Overweight and obesity have instituted numerous health complications that has risen steadily over the last two decades. For example, recent data shows that adult overweight and obesity in most European countries has risen alarmingly, with 27% and 38% of men and women respectively considered to be obese (Sallis & Glanz 2009, p.128).
Even children are not spared, with statistics showing that 27% of UK children overweight and that there is increasing number of children with type 2 diabetes signifying obesity (NICE 2006, p.90).
Australian study found out that slightly more than a half Australians adults and a quarter of Australian children are either overweight or obese, resulting to numerous health and economic consequences such as diabetes, morbidity and mortality, and the estimated financial cost of $3.8 billion, with a further $ 17.2 billion in non-financial costs as a result of lost wellbeing (Wilson, Watts, Signal & Thomson 2006, p.2156). The paper outlines and critically analyses the population based strategy as a method of managing and preventing obesity used in United Kingdom.
Introduction
The global health complications associated with overweight and obesity problems has risen steadily over the last two decades, a significant justification that the global obesity has risen exponentially over this period. For example, recent data show that adult overweight and obesity in most European countries has risen alarmingly, with 27% and 38% of men and women respectively considered to be obese (Sallis & Glanz, 2009, p.128).
Approximately 46% of men and 32% of women in England have a body mass index between 25 and 30 kg/m2, therefore considered overweight, and further 17% of men and 21% of women have body mass index of more than 30 kg/m2 implying obesity (House of Commons Health Committee, 2004, p.78).
Underestimated as a serious cause of ill-health, obesity’s steady rise in prevalence has caused many problems in England, where the overweight prevalence has risen by over 50% in the past two decades and obesity incidences has even trebled (National Audit Office 2006, p.65).
Even children are not spared, with statistics showing that 27% of UK children overweight and that there is increasing number of children with type 2 diabetes signifying obesity (NICE 2006, p.90). Between 1995 and 2002 alone, there was a double increase in obesity between boys aged 2 and 15, representing a rise from 3% to 6%, and obese girls increased from 5% to 9% (Penny Gibson et al. 2003, p. 88).
A survey conducted in Hong Kong was even more astonishing, indicating that 38% and 57% of boys and girls respectively between the age of 9 and 12 were obese, with body mass index exceeding 95th percentile (Grundy 2004, p.557).
More research revealing that obesity is highly associated with diabetes is even more worrying to the health professionals and the society as a whole, with the Hong Kong findings revealing that both obese children showed higher systolic blood pressure, triglyceride, and insulin and lower HDL cholesterol more than the average weight (Grundy 2004, p.557).
Another recent data in Australia showed that slightly more than a half Australians adults and a quarter of Australian children are either overweight or obese, resulting to numerous health and economic consequences such as diabetes, morbidity and mortality, and the estimated financial cost of $3.8 billion, with a further $ 17.2 billion in non-financial costs as a result of lost wellbeing (Wilson, Watts, Signal & Thomson 2006, p.2156). These global statistics indicate that obesity is ha no physical boundary and what happens in one country can happen in another country.
What causes obesity?
Although experts agree that there is the connection between genetics as well as biological factors in the obesity prevalence, it is universally acknowledged that there are some behavioral risk factors such as diet and physical activity, which nonetheless are the major causes for obesity (Sigal et al. 2006, p. 43).
The environmental factors such as lack of access to grocery stores, increasing cost of healthy foods, and inadequate play grounds limit the possibility of healthy lifestyle among the people in modern society (Hill & Peters 1998, p.280; Minkler 1989, p.59).
Furthermore, the more sedentary lifestyles prompted by the modern working conditions have pushed the possibility of good exercise at the periphery of the work programs, thereby aggravating the obesity epidemic in the UK major cities(Story et al. 2005, p.231).
Strategies for controlling obesity
Considering the consequences of obesity, efforts to understand the best ways to prevent it are still the priority number one for health experts and government of UK. There have been numerous separate strategies designed to control obesity based on parameters associated with medical, scientific, social, and economical criteria (Tones & Tilford 2001, p.159).
The strategies have been separate because of the cultural and linguistic diversity that exist among the communities of the world.
There is published evidence showing that the intensity of the chronic disease as well as exposure to attendant risk factors is unevenly distributed among the ethic groups in the United States (Trayhurn & Beattie 2001, p.657). This paper critically analyses the population based strategy for obesity control and management in the UK, considering the past and present studies related to the epidemic.
