The Westminster City Councils Response to Childhood Obesity - Literature review Example

The Westminster Council’s Response to Childhood Obesity: An Analysis Introduction Childhood obesity is increasingly challenging public health worldwide (Wang 2001; British Medical Association [BMA] 2005; Procter 2007; National Health Services Westminster [NHSW] 2009) with London registering high prevalence compared internationally and highest prevalence compared nationally (Cronberg et al 2010; Greater London Authority [GLA] 2011; London Assembly – Health and Public Services Committee [LA-HPSC] 2011; London Health Improvement Board [LHIB] 2012). London’s childhood obesity prevalence varies greatly between boroughs with Westminster leading at 12% in Reception and 23% in Year 6 (Child and Maternal Health Observatory [ChiMat] 2012, p. 1). Childhood obesity is complex, as it is affected by various intermingling factors, and problematic with its profound lifelong impacts, threatening the individual and the society as a whole. (BMA 2006, NHSW 2009, LA-HPSC 2011; LHIB 2012) Failure to arrest it will result ultimately to an unhealthy population that will be both financially and socially costly (Local Government Information Unit [LGiU] 2012). Hence this essay intends to answer the question: How does the WCC perceive and respond to the problem of childhood obesity? Related to this are two questions to be answered – How severe is childhood obesity in Westminster? And, what is the WCC response against it? Childhood Obesity in Westminster Obesity is generally understood as excessive body fatness – the excess fat accumulated in adipose tissue – that can potentially impair the body’s healthy functioning (Dehghan et al. 2005; NHSW 2009). As such, the best way to determine obesity is to measure the adipose tissue mass. Unfortunately, this is laborious and expensive, requiring sophisticated technology. In replacement thereof is the use of an index of body weight. Of which, widely used is the Quetelet’s index or the body mass index (BMI) – measured as weight in kilogram divided by the height in meter2. However, children’s rapid growth and development make the determination of their weight status and adipose level difficult and uncertain. Additional difficulty is the lack of a reliable international or regional weight status standard for children due to culture differences. (Guillaume 1999; Cole et al. 2000; Lahti-Koski and Gill 2004; Flegal et al. 2006) In response, the UK uses its own conservative weight status standard – 85th percentile for overweight, which to the US is only at risk of overweight, and above the 95th percentile BMI for obesity, using UK’s 1990 historical reference data (Shield and Summerbell 2009, p. 509). Furthermore, understanding childhood obesity prevalence necessitates grasping its urban context and determinants (primary and secondary), thus the examination of Westminster. Westminster, London’s centre, is one of England and London’s most densely populated boroughs inhabited by almost 9,000 people/km2. Its built environment is characterised by a modern transport infrastructure where most of London’s underground stations are located, with 87 public open spaces, with fewer sports facilities compared to London and England, and with 66 sites offering health and fitness facilities but only seven under Local Authority ownership. Within its boundaries are some of London’s most famous landmarks and districts (i.e. Buckingham Palace, the Houses of Parliament, Westminster Abbey, Big Ben), as well as England’s most deprived areas (i.e. Queen Park, Harrow Road, Westbourne, Church Street). Being home to London’s business, academic, and government centres, Westminster looks wealthy; but the 2007 Index of Multiple Deprivation ranked it is England’s 72nd most deprived local authority. Its population is ethnically and culturally diverse (i.e. White, African, Asian, mixed races) and internationally mobile, causing its demography changing frequently. Its relatively large children population – 17% of Westminster’s population is aged under 20 and 5% is aged 0-4 years (Healthy Schools 2007, p. 1) – is in Church Street, Queen’s Park, Regent’s Park and Westbourne wards which, excluding Regent’s Park, are all classified as the country’s most deprived areas. Whereas, its education system services 16,500 school children of which 11,000 are in primary schools. (NHSW 2009, pp. 7-9, 13, 16, 22, 138) About 83% of school children belong to a black or minority ethnic group; whereas 38% live in poverty – a figure higher than London (33.9%). (Healthy Schools 2007, p. 1) Childhood obesity in Westminster is increasingly prevalent. In 2007-08, 11.8% of Reception (4-5 years old) and 24.8% of Year 6 (10-11 years old) are found obese. Worst, these figures are above London’s average – Reception (10.9%) and Year 6 (21.6%) – and England’s – Reception (9.6%) and Year 6 (18.3%). Furthermore in both years (2006-07 and 2007-08), more boys are found obese than girls in Reception (14.4% and 9.3%, respectively) and in Year 6 (26.8% and 22.9%) respectively. Also children from ethnic groups found more vulnerable to obesity are the Black and Mixed ethnic groups; whereas children studying in the City’s most deprived areas are more likely to become obese than those studying in more wealthy areas. (NHSW 2009, pp. 66-68) Additionally, children from Mixed, Asian and other ethnic groups in deprived areas are found of greater risk than White children; but since the relationship between BMI and body fat differs by ethnicity, interpreting data requires caution (LHIB 2012). In sum, data above shows that childhood obesity prevalence in Westminster differs in terms of age, gender, socio-economic status, ethnicity, and geography. Childhood obesity is a multisystem illness with great encumbering effect. It stigmatises the afflicted and increases health risks. (City of Westminster 2006; Procter 2007; NHSW 2009; O’Connor 2011) Though it rarely breeds serious health problems; its lifelong impacts are profound (BMA 2006, LA-HPSC 2011; LHIB 2012). Obese children may acquire hypertension, hyperinsulinaemia, dyslipidaemia, chronic inflammation, increased blood clotting tendency, endothelial dysfunction, and early atherosclerosis) early in life increasing the likelihood of earlier deaths (Cole et al. 2000; Ebbeling et al. 2002) and the development of adult obesity. In Westminster, nearly 13% of all deaths from 2002-07 were obesity-related. In the same period, the number of years of life lost (YLL) due to obesity-related diseases at crude rate per 10,000 population are as follows: all cancers = 102.63, CHD = 42.78, CVD = 103.51, diabetes 2.97. These figures are lower than London (all cancers = 130.65, CHD = 69.74, CVD = 128.54, diabetes 4.44, respectively) and England (all cancers = 162.82, CHD = 87.29, CVD = 143, diabetes 4.97, respectively). But Westminster’s number of YLL due to obesity-related hypertension (8.94) is higher than London (5.51) and England (3.44). Whereas, obesity in adults (16+ year-old) is at 24% mostly located in the City’s most deprived areas, where ethnic groups thrive. (NHSW 2009, pp. 71-73, 85) Added to pathological problems are psychological problems associated with obesity, such as anxiety and depression – found to be 3-4 times higher in obese people – lower self-esteem, negative self-image, disordered eating, bulimia, body dissatisfaction and even poor sexual relations. (Mulvihill and Quigley 2003; NHSW 2009) Unsurprisingly so, obesity can be financially and socially costly (LGiU 2012). In 2007, obesity treatment had directly cost NHS Westminster £36.4 million which may increase to £48.3 million by 2030 if current trends in obesity prevalence are not averted. (NHSW 2009, pp. 102-103) City Assessment and Response Basically obesity occurs due to excess calorie intake as against calorie use (LA-HPSAC 2011). But acquiring this illness is multi-factorial, being both driven genetically and environmentally. The individual’s genetic construction and behaviour – i.e. eating and drinking behaviour (energy intake) and physical behaviour (energy expenditure) – mainly influence the energy balance in the individual. But these factors are further confounded by economic, psychological, social, and cultural factors (Mulvihill and Quigley 2003; NHSW 2009) that create an obesogenic environment – “The sum of influences that the surroundings, opportunities or conditions of life have on promoting obesity in individuals or populations” (Procter 2007, p. 33-39). The City’s assessment on its increasing problem of childhood obesity reiterates UK’s 2007 Foresight Report on obesity as “primarily caused by people’s latent biological susceptibility interacting with a changing environment that includes more sedentary lifestyles and increased dietary abundance” (LA-HPSC 2011, p. 14). In concurrence, the NHSW’s (2009, p. 107) 2007-08 Annual Public Health Report states that “the modern food environment has contributed to too much saturated fat, added sugar and salt and not enough fruit and vegetables in the UK diet; and the modern physical environment has contributed to increasingly sedentary lifestyles.” Thus among those factors that the NHSW (2009) considered in assessing Westminster’s increasing problem of childhood obesity are the children’s physical activity and dietary intake, the food environment and physical environment, and the socio-economic and psychological factors. Their findings show a confluence of these factors to perpetuating perceptions and conditions favourable to obesity. The low physical activity of children is seen attributable to the increasing availability and attractiveness of home entertainment (children watch TV, use computer or play video for more hours at 35-40 hours/week on average), to the convenience