Two chefs have been all over the news in the UK for the past week. Jamie Oliver is probably fairly well known world-wide, Hugh Fearnley-Whittingstall probably less so. Both are passionate about food, cooking and, in more recent years, using their celebrity to try to do something about the obesity epidemic – particularly in children. They have nine children between them! Hence the interest is personal.
The UK statistics are sobering. A comprehensive paper in The Lancet in 2014 reported on the global incidence of overweight and obesity in children and adults (Ref 1). Children were defined as those under the age of 20. I wrote an article in The Guardian on this at the time (Ref 2). UK girls topped the European list with 29.2% overweight or obese. Greece was second with 29.1% and Portugal third with 27.1% of girls overweight or obese. UK boys fared a bit better at 26.1% for overweight and obese combined. This was 10th in the European table, but only because there were many other countries with particularly high rates of overweight and obesity in young males. Greek, Maltese and Israeli boys were topping 30%, for example.
In the Lancet report, 24.4% of Australian boys and 23% of Australian girls were overweight or obese. These figures were 29.6% and 28.7% for NZ boys and girls respectively. South Africa reported 18.8% of boys overweight or obese and 26.3% of girls. Completing the data for the most common nations where recipients of this note reside: 25.5% of Canadian boys and 22% of Canadian girls were overweight or obese. The numbers for the US were 28.8% of boys and 29.7% of girls.
This is not a UK problem, therefore. In the English-speaking so-called developed nations, one quarter to one third of our children are overweight or obese. In 2014, the US Centers for Disease Control and Prevention reported that there were promising signs that US childhood obesity was improving (Ref 3). The data claimed a “significant decline” in obesity among children aged 2 to 5 years. There was talk that Michelle Obama’s “Lets Move” campaign had made the difference. An alternative examination of the data showed that childhood obesity was still growing – just not as fast as it had been (Ref 4). Certainly the Lancet 2014 data suggest that the US problem is as big as anywhere else.
A letter to the Prime Minister
On 25th April 2018, Jamie Oliver wrote to British Prime Minister, Theresa May. The letter was entitled “A comprehensive strategy to tackle childhood obesity” and it was countersigned by the leaders of the other main parties in the UK: Labour; Liberal Democrats; Scottish National Party; and the Green Party (Ref 5). On 1st May, Jamie and Hugh appeared in the British Parliament before a health select committee to present their case for a multi-pronged childhood obesity strategy. The day after their appearance, a number of national newspapers reviewed the session and described their contribution as frank, refreshing and well presented.
I did a couple of radio interviews about their initiative. One of the things that most interested me about Jamie’s letter was the reference to the success that has been achieved in Amsterdam (Ref 6). Success in tackling obesity is so rare; it is wise to gravitate towards anything that has been shown to work. Amsterdam reported a 12% drop in childhood overweight and obesity within the first 3 years of their ‘A Healthy Weight for All Children’ programme. The best results were seen in the lowest socio-economic groups, which was especially gratifying. There were so many aspects to the Amsterdam approach that I won’t list them here. If you are interested in the detail, the reference provides an excellent summary. It is easy to see how this inspired Jamie and Hugh that a multi-faceted approach is necessary to achieve significant change.
Children, junk and brands
On the day that Jamie sent his letter to the Prime Minister, Hugh had a one hour programme on the main UK channel: BBC1. It was called “Britain’s Fat Fight” (Ref 7) and it was the first in a series of three programmes. I really enjoyed the first one. It opened with a powerful and memorable activity. Hugh went into a supermarket with five children (I estimated them to be approximately six to eight years old). He gave them three trolleys between them and invited them to do the family shop for the week. The two key outcomes were i) they went for junk (confectionery, biscuits, crisps, fizzy drinks, sugary cereals) and ii) they went for brands (Kinder eggs, Coca-cola, Pringles, Cadbury, Kellogg’s, Nestle). It was also interesting to note that NO vegetables whatsoever went into any trolley, although a number of fruit items were chosen (sugar in a different form.) The most popular junk/branded product chosen by the young shoppers was sugary cereals. This is one of the products most ruthlessly advertised to children, using cartoon characters, toys in packets, and with adverts at bus stops, online and during popular evening TV programmes.