Population-based promotional strategies
The population- based promotion control is a common strategy to control obesity (Leddy 2006, p.676). In this section of the paper, I will critically look at the population-approach strategy in relation to childhood obesity. As early stated, children and adolescent obesity has dramatically increased exponentially over the last years.
However, the definition for childhood obesity has posed a great challenge to medical fraternity, with some experts simply referring to it just as “an excess of body fats” (Wilson et al. 2006, p.137). But all the frequently used definitions use body mass index as a point of reference to make the variations.
Pi-Sunyer (1993, p.31) states that although BMI is a useful and feasible parameter outside the realm of scientific research for identifying overweight children and adolescent, it is not an accurate measurement for excess depository, normally referred to as the excess accumulation of lipids in a body site or organ.
Another method of identifying and monitoring obesity in children and adolescent is through the measurement of skin-fold thickness (Grundy, Brewer, Cleeman, Smith & Lenfant 2004, p.436)
5th– 85th percentile BMI is taken normal, 85th to 95th percentile BMI is at risk of obesity, and more than 95th BMI percentile is considered obese (Trayhurn & Beattie 2001, p.12). What actually causes obesity in children? Even its causes are said to be complex, obesity is associated with imbalance in the intake of energy and body expenditure (WHO 2002, p.51).
One study found out that children’s BMI is related to adiposity in adulthood and that “overweight children had a greatly increased risk of becoming obese adults” (Freedman, Khan, Serdula, Dietz, Srinivasan, Berenson, 2005, p.412).
Childhood school interventions
To respond to the alarming rise in obesity, the UK government proposed several intervention strategies, setting the public service agreement targets in the year 2004. According to National Audit Office (2006, p.3), with the main objective being to halt the obesity cases in children under the age of 11, several government departments comprising of health, culture, Media and sport, and education departments were outlined as the key stakeholders.
This was after identifying key problem in obesity management among the children population in the UK that is diverse socially, ethnically and economically, and thus the need for a “multi-agency coordination” together with partnership for success.
This intervention focused on the diet improvement and addition of more physical activities among the population’s schedule, thus the inclusion of parental participation that was considered to be very important (NICE 2006, p. 7)
According to Seidell, Kahn, Williamson, Lissner & Valdez (2001, p.675) schools in England and any other country provide opportunity to offer a proactive approach to obesity management in a positively proactive, broader, and more cost effective. They highlight that schools provide critical intervention base since the disadvantaged group can be reached at ease (p. 676).
Furthermore, schools have a great influence on the children in terms of promoting a healthy diet, physical activity and other healthy behaviors (WHO 2002, p.12). However, there is little evidence that supports such multifaceted approaches like the school- based intervention strategy according to the meta-analysis of the applied strategies (Campbell et al. 2002, p. 2).
The analysis revealed that the approach that targeted both parents and their children had “mixed reviews in terms of success and evidence” that was rather inconclusive in relation to the strategy effectiveness (p. 8).
Furthermore, Bracht (1999, p.2786) and Teague (1987, p.123) had earlier refuted the claim of success of such strategies by stating that even a Cochrane review produced no supporting evidence to the child obesity management strategies, citing limited data on BMI reporting, lack of process indicators, and lack of sustainability and ability to generalize results as the main barrier to the success of the strategy.
For the success of this process, the design should be made with some specific information about the target audience, children and adolescents in this case (Sim & Mackie 2009, p.49). They state that this process should identify some specific issues considered to be critically important for children and adolescents, considering their “social and cultural values, incentives and disincentives” (p.58).
It’s therefore advisable to identify and emphasize on factors that will increase their attention, motivation and participation, and most importantly, when making decisions. “Obesity intervention education in schools should discuss the environmental and socio-cultural factors that contribute to obesity, such as levels of physical activity, the selection of healthy food options at home and school, the impact of television fast-food advertisements, attitudes, perceptions, beliefs around food, intake of energy-dense nutrition and sedentary child entertainment activities” (Cheung 2007, p.453).
Another controlled evaluation study on the impact of nutritional education to reduce the consumption of carbonated drinks among school children between the ages of 7 and 11 in England (James, Thomas, Cavan & Kerr 2004, p.459). The component of the intervention entailed one-hour lesson, conducted three times a week by a trained personnel assisted by teachers, who would reiterate the same message in their later lessons in class.
The sessions dwelled on promoting drinking water or diluted fruit juice and tasting fruit to establish natural sweetness, music competition, and quiz (James et al., 2004, p. 1237). The students were encouraged to compose songs with positive message and were exposed to all information from the project website (Lucas & Lloyd 2005, p.876).
