ensure collaboration between different groups of investigators, and agreement on methods for preparation of publications. The Cochrane database can offer advice and guidance on registering a prospective metanalysis and gives examples in progress, such as the Prospective Pravastatin Pooling Project463. It remains to be seen whether health promotion interventions can conform to

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the requirements of a prospective meta -analysis. There are also concerns that this will continue the focus on localised interventions which may have high contextual specificity, and that it will divert attention and resources away from population-wide, upstream interventions. Contextual concerns This report has highlighted the need to consider the social and economic determinants of obesity in order to develop effective policies and strategies for its prevention. As suggested in this document, attempts to reduce obesity prevalence at one level say the school may be undermined by a failure to improve the environment at another level, be it below, in the home, or above, in the social and cultural context involving food marketing and advertising, lost recreational facilities or unsafe streets. Interventions need to consider their context in this respect: a strategy to improve nutrition labelling on foods may have little or no impact if the purchasers are not sensitised to the importance of the information being displayed. The provision of plentiful fruit and veg etables on school menus may not affect dietary intake if the policy is not well implemented, if the quality of these foods is poor, if little effort is made to promote their consumption, if children are still free to avoid the fruit and vegetables or if there are no obvious incentives for them to choose these items or even to attend the canteen. Equally, there may be unintentional outcomes from population-based health approaches to obesity prevention for example health education in pre-school centres encouraging mothers not to overfeed their babies may result in excessive dietary restrictions by concerned parents. In summary, the context of the intervention will need considerable understanding and attention if the evaluation of the outcome, and the interpretation of the results, are to be reliable. Those undertaking evaluation need to ensure they are familiar with the (often overlapping) areas that need evaluation, including formative evaluation (assessing the design, implementation and context), process evaluation (assessing the responses of the participants and the impact on intermediate measures) and summative evaluation (assessing the final results in terms of the intended goals). It is important to recognise that participants in the intervention can provide valuable insights to assist these assessments. Upstream analyses In a review of the determinants of dietary trends, Haddad (464) notes the need to consider several macro-economic factors, including income growth, urbanisation, and the relative prices of foods and their availability which are affected by mass production technology and commodity costs, along with retail distribution chains and catering outlets.

Price elasticities appear to be potential areas for further research: Haddad notes that one study of US food supply price elasticities showed that an increase in the price of oils would lead to a decrease in fat consumption and total energy intake, and an increase

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in the consumption of most other nutrients ( 465). The cost of commodities are in turn affected by agricultural support policies and trade regulations. Food prices must also absorb marketing and promotion budgets. Marketing itself interacts with consumer awareness and cultural practices.

There is remarkably little publicly available data on the impact of commercial marketing strategies on childrens behaviour, including the effects on diet and physical activity and consequential weight gain. It is highly likely that some valuable data is held by the commercial interests themselves. A govern ment initiative to acquire this data on behalf of consumers would be a valuable research resource, on a par with the commercial papers that were released during litigation against the tobacco companies. In respect of marketing, the evidence needed should include not only direct marketing strategies, such as television advertising and promotional internet sites, but also product placement on film and television programmes, cross branding of recognisable elements of food brands on non-food items, the use of c olouring and flavour-boosting food additives to promote sales, the use of sponsorship and celebrity endorsement of products, the licensing of childrens cartoons for use on food labels and other techniques aimed to influence childrens food and leisure choices.

Food and beverage supplies are also rarely examined for their impact on obesity through dietary choices, largely as a result of product prices and product availability as well as factors such as consumer knowledge and marketing. Consumer choices need to be linked to the relative price of the foods available, and the impact of changes in price on reducing or increasing the amounts purchased, and trade-off between different types of product as the relative prices change (i.e. the price elasticity and the cross -price elasticity). The impact of sales taxes and luxury taxes on foods can be estimated from these data and the subsequent changes in dietary patterns can then lead to an assessment on obesity. Such modelling work is still in its infancy.

Food and beverage product availability and prices are themselves influenced by commodity prices and agricultural supplies, but again these have not been modelled for their potential impact on foods available and subsequent diet and obesity patterns.

Similarly, the impact of investment strategies including, in a developing country, foreign direct investment in sectors affecting food supplies agriculture, food manufacturing, retailing and catering (e.g. fast food catering) have not been analysed for their potential effects on food prices and availability, diet and health.