of using transportation in going to school (the proportion of children walking to school fell from 61% to 39% as against the increased proportion of those being driven to school from 30% to 39%), to the accessibility of schools lessening children’s walk (only 53% of school children walk to school because 72% live near their schools), to the low level of consciousness of children on the necessity of being physically active for at least 60 minutes every day, to the school environment which though had improved school children’s participation rate for high quality Physical Education from 23% (2004-05) to 64% (2007-08) remains the second lowest proportion in London and below London and England’s average (74% and 78%, respectively), and to the modern physical environment that caters least to walking, biking, and outdoor play. And, the children’s unhealthy dietary intake is seen attributable to the City’s modern food environment which makes high-calorie food not only widely available and accessible but also desirable to children. This is further aggravated by the changing social norms which give children more discretion in their choice of food, popularised eating in food chains, and make habitual grazing, snacking and eating common. Another significant factor seen is the influence of parent’s lifestyles on children’s behaviours and dietary choice. (NHSW 2009, pp. 111, 114, 124, 126) Findings of the NHSW (2009) can be summarised as follows: (1) the prevention of childhood obesity can potentially prevent adult obesity; (2) obesity is a preventable disease but its multifactorial causality makes its prevention difficult and requires collaborative action among various partner agencies and stakeholders, (3) obesity is a life course incidence where susceptibility to gaining weight becomes stronger at certain points in life thus the importance of a life course approach (i.e. healthy lifestyle is best established at pre-school, obesity should be prevented in women before and during pregnancy, breastfed babies are less likely to become obese); (4) childhood obesity is differentiated by age, gender, socio-economic status, ethnicity, and geography; (5) parental obesity significantly predicts childhood obesity thus the importance of a whole family orientated approach; and (7) the formative years of children are best spent in schools thus the important role of schools in preventing obesity in children. Thus the national government’s strategy ‘Health Weight, Healthy Lives’ against the rising prevalence of obesity is focused on children aged 0-11 years. Generally the City’s strategy to address childhood obesity is to promote healthy eating among children and to increase their physical participation. Thus WCC offers children a wide program of sporting and leisure activities, such as free swimming and swimming lessons, 120 hours a week of free activities, including football, table tennis and weights and fitness in the City’s deprived areas, and more. These are to be achieved in coordination with all partner agencies (i.e. Department of Health, Department for Education and Employment, Department for Culture, Sports and Media, and Department for Transport) in Westminster, as well as relevant organisations at London and national levels. A tiered approach is adopted with four levels of treatment intervention for obese children: Level 1 includes the provision of brief interventions in healthcare settings, including the provision of key messages about healthy eating and physical activity Level 2 includes the provision of community-based weight management programmes Level 3 includes the provision of specialist dietetics support for obese individuals Level 4 includes the provision of highly specialist care. (NHSW 2009, p. 159) Analysis Childhood obesity in Westminster is severe and most prevalent among London’s borough, confirming the ‘sick city hypothesis’ which argues that the human density of the city makes it a channel of diseases. In the case of Westminster, the primary determinants of childhood obesity is confounded by secondary determinants attributable to the City’s urban make-up, such as the modern food environment which promotes unhealthy diets, making it available and accessible to children; the modern physical environment which made life more convenient (i.e. modern transportation, televisions, computers, video games, elevators, ), resulting to reduced physical activity and increased sedentary activities in children; the cultural environment which through mass media made children and parents’ food choices and lifestyle obesogenic; the psychological environment which fosters a high level of fear of crime, dissuading people’s physical activity like playing in open public spaces; and the socio-economic environment which deprived areas are inhabited mostly by ethnic minority whose children are found prone to obesity, understandably due to their