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Childhood obesity: bringing children's rights discourse to public health policy.

Abstract

Childhood obesity is widely understood as a public health issue, but is not commonly understood from a legal perspective. Children's rights discourse can add significant empowerment to public health-based policy, which alone lacks effectiveness in the face of commercial and other counteracting influences. The United Nations Convention on the Rights of the Child has the potential to be used by advocates for children's health to facilitate child health policies pertaining to the issue of childhood obesity. This is because children's rights, as defined in the articles of the convention, establish the essential conditions required by children to achieve optimal health and wellbeing. A rights-based approach may improve children's welfare by encouraging a less fragmented approach to the issue of childhood obesity. The articles of the convention can be used as a template for interdisciplinary collaboration, with a more coherent outcome possible. By articulating childhood obesity as a children's rights issue--not just a public health issue--a more effective strategy for addressing the problem can be developed and implemented.

Key words

Childhood obesity, children's rights, public health, interdisciplinary collaboration

Introduction

Childhood obesity is becoming a significant public health concern with serious long-term implications for society. The government recognises that it is an issue that urgently needs to be addressed, and a raft of public health policies and new initiatives are being developed to tackle the problem (see Table 1). However, the issue is a complex one requiring a preventive strategy to be implemented at a number of levels, together with a number of groups, including the family, schools, government, the food industry, town planners, transport agencies and the media. With so many groups involved, there is a danger of a fragmented approach to the problem, with each group developing their own policies and initiatives in isolation of each other.

Aim

It was decided to explore the way in which a rights-based approach could be used to articulate the issue of childhood obesity and provide a focus for the groups involved, directing each to meet the overall needs of children with policies that support their health and wellbeing.

Methodology

A literature-based study was undertaken with the current public health approach outlined using primary sources of information obtained from recent government policy documents. Legislation and international instruments were examined when considering how a legal approach to childhood obesity could be articulated.

Prevalence in the UK

Overweight and obesity are conditions in which weight gain has reached the point of endangering health. (1) The most appropriate measurement for identifying overweight and obesity is the body mass index (BMI), which is determined both by weight and height. A BMI above the 95th percentile is regarded as obese, while a BMI above the 85th percentile is regarded as overweight. (2) Between 1995 and 2006, the percentage of boys aged two to 10 years who were overweight or obese in England increased from 22% to 29%, while for girls the figures rose from 23% to 26%. (3)

Health implications

This rising prevalence is of particular concern as there is now mounting evidence that obesity in childhood may have implications for physical health even at a young age. Studies have found that overweight and obesity in young people can be linked to the early development of risk factors for increased incidence of coronary heart disease, the rise in the diagnosis of type 2 diabetes (4) and an increased risk of iron deficiency anaemia. (5) Evidence on whether obesity impacts on psychological wellbeing is less conclusive, with some studies showing that many children experience low self-esteem, (6) are more likely to be victims of bullying (7) and score lower on measures of health-related quality of life compared to normal weight children, (8) while others find that despite moderate levels of body dissatisfaction, few obese children are depressed or have low self-esteem. (9)

There is considerable debate regarding the reasons for the increasing prevalence of childhood obesity, but one contributory factor would seem to be the increase in children's energy intake and the decrease in children's energy expenditure.

The energy intake of children

The consumption of diets high in fat and sugar is a major contributory factor in the rising trend in obese children, with the average proportion of children's food energy derived from these foods significantly exceeding government recommendations. (10) The consumption of fizzy drinks has almost doubled in the past 15 years (10) and a positive association has been identified between the consumption of sugar-sweetened drinks and childhood obesity. (11)

Lifestyle trends tend to support the consumption of pre-prepared convenience foods and fast foods, with around two billion meals eaten at 'quick service' catering outlets in the UK in 2001. (12) Meals and snacks eaten outside the home have been found to contain higher levels of fat. (10) There is concern that the number of occasions that a family eats together has declined (13) and this trend may have led to a growing snacking culture among children, which favours the consumption of foods high in fat and sugar.