In all the above suggestions, similar analyses could be undertaken relating to the products which affect the physical environment and influence physical activity, or which encourage sedentary behaviour. The commercial and upstream production and marketing of products relating to physical activity such as television program consumption, video game playing, passive music playing, use of cars for short journeys, street design, building design, safety of outdoor play areas and parks are all in need of better research understanding in order to show to policy-makers that interventions can be worthwhile.

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Recommendations on evidence and research The Kobe expert meeting reached a number of conclusions , indicated in the discussion above, and which can be summarised as the following recommendations: All interventions should include process evaluation measures, and provide resource and cost estimates. Evaluation can include impact on other parties, such as parents and siblings, can include other health indicators and behaviour change. Different levels of evaluation are needed to assess the relative effects of educational input, environmental changes and policy changes. Interventions using control groups should be explicit about what the control group experiences. Phrases like normal care or normal curriculum or standard school PE classes are not helpful, especially if normal practices have been changing over the years. Interventions should be clear about the intervention duration: for example a one year intervention may actually be one school year which amounts to less than eight months of school attendance. There is a need for more interventions looking into the needs of specific subpopulations, including immigrant groups, low income groups, and specific ethnic and cultural groups. There is a shortage of long-term programmes monitoring interventions. Long-term outcomes could include changes in knowledge and attitudes, behaviours (diet and physical activity) and other health outcomes as well as adiposity outcomes. New approaches to interventions, including prospective meta-analyses , should be considered. Community-based demonstration programmes ca be used to generate evidence, gain experience , develop capacity and maintain momentum. Monitoring schemes in school age children should be put in place and yearly data should be collected. Programmes for action can be viewed as investments, and recommendations can be based on the best evidence available rather than the best evidence possible. Evidence can be viewed in several dimensions, including likelihood of success , reach and impact on the population, sustainability, acceptability and cost. There is a need for an international agency to encourage networking of communitybased interventions, support methods of evaluation and assist in the analysis of the costeffectiveness of initiatives. The Kobe meeting also expressed concern at the role of interested parties in the funding and evaluation of research. The meeting recommended that research reviews should not be funded by commercial interests. The meeting identified a need to evaluate the impact of programs funded by industry and other sources of potential bias, in order to examine their contribution to the evidence base.

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Appendix: Table of evidence from the Cochrane review of obesity prevention

Study Baranowski 2003

Methods RCT Randomisation concealment: Reported. Follow -up: Twelve weeks. Blinded assessment: Not reported Differences in baseline characteristics: Reported Reliable outcomes: Yes for anthropometry and accelerometry. Protection against contamination: Not reported, but set in two camps. Unit of allocation: Child Unit of analysis: Child. RCT Randomisation concealment: Not described.

Participants N (controls baseline) = 16 N (controls follow up) = 16 N (interventions baseline) = 19 N (interventions follow -up) = 19 Recruitment: all consenting 8 year-old, African American girls =50th percentile for age and gender BMI, with a parent willing to be involved. Set in Texas, US Proportion of eligibles participating: Not stated, but children needed access to internet Mean Age: I: 8.3 (SD 0.3) years; C: 8.4 (SD 0.3) Sex: girls only N(controls baseline) = 18 N(controls follow -up) = 18 N(child intervention baseline) = 21 N (child intervention follow-up)

Interventions Outcomes Set in a summer camp and Body Mass Index homes, the intervention was Waist circumference delivered by trained Physical maturation personnel in camp and DEXA for % Body fat researchers via a website. The intervention was Physical activity: accelerometer designed to prevent obesity CSA, and aimed to increase fruit, a modification of the Selfvegetable and water Administered Physical Activity consumption, and enhance Checklist (SAPAC), physical activity. The pilot GEMS Activity also evaluated the feasibility Questionnaire(GAQ) computeris of a larger trial. Dietary intake measured by two hour recalls using Nutrition Data System (NDS-R). Monitoring website usage.

Beech 2003

School and home based intervention delivered by a trained researcher and a community lay health educator. The intervention

Body Mass Index Waist circumference Physical maturation DEXA for % Body fat Blood samples for insulin

Follow -up: Twelve weeks. Blinded assessment: Not reported Differences in baseline characteristics: Reported. Reliable outcomes: Yes for anthropometry and accelerometry Protection against contamination: Not reported. Unit of allocation: Child Unit of analysis: Child.

