may 2022

Obesity: a key public health challenge of the 21st century

THE SITUATION

Childhood obesity presents a major public health challenge, with the worldwide prevalence having increased more than 8-fold over the last 4 decades (1). It is estimated that in 2016 globally, 41 million children aged under 5 years were overweight or obese (2), and 51 million girls and 74 million boys aged 5-19 years were obese (3). World Obesity Day highlighted the complexity of obesity and the need for all sectors to work together to target the root causes.

How does this affect children and young people across Europe?

The World Health Organisation (WHO) estimates that at least 2.6 million people worldwide die each year as a result of being overweight or obese (2). Whilst the most significant consequences of overweight and obesity may not become apparent until adulthood, overweight and obese children are more likely to stay overweight into adulthood and to develop these complications at an earlier age. There is a proven relationship between overweight and obesity and non-communicable diseases (NCDs) such as cardiovascular disease (including heart disease and stroke), diabetes, musculoskeletal conditions such as osteoarthritis and certain types of cancer (colon, breast and endometrial) (2).

The COVID-19 pandemic also highlighted the risk that obesity poses. Public Health England (PHE) estimated that in the adult population, a BMI of 35 – 40 could increase risk of death due to COVID-19 by 40%, and a BMI greater than 40 increased risk by 90% (3)

Obesity is multifactorial. The Federation of International Societies of Paediatric Gastroenterology, Hepatology and Nutrition (FISPGHAN) released a position paper in 2020 to highlight opportunities for preventative work (4). Infancy and childhood is a key time for intervention.

Opportunities to intervene start prior to conception. The concept of fetal programming suggests that environmental factors during intrauterine development influences postnatal development – maternal overweight or obesity at the time of conception is a strong predictor of obesity in children (4), and poor maternal nutrition may influence susceptibility to NCDs in later life (5). Infant feeding is important – rapid weight gain in the first two years of life is associated with later obesity. Breastfeeding has been shown to have a protective effect (4), and infant formulas with high protein contents were shown to increase obesity risk (4).

Dietary interventions may be helpful, as regular consumption of sugar-containing drinks are linked to obesity (6). However, approaches including various risk factors may provide added benefits. External influences such as TV advertising have a significant impact. For every 1 hour increase in TV viewing per day, there is an increase in intake of sugar sweetened beverages, fast food, red and processed meat and overall calories (7). Children who watch more than 3 hours of TV per day are 50% more likely to be obese than children who watch less than 2 (7). As well as advert exposure, sedentary behaviours contribute (4) and physical activity should be promoted. Companies and advertising agencies also have a responsibility to ensure that adverts are responsible. Paediatricians advocate to restrict advertising only to products that have a good nutrient profile, as indicated by a NutriScore A or B.

WHO recommends front of package labelling (FOPL), aiming to guide consumers towards healthier choices by clearly displaying nutritional content.

There are several different systems in use worldwide, including endorsement symbols, multiple traffic light (MTL), NutriScore and warning levels. The European Academy of Paediatrics (EAP) recommends that a consistent, easily interpretable colour-coded FOP food labelling system is introduced as a mandatory labelling requirement for packaged foods marketed in European countries, as one element of a broader obesity prevention strategy and strongly supports the EU-wide mandatory introduction of the Nutri-Score (Dereń, Dembiński et al. 2021).

Our recommendations

EAP and Young EAP would strongly recommend cross-sector collaboration to address not only the medical consequences of obesity but also the societal contributing factors. Childhood is a key time for intervention as studies have shown that children with overweight or obesity are more likely to stay overweight or obese into adulthood and suffer complications at an earlier age. Chances to change this trajectory start prior to conception and throughout infancy and childhood. Optimum prenatal and antenatal health of mothers is vital, and education for families around feeding choices, lifestyle and dietary choices is key. The education sector can encourage activity in schools and reduce sedentary activity time. Advertising agencies and regulatory bodies have a role to play with regards to advertising and food labelling, and governments should consider the needs of and impact on children when making policy decisions. Mandatory front of pack labelling of food products with the easily interpretable colour-coded the NutriScore should be introduced in the European Union. Paediatricians should advocate for the protection of children from harmful advertising and take any opportunity when seeing children and families to promote healthy choices.

REFERENCES

1. NCD Risk Factor Collaboration. Worldwide trends in body mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults. Lancet2017; 390:2627–2642.
2. Non-communicable diseases: Childhood overweight and obesity. World Health Organisation 2020 Noncommunicable diseases: Childhood overweight and obesity (who.int)
3. BMJ2020;371:m4130
4. Koletzko, Berthold∗; Fishbein, Mark†; Lee, Way S.‡; Moreno, Luis; Mouane, Nezha||; Mouzaki, Marialena; Verduci, Elvira, Prevention of Childhood Obesity: A Position Paper of the Global Federation of International Societies of Paediatric Gastroenterology, Hepatology and Nutrition (FISPGHAN), Journal of Pediatric Gastroenterology and Nutrition: May 2020 – Volume 70 – Issue 5 – p 702-710 doi: 10.1097/MPG.0000000000002708
5. Agata Chmurzynska, Fetal programming: link between early nutrition, Dna methylation, and complex diseases, Nutrition Reviews, Volume 68, Issue 2, 1 February 2010, Pages 87–98, https://doi.org/10.1111/j.1753-4887.2009.00265.x
6. Deren K, Weghuber D, Caroli M, et al. Consumption of sugar-sweetened beverages in paediatric age: a position paper of the European Academy of Paediatrics and the European Childhood Obesity Group. Ann Nutr Metab2019; 74:296–302
7. The impact of food advertising on childhood obesity (apa.org)
8. Croker, H., Packer, J., Russell, S., Stansfield, C.& Viner, R.M.(2020) Front of pack nutritional labelling schemes: a systematic review and meta‐analysis of recent evidence relating to objectively measured consumption and purchasing. J Hum Nutr Diet. 33, 518– 537 https://doi.org/10.1111/jhn.12758

About the authors:

Sian Copley (UK) is the Young EAP Secretary and UK representative and a 7th year paediatric resident

Andreas Trobisch (Austria) is a former member of Young EAP. He is a consultant neonatologist at Medical University of Graz, Austria.

Reviewed by:

Berthold Koletzko is a Prof. of Paediatrics at the Ludwig-Maximilians-University of Munich (LMU), a paediatrician at the Children’s Hospital and Children clinic of the Dr. von Hauner Children’s Hospital, and a EAP member.