Advertising on children's television presents an imbalanced nutritional message, with the majority of products containing high levels of fat and/or sugar, creating a conflict between the types of food promoted to children and national dietary recommendations. (14,15) A review of the literature on the effects of advertising on children has identified a modest direct effect of advertising on food preference, consumption and behaviour (16) and a national report has highlighted the need for action to address the major imbalance in children's food advertising. (17)

The energy expenditure of children

Changes in patterns of physical activity and the adoption of more sedentary lifestyles are also likely to be important factors in causing childhood obesity. Young people in this country are becoming increasingly inactive, with 30% of boys and 41% of girls aged two to 15 not meeting the recommended levels of physical activity. (3)

All of these factors combine to make childhood obesity a complex issue, with its prevention and management requiring a range of co-ordinated policies to improve diet and physical activity levels. The government recognises that it is an issue that urgently needs to be addressed and has set a target to reduce the proportion of overweight and obese children to 2000 levels by 2020 in the context of tackling obesity across the population. (18)

Public health approach

The current approach favoured by government in tackling childhood obesity is the public health approach (see Table 1), but this has a number of weaknesses.

Financial constraints

Finance may prove to be a barrier to the provision of healthier food in schools. Vending machines bring in much needed income, and marketing in schools is particularly sought by manufacturers of crisps, soft drinks and sweets. Schools may also lack control over food provision if contracted catering companies decide what food to provide. These companies may be resistant to moves toward healthier provision that may be less popular with pupils and affect the profits or financial viability of their operation.

Ineffectiveness of voluntary controls

Consumer groups are not confident that the food industry will adhere to voluntary controls, and argue that only statutory controls will sufficiently protect children from exploitation by advertisers. The healthy eating messages coming from the government are counterbalanced by the heavy advertising of unhealthy food coming from the food manufacturers.

Public health programmes and policies, as outlined above, seek to provide individuals with information and education about risks associated with diet or lack of exercise. They are designed to address health-related behaviours, over which it is generally assumed individuals have, or want to have, complete control. However, surveys of consumer awareness (28) show that most respondents already know what constitutes a healthy diet. However, they often lack awareness of what such general information means in practice, or lack the ability through causes beyond their control to put their knowledge into practice. With regards to levels of physical activity, evidence shows that play space is frequently restricted for school-aged children and green space that is accessible to children continues to be sold off. (29)

Lack of opportunity to exercise and play outside, advertisements that emphasise unhealthy food and drinks, and a food industry that controls the content of foods can all be seen to contribute to an environment that encourages obesity. Many of these causes lie beyond the control of the individual. An alternative approach to address the issue of childhood obesity is therefore required that focuses on changing the wider environmental determinants within which obesity flourishes. Children's rights discourse can provide an alternative way of addressing this by constructing the issue of obesity as a legal problem, (30) with responsibility for addressing these wider determinants lying with the state, rather than the current focus on individual lifestyle choices with responsibility resting on the individual.

Children's rights discourse

Over recent years, there has been an increasing interest in children's rights due to two main factors. First, there is a greater rights consciousness generally, as a result of the Human Rights Act 1998. Second, there is an increasing appreciation of the UK's obligations under the United Nations (UN) Convention on the Rights of the Child 1989.

The Human Rights Act 1998

In October 2000, the Human Rights Act was implemented and the European Convention on Human Rights (ECHR) was incorporated into domestic law. Since then, we have become increasingly aware of the importance of human rights in the provision of healthcare services. This has been particularly the case in the context of medical treatment and the relationship between individual patient and healthcare provider. Less attention, however, has been given to the role of human rights in public health. Children are also entitled to claim the rights guaranteed by the ECHR, as it guarantees the fundamental human rights of all people living within the boundaries of the states that ratified it, irrespective of age. The Human Rights Act also requires government departments to review carefully any new draft legislation that affects children, to ensure its compatibility with their convention rights.

The UN Convention on the Rights of the Child

The UN Convention on the Rights of the Child was passed by the UN General Assembly on 20 November 1989, and the UK ratified it on 16 December 1991.