= 21 N(parent intervention baseline) = 21 N (parent intervention followup) = 21 Recruitment: all consenting 8-10 year-old, African American girls =25th percentile for age and gender BMI, with a parent willing to be involved. Set in Tennessee, US Proportion of eligibles participating: Not stated Mean Age: I (C): 8.7 (SD 0.8) years; I (P): 9.1 (SD 0.7) years; C: 8.9 (SD 0.8) Sex: girls only

aimed to prevent obesity and had three arms: girls, parents and a comparison group. The aim was to improve physical activity and improve diet, and to examine the psychological aspects of both. The pilot also evaluate d the feasibility of a larger trial

Physical activity: accelerometer CSA, a modification of the SelfAdministered Physical Activity Checklist (SAPAC), GEMS Activity Questionnaire(GAQ) computeris

Dietary intake measured by two hour recalls using Nutrition Data System (NDS-R).

Caballero 2003

RCT (cluster randomised trial) Randomisation concealment: Not described. Follow -up: Three years. Blinded assessment: Adequately addressed Differences in baseline

N(controls baseline) = 835 N(controls follow -up) = 682 N(interventions baseline) = 879 N (interventions follow -up) = 727 Recruitment: all consenting American Indian students in grades 3-5 from 41 schools in Arizona, New Mexico, South Dakota, US

School-based multicomponent trial utilising school curriculum and existing staff resources trained by licensed SPARK instructors and Pathways personnel who also acted as mentors. The intervention aimed to attenuate obesity and reduce percentage body fat.

Psychological variables: Body silhouettes McKnight Risk Factor Survey, and Stunkard et a 1983. Parental food preparation practic Self-Perception Profile for Child Healthy Growth Study for physi activity expectations, and a self efficacy measure. Body Mass Index Triceps and subscapular Skinfol Bioelectrical impedance. Physical activity: accelerometer TriTrac R3D, a checklist standardised from pilot work wa used as a 24 recall questionnaire Knowledge attitudes and beliefs: self report questionnaires developed in pilot. Dietary intake measured by
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characteristics: Reported. Reliable outcomes: Yes for anthropometry and accelerometry. Protection against contamination: Adequately addressed. Unit of allocation: School Unit of analysis: Child. Proportion of eligibles participating: Not stated, but schools had to provide: >15 3rd graders; 90% American Indian; retention of 3-5 grades over 70% in past 3 years; school meals prepared on site; facilities for PA programme; approval of study by school, com munity and tribal authorities Mean Age: 7.6 (SD 0.6) years Sex: both sexes included but no figures given Dennison 2004 RCT (cluster randomised trial) Schools stratified by mean child age Randomisation concealment: Reported. Follow -up: Twelve weeks. Blinded assessment: Not done. Differences in baseline characteristics: Not reported. Reliable outcomes: anthropometric measures yes. Protection against contamination: Reported N (controls baseline) = 83 N (controls follow -up) = 73 (8 centres) N (interventions baseline) = 93 N (interventions follow -up) = 90 (8 centres) Setting: School Geographic Region: New York State, US Proportion of eligibles participating: Not stated Mean Age: 4.0 years Sex: both sexes included but no figures given

Four components included improved physical activity, food service, class-room curriculum and family involvement programme.

modified 24 hour recall Observations of school meals. Analysis of school menus for energy, protein, carbohydrate, fa sodium and fibre using the Nutrition Data System.

Preschool and day care centre based intervention delivered by one early childhood teacher and a music teacher. This was part of larger 'Brocodile the Crocodile' health promotion programme which lasted for 39 weeks for 1 hour each week including 32 sessions on healthy eating. Seven educational sessions assessed intervention to encourage reduction of TV viewing for both parents and children.

Body Mass Index Triceps Skinfolds.

Parental estimates of child's sedentary activity in previous we in hours, and to estimate number hours usually spent in these activities for each weekend day each week day.

Alternate activities as a result of reduced TV viewing were not stated/measured.

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Unit of allocation: Nursery Unit of analysis: Unclear. Donnelly 1996 CCT. Randomisation concealment: Not done. Follow -up: Over two years. Blinded assessment: Not done. Differences in baseline characteristics: Reported. Reliable outcomes: Most measures adapted from existing measures for this age group. Dietary measure is reportedly weak as is self-report measure of physical activity outside school. Protection against contamination: Not clear Unit of allocation: School Unit of analysis: Child. Epstein 2001 RCT. Randomisation concealment: Not For percentage of overweight (height and weight measured but not reported) Families with obese parents and non-obese children were randomized to groups Percentage of overweight Servings per day of fruits and vegetables N(controls baseline) = 236 N(controls follow -up) =100 N(interventions baseline) = 102 N (interventions follow -up)=100 Also had a subset of students for detailed analysis: C=64, I=44 Recruitment: all consenting students in grades 3-5 from two school districts in Nebraska Proportion of eligibles participating: Not stated Mean Age: Only grade reported not age.Mean Grade was 4.8 (SD=1.1) Sex: both sexes included but no figures given School-based interdisciplinary trial utilising school curriculum and existing staff resources which aimed to attenuate obesity and improve physical and metabolic fitness. Components included a nutrition intervention (changes to food supply and nutrition education in curriculum) and physical activity intervention.