In my 2010 obesity book I mentioned a fabulous programme, which was presented by Nick Cohen on Channel 4 in 2004 where Nick showed that children could more readily recognise Tony the Tiger (Frosties) and Ronald McDonald than they could Jesus or their Prime Minister! It would appear that nothing has changed in 14 years.
What might work?
1) Marketing and selling to children.
Because of the power of junk food, brands and advertising, the following measures outlined in Jamie’s letter are highly likely to be effective:
– “An end to junk food marketing on TV before 9PM, and mandatory measures to stop junk food marketing to children online.
– “An end to ‘buy one get one free’ and other multi-buy junk food offers.
– “A ban on licensed characters, cartoon characters and celebrities being used to promote junk food to children.
– “Age restrictions on the sale of energy drinks to under 16s.”
These are excellent initiatives and are likely to be strongly resisted by the processed food industry precisely because they would be so effective. Just one of these – stopping the cartoon and celebrity promotions – would be a momentous strategy. Pepsi alone has a long history of paying the best known entertainers in the world – from Michael Jackson to David Beckham to Beyoncé to One Direction – to make it seem cool to drink sweet fizzy crap. I’m not sure how the UK could unilaterally ban global celebrity endorsed promotions, but the aim is laudable.
My one concern with these measures is that Hugh and Jamie repeatedly refer to “Sugar, Salt and Fat” as the key words to define junk food. If the definition of junk food is established as any product with all three of these items, this might capture the right things. However, the problem with the phrase is twofold: i) Only one of these three things is unhealthy – salt and fat, as found in real food, are both utterly life vital. The repeated use of this ‘holy trilogy’ will only serve to continue to spread misinformation and misunderstanding about salt and fat. ii) As we will see when we move on to the traffic light recommendation, demonising foods high in salt and fat turns anchovies, herring and olives into junk food and this is clearly absurd.
2) Fiscal measures.
Jamie’s letter included the proposal: “Further use of the tax system to make healthy food cheaper and discourage unhealthy choices both at home and on our high streets.”
Drastic problems require drastic measures and childhood obesity falls into this category. I am a supporter of using taxation to make junk less affordable and real food more affordable (and the two must happen in parallel). The major caveat I have with taxation is that the government is clueless about what is UNhealthy and thus a fat or salt tax could be imposed when the focus of fiscal measures needs to be sweetness.
As I explained in one of the radio interviews, there is a concept called “price elasticity” – how much consumer demand changes in response to price changes. For items deemed necessities, demand changes little even if prices change a lot (we need water/fuel etc – if the prices goes up, we still buy these essentials). The same goes for items to which we may be addicted. Many people continue to buy cigarettes, despite substantial taxation, because they ‘can’t live’ without their fix. To an extent, the same goes for junk (sugary) food. To change behaviour therefore, taxation on sugar needs to be large. The target for taxation needs to be sweetness, and thus it needs to include sweeteners, or manufacturers will just harm us with aspartame instead of sucrose and our cravings for sweet things will remain unabated.
In my 2010 obesity book, I proposed doubling the price of any product containing non-naturally occurring sugar (any added ‘ose’)/sweetener. That would immediately discourage food manufacturers from adding sugar, completely unnecessarily, to ham, cottage cheese, tins of chick peas, kidney beans and other healthy products. I would put at least a 200% tax on any product where all sugars added together are the majority of the composition of the product. For any product (e.g. children’s sweets) where the entire product is essentially sugars (with a bit of crushed animal innards, gelatine, for bonding), we should multiply the current price by four or five. The proceeds from taxes on sugar and sweeteners should subsidise real food for people who are currently least able to afford it. We cannot hope to solve an obesity epidemic when we can buy ten doughnuts or one cucumber for the same price.
