Childhood obesity inquiry response (April 2018)

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

We take a programmatic approach to complex urban health issues, testing and exploring ideas with others. The content of this submission relates to insights from this approach. Our submission is forward looking, focusing on the priorities for further action in the UK.

In February 2018 we published a new report which explores childhood obesity in inner-city environments. It takes a detailed look at the evidence on behaviour change relating to deprived, urban and diverse environments.

On deprivation, we found that the relationship between income and childhood obesity is complex and influenced by factors beyond money itself. This complexity has implications for tackling the problem. For example, financial constraints may limit the effectiveness of promoting healthier but costlier foods. Likewise, encouraging parents to plan meals in advance and take the time to prepare fresh meals could be hampered by a lack of time and cognitive bandwidth.

Interventions that do not require individual action but are rather applied across the board, or are easy to take up, are likely to reduce health inequalities. This means prioritising “upstream” interventions, such as price promotion in shops at the point of purchase over “downstream” interventions like in-person dietary advice. Above all, it’s critical that policies do not rely heavily on resources that people may not have. Minimising the time, effort and costs of improving the diet and exercise of children is not only more likely to be effective, it is also less likely to increase health inequalities.

On urban settings we found that the built environment is a factor in driving the behaviours which lead to the development of childhood obesity. Many of these factors are exacerbated in urban areas. Perception of the environment also plays a part in influencing health-related behaviours.

When it comes to tackling the problem, these conclusions present both challenges and opportunities. On the one hand changing the physical environment is difficult and costly. Changes to planning regulations to reduce the density of fast food outlets are a legislative challenge, while building supportive facilities such as parks and cycle lanes is expensive. On the other, we have an opportunity: by changing perceptions about the environment we may be able to change how it influences behaviour. An example of this is reframing a commute as an opportunity for exercise. “Walk in to work out” was the slogan used in a randomised controlled trial in workplaces in Glasgow. Those that received a pack of interactive materials reframing commuting as an opportunity for exercise were twice as likely to increase walking compared to the control group.

On diversity we found that while there are consistent differences in childhood obesity rates across ethnicities, evidence suggests these are primarily due to environment rather than culturally specific behaviours.

As a result, ethnic and cultural practice might best be seen as an opportunity to take account of the communities in which children live, since this may allow for more effective interventions. For example, in some communities childhood obesity interventions recruiting children via places of religious worship have greater response rates compared to recruitment made through schools.

1. If we are to make progress and reduce rates of childhood obesity, it is essential that we approach the problem as one of environment not willpower and understand why its effects are disproportionately centred on poorer families.
2. When the environment in which people live is biased towards unhealthy decisions, the likelihood is that interventions that ignore the complexity of the issue will be ineffective and is more likely to widen health inequalities.
3. It’s important to have realistic expectations of the amount of spare time and cognitive effort people have; particularly those living in disadvantaged areas for whom scarcity will have a disproportionate impact. There needs to be a more realistic and broader understanding of people’s eating behaviour and these considerations need to be taken into account when designing the environments – schools, shops and cities – in which families operate.
4. The relationship between deprivation, diversity and the urban context is often unpredictable and nonlinear. Despite this, the complexity of what drives childhood obesity does not mean that interventions must be equally complex. Indeed, a broad range of relatively simple interventions – applied consistently at both the individual and community levels – has the most potential to tackle childhood obesity when aggregated at the population level.
5. Government should aim for all children to have the best opportunities for good health regardless of where they live. At present, children living in the poorest areas in the UK are twice as likely to be obese than their wealthier peers.  A focus on breaking the link with deprivation would halve the rates of childhood obesity in the poorest areas.
6. We think focus now needs to be on identifying “what actions are required by which stakeholders” to make impact. While it is encouraging that there is increased focus on the importance of “whole systems” approaches to the issue, we believe that this is still articulated more in theory than genuinely attempted in practice. This should build on existing evidence, reward those who lead the way, and hold others accountable to follow.
7. Tackling this issue takes time and sustaining a collective effort requires strong political leadership. Bold government action is essential as solutions will require significant structural change. Political leadership will be needed to bringing decision-makers together under one shared mandate: to create and sustain healthy food and activity environments for children.