incapability to make healthy choices. The negative living environment in Westminster’s deprived areas impact significantly on women which may have negatively impacted on pregnancy and weaning practices that are found significant in making children not susceptible to obesity. On a positive note, the City’s strategy against obesity makes use of the urban advantage, specifically the exploitation of modern technology (i.e. geographic information system) to map out and monitor the prevalence of childhood obesity in the city. This enables the NHSW to identify specific population groups that need focus intervention. The strategy of the national and local government to focus on children in preventing the rising prevalence of obesity is strategically correct for two important reasons. First, the prevention of obesity in children will not only arrest the strong possibility for children to acquire other obese-related fatal diseases but will also significantly reduce the potential increase of adult obesity. In this sense, preventing childhood obesity is hitting many birds in one stone. Second, the prevention of obesity in children is one way to keep them healthy and keeping children healthy is generationally important, especially so that the UK’s population is largely ageing. With Westminster having a far smaller proportion of children population (15%) makes it more strategically important to keep children healthy. However, the WCC’s tiered approach does not fully address the urban characteristics that are important to children’s health most especially the improvement of their socio-economic status – This is vital to arresting childhood obesity which is basically behavioural in nature. As Licari et al (2005) say, the educational level of parents strongly influence the children’s risk awareness and lifestyles. Thus educating parent on nutritious dietary intake and healthy lifestyle and economically empowering them is important in combatting childhood obesity. The City’s recognition on the necessity of supporting environmental change though laudable is a daunting task for Westminster, given its frequently constantly changing demography and its historical and economic importance to London and England. It does not simply require an education-propaganda campaign regarding the importance of physical activity and healthy diet, wherein the media, the schools, and the family can be mobilised for this endeavour. It requires changing the built obesogenic environment, which means subjecting Westmisnter’s urban plan to possible change. For this to happen, various interest groups, especially the powerful business group, should be convinced to participate and cooperate. Thus it requires an overwhelming political will. Clearly so, obesity is a complex problem. Though Westminster’s culturally and ethnically diverse population is considered in the investigation of its prevalent childhood obesity, it nonetheless fails to clarify the cultural practices of ethnic groups that impact on childhood obesity. And though intervention against childhood obesity is recommended to target particular vulnerable groups, like the ethnic minority groups, WCC strategy is not clear as to how this should be achieved. Conclusion Childhood obesity is a preventable but a highly complex illness that requires political will and a multi-factorial approach. The nature of Westminster’s severe problem of prevalent childhood obesity clearly supports the ‘sick city hypothesis’ thus the need to subject its urban planning. The WCC strategy is strategically correct, but tactically insufficient, as it does not clearly address the improvement of the socio-economic status of the families of obese children. Reference List British Medical Association. 2005. Preventing childhood obesity. [online] Britain: BMA Publications. Available at: http://www.iaso.org/site_media/uploads/Preventing_childhood_obesity_2005.pdf [Accessed March 7, 2013]. Child and Maternal Health Observatory. 2012. Child health profile: Westminster. Available at: http://www.chimat.org.uk/resource/view.aspx?RID=119977 [Accessed March 6, 2013]. City of Westminster. 2006. Westminster obesity prevention and treatment: strategy 2006-2009. Available at: http://www3.westminster.gov.uk [Accessed March 7, 2013]. Cole, T. J., Bellitzi, M. C., Flegal, K. M. and Dietz, W. H. 2000. Establishing a standard definition for child overweight and obesity worldwide: international survey. British Medical Journal [online] 320 (Papers) May, pp. 1-6. Available at: http://www.bmj.com/highwire/filestream/350165/field_highwire_article_pdf_abri/0 [Accessed April 11, 2013]. Cronberg, A., Wild, H. M., Fitzpatrcik, J. and Jacobson, B. 2010. Causes of childhood obesity in London: diversity or poverty? [online] London Health Observatory. Available at: http://www.lho.org.uk/Download/Public/16724/1/NCMP%202008-09%20Ethnicity%20and%20deprivation%20FINAL.pdf [Accessed