Body Mass Index 1 mile walk/run to assess fitness nutrition knowledge test self-reports of physical activity outside of school SOFIT procedure used to test classroom physical activity Peak aerobic capacity measured treadmill testing. Blood chemistry included lipids, insulin/glucose, iron and ferritin Blood Pressure Dietary intake measured by modified 24 hour recall Analysis of school menus for energy, protein, carbohydrate, fa sodium and fibre

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described. Follow -up: One year. Blinded assessment: Not clear. Differences in baseline characteristics: Reported Reliable outcomes: Yes for height and weight. Protection against contamination: Not clear. Unit of allocation: Child Unit of analysis: Child.

N(controls baseline) = 13 (low fat/sugar) N(controls follow -up) = 13 N(interventions baseline) = 13 (fruit and veg) N (interventions follow -up) = 13 Two interventions, 13 children in each intervention group. 30 started but only 26 children provided baseline data. Proportion of eligibles participating: Not stated Mean Age: 8.8 (1.8) (low fat/sugar) 8.6 (1.9) (fruit/veg) Sex: both sexes included males/females 6/7 (low fat/sugar) 3/10 (fruit/veg) N (intervention baseline) = 43 N (control baseline) =38 54% of total population (I&C) reported to be girls - no breakdown provided. N (intervention follow -up) = 26 girls, number of boys not reported N(control follow-up) = 23 girls, number of boys not reported No data regarding:

in which parents were provided a comprehensive behavioural weight-control program and were encouraged to increase fruit and vegetable intake or decrease intake of high fat/high sugar foods.

Servings per day of high fat/high sugar foods

Flores 1995

RCT(cluster randomised trial) Randomisation concealment: Not done. Follow -up: Twelve weeks Blinded assessment: Not done. Differences in baseline characteristics: Not reported. Reliable outcomes: Yes.

School-based, activityfocussed intervention that substituted aerobic dance session for usual practice in existing physical activity sessions. A health education component was also added.

Body Mass Index Timed mile run Resting heart rate Attitudes towards physical activ

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Protection against contamination: Not clear. Unit of allocation: Class Unit of analysis: Child. Gortmaker 1999a RCT (cluster randomised trial). Randomisation concealment: Done. Follow -up: Over two school years (18 months). Blinded Assessment: N ot done.

proportion of eligible population enrolled, numbe r, nor characteristics of dropouts, eligibility for inclusion, sex Age: 10-13 years

N(intervention follow-up)=641 N(control follow-up)= 654 Outcome data collected for: 82% of baseline N enrolled:(81% I and 82%C) 65% of eligible population = 1560 N participant: 1295

Differences in baseline characteristics: Reported. Reliable outcomes: Self report outcome measures were developed or modified from existing measures. If not designed for youth sample the measures were validated for use in this sample. Protection against contamination: Not clear. Unit of allocation: School Age: mean age 11.7 years Sex: 48% female

School-based interdisciplinary intervention utilising the school curriculum and existing school teachers to promote 4 major subjects and physical education. Sessions focused on decreasing television viewing, decreasing consumption of high-fat foods, increasing fruit and vegetable consumption and increasing moderate and vigorous physical activity.

Body Mass Index Triceps Skinfold. Food and activity survey 11-item TV and video Measure

Youth Activity Questionnaire us to measure moderate and vigoro physical activity

Food Frequency Questionnaire used to measure aspects of dietar intake including % energy from and saturated fat, fruit and vegetable intake and total energy intake

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Harvey-Berino 2003

Unit of analysis: Child. RCT Randomisation concealment: Not described. Follow -up: Sixteen weeks. Blinded assessment: Adequately addressed Differences in baseline characteristics: Reported. Reliable outcomes: Yes for anthropometry and accelerometry. Protection against contamination: Not reported. Unit of allocation: Child Unit of analysis: Child.

