Childhood obesity: the case for binding international legislation

Introduction

The growth in childhood obesity is a global public health crisis, meriting a specially-convened Expert Consultation at the WHO in June 2005.¹ The prevalence of overweight and obese children throughout Europe has risen from <10% in the 1980s to >20% on current estimates, with some countries reporting prevalence rates >30%.² Higher body mass is not only well known as a factor in many diseases of adulthood but can also lead to debilitating diseases and problems in childhood and adolescence.³

The majority of humans appear genetically predisposed to gaining weight in an environment offering plentiful food and little need for physical activity. There is growing recognition of the contribution of this environment to the growth of childhood obesity, with attention focussing on the role of energy dense fast foods and soft drinks and the ways in which their consumption is being promoted.

Part of a balanced diet?

The film ‘Supersize me’, in which an individual experienced severe health effects after eating only at one major fast-food chain for several weeks, raised popular awareness of the risks of energy-dense fast foods.⁴ This film was, unsurprisingly, criticised by the fast food industry, which argued that their products should be seen as one element in a balanced diet.⁵ However, their products are distinctive. First, they are especially concentrated sources of energy. A British study found that items served at fast food outlets had more than twice the energy density of foods recommended for healthy diets.⁶ Second, their consumption unbalances the overall diet, with an American study showing how on days when children consumed fast food products their total energy intake, energy density per gram of food consumed, and fat intake were all higher, as was their consumption of soft drinks, while their fruit, vegetable, and milk intake was lower.⁷ Consumption of fast foods is also associated with greater levels of television viewing and thus lower levels of physical activity, although an understanding of the causal pathway requires further study.⁸

Third, they are served in unduly ‘giant’ and ‘king size’ portions. Controlled studies show that increasing portion size increases energy intake⁹ in children as young as 5 years of age.¹⁰

Fourth, they are often consumed with sugar-sweetened soft drinks,¹¹ which now comprise the largest single source of non-milk-extrinsic sugar intakes by young people in the United Kingdom.¹² A positive association has been demonstrated between the intake of sugary soft drinks and obesity in 11- and 12-year-old children.¹³ Some argue that less sugary soft drinks would be ‘one of the simpler ways to reduce obesity’:¹⁴ reducing intake by about half a portion a day in one study was associated with slight reduction in overweight in intervention-group children, while overweight increased in the control group.¹⁵

Fifth, a higher density of fast food outlets is associated with increased obesity levels¹⁶ and health inequalities: an Australian study found that families living in the poorest areas are 2.5 times more exposed to fast food outlets than those in the wealthiest areas.¹⁷

In summary, fast food is not just any food and it has a series of characteristics that link it clearly with the obesity epidemic.

Selling the image

What are the forces driving the change in children's diets? Children's decisions about what to eat are not only shaped by their peers, family, and schools, and the foods available to them, but also by the media they are exposed to. Children are particularly responsive to sophisticated marketing efforts.^18,19 The foods most frequently advertised on television are energy-dense, nutrient-poor²⁰, and convincingly linked to an increased risk of weight gain.²¹ Children's television programming may contain up to 12 food advertisements each hour²⁰, and in most European countries children are exposed to several hundred food-related advertisements each year.²² Claims by the industry that this advertising is designed to promote brand switching rather than increasing the volume of total sales are unsupported by the evidence^23,24 and the intensity of food advertising on children's television correlates positively with the prevalence of child overweight.²⁵

Of course, marketing takes many forms other than direct advertising. Food labelling and added colourings and flavourings as well as the inclusion of toys and vouchers in children's food products and the placement of products on lower shelves and at supermarket check-outs are all designed to increase sales to children. Innovative marketing to children via the internet, mobile telephones, cross-branded toys, and food-branded story books is also used increasingly.^26,27

The debate about the legitimacy of this intensive marketing has echoes of other public health issues where there is a tension between individual freedom and state action.²⁸ One view is that individuals are perfectly informed consumers who are best placed to ascertain their own best interests. While conceding that children may not be fully informed, they are considered ‘evolving consumers’²⁹ and are urged to confer with their parents about eating choices lest they be ‘den[ied] an opportunity to develop important life skills’.³⁰ From this perspective, the concept of pressure on parents from ‘pester power’ or the ‘nag factor’³¹ is discounted. Any attempt to constrain the flow of information on products that are legitimately sold on the market is criticised as paternalism or promotion of a ‘nanny-state’.³²

A contrasting view accepts the right of informed individuals to make decisions about their lifestyle but argues that children and their families are often poorly prepared to critically assess the onslaught of unbalanced and influential messages to which they are exposed. Furthermore, informed choices are often difficult to make because of structural, organisational, financial, and other constraints. Those involved in the development of food policies must be clear about where they stand in this debate and the evidence they can draw on, especially when they work on the interface between the public and private sectors.

Working together?