March 7, 2013]. Dehghan, M., Akhtar-Danesh, N. and Merchant, A. T. 2005. Childhood obesity, prevalence and prevention. Nutrition Journal [online] 4 (24) September, pp. 1-8. Available at: http://www.nutritionj.com/content/4/1/24 [Accessed March 15, 2013]. Ebbeling, C. B., Pawlak, D. B. and Ludwig< D. S. 2002. Childhood obesity: public-health crisis, common sense cure. The Lancet [online] 360 (Seminar) August, pp. 473-82. Available at: www.thelancet.com [Accessed March 15, 2013]. Flegal, K. M., Tabak, C. J. and Ogden, C. L. 2006. Overweight in children: definitions and interpretation. Health Education Research: Theory & Practice [online] 21 (6) October, 755-760. Available at: http://her.oxfordjournals.org/content/21/6/755.full.pdf [Accessed April 3, 2013] Greater London Authority. 2011. Childhood obesity in London. [online] London: GLA. Available at: http://www.london.gov.uk/sites/default/files/Embargoed%2014-04-11_GLA%20IU_Childhood%20Obesity_full.pdf [Accessed March 6, 2013]. Guillaume, M. 1999. Defining obesity in childhood: current practice. The American Journal of Clinical Nutrition [online] 70 (suppl), 126S-130s. Available at: http://ajcn.nutrition.org/content/70/1/126S.full.pdf [Accessed April 3, 2013]. Healthy Schools. 2007. City of Westminster: Child health profile. Available at: www.healthprofiles.info [Accessed March 7, 2013]. Lahti-Koski, M. and Gill, T. 2004. Defining childhood obesity. IN: Kiess, W., Marcus, C. & Wabitsch, M. eds. Obesity in childhood and adolescence. [online book] Switzerland: S. Karger AG, pp. 1-19. Available at: http://books.google.com.ph/books?id=t6keEJi6XAAC&printsec=frontcover&hl=fil#v=onepage&q&f=false [Accessed April 3, 2013]. Licari, L., Lemer, L. and Tamburlini, G. 2005. Children’s health and environment: developing action plans. [online book] Denmark: WHO Regional Office for Europe. Available at: http://books.google.com.ph/books?id=z1txV4y53ZIC&printsec=copyright&hl=fil&source=gbs_pub_info_r#v=onepage&q&f=false [Accessed April 12, 2013]. Local Government Information Unit. 2012. A dose of localism: the role of councils in public health. [online] City of Westminster. Available at: http://www.lgiu.org.uk/wp-content/uploads/2013/01/A-Dose-of-Localism-The-Role-of-Councils-in-Publi.pdf [Accessed March 6, 2013]. London Assembly – Health and Public Services Committee 2011. Tipping the scales: Childhood obesity in London. [online] London: GLA. Available at: http://www.london.gov.uk/moderngov/documents/s3639/Appendix%201%20-%20Tipping%20the%20Scales.pdf [Accessed March 6, 2013]. London Health Improvement Board. 2012. Tackling childhood obesity in London: the case for action. Available at: http://lhib.org.uk/attachments/article/96/Obesity_Case_for_action.pdf [Accessed March 12, 2013]. Mulvihill, C. and Quigley, R. 2003. The management of obesity and overweight: An analysis of reviews of diet, physical activity and behavioural approaches: Evidence briefing. Health Development Agency [online] Available at: http://www.nice.org.uk/niceMedia/documents/obesity_evidence_briefing.pdf [Accessed March 15, 2013]. National Health Services Westminster. 2009. Annual Report of the Director of Public Health 2007-08. Available at: http://westminstercitypartnership.org.uk/Partnerships/Health%20and%20Wellbeing/JSNA%20%20Completed%20Needs%20Assessments/Public%20Health%20Annual%20Report%2007-08%20-%20Obesity.pdf [Accessed March 6, 2013]. O’Connor, LK. 2011. Weight-based stigma and deficit thinking about obesity in schools: How neoliberal conceptions of obesity are contributing to weight-based stigma. [online] Master of Arts thesis, Department of Theory and Policy Studies, Philosophy of Education, Ontario Institute for Studies in Education, University of Toronto (St. George Campus). Available at: https://tspace.library.utoronto.ca/bitstream/1807/30101/1/OConnor_Linda_K_201111_MA_thesis.pdf [Accessed March 15, 2013]. Procter, K. L. 2007. The aetiology of childhood obesity: a review. Nutrition Research Reviews [online] 20, 29–45. Available at: http://journals.cambridge.org/download.php?file=%2FNRR%2FNRR20_01%2FS0954422407746991a.pdf&code=cd5935d9e425a182d4063bbf512011e1 [Accessed April 11, 2013]. Shield, J and Summerbell, C. 2009. Obesity in childhood. In: Williams, G. & Frühbeck, G. eds. Obesity: science to practice. [online book] UK: Wiley-Blackwell, pp. 507-539. Available at: http://books.google.com.ph/books?id=zFE03wY-eUAC&pg=PA509&dq=UK+definition+of+childhood+obesity&hl=fil&sa=X&ei=HhVbUfD2O4P9rAegh4HwAg&ved=0CD0Q6AEwAw#v=onepage&q=UK%20definition%20of%20childhood%20obesity&f=false [Accessed April 3, 2013]. Wang, Y. 2001. Cross-national comparison of childhood obesity: the epidemic and the relationship between obesity and socio-economic status. International Journal of Epidemiology [online] 30, pp. 1129-1136. Available at: http://www.bvsde.paho.org/texcom/nutricion/1129.pdf [Accessed March 13, 2013]. Read More