Mother and child crossing the street

Childhood obesity

Childhood obesity inquiry response (October 2019)

10 October 2019
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15 min read

Our response to the Health and Social Care Committee

Executive summary

Note: Impact on Urban Health is part of Guy’s and St Thomas’ Charity.

 

  • Guy’s and St Thomas’ Charity is one of the UK’s biggest charitable foundations. We work in inner-city London on complex urban health challenges
  • The Charity submitted a written response to the Health Select Committee inquiry – Child Obesity: Time for Action – in April 2018. Our suggestions were based on findings from our first report – Bite Size: Breaking down the challenge of inner-city childhood obesity – written in partnership with the Behavioural Insights Team
  • We are now three years into our ten-year programme. Since our submission to this inquiry in 2018, we have published an additional two reports that contribute to the evidence base supporting policy makers and others to develop effective initiatives that provide opportunities to support children’s health
    • Bite Size – (initial report) developed with the Behavioural Insights Team explores how the characteristics of an inner-city setting contribute to the behavioural drivers of childhood obesity; focusing on three key characteristics of deprivation, diversity and urbanisation
    • Families and Food – ethnographic research undertaken by Shift to explore the influence of deprived, inner city environments on local families’ food behaviours, from the perspective of families living in the boroughs
    • Healthy Returns – an exploration of patterns in food purchasing amongst families on low incomes and opportunities for challenger brands to play a role in tackling childhood obesity by providing affordable healthy food products (developed in partnership with Big Society Capital and the Food Foundation)
  • In this submission we assess the Government’s progress in introducing measures to tackle childhood obesity in relation to the recommendations we made in our previous submission and give our views on the next steps that the Government should take based on a solution focused evidence base
  • We set clear policy recommendations to take forward in Chapter 3 of the Child Obesity Strategy and identify a few projects that we suggest can be replicated nationally and funded through existing government funds without the need for extra funds

 

Introduction

Guy’s and St Thomas’ Charity is one of the largest independent health foundations in the UK. We focus on improving urban health. We take a place-based and programmatic approach, targeting complex health issues that affect the population of the London boroughs of Lambeth and Southwark. These include tackling childhood obesity, slowing progression to multiple long-term conditions and addressing health issues arising from poor air quality.

Our programmatic focus: improving health in urban areas – For us, urban health exists in the intersection between the built environment of a place, the diversity of its communities and the often wide range of household incomes. The interplay between these factors is complex and frequently results in marked health inequalities.

Our current programmes address three issues:

  • reducing childhood obesity
  • improving the health and care of people with multiple long-term conditions
  • addressing the effects air pollution has on people’s health (launching early 2020)

These issues are prevalent across London, complex in nature, and of interest beyond our boroughs. We aim to scale the impact of these programmes by sharing learning nationally and internationally. We collaborate with those who have the best approaches and share our drive to make them happen, from grassroot community groups to businesses. Whenever possible, we fund jointly with others.

We focus on childhood obesity because London has the highest rates of any major global city, because it disproportionately affects the most disadvantaged communities, and because its effects play out over a lifetime. See Annex A: child obesity in numbers for further details.

Background

The Charity submitted a written response to the Health Select Committee inquiry – Child Obesity: Time for Action – in April 2018. Our suggestions were based on findings from our first report – Bite Size: Breaking down the challenge of inner-city childhood obesity – written in partnership with the Behavioural Insights Team.  The key findings of this work emphasised: the role of environment, inequality driving the problem and; the need to take a long-term view.

Our submission used insights from this work to inform what the most effective interventions might be to reduce health inequalities in childhood obesity and; focused on the need to break the link with deprivation.

We are now three years into our 10-year programme. Since our submission in 2018, we have published two additional reports that build the evidence base to support policy makers and others to develop effective initiatives that provide opportunities to support children’s health.

