Childhood obesity is a matter of concern in both developed and developing countries, differing perhaps in degrees, and can only be controlled through combined effort of public health programmes initiated at government or equivalent levels and the conscious effort of parents, says Dr Sitanshu Kar. Also, tips for parents.
1. The social inequality that has a direct association with obesity seems to be reversed in developed countries. In developed countries such as the USA, the lower socioeconomic classes face obesity while in underdeveloped countries it is the reverse, Can you explain this disparity?
Obesity and all major chronic diseases (Diabetes, Heart disease and Cancer) were affecting the elite group and that’s why it was considered to be a disease of the rich. Gradually, as the awareness regarding these conditions increased, the elite group having access to health information and resources adopted healthy lifestyles. So the burden of obesity started to decrease in the elite. Hence, there is a reversal of burden in high socio-economic status.
As the unhealthy food practices and access to poor habits are cheaper, the access to such items is more in children belonging to lower socio-economic strata. As the intake of oily food and fried items increase, fruit and vegetable intake decreases because of high cost. The living condition of the poor also play an important role: no access to play grounds, or parks also limits their physical activity level. Hence, the children belonging to lower socio-economic status are affected more by obesity.
This phenomenon is known as reversal of social gradient in distribution of risk factors and chronic disease. This phenomenon is not specific to any particular region it is happening all over the globe. Only thing that differentiates between two countries is “time”. India is around 20-30 years behind the US and other developed countries in experiencing this occurrence.
Currently, with advent of smart phone, cultural norms are getting more complicated and obesogenic environment is created everywhere. Spending time with smart phones, tablets and all other gadgets reduces the time children spend on playing outdoor games. The attractive nature of the graphics and various softwares are very addictive to children from a very young age.
2. Is childhood obesity being controlled or is reducing in the developed countries? If not, then why should we in India adopt those same practices? If yes, then what did you think were the most adaptable practices?
Many studies have shown an unexpected plateauing or even decline in the trend of prevalence of childhood obesity for the past 10-15 years in developed countries. The results are reasonably attributed to the cumulative effect of public health programmes at the national, state and local levels from the Government and Non-Government sectors in these countries(1). The vast majority of overweight or obese children live in developing countries, where the rate of increase has been more than 30% higher than that of developed countries(2).
Culturally, we think that “Fat child is equivalent to Healthy child”. This is a myth. It is very difficult to change the age old food practice. There are various best practices reported in literature from developed world. The most adaptable practices would be the behavioural change programmes along with policies targeting social determinants, i.e. upstream approach. Some examples would be - ‘New South Wales Initiative’ in Australia, ‘Pick a Tick initiative’ by National Heart Foundation, Australia, ‘Healthy Weight, Healthy Lives: A cross-government strategy’ in England, ‘EPODE initiative’ in Europe, Canadian initiative to prevent childhood obesity and ‘White House Task Force on childhood obesity’ in the US.(3)
But we must be careful in recommending these practices to our scenario as our culture and settings are different!
3. Do you think reversing obesity is easier in children than adults? Why is that?
Reversing obesity is a very big task in all age groups. Once an individual is overweight or obese, reversing the energy balance to restore a healthy weight is a significant challenge. However, I feel it is easier to reverse the obesity in children than adults as children are prone to behaviour change and can be moulded to adopt a healthy lifestyle. Hence addressing the issue as early as possible will save the person from a lifelong misery of associated illnesses and stress.
4. Should the food industry leaders be involved in any obesity prevention programs such as the White House Task Force? What is the fallback of such associations?
Advertisement of ready to eat and other energy dense food is a significant influencer in food preference. Food industry leaders, being a stake holder has a definite role to play in obesity prevention. They can be persuaded through Government regulation to make healthy options cheaper and increase tax on unhealthy food options.
But, the fall back of such associations will be the possibility of bias as the prominent food industry corporates are based on profit and thus may result in lax regulations and blurring limits. So, the involvement of them should be supervised and carefully structured so that those who are being affected by the regulations have no power in diluting the interests of the committee.
5. How fat-free are the fat-free labelled processed foods?
We find in the market a lot of products including soft drinks, snacks, vegetable oil etc. that claim to be either low-fat, fat-free, low calorie, light (lite) etc. and these descriptions are used interchangeably.(4) For a product to be labelled as trans-fat free, the Food Safety and Standards (Packaging and Labelling) Regulations, 2011, states that there needs to be less than 0.2 grams of trans fat per serving.(5)
As far as my knowledge goes, we don’t have enough scientific evidence to test this claim. However, many a times, the labels are often misleading and exaggerated to an extent that they are only used a tool for advertising.
6. The EPODE initiative in Europe sounds like an ideal program. Do you think it’s doable in India? Would all involved stakeholders be willing?