The WHO's recent Global Strategy on Diet, Physical Activity, and Health has made a compelling case for concerted action to address the threat of foods high in fats, sugars, and salt,³³ and several European governments, as well as the European Commission, are now asking whether there is a need for some statutory restraint on the activities of the food industry.³⁴ The WHO's strategy document explicitly states ‘Food and beverage advertisements should not exploit children's inexperience or credulity’ and adds ‘Governments should work with consumer groups and the private sector (including advertising) to develop appropriate multisectoral approaches to deal with the marketing of foods to children, and to deal with such issues as sponsorship, promotion and advertising.’

This view is shared by a former Director General of the WHO, Gro Harlem Bruntland, who has argued that ‘chronic disease problems are so serious they will require joint collaboration with the food industry’³⁵ and others who contend that ‘the food industry at all levels can be part of the solution’.³⁶ Companies expressing social responsibility are to be welcomed; however, a note of caution is required as only ‘external auditing and time’ will tell whether these are real fundamental transitions or simply ‘window dressing’.³⁷

This uncertainty about whether the food industry is making real changes poses questions for governments about how to respond, as illustrated by the experience in the UK, where a parliamentary Health Committee report on obesity argued that in order ‘to tackle obesity successfully education must be supported by a wider range of measures designed to remove the key barriers to choosing a healthy diet’.³⁸

The magazine Marketing Week used this report to warn its readers that the British government was going to get tough on industry, arguing that the subsequent White Paper ‘Choosing Health’ was an additional cause for ‘concern’³⁹ in that it threatened ‘action through existing powers or new legislation to implement a clearly-defined framework for regulating the promotion of food to children’ if changes in food promotion were not apparent by 2007.⁴⁰ A similar approach is being taken by the European Commission, with Commissioner Markos Kyprianou stating that ‘the signs from the industry are very encouraging, very positive. But if this doesn't produce satisfactory results, we will proceed to legislation’.³⁴ He gave the industry a year to introduce advertising controls, although he has yet to specify exactly what results he has in mind or how this will be evaluated.

Inevitably, the food industry argues forcefully that it can make an effective contribution to tackling the epidemic of childhood obesity without the need for statutory regulation (although other experiences where the food industry used voluntary codes of conduct have proven disappointing⁴¹). It does, however, have a problem of credibility. It is being asked to take action that would reduce its sales to a population group whose attention it must capture if it is to ensure future sales. This creates a fundamental paradox. The behaviour of a public company is driven, ultimately, by the pursuit of shareholder value: this is a legal requirement, written into the company's founding articles. Corporate Social Responsibility clauses and industry self-regulation schemes are not altruistic. A corporation will not ‘spend stockholders’ money for purposes which it regards as socially responsible but which it cannot connect to its bottom line'.³¹

The global dimension

National governments, and regional groupings such as the European Union, that decide that voluntary agreements are insufficient face a major problem. This is the global reach of the food industry, a factor that has been appreciated by those involved in tobacco control: ‘the global aspect is critical … Without it, national actions in many areas would be undermined.’³⁶ The leading food companies market soft drinks and fast foods on a global basis, using similar campaigns in Europe as in other regions of the world. Packaging and logos transcend national borders. Sponsorship of major sporting events achieves global brand recognition. Advertising involving celebrities appeals to young people of all nationalities. In practical terms, messages distributed through satellite television, the internet, or text messaging circumvent national efforts to legislate.

These factors argue strongly for a regulatory approach with a global reach. There is now a clear precedent in the Framework Convention on Tobacco Control, an instrument whose enactment has invigorated the debate on the scope of global public health law. Perhaps surprisingly, there may be some support for such a move from some investors in the food industry, with one analysis arguing that regulatory controls on advertising would bring down the costs for all the major players without giving any of them a particular marketing advantage.⁴²

The experience in tackling the smoking epidemic may provide other lessons.⁴³ While accepting that the food industry is not the tobacco industry (although some conglomerates are active in both sectors) and that, unlike cigarettes, consumption of food is a necessity for survival, there is now a great deal of experience with voluntary self-regulation by the tobacco industry. This provides grounds for considerable caution and the food policy community should be aware of the massive efforts by the tobacco industry to manipulate and distort scientific evidence and lobby for policies that protect their business practices.⁴⁴ It also offers lessons on how to bring about change, highlighting what can be achieved by a global movement linking international and domestic action, involving national coalitions, NGOs, the media, and mobilisation of the public to create sustained pressure for change.⁴⁵

It is possible that success might be achieved without global regulation but it is essential that the option is not ruled out. Some elements of the food industry have adopted policies that are likely to be beneficial but there is still a very long way to go. The global public health community might usefully recall Theodore Roosevelt's advice to ‘speak softly but carry a big stick’.⁴⁶

The views expressed here are not necessarily those of the authors' organisations. The authors report no competing interests.

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