The evaluation team assessed the situation after twelve months and there were no significant difference in the interventions and the control classes. However, the intervention group reported the reduction in soft drink consumption after just three days, in contrast to the controlled group who never participated in the program (Lucas & Lloyd 2005, p.877).
In addition to the insignificant nature of the population based approach to obesity management, the epidemiological studies are said to posses several bias i.e. the way the study subjects are designed, selected or classified are always “loaded “ with bias (Stanhope & Lancaster 2006, p.621). Stanhope & Lancaster classifies some of the factors that lead to bias into three categories as follows:
- Selection or the way subjects enter study, thus the selection of the population bias that may involve self-selection factors. For example, are the teenage populations who accept to complete questionnaires related to alcohol, tobacco and other drugs are a representative data of the total teenage population?
- classification or misclassification bias; there is likely to be misclassification of subjects already in the study leading to insufficient information,
- Confounding or bias resulting from the relationship between the outcome and study factor with some third factor not accounted for. For example, studies reveal that there is a real association between maternal smoking during pregnancy and low-birth weight babies. Another is the association between alcohol and cigarettes, i.e. smoking neither make neither one drink alcohol nor does drinking alcohol make someone smoke. If a researcher was to investigate the relationship between alcohol consumption and low birth weight, smoking would be a confounder because it is related to both alcohol consumption as well as low birth-weight. The existing failure to account for smoking in the subsequent analysis would bring bias (Stanhope & Lancaster 2006, p.622).
Governments’ interventions
According to the recent research findings, protein-energy malnutrition and obesity interrelate among many populations in global villages especially families in Africa, Asia, Middle East and Latin America (WHO 2002, p.54).
The new evidence show that nutrition deprivation in early childhood and even in pregnancy results in much more chances of getting obesity in children and adulthood, since the child and the unborn baby is susceptible to the selective deposition of abdominal fat, “with all its enhanced morbid effects, when weight gain subsequently occurs” (James 2002, p.32).
It is a common knowledge that malnutrition is basically common among the low socio-economic group of people, clear evidence that obesity has not spared even the poor. In fact, obesity in women is mainly linked to the low nutrition transition phase common in developing countries (Leddy 2006, p.59).
As stated earlier, the availability of cheapest food stuff which is high in fat and sugar, and weight-inducing especially in urban settings, and the poor access to more nutritious staple foods composed of vegetables and fruits are the major cause of obesity (Walford & Ha 2004, p.54).
Furthermore, many universal approaches to eliminating malnutrition among the disadvantage groups in the society have also been associated with obesity prevalence among the members of these communities, as the focus on the provision of substantial meal and hospitality may not conform to the dietary requirements of these individuals hence the possibility of weight gain, obesity, and even diabetes (Stevens, Raferty & Mant 2004, p.646; Baranowski et al. 2003). It is therefore prudent to conclude that policies that are focused towards eliminating or reducing obesity should be inclined towards nutrition problems.
The UK Government has also tried to establish some of the strategies that would guide the management of obesity through the population based approach. This follows the establishment of the A new Direction for Hunter New England Health Service Strategy Plan Towards 2010 (House of Commons Health Committee, 2004, p.78).
The plan gives the strategic guideline on the area’s population corporate vision, objective as well as strategic initiatives up to between 5 and 10 years (p.95). This plan outlines specific details targeting a particular group of population that would ensure their continual access to high quality health services responsive to guide the consumption of health products.
According to the plan, the framework to support the identified adults manage obesity is to ensure the objective of improved health and well- being for all, thereby doing the evaluation with the use of percentage factor of the number of people who have adopted the healthy eating and exercise habit.
Just as has been highlighted, population based approaches are commonly used but the limitations and their ineffectiveness have been worrying many scholars and the authorities alike (Seidell et al. 2001, p. 912; Barlow 2002, p.55).
According to Hillsdon et al. (2004, p.11), targeting individuals through balanced diet educational initiatives or even more physical activities is “either naïve, or in keeping with the western food industrial drive to dissemble while continuing to amplify sales, using tactics that remarkably parallel those employed by the tobacco industry.”
The fact that the pre-school and school- going children in England are targeted by the commercial brands in an attempt to popularize their brands among this group is a clear indictor that things are yet to change, since it is what increases the poor eating habits among the students.