EPODE stands for “ensemble-prévenons-lobésité-des-enfants” meaning “Together Let's Prevent Childhood Obesity” is a community initiative which was launched in 2004 in 10 towns in France and is an intervention for children aged 5–12 who are overweight or at risk of weight gain. Obesity and other NCD prevention calls for a whole of society approach meaning we need to look beyond health sector and involve all relevant non-health sector (Education, Agriculture, Law, Urban Planning, Women and Child Development) to tackle this issue.
(a) The EPODE initiative is definitely doable in India. What we need is the mind set to sit and discuss issues across table. We need to involve many related sectors to develop an action plan and fix responsibility for its implementation. In 2012, EIN (EPODE International Network) lead the evaluation workshop for Healthy Kids during the “Nestlé Global Creating Shared Value Forum” in New Delhi, India.
(b) EPODE promotes the involvement of multiple stakeholders at central level (endorsement from ministries, support from health groups, NGOs, and private partners) and relies on the guidance of an independent scientific advisory board for general recommendations on content and messages. Though Difficult, it is not an impossible task! Yes, I think, all stakeholders will be willing only if there is a political will and a shared vision to prevent childhood obesity.
7. Is food labelling a difficult task to implement in India?
The food labelling is already being implemented in India as per “Food Safety and Standards (Packaging and Labelling) Regulations, 2011”. Every packaged food article for the domestic use has to be labelled in accordance to the related Indian Food Law i.e. Food Safety and Standards (Packaging and Labelling) Regulations, 2011, notified by Food Safety and Standards Authority of India (FSSAI).
In order to safe guard the interest of the consumer, The Food Safety and Standards (Packaging and Labelling) Regulations, 2011, provides that every packaged food article has to be labelled and it shall provide the following information – name of food item, list of ingredients, nutritional information, declaration regarding veg or non-veg, declaration regarding food additives, name and complete address of the manufacturer or packer, net quantity, code No,/Lot No./Batch No., date of manufacture or packing, best before and use by date, country of origin for imported food and instructions for use.
Consumer awareness is another challenge, even if there is labelling on an item, we don’t take advantage of this and consumer awareness is quite low in India. A cross sectional study conducted among 1832 consumers in two metro political cities of India, New Delhi and Hyderabad reported only one fifth of the participants reported that they will check food labels for nutritive values.(6) This may be even low in smaller cities.
Food labelling is a good intervention and is being implemented in India but it has to be coupled with awareness generation activities among the masses.
8. You mention great strategies for effective policies. How do you propose to take these policies forward?
Effective policies can be taken forward by effective planning. For any successful policy implementation six building blocks are required i.e, governance, managing risk, engaging stakeholders, planning, resources& monitoring, and review& evaluation. Having a shared vision and creating a culture of health with community participation is the way forward for childhood obesity prevention.
Ministry of Health and Family Welfare, government of India is implementing a centrally funded programme called NPCDCS - National Programme for prevention and control of Cancer, Diabetes, Cardiovascular disease and Stroke since 2010. One of the objectives of the programme is to promote health through behaviour change with involvement of community, civil society, community based organization to control & prevent major non-communicable diseases along with their risk factors. The strategies of the programme are on health promotion, awareness generation and healthy lifestyle promotion at various settings (community, workplace and schools). This provides a great platform to integrate our efforts and involve various other non-health sectors to work for the common cause.
9. Do you know of any programs currently running in the country?
As mentioned in the previous question, the NPCDCS is the programme initiated by Government of India to tackle major NCDs (Cancer, Diabetes, Cardiovascular Disease and Stroke) with their common risk factors (Unhealthy diet, Physical Inactivity, Obesity, Tobacco and alcohol use).
The following are some of the targeted schemes and programs running in India for children with focus on nutrition:
Mid-day Meal Scheme: National program for nutritional support in primary school was started in 1995 to increase the enrolment, retention and retention in the schools. The main aim of the program was to improve the nutritional status of children in classes one through five in government schools and government aided schools, to encourage children from disadvantaged backgrounds to attend school regularly and help them concentrate in school activities and to provide nutritional support to students in drought- ridden areas throughout summer vacation.
Integrated Child Development Scheme: The Integrated Child Development Scheme (ICDS) comes under the purview of the Ministry of Women and Child Development (MWCD) was launched in 1975 has been working diligently to eliminate hazards to child health and development. The following are some of the objectives of ICDS: to advance the nutritional and health standing of children in the age-group 0-6 years, and to create a system that tackles the proper psychological, physical and social development of the child.
Kishori Shakti Yojana: KSY aims at empowering adolescent girls so that they may become responsible citizens. It looks at all aspects of adolescent girl development. The large objective of the scheme is to advance the nutritional, health and development status of adolescent girls, support increasing knowledge of health, hygiene, nutrition and family care, and to integrate them with opportunities for learning life skills, going back to school, helping girls grow to understand their society and become prolific members of the society.
