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Consideration of the Evidence on Childhood Obesity for the Commission on Ending Childhood Obesity

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Consideration of the Evidence on Childhood Obesity for the Commission on Ending Childhood Obesity Consideration of the evidence on childhood obesity for the Commission on Ending Childhood Obesity Report of the Ad hoc Working Group on Science and Evidence for Ending Childhood Obesity Geneva, SWITZERLAND WHO Library Cataloguing-in-Publication Data Consideration of the evidence on childhood obesity for the Commission on Ending Childhood Obesity: report of the ad hoc working group on science and evidence for ending childhood obesity, Geneva, Switzerland. 1.Obesity - prevention and control. 2.Child Welfare. 3.Exercise. 4.Food Habits. I.World Health Organization. ISBN 978 92 4 156533 2 (NLM classification: WD 210) © World Health Organization 2016 All rights reserved. Publications of the World Health Organization are available on the WHO website (http://www.who.int ) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; email: [email protected] ). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (http://www.who.int/about/licensing/copyright_form/index.html ). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. 2 CONTENTS 1. INTRODUCTION 2. CONCEPTUAL FRAMEWORKS 2.1. The life-course model 2.2. The total environmental assessment model for early childhood development 3. EPIDEMIOLOGY 3.1. Estimated prevalence and trends of childhood obesity worldwide 3.2. Other epidemiological considerations 3.3. The health consequences of childhood obesity throughout the life-course 3.4. The psychosocial determinants and consequences of childhood obesity 4. ECONOMIC ASPECTS 4.1. A conceptual framework 4.2. A review of the literature on the economic implications of childhood obesity 5. RISK PATHWAYS AND POTENTIAL FOCAL AREAS FOR INTERVENTION 5.1. An overview of potentially modifiable risk factors 5.2. The development of taste and flavour preferences during early childhood 5.3. The role of nutrition literacy in the prevention of childhood obesity 5.4. The obesogenic impact of global marketing and advertising aimed at children 6. INTERVENTIONS TO ADDRESS CHILDHOOD OBESITY 6.1. Preconception and pregnancy: reducing obesity risk 6.2. Obesity prevention in infants, preschool children, school-age children and adolescents 6.3. Interventions to address those affected by obesity 6.4. Policies that address obesity in diverse sectors of society 7. SUMMARY OF EVIDENCE REVIEWS 7.1. Rationale 7.2. Potential interventions 8. CONCLUSIONS REFERENCES ANNEX 1: Consideration of the types of evidence used to assess interventions ANNEX 2: Conceptual frameworks for interventions to address obesity ANNEX 3: Approaches to health service delivery for those affected by obesity ANNEX 4: Policies that address childhood obesity in diverse sectors of society APPENDIX: Members of the Ad hoc Working Group on Science and Evidence 3 1. Introduction The prevalence of childhood obesity is increasing in all countries, with the most rapid rise in low- and middle-income countries; the 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. Children who are overweight or obese are at greater risk of asthma and cognitive impairment in childhood, and of obesity, diabetes, heart disease, some cancers, respiratory disease, mental health, and reproductive disorders later in life. The consequences of the rapid rise in obesity include not only health consequences but also negative impacts on the opportunity to participate in educational and recreational activities and increased economic burden at familial and societal levels. The rapidly rising rates of childhood obesity and subsequent increasing burden of disease and disability has grave social and economic consequences, contributing to rising cost of health services and limiting economic growth. Overweight and obesity are critical indicators of the environment in which children are conceived, born, and raised. Childhood obesity is driven by biological, behavioural, and contextual factors. Biological drivers include maternal malnutrition (including both under- and overnutrition) during pregnancy, and gestational diabetes. Inappropriate infant feeding behaviours include inadequate periods of exclusive breastfeeding and inappropriate complementary foods, as taste, appetite and food preferences are established in early life. Physical activity behaviours are also established in early childhood. Contextual and wider societal factors include socioeconomic considerations, nutritional literacy within families, availability and affordability of healthy foods, inappropriate marketing of foods and beverages to children and families, lack of education and reduced opportunity for physical activity through healthy play and recreation in an increasingly urbanized and digital world. Childhood obesity is a critical target as part of a strategy to promote a healthy life expectancy. Life- course studies suggest that interventions in early life when biology is most “plastic” are likely to have sustained effects on health, particularly because it can influence responses to later lifestyle factors. Early life represents a phase in the life-course when most societies are able to intervene constructively. It is also an area in every society where there is strong political consensus that action is desirable, including considerations of equity. This combination of short-term direct and indirect benefits and longer-term effects on the primary prevention of noncommunicable disease creates a powerful economic and social argument for action. Addressing childhood obesity has a compelling logic and the science offers many opportunities for intervention. However, at present there is no clear consensus on what interventions and which combinations are likely to be most effective in different contexts across the globe and no global accountability mechanism for stakeholders currently exists. If childhood obesity could be successfully addressed, the spill-over benefits could be enormous. In addressing childhood obesity as a specific target, it is likely that there would be improvements in both maternal and child health in 4 general, there would be benefits for cognitive development and a reduction in other comorbidities in children, the nutritional status in the whole family would improve and there would certainly be major effects on long-term burden of noncommunicable disease. The Ad hoc Working Group on Science and Evidence In order to develop a comprehensive strategy to address childhood obesity, in May 2014, the Director-General of the World Health Organization (WHO) established the Commission on Ending Childhood Obesity. This Commission comprises 15 eminent individuals from a variety of relevant backgrounds. To support the work of the Commission, two ad hoc working groups were also established – one on science and evidence and the other on implementation, monitoring and accountability for ending childhood obesity. The working groups reported to the Director-General who transmitted their findings to the Commission. In turn, the Commission requested further information from the working groups on specific topics through the Director-General. The Ad hoc Working Group on Science and Evidence consisted of academics, researchers and experts in the diverse fields that relate to childhood obesity, including epidemiology, paediatrics, nutrition, developmental origins of health and disease, health literacy, marketing to children, health economics, physical activity, gestational diabetes, etc. The full list of working group members is available in the appendix of this report. The membership of the working group was posted online for public comment prior to being finalized and all members of the working group completed a declaration of interest. Objectives of the Ad hoc Working Group on Science and Evidence for Ending Childhood Obesity To provide advice to the WHO Director-General on three core areas: 1. Epidemiology and burden: what is the current and estimated prevalence of childhood obesity and what are the health and social consequences? 2. Economic impact: what are the economic implications of increasing childhood obesity, especially in low- and middle-income countries? 3. Interventions: what are the evidence-based,
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