High priority elements
Promotion and support of breastfeeding and improved education on appropriate complementary feeding practices
Breastfeeding provides a range of health benefits to mothers and infants. Evidence supports a protective effect of breastfeeding against obesity and risk of cardiovascular disease in later life[xiii]. This association is strongest for exclusive and longer duration breastfeeding. Therefore, mothers should be encouraged - where possible - to breastfeeding exclusively until the introduction of complementary feeding. In view of this, the BDA strongly recommends that the government’s childhood obesity strategy should include initiatives to encourage and support breastfeeding. Initiatives should include education for prospective and new mothers and training for healthcare professionals to help mothers to breastfeed. Further measures are recommended to support mothers to breastfeed in the home, at work and in public places.
Government should ensure access to research funds to investigate appropriate infant feeding practices including responsive feeding and the introduction of solids (timing, amount and type of foods needed to support optimal growth and development and reduce obesity risk).
Complementary feeding is needed from around six months of age to support healthy growth and development in infants. Evidence suggest early complementary feeding (before four months) is associated with increased risk of obesity[xiv]. The timely introduction of appropriate complementary foods from around six months of age, and not before four months is recommended in line with the BDA’s policy and advice on complementary feeding[xv][xvi].
Improved access to evidence-based multi-component interventions starting with expectant mothers, infants and preschool children and their families
Evidence suggests that overweight mothers are more likely to give birth to large for gestational age infants for a variety of reasons, including effects in utero[xvii]. Larger infants are at increased risk of being overweight in childhood[xviii]. This suggests that interventions should start early, even before a child is born. Interventions to improve diet and lifestyle in pregnancy have benefits for both the mother and child[xix]. However, these have not been able to show a reduction in large for gestational age births. Evidence shows1 that most excess weight before puberty is gained before five years of age and this is a particularly important contributory factor in later childhood obesity; therefore, interventions should target preschool age children.
The National Institute for Health and Care Excellence (NICE) has clear guidelines[xx] on how interventions such as these should be commissioned, and on the core elements of any such programmes. The BDA supports the view that all lifestyle weight management programmes are designed and developed with input from a multidisciplinary team, which should include a registered dietitian.
A small number of interventions that aim to tackle obesity in preschool children are available in the UK. These target parents and preschool children and are community, school, or home based. Interventions have found improvements in obesity risk through a reduction in BMI z-score[xxi] or improvements in dietary habits[xxii]. However, these are not consistently available across England and are at threat from reductions in public health funding.
In the United Kingdom, the percentage of National Health Service costs attributable to overweight and obesity is high and rising. If interventions are effective in reducing childhood obesity they have the potential to be cost effective over the lifetime of the child. For example an economic analysis carried out in the UK found that interventions that resulted in a median reduction in BMI SDS at 12 months and were of moderate cost (£108-£662) were associated with increased life expectancy and reductions in treatment costs[xxiii].
The BDA strongly recommends that the UK government should take steps to support interventions that aim to prevent childhood obesity and support CCGs and local authorities to provide them. This is in line with NICE guidance that recommends all local areas should ensure that family-based, multi-component lifestyle weight management services for children and young people are available as part of a community-wide, multi-agency approach to promoting a healthy weight and preventing and managing obesity. This responsibility lies with Health and Wellbeing boards, local authority commissioners and clinical commissioning groups. However, support needs to be provided by NHS England and PHE. The BDA continues to support the government’s Healthy Start scheme[xxiv] recognizing the importance of this in optimizing nutrition in infants and preschool children and recommends continued investment and improved promotion.
Strong controls on promotion, marketing and advertising of unhealthy food and drink e.g. HFSS and highly processed foods
There is broad support amongst health professionals and campaign groups for changes to the way unhealthy foods and snacks are promoted to children. The BDA would support measures to control price promotions, inappropriate product placement and marketing campaigns aimed at children.
Evidence shows that price promotions are more common in the UK than in other European countries and that they are most common for unhealthy foods and snacks. Public Health England has shown that price promotions increase the amount of food and drink people buy by around one-fifth and increase the amount of sugar purchased from higher sugar foods and drinks by 6%[vi].
We are encouraged by the leadership demonstrated by NHS England in committing to a ban on sugary drink sales on hospital premises if voluntary targets to reduce sales are not met by retailers[xxv].
The strategy should include measures to restrict advertising to children, and the BDA supports the Commons’ Health Select Committee’s call to restrict all advertising of high fat, salt and sugar foods and drinks to after the 9pm watershed. Steps should also be taken to close loopholes that allow inappropriate advertising to children through other forms of media.
The BDA also supports the Children’s Food Campaign’s “junk free checkouts” initiative[xxvi] to encourage supermarkets and other retailers to act on long-running customer concern and permanently remove unhealthy snacks from all their checkouts and queuing areas.
Continuing collaboration with the food industry to drive reformulation to reduce sugar and calories in food and drink, without increasing fat, saturated fat and salt levels
The Soft Drinks Industry Levy is designed to encourage producers to reduce the amount of sugar in their products. There are two tax bands: 18p/litre for drinks containing >5g sugar/100ml and 24p/litre for drinks containing >8g sugar/100ml. Pure fruit juice and vegetable juices along with milk-based drinks are excluded from the levy.
However, whilst taxation may be one method of driving reformulation, and is something the BDA has called for5 and welcomed[xxvii], research indicates that such measures could be applied more widely to other “unhealthy” products[xxviii].
Alongside the Soft Drinks Industry Levy, a sugar reduction programme is running, which is led and run by PHE. The programme applies to all sectors of the food industry – retailers, manufactures and the out-of-home sector with the aim of reducing overall sugar across a range of products that contribute the most to children’s sugar intakes by at least 20% (from a 2015 baseline) by 2020, including a 5% reduction in the first year of the programme. Calorie and portion size guidelines for specific single-serve products have also been laid out. PHE has since announced that fruit/vegetable juices and milk-based drinks will now be included under the sugar-reduction work.
PHE have also outlined the calorie reduction programme which challenges the food industry to achieve a 20% reduction in calories by 2024, in those foods that significantly contribute to the calorie intake of children. Together with the sugar reformulations, this will account for approximately 50% of children’s calorie intake.
The BDA supports this work and is glad to see that PHE have been clear that any reductions must not be done at the expense of increasing fat, saturated fat and salt levels. As the success of these programmes becomes known, the BDA will continue to ask the question about what else needs to be done if this voluntary approach is not successful. The BDA is also in a good position with its skilled membership to help companies that need additional support with meeting the reduction targets.
Action to reduce portion sizes and improve labelling of products
Controlling portion sizes is key in achieving energy balance, but many consumers have poor understanding of portion sizes appropriate for age and activity level. The government’s Foresight report[xxix] makes clear that reduced exposure to an obesogenic diet includes a focus on reducing portion sizes. The BDA supports PHE’s suggestion that relevant foods and drink should have portion sizes capped, especially when marketed to children.
The BDA supports measures to further improve food labelling, and to highlight appropriate portion sizes for children and adults. This is particularly relevant to foods and drinks that are high in fat and sugar. Additionally, there is a need to highlight foods and drinks that can be included as part of a healthy diet, such as fruit juices, but which can be high in sugar and therefore should only be consumed in small quantities (150ml a day). The BDA also believes that the current voluntary traffic light system should be made mandatory for all manufacturers. The childhood obesity strategy should also include measures to improve people’s understanding of food labelling in line with advice offered in the BDA’s Food Fact Sheet on labelling[xxx].