Pender, Murdaugh & Parsons (2006, p.657) state, “schools and parents are now the focus of marketing schemes, including those touting increased portion sizes, to enhance inappropriate purchase and consumption. The intense lobbying coupled with heavy political and financial support by industry ensures the maintenance minimum restriction on “free trade” and marketing” (Seedhouse 1997, p. 912; Pate et al. 1995, p.76)
In essence, many of the population- based programs to control obesity have been quite successful in many aspects of behavioral changes and the establishment of good health habit among the child and adolescent population in UK. However, it has not been effective in lowering the BMI as widely expected, a critical aspect in the control of obesity among the population (Bartholomew et al. 2006, p.42).
According to Guo et al (1994, p.143) the success and sustainability of the population- based program in schools depends on the ability of the implementers to involve the whole community stakeholders, and the ability of the implementers to grasp the some fundamental cultural practices.
Several studies have intimated that modification of environment into a healthy desirable factor is one step for the management of obesity and its consequential diseases. Some of the modifications are based on improved fast food, media control and increased involvement of the community (Green & Kreuter 1999, p.10).
However, the challenge is greater since majority of people in the UK have no basic knowledge on the mechanism for controlling obesity Green & Kreuter 1999, p.785; Garrow & Summerbell 2000, p.1843. This has led to drastic response from various governments and regional bodies, who have designed various charters in the UK to manage and control on environmental factors (Chenoweth 2007, p.996; Edelman & Mandle 2006, p.61).
European charter on Environment and health
“The World Health Organization (WHO) strategy for health for all in Europe, the report of the world Commission on Environment and Development and the related Environmental Perspective to the Year 2000 and beyond (resolution 42/187 and 42/186 of the United Nations General Assembly) and World Health Assembly resolution WHA42.26 resolved among other things;
- that it recognizes the dependence of human health on a wide range of crucial environmental factors,
- that they consider the international character of many environmental and health issues and the interdependence of nations and individuals in these matters,
- that taking into consideration the account existing international instruments (such as agreements on protection of the ozone layer) and other initiatives relating to the environment and health (WHO 2002, p.50)
These issues have been adopted by the UK government together with regional bodies in resolving the respective environmental issues. One such body is the European Union government.
According to European charter, “every individual is the entitled to, among other things; an environment conducive to the highest attainable level of health and well being, and that all sections of society are responsible for protecting the environment and health as an intersectoral matter involving many disciplines; their respective duties should be clarified” (Sim & Mackie 2009, p.979).
With the increased cost of obesity in terms of healthcare cost and workforce redundancy, the countries in Europe UK in particular have state-based social systems to strengthen their social system to safeguard the health of the future generation (O’Donnell 2002, p.14; Cottrell, Girvan & McKenzie 2008, p. 99).
Recommendations
World Health Organization proposed a broad strategy to combat health and diet related complications are widely considered the best approach that should be adopted by the governments of the world (WHO 2002, P.64). The WHO suggests a life-course approach that focuses on the development of obesity resistant generation from fetus to old age (Department of Health 2003, p. 71).
The best approach to counter the barriers posed by large multinationals and corporations that criticize the World Health Organization is to establish government policies and regulations that will see changes in advertisements and marketing, especially the ones targeting children in the United Kingdom (Murray, Zentner & Yakimo 2009, p.54).
Additional regulations should be put on trade, financial, social, agriculture, urban panning, and traffic policies (Cheung 2007, p.657; Kurscheid & Lauterbach 1998, p.1321). Such protective measures have been observed in Norway and Finland, a method that has prompted dramatic improvement in national cardiovascular mortality rates in the two countries (Sim & Mackie 2009, p.980; Foster 2004, p.183).
In essence, a population based approach will be more realistic if it targets the specific section of the population e.g. children, marginalized groups, elderly, disabled, etc, with proper objectives and measurable parameters for measuring results (Sim & Mackie 2009, p.980).
Such initiatives would involve across the board opening of reliable health centers, establishing appropriate UK’s school playing grounds, adequate road systems and networks that accommodate cycling and walking, promoting physical activities and breastfeeding, and reviewing the taxation policies on these food products (Green & Lewis 1986, p. 45; Garrow & Summerbell 2000, p.66).
The five life-course strategy that involve the monitoring obesity prevalence from fetus-infants-adolescents-adults-old age should be given priority, by the measurements of both children and the patients body mass indices, promoting infants and children feeding policies (Scand 2008, p.456; Edelman & Mandle 2006, p.77; Naidoo & Wills 2000, p.34)
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