N(controls baseline) = 20 N(controls follow -up) = 17 N(intervention baseline) = 20 N (intervention follow -up) = 20 Recruitment: Child between the ages of 9 months and 3 years, child was walking, mother BMI >25, mother agreed to keep all appointments. Set in Northern New York State, US, Quebec and Ontario, Canada Proportion of eligibles participating: Not stated Mean Age: 21 months (no SD reported). Sex: both sexes included; 54% male

Home visiting programme delivered by an indigenous peer educator who was extensively trained. The intervention was an adaptation of the Active Parenting Curriculum where 11 parenting topics were covered in 16 weeks. The focus for the treatment group was exclusively on how to improve parenting skills to develop appropriate eating and exercise behaviours to prevent obesity.

Maternal Body Mass Index N classified >85th and 95th WH and WHZ scores.

Diet: Diet: 3 day food records analyse for total calorie and fat intake us Nutritionist IV. Physical activity: Tritrac R3D (mother and child) Psychological variables: Outcomes Expectations Self-efficacy Intentions Child Feeding Questionnaire

James 2004

RCT (cluster randomised trial) Randomisation concealment: Described. Follow -up: One year. Blinded assessment: Not reported

N (intervention baseline and follow-up) 325 (15 classes) N (control baseline and followup) = 319 (14 classes) Outcome data collected for: 100% of sample. % of eligible population

School-based educational intervention aiming to prevent obesity by reducing consumption of carbonated drinks, delivered by the author and supported by existing staff. Three sessions, one per term, promoted drinking water

Body Mass Index Carbonated drink consumption a water consumption using a drink diary.

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Differences in baseline characteristics: Reported. Reliable outcomes: Yes for height and weight. Protection against contamination: Not reported. Unit of allocation: Class Unit of analysis: Class. Kain 2004 CCT (cluster case controlled trial) Randomisation concealment: Not done. Follow -up: Six months Blinded assessment: Not done. Differences in baseline characteristics: Reported. Reliable outcomes: Yes Protection against contamination: Not clear. Unit of allocation: School Unit of analysis: Unclear. Mo-Suwan 1998 RCT (cluster randomised trial).

enrolled: Not stated Setting: School Geogr aphic Region: Southern UK Age: 8.7 years (range 7-10.9 years) Sex: both sexes included; C: 51% girls; I: 48% girls

and a reduction of carbonated drinks.

N (intervention baseline and follow-up) = 2141; N (control baseline and followup) = 945. Outcome data collected for: 100% of sample. % of eligible population enrolled: Not stated Setting: School Geographic Region: Chile Age: 10.6 (SD2.6) Sex: both sexes included; C: 52% boys; I: 53.5% boys

School-based multicomponent intervention aimed to change adiposity and physical activity levels, delivered by a nutritionist and a PE teacher. Nutrition education was available for children and parents supported by healthier food kiosks. Sessions included 90minutes additional physical activity weekly for 3rd to 8th grade for 6 months and 15minutes of activity in recess per day, for last 3 months.

Body Mass Index Triceps Skinfolds Waist Circumference Fitness: Shuttle run test (20m Leger and Lambert test) Sit and reach for lower back flexibility.

Follow -up at 6 months: N(intervention baseline) = 158

Kindergarten-based physical activity program conducted

Body Mass Index Triceps Skinfold

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Randomisation concealment: Done. Follow -up: Over one year. Blinded assessment: Not clear. Differences in baseline characteristics: Reported. Reliable outcomes: All measures validated in children over 6 years of age. Protection against contamination: Not clear. Unit of allocation: Class Unit of analysis: Child. RCT (cluster randomised trial). Randomisation concealment: Not clear. Follow-up: One year (still ongoing further follow -up to be done at 4 and 8 years). Blinded assessment: Not clear. Differences in baseline characteristics: Reported

N(intervention follow-up)=147 N(control baseline)=152 N(control follow-up)= 145 Outcome data collected for: 94% of baseline N followed up 75% of eligible population enrolled = 310 Age: 4.5 (0.4) years Sex: both sexes included

by specially trained staff and including a 15 minute walk and a twenty minute aerobic dance session 3 times a week. Study objective was to evaluate the effect of a school-based aerobic exercise program on the obesity indexes of preschool children.