  • Families and Food – ethnographic research undertaken by Shift to explore the influence of deprived, inner city environments on local families’ food behaviours, from the perspective of local families
  • Healthy Returns – an exploration of patterns in food purchasing amongst families on low incomes and opportunities for challenger brands to play a role in tackling child obesity by providing affordable healthy food products (developed in partnership with Big Society Capital and the Food Foundation).

Our 2018 submission drew clear links between the impact of environment, deprivation and childhood obesity. By environment we mean – i.e. the places that children and families spend their time and the opportunities it provides for healthy eating and actives lives. Based on evidence and research in the London boroughs of Lambeth and Southwark, our key point was clear: despite the complex nature of childhood obesity interventions to address it, taking action does not need to be complex. Instead, we offered that a broad range of relatively simple interventions – applied consistently at both the individual and community levels – had the most potential to tackle childhood obesity when aggregated at the population level.  See ANNEX B: Principles for tackling childhood obesity for further detail.

This submission will review the Government’s progress in introducing measures to tackle childhood obesity in relation to the recommendations we made in our previous submission and give our views on the next steps that the Government should take based on a solution focused evidence base.

Progress

This submission assesses Government’s progress on tackling childhood obesity by reviewing the following sources;

  • Government’s Response to the Health Committee’s previous inquiry
  • Chapter 2 of the Childhood Obesity Plan
  • Advancing our health; Prevention in the 2020’s Green Paper – which encompasses Chapter 3 of the Child Obesity Plan and;
  • monitoring of relevant Parliamentary Questions and speeches

We are encouraged to see that there has been progress made in some areas, and a public willingness from the Government to engage in the debate around legislative issues such as advertising, marketing and labelling of unhealthy foods, and banning energy sugary drinks to under 16s.

Whilst we are pleased to see the Government publishing further commitments on childhood obesity, through its Prevention Green Paper, much of our review of the Government’s plans surfaced policy suggestions, not actions. This does not go far enough to safeguard our children’s health and achieve the government’s stated goal of halving childhood obesity by 2030.

Our review showed the Government’s growing understanding of the impact of environment on the issue. It is acknowledged that a place-based approach is needed, and the importance of environment is clearly noted in the Prevention Green Paper and Chapter 2, but there has been little direct action in this area.

The ‘trailblazer’ programme involving Local Authorities, is the main action delivered on childhood obesity since our last submission. We welcome this local, place-based approach.  However, while the trailblazer programme focuses on understanding and overcoming local obstacles to providing healthy options and opportunities to active living, there is a lack of clarity on how the insights gained from these pilots will support meaningful recommendations for government that can inform national policy.  Further information on how these programmes will inform policy to ensure that environments across the UK in which children live, provide equitable access to healthy food and opportunities to live an active life, will give added validity to them.

Aside from this programme, Government has left the onus of creating healthier environments as a job for Local Authorities, with little support from national government at a regulatory or legislative level. This is problematic.  Cuts in Local Authority budgets means they have increasingly limited resources, and in some cases, limited political will, to tackle childhood obesity as a priority in the face of more immediate pressures and pulls on resources.  This is especially true of deprived boroughs, particularly those in urban areas that face additional complexities of population mix, movement and density.

Government has made commitments to halve obesity by 2030, yet no firm commitment has been made to addressing deprivation or inequalities as factors in childhood obesity. Our review revealed there was also little evidence to suggest policy commitments on addressing the link between deprivation and childhood obesity. We need to be very clear here — without materially addressing this connection, government will fail on its stated target to halve obesity within the next 10 years.

Conclusion

For Government to achieve its target in ten years, it will need to use the full range of its regulatory and political power to create a fairer playing field for children, no matter where they live.

We were encouraged to see that the Chief Medical Officers’ recent independent report on child obesity (Time to Solve Childhood Obesity, 10.10.19) sets out a very clear framework for action. We would encourage the Government to be bold in implementing the recommendations in the report. At its core are two fundamental principles based on evidence we’re seeing in our own work tackling childhood obesity in South London: that inequality is at the heart of the problem and that the spaces where families and children spend their time, especially in inner cities, are often flooded with cheap, unhealthy food options.