The recent UK soft drinks levy is too small. It doesn’t go far enough (the soft drinks association is right to point out that soft drinks form barely 2% of UK calorie intake (Ref 8)) – the sugar tax should apply to all added sugar. It doesn’t include sweeteners and there may be unintended harm from this (Ref 9). Finally, one of the daftest things I have ever seen is the plan for using the revenue from the soft drinks levy. It is planned to fund breakfast clubs, so that the money raised from reducing consumption of sugary drinks can be delivered in the form of sugary cereal and bagels instead (Ref 10). You couldn’t make it up!
What won’t work?
I am less positive about a number of other recommendations in Jamie’s letter:
– I don’t agree with “Reformulation of junk food to reduce sugar, calories, salt and fat.” We need to educate children and parents to avoid junk, not to make junk products smaller or with more sweetener/less sugar. Again we have salt and fat lumped in with sugar.
– I don’t agree with “Mandatory traffic light front of pack labelling and an end to fake health claims.” I wrote about the Traffic Light Label plan in 2012 and my view hasn’t changed (Ref 11). Whiz down to the “unintended consequences” in that post to see the problem: diet coke sails through the traffic light scheme, as do nutritionally pointless white bread and pasta. Meanwhile olives, sunflower seeds and oily fish all clock up warnings.
– I don’t agree with the education measures in Jamie’s letter “Adequate training, tools, and time for health professionals to better support patients’ nutritional needs” and “Support for food education and improvement of the wider food environment for workers. More support for working parents.” This is because our dietary guidelines are wrong and for as long as they are wrong, any training to reinforce them will be counter-productive. We’re back to the ignorance about fat and salt again.
What also won’t work, however, is the childhood obesity strategy published by the UK Government in August 2016 (Ref 12). This was a fourteen point plan (no – I can’t remember any of them either). To this end, the sentiment of the UK activity over the past week is spot on. I whole heartedly support the intentions of Hugh and Jamie and his counter-signatories, albeit that a couple of the measures are misguided. I admire their commitment to the childhood obesity cause and I fully agree with them that something serious and impactful needs to be done.
The final bullet in Jamie’s letter is:
“The ambition to halve child obesity by 2030, with a clear definition and baseline, and clear milestones to measure progress towards this goal.”
This surely must be an ambition that we should all share – let’s work to agree on the best way to achieve this and much of what a couple of UK chefs have come up with is a great place to start.
Ref 1: Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet 2014
Ref 2: https://www.theguardian.com/commentisfree/2014/may/30/diets-fat-real-food-obesity
Ref 3: https://www.cdc.gov/media/releases/2014/p0225-child-obesity.html
Ref 4: https://www.eurekalert.org/pub_releases/2016-04/dumc-dec042016.php
Ref 5: https://cdn.jamieoliver.com/home/wp-content/uploads/2018/04/Childhood-Obesity-Letter.pdf
Ref 6: http://www.obesityactionscotland.org/international-learning/amsterdam/amsterdam-tackles-childhood-obesity/
Ref 7: https://www.bbc.co.uk/iplayer/episode/b0b0y27w/britains-fat-fight-with-hugh-fearnleywhittingstall-series-1-episode-1
(UK residents only sadly and only available in the UK for 30 days from 25th April 2018)
Ref 8: http://www.zoeharcombe.com/2017/02/what-the-uk-eats-2014/
Ref 9: https://drmalcolmkendrick.org/2018/04/28/will-taxing-sugar-end-up-damaging-the-health-of-the-nation/
Ref 10: https://www.cypnow.co.uk/cyp/news/2005036/sugar-tax-to-provide-gbp26m-for-school-breakfast-club-expansion
Ref 11: http://www.zoeharcombe.com/2012/10/traffic-light-labelling-how-does-it-work/
Ref 12: http://www.zoeharcombe.com/2016/08/uk-childhood-obesity-strategy/ (I do have to eat my words here, as I predicted that the soft drinks levy wouldn’t happen and it did).