WHCU (ratio of wt in kg divided by ht cubed in meters)

Computation of BMI, WHCU an TSF slopes (Moore et al)

Mueller 2001

For weight, height and TSF N(controls baseline) = 161 N(controls follow -up) =161 N(interventions baseline) = 136 N (interventions follow -up)=136 Recruitment: all consenting school pupils aged 5 years. -7 General recruitment took place as part of health examinations by the school physicians. Proportion of eligibles participating: 30.2 %

School-based interventions. At school, an 8 hour course of nutrition education including 'active' breaks was given by a skilled nutritionist and a trained teacher. The course included the following messages: 'eat fruit and vegetables each day', 'reduce intake of high fat foods', keep active at least 1 hour each day', 'decrease TV consumption to less

Body Mass Index Triceps skinfold thickness % fat mass of overweight childr Nutrition knowledge Daily physical activities Daily fruit and vegetable consumption Daily intake of low fat food

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Reliable outcomes: Yes for weight, height, TSF(but method of measurement not reported). Protection against contamination: Not done. ( Every alternating year schools change and control schools become intervention schools and intervention schools become control schools). Unit of allocation: School Unit of analysis: Child. NeumarkSztainer 2003 RCT (cluster randomised trial). Randomisation concealment: Not reported. Follow -up: Eight months. Blinded assessment: Poorly addressed. Differences in baseline characteristics: Reported Reliable outcomes: Yes for weight, height, TSF (but method of measurement not reported). Protection against contamination:

Mean Age: Not reported (children aged 5-7 years) Sex: both sexes included but not reported for the 297 (136+161) children followed up for weight, height and TSF.

than 1 hour per day'. (In addition a family -based intervention plus a structured sports programme were offered to families with overweight or obese children and to families with normal weight children but obese parents).

N (intervention baseline) = 89 N(intervention follow-up)= 89 (3 high schools) N(control baseline)= 112 N(control follow-up)= 112 (3 high schools) Outcome data collected for all those enrolled - i.e.: 100% follow-up % of eligible population enrolled = 86.8% of intervention school, 83.6% of control school Geographical setting; Minnesota, US Mean Age: I: 14.9 (SD0.9) years; C: 15.8 (SD1.1).

High-school based girls only, intervention with priority given to girls with BMI at or above 75th percentile and who did less than 30 minutes per day 3 times per week physical activity (eating disorders excluded). Delivery was by school staff and research team, with local guest instructors. Intervention addressed socioenvironmental, personal and behavioural factors, with physical activity four times per week, nutrition and social support session every

Body Mass Index

Physical activity Stages of chang (based on the Stages of Change Model) Participation in PA based on Go and Sheppard.

Dietary intake adapted from You and Adolescent Food Frequency Questionnaire Binge eating adapted from the Minnesota Adolescent Health Survey.

Personal Factors Harter's self perception profile fo children


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Not done. Unit of allocation: School Unit of analysis: Child. Pangrazi 2003 RCT (cluster randomised trial) Randomisation concealment: Not described. Follow -up: Twelve weeks. Blinded assessment: Not reported Differences in baseline characteristics: Not reported. Reliable outcomes: Yes for anthropometry and accelerometry. Protection against contamin ation: Adequately addressed. Unit of allocation: School Unit of analysis: Group. RCT (Cluster randomised trial). Randomisation concealment: Done. Follow -up: Over six months.

Sex: girls only

other week for total of 16 weeks with an 8 week maintenance component of lunch time meetings. School based intervention aimed at increased physical activity with a secondary intention of preventing obesity and delivered by school staff who were specially trained. The intervention has three elements: to promote play behaviour, followed by teacher directed activities and then self-directed activity was encouraged. This was achieved by incorporating 15 minutes of daily activity in the school day and encouraging 30 minutes of out of school play by the end of the intervention. School-based intervention utilising existing teaching staff, that aimed to assess the effects of reducing television , videotape and video game us e on changes

Media internalisation Self-efficacy to be active Socio-environmental support

N at baseline 606 N of controls and treatment group not reported Recruitment: all consenting 4th grade children in 35 schools in Arizona, New Mexico, US Proportion of eligibles participating: Not stated, but restricted to 4th graders as they would not know about PLAY Mean Age: 9.8 (SD 0.6) years Sex: both sexes included C: 57% girls; I: 50.5% girls

Body Mass Index Physical activity: accelerometer CSA.