Childhood obesity is a complex issue and a growing problem, but the evidence shows us that progress is possible. Our work identifies three key principles to developing an effective Child Obesity strategy through Chapter 3.

The Child Obesity Strategy should focus on addressing the incredibly strong link between childhood obesity and low incomes. We know there is a clear link between an area’s average income and obesity. Five-year-olds from the poorest income groups are twice as likely to be obese compared to their most well-off counterparts. By age 11, they are three times more likely.

The development of Chapter 3 of the Child Obesity Plan is an opportunity for the Government to lead the way internationally in tackling the link between childhood obesity and income. We believe that by designing interventions around families and children on the lowest incomes, they’re likely to work for everyone.  There remains no silver bullet but emerging evidence from our programme in South London and others across the world, demonstrates the real opportunity to help children in the UK achieve and keep a healthy weight.

To do this, the Strategy needs to look at the whole food environment and start where people are, building on existing habits. The environments children and families spend their time – their home, school and streets – hold many of the cues that drive eating and physical activity. This is particularly so of streets (the commercial food environment). Children now have easier access to a wider variety of highly palatable, energy dense food than ever before. This food is cheap and widely promoted, both in the media and in stores through special offers, advertising, attractive packaging and child-height shelf positioning. These environments are influenced by businesses, government and our own communities – so change will require working with a range of partners in a variety of ways.

Our evidence to date reinforces the need for as broad a focus as possible – beyond the default spotlight on chicken shops. We know that families on low incomes are up against it, so need to find solutions that build on existing habits and journeys rather than demanding large scale changes to people’s routines or behaviours.

To make real progress at a national level, the Government can play a key role in shifting the frame of the public conversation. Public understanding of childhood obesity is a key barrier to evidence-based childhood obesity solutions.  Through research undertaken by the FrameWorks Institute we have identified a significant disconnect between the evidence and public opinion.  This means responsibility for the problem is placed squarely with parents and weak individual willpower – rather than understanding how environment and context shapes food options. This is a key barrier to evidence-based childhood obesity solutions.

Government can play a leading role in helping change the conversation and shift public perception on this critical issue through proactive application of the recommendations from this research.

Finally, as a funder we are running the UK’s largest philanthropic programme to tackle childhood obesity. As food environments are influenced by businesses, statutory authorities and communities, creating change requires working with a wide range of partners. In practice, this means we layer up different activities and work with a range of organisations – locally, nationally and internationally – to test and run projects that can tackle the issue from many angles. Given the clear link between an area’s average income and obesity, we focus our efforts in the areas with lower average incomes, where childhood obesity rates are highest.

Policy

We would prioritise five policy areas for further action. Based on our work these practical initiatives are vital if government is to achieve its goal of halving childhood obesity by 2030:

  • Give Ofsted the remit to enforce School Food Standards and Physical Activity Guidelines as part of their rating process – While the Prevention Green Paper lays claim to wanting all government departments to “pull in the same direction”, it fails to acknowledge the leverage school environments have in providing opportunities for promoting good health. Schools should be provided with clear policies on how to reach the standards, including advice on choice architecture in canteens, packed lunch policies and making drinks provision water-only.
  • Stronger regulation to set an even playing field – the Prevention Green Paper’s recommendations around Infant feeding, clear labelling and improving the nutritional content of food and drink should be stronger and carry greater commitment. Government should lead the way in mandating calorie reduction targets, banning advertising by fast food outlets and unhealthy food products targeted at children, stronger advertising regulation and ensuring that all Local Authority controlled contracts and events are health maximising.
  • Invest in shifting public perception on childhood obesity – proactively apply the recommendations from our research with FrameWorks Institute in order to grow support for evidence-based initiatives aiming to tackle the problem.
  • Maximise the potential of National Child Measurement Programme – here, current plans set out in the Prevention Green Paper make a good start. We recommend Government go further and expand the programme to a wider age range and include other biometrics such as strength and balance (as achieved in Amsterdam), to make it a more holistic report targeted towards intervention as well as detection and encourage greater parental involvement with the programme.
  • Take action to implement early years nutrition initiatives better designed around parents’ needs: The Prevention Green Paper rightly acknowledges the importance of breastfeeding in terms of reducing future childhood obesity, and the UK’s extremely low figures relative to other countries, and we encourage concrete plans to tackle this. Alongside industry actions listed above, more could be done to implement global initiatives aimed at building a supportive culture around breastfeeding – including increased support for local areas to achieve baby friendly city accreditation. Secondly, we know that take up of Healthy Start Vouchers is low, and there is existing research as to why. Barriers exist for both eligible families and voucher distribution points. Schemes such as the Alexandra Rose Voucher schemes present real examples of how this process could be designed in a way that is much more suited to user-need. We call on Government to implement pilots that test a new process for distributing these vouchers, based on the existing research, and to hold itself accountable to increasing take up and impact of this scheme within the next two years.

Practical action

Below we’ve listed a few projects that we are investing in that could be ripe for national replication – many of which could be funded through existing Government funds, and without the need for extra spend. We would be delighted to meet with the relevant teams to discuss these in greater depth:

  • Increasing access to fruit and veg – The Alexandra Rose Charity provides Rose Vouchers for Fruit & Veg which give families on low incomes the opportunity to buy healthier produce from their local market in Southwark, South London. Eligible families can get paper vouchers from local children’s centres and redeem them for fresh fruit and vegetables at any of the participating traders at their local market in. Through the project we are looking to support up to 1,000 families over the next three years. This could be funded through the Healthy Start vouchers scheme.
  • Creating healthier shopping baskets – we’re working with The Consumer Goods Forum to bring an ambitious collaboration together including retailers Tesco and Sainsbury’s, food manufacturers like Danone and more to test ways to move consumers towards healthier shopping baskets. Through a mix of interventions in-store and online including special signage and promotions on fruit and vegetables, the collaboration aims to help customers and employees access healthier options. Activities will be tested in Lambeth and Southwark and formally evaluated to inform wider roll-out. This kind of localised testing hasn’t been done before on this scale and has the potential to reach 600,000 people across 239 retail stores. Government could bring extra profile to companies that roll out these positive nudges.
  • Taking a community led approach – working at neighbourhood level, Healthspace, co-funded by Battersea Power Station Foundation, is designing and running activities that will work together to help reduce levels of childhood obesity within a small geography. Led by Oasis Hub Waterloo, this neighbourhood scheme is co-producing innovative and scalable activities with local Oasis schools, small businesses, and over 800 local children and their families to achieve environmental shifts and find lasting solutions for the high rates of childhood obesity locally. This could potentially be funded through an outcomes-based commissioning approach or social impact bond.
  • Investors as a lever for change – we’re supporting ‘Healthy Markets’, a campaign to harness the power of the investment system to create and support healthier food options for consumers with responsible investment charity ShareAction and Access to Nutrition Initiative. The campaign will bring investors together to ask major food and drinks companies operating in the UK market to produce healthier, affordable products, limit marketing of sugary products to children, and provide clear and accurate food labelling. Given local authorities’ responsibilities for public health, Government could provide guidance to LA pension funds as to how to support this type of campaign.
  • Increasing affordable healthy food options – we’re working with Big Society Capital and Grocery Accelerator to explore, design and test support for healthy, affordable and convenient products for families living on low incomes. We’re specifically looking at opportunity areas of snacks and drinks, convenience stores, ready meals and school catering suppliers. Grocery Accelerator are helping us identify a small portfolio of brands and understand the support required to make these products available to families on low incomes. SME lending schemes and government innovation funds could be directed to support this area.
Annex A
Annex B