10. What is your advice to parents and young adults?
Advice to parents:
- Nutrition: Parents should expose their children to the concept of “healthy eating” from a very young age. Children should be given a “rainbow diet” i.e. all the colours should be included in the plate. E.g. orange colour for carrots or green colour for spinach etc. Parents should encourage their children to eat all kinds of healthy nutritious food. Sugar and salt intake should be controlled and instead honey or jagerry can be used as a sweetener in place of sugar.
- Physical Activity: Parents should encourage their children to do outdoor physical activities like sports, dance, aerobics, outdoor games etc. These build confidence in the children and also develop extracurricular skills. Also their (children’s’) stress levels are reduced by physical activity due to endorphin secretion. 60-90 minutes of outdoor activity should be encouraged.
- Sleep: A child should be encouraged to sleep on time and this routine should be maintained. A good sleep is a prerequisite for the normal development of the child.
- Fixed timings in front of TV and gadgets: It is very important to limit these activities to 1 hour per day.
Childhood obesity - Signs and Prevention
Advice to young adults:
- Eating according to Appetite: Children are able to decide how much food they need for activity and growth if allowed to eat according to their appetite. Forcing children to ‘clean the plate’ or giving sweets as rewards may lead to problems of overeating later in life.
- Lunchbox culture: This culture should be encouraged in the schools by the teacher and at home by the parents. A child should learn to carry lunchbox so that she/he doesn’t get involved in eating unhealthy foods outside.
- Healthy Snacks Suggestions: Snacks are an important part of a child’s food intake for energy and nutrients. What children eat is more important than when they eat. Children who snack on lollies and chips may not get all the nutrients needed for good health. Everything in moderation should be the mantra of eating. Say no to tobacco & alcohol.
- Fruits, vegetables, legumes (e.g. lentils, beans), nuts and whole grains (e.g. unprocessed maize, millet, oats, wheat, brown rice). At least 400 g (5 portions) of fruits and vegetables a day. Potatoes, sweet potatoes, cassava and other starchy roots are not classified as fruits or vegetables.
- Less than 10% of total energy intake from free sugars which is equivalent to 50 g (or around 12 level teaspoons) for a person of healthy body weight consuming approximately 2000 calories per day, but ideally less than 5% of total energy intake for additional health benefits. Most free sugars are added to foods or drinks by the manufacturer, cook or consumer, and can also be found in sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates.
- Less than 30% of total energy intake from fats. Unsaturated fats (e.g. found in fish, avocado, nuts, sunflower, and olive oils) are preferable to saturated fats (e.g. found in fatty meat, butter, palm and coconut oil, cream, cheese, ghee and lard). Industrial trans fats (found in processed food, fast food, snack food, fried food, frozen pizza, pies, cookies, margarines and spreads) are not part of a healthy diet.
- Less than 5 g of salt (equivalent to approximately 1 teaspoon) per day and use iodized salt.
- Treats Suggestions: Children should be encouraged to limit the intake of sugar and treats should be taken only during special occasions like birthday parties.
- Regular Check-up: A child should have friendly and cordial relations with the doctor. She/he should have a routine check-up planned in the school or in home by a family physician. This practice will allay fear (white coat fear) from the child’s mind about the doctor and will go a long way in adapting healthy lifestyle.
References:
1. Kar SS, Thakur JS, Kaur N, Jain S, Kumar R. Risk factors of cardio-Vascular diseases: Is social gradient reversing in Northern India? Natl Med J India. 2010 Jul-Aug; 23(4):206-9.
2. Wabitsch M, Moss A, Kromeyer-Hauschild K. Unexpected plateauing of childhood obesity rates in developed countries. BMC Med. 2014 Jan 31;12(1):1.
3. WHO | Facts and figures on childhood obesity [Internet]. WHO. [cited 2016 Apr 2]. Available from: https://www.who.int/end-childhood-obesity/facts/en/
4. Kar SS, Kar SS. Prevention of childhood obesity in India: Way forward. J Nat Sci Biol Med. 2015;6(1):12–7.
5. Baisya RK. Changing Face of Processed Food Industry in India. Ane Books Pvt Ltd; 2008. 257/344 p.
6. What food labels don’t say - Times of India [Internet]. The Times of India. [cited 2016 Apr 2]. Available from: https://timesofindia.indiatimes.com/home/science/What-food-labels-dont-say/articleshow/13066871.cms
7. Vemula SR, Gavaravarapu SM, Mendu VVR, Mathur P, Avula L. Use of food label information by urban consumers in India-a st.
Dr. Sitanshu Sekhar Kar is an Associate Professor in the department of Preventive and Social Medicine, at JIPMER, Puducherry with 13 years of teaching/ research experience. Prior to this, he has served in WHO Country office for India as National Consultant in NCD & Mental Health Cluster and was responsible for providing technical assistance in development of National Programme on Prevention and Control of Cancer, Diabetes, CVDs and Stroke (NPCDCS). He has 70 research publications in peer reviewed journals to his credit. Areas of interest include medical education, health system strengthening and chronic disease prevention.