Robinson 1999

N (intervention baseline) = 92 N(intervention follow-up)= 92 N(control baseline)= 100 N(control follow-up)= 100 Outcome data collected for all those enrolled - ie: 100% follow -

Body Mass Index Triceps skinfold Waist and hip circumference 2-day self report of TV , video viewing or playing video games. Parental estimates of child's

142

Blinded assessment: Done. Differences in baseline characteristics: Reported. Reliable outcomes: All measures validated for this age group. Protection against contamination: Not clear. Unit of allocation: School Unit of analysis: Child.

up % of eligible population enrolled = 86.8% of intervention school, 83.6% of control school Mean Age: 8.9 years Sex: both sexes included

in adiposity, physical activity and dietary intake. The intervention consisted of incorporating 18 lessons of 30 to 50 minutes into the standard curriculum. Early lessons included self-monitoring and selfreporting of television, videotape and video game use to motivate children to want to reduce the time they spent in these activities. Followed by a television turnoff and then encouragement to follow a 7 hour per week budget. After school dance classes set in community centers designed to improve physical activity, reduce sedentary behaviours and enha nce diet. The intervention called START (sisters taking action to reduce television) was delivered by trained university based dance instructors and a female African American intervention specialist. The programme consisted daily dance classes during school

sedentary activity (as above) on weekend day. Child/parental estimates of time spent in other sedentary activity. Child and parent completed 24 hour activity checklist (yesterday Child completed 1-day food frequency recalls (yesterday). Child and parent report of food eaten with television on or snack while watching television/video playing video games. Maximal, multistage, 20-m, shut run test (20-MST) used to asses cardio-respiratory fitness.

Robinson 2003

RCT Randomisation concealment: Not described. Follow -up: Twelve weeks. Blinded assessment: Adequately addressed Differences in baseline characteristics: Reported. Reliable outcomes: Yes for anthropometry and accelerometry.

N (controls baseline) = 33 N (controls follow -up) = 33 N (interventions baseline) = 28 N (interventions follow -up) = 28 Recruitment: all consenting 8-10 year-old, African American girls =50th percentile for age and gender BMI, with a parent having a BMI =25, willing to be involved. Set in Oakland and Palo Alto, California, US Proportion of eligibles participating: Not stated, but criteria kept broad. Intended to

Body Mass Index Waist circumference Physical maturation DEXA for % Body fat

Physical activity: accelerometer CSA, a modification of the SelfAdministered Physical Activity Checklist (SAPAC), GEMS Activity Questionnaire(GAQ) computeris

Dietary intake measured by two hour recalls using Nutrition Data System (NDS-R).
143

Protection against contamination: Not reported. Unit of allocation: Child Unit of analysis: Child. RCT (cluster randomised trial). Randomisation concealment: Done. Follow -up: One year. Blinded assessment: Not done. Differences in baseline characteristics: Reported. Reliable outcomes: Yes for height and weight. Protection against contamination: Not done. (schools which were controls one year received the intervention the following year) Unit of allocation: School Unit of analysis: Child.

recruit 50 and 61 were enrolled Mean Age: I: 9.5 (SD 0.8) years; C: 9.5 (SD 0.9) Sex: girls only For weight and height: N(controls baseline) = 312 N(controls follow -up) = 303 N(interventions baseline) = 301 N (interventions follow -up)= 292 Recruitment: Not clear Proportion of eligibles participating: For weight and height: control 97% intervention 96% (from 5 control schools and 5 intervention schools). Mean Age: control 8.42 (0.63) intervention 8.36 (0.63) Sex: both sexes included control boys 59% girls 41% intervention: boys 51% girls 49% N = 6 schools randomised and 1 extra school added to control

weeks and reducing television was covered in five home based lessons. Four community lectures were also provided. School-based intervention Active Programme Promoting Lifestyle in Schools (APPLES). The programme was designed to influence diet and physical activity and not simply knowledge. Targeted at the whole school community including parents, teachers and catering staff. The programme consisted of teacher training, modifications of school meals and the development and implementation of school action plans designed to promote healthy eating and physical activity.

Sahota 2001

Body Mass Index Dietary intake - 24 hour recall an 3 day food diaries Physical activity - frequency of physical activity and sedentary behaviour was measured by questionnaire. Psychological measures - three validated measures including a s perception profile for children, a questionnaire to distinguish glob self-worth from competence and measure of dietary restraint.

Sallis 1993

Random allocation: Schools stratified by % of ethnic minority students and

School-based intervention. Followed the SPARK

Weight Status: BMI presented a fall 1990, spring 1991, fall 1991

144

size. Blinded assessment: Children: Unclear Providers: Unclear Differences in baseline characteristics: Reported. Reliable outcomes: Yes for anthropometry and accelerometry. Length of intervention and followup:18 month follow -up Protection against contamination: Unclear Unit of allocation: School Unit of analysis: Child. RCT Randomisation concealment: Not described. Follow -up: 12 weeks. Blinded assessment: Not clear. Differences in baseline characteristics: Reported. Reliable

group. 549 children completed Weight entry criteria: No details given Weight on entry (mean):BMI =17.7 (estimated from graph) Setting: School Geographic Region: California, US Age range (mean) 9.25 years Sex: both sexes included; 55.5% male

intervention, incorporating physical education and selfmanagement into the school curriculum. Two intervention schools, led by either 1. Certifie d physical education specialists or 2. Classroom teachers evaluated against a control.

and spring 1992.

Stolley 1997

N (intervention baseline) = 32mothers and 32 daughters N(control baseline)= 30 mothers and 33 daughters N(intervention follow-up)= 20 mothers and 23 daughters have dietary data reported however, stated that in all 51 mothers (78%) and 54 daughters (83%) had data collected . Unable to separate intervention from

Set up within a community based tutoring program this intervention examined the effectiveness of a culturally specific obesity prevention program for low-income, inner-city African American, preadolescent girls and their mothers. Program focused on adopting a low-fat, low -

Mother and daughters: Body weight and height Percentage overweight Daily caloric intake, total fat gra intake, % calories from fat, sat fa diet chol assessed by Quick Che for Fat (QCF) and analysed with quick Check Diet (QCD). Parental completion of a self measure of parental support and role modelling around food.
145

outcomes: Validation of dietary measure only in adults (but used here in children). No reliability data for this measure. Protection against contamination: Not possible. Unit of allocation: Child Unit of analysis: Child. Story 2003a RCT Randomisation concealment: Not described. Follow -up: Twelve weeks. Blinded assessment: Not reported. Differences in baseline characteristics: Reported. Reliable outcomes: Yes for anthropometry and accelerometry. Protection against contamination: Not reported. Unit of allocation: Child Unit of analysis: Child.

control figures with data provided. Age: 7-12 years, mean age 9.9 (I0 and 10.00 (C) Sex: females only

calorie diet and increased activity.

N (controls baseline) = 28 N (controls follow -up) = 28 N (3 interventions baseline) = 162 N (3 interventions follow -up) = 130 Recruitment: all consenting 5-7 year-olds from 3 primary schools. Set in central UK Proportion of eligibles participating: Not stated Mean Age: 6.1 (SD 0.6) years Sex: both sexes included; 51% boys

After school classes set in schools designed to improve skill building and practice in support of health behaviour messages in the programme. These included drinking water, eating more fruit, vegetables and low fat foods, increasing physical activity reducing TV watching and enhancing self-esteem. The intervention was delivered by African American GEMS staff. Family contact and activities supported the intervention.

Body Mass Index Waist circumference Physical maturation DEXA for % Body fat

Physical activity: accelerom CSA, a modification of the SelfAdministered Physical Activity Checklist (SAPAC), GEMS Activity Questionnaire(GAQ) computeris

Dietary intake measured by two hour recalls using Nutrition Data System (NDS-R).

Psychological variables: Body silhouettes McKnight Risk Factor Survey, and Stunkard et a 1983. Healthy choice Behavioral Intentions (diet)
146

Self-Efficacy for Healthy Eating Physical Activity Outcomes Expectations, and a self-efficacy measure. Warren 2003 RCT Randomisation concealment: Not described. Follow -up: Fourteen moths. Blinded assessment: Poorly addressed. Differences in baseline characteristics: Reported. Reliable outcomes: Height and weight and dietary measures validated for this age group. Protection against contamin ation: Not reported. Unit of allocation: Child Unit of analysis: Child. N (controls baseline) = 50 N (controls follow -up) = 42 N (interventions baseline) = 26 N (interventions follow -up) = 26 Recruitment: all consenting 8-10 year-old, African American girls =25th percentile for age and gender BMI, with a parent willing to be involved. Set in Minnesota, US Proportion of eligibles participating: Not stated, but criteria kept broad. Intended to recruit 50 and 61 were enrolled Mean Age: I: 9.3 (SD 0.9) years; C: 9.4 (SD 0.9) Sex: girls only School and family-based interventions focussing on nutrition, physical activity, or both, upon the prevalence of overweight/obesity. The setting was lunchtime clubs where an interactive and age-appropriate nutrition and/or physical activity curriculum was delivered by the project team.

Body Mass Index Skinfolds measured at five sites (biceps, triceps, subscapular, supra-iliac, calf).

Nutrition knowledge: validated questionnaire (Calfus et al. 1991

Physical activity: children and parents completed basic question about habitual activity (not validated). Diet: parents reported on behalf children a 24h recall and a food frequency questionnaire (Hammond et al. 1993).

147

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