The particular task of the convention is to emphasise that children too are holders of human rights, and the list of 54 convention articles constitutes an attempt to define children's needs and aspirations and commit ratifying states to their accomplishment. The convention emphasises that states must not only protect children and safeguard their fundamental freedoms, but also devote resources to ensuring that they realise their potential for maturing into healthy and happy adulthood.

Like many other countries, the UK has not incorporated the convention into domestic law, so it is of persuasive influence only. However, governments are directed to undertake 'all appropriate legislative, administrative and other measures' to implement the rights contained in the convention (Article 4). In addition, Article 42 obliges ratifying governments 'to make the principles and provisions of the convention widely known, by appropriate and active means, to adults and children alike.'

Article 44 also requires that state parties produce regular reports to the Committee on the Rights of the Child on their progress toward implementation of the convention, and so, although not part of English law, it exerts an increasingly powerful influence on the developing law. The children's commissioner appointed in 2005 must also have regard to compliance with the convention and to influence policy-makers and practitioners to take greater account of the human rights of children, as well as seeking to ensure that children have an effective means of redress when their rights are violated or disregarded.

When considering the issue of childhood obesity, the articles of the convention listed in Table 2 are particularly relevant.

Discussion

Many healthcare professionals are fully committed to the idea that children have rights, but are uncertain as to how to promote such a notion in a way that improves children's lives at a practical level.

The UN convention can be utilised as a powerful tool by healthcare professionals (31) to address contemporary determinants impacting upon child health outcomes when considering the issue of childhood obesity. The articles of the convention can be used to give added influence to current public health policies and establish a framework for dealing with issues that impact on childhood obesity. Articles 24 and 27 could be used, for example, to give added influence to securing the resources needed to promote and support breastfeeding and to ensure that children receive a healthy diet in order for them to grow up to reach their full potential. Article 31 can be utilised in campaigns to secure the provision of safe play and recreational facilities for children. Article 36 could be used to support any campaign or policy that protects children from the effects of advertising unhealthy foods.

A focus on children's rights as a strategy to establish improvements in child health outcomes is a paradigm shift from current child health practice. Simpson and Simpson (30) argue that such a strategy is not about public health practitioners lobbying for changes to the law, but is instead about how, within current legal discourse, there is the potential to argue for changes that are consistent with both public health objectives and the law, and that articulating the problem of childhood obesity as one that involves issues of children's rights might shift thinking to such an extent that behaviour will change. They state that 'the public health practitioners who can articulate health issues in human rights terms may cause social change ... because the connection of health issues with human rights affects attitudes and the consequent behaviour of those with the power to bring about fundamental shifts in how things are done' (30) (p55).

It is the articulation of children's rights, as contained within these articles, that changes the issue of childhood obesity from being one that focuses solely on the responsibility of the individual into one that incorporates the legal responsibility of the state, by requiring that consideration be given to the provision of safe play facilities, safer transport options that would facilitate children being able to walk or cycle to and from school, and adequate resources to ensure optimal nutrition and avoidance of exploitation from food advertisements.

One of the most valuable ways in which such a rights-based approach can improve children's welfare is to encourage a less fragmented approach to the issue of childhood obesity. A rights-based approach would address the problem of children being the focus of a number of disparate groups, rather than their overall needs being addressed. By placing the differing aspects of childhood in a framework of rights rather than, for example, in a health or educational-based context, the boundaries between the various disciplines start to become irrelevant, with a far more coherent outcome being possible. (32) The adoption of a rights-based framework is inclusive, as it would give all children the same basic entitlements, but would not rule out targeting resources at the neediest within the group.

If healthcare professionals and policy makers choose to adopt a rights-based framework for their work, then they will need to be clear about what children really need in order to improve their wellbeing. This can only be determined by the inclusion of consultation with children themselves, and such an approach accords with Article 12 of the convention--the right of children to express their views in all matters that affect them.

Conclusion and implications

The articles of the UN convention can be used to construct the public health issue of childhood obesity as a legal problem. This gives the opportunity to strengthen the challenge against commercial influences, which are constrained only by limited self-regulation, as well as to strengthen the case for the provision of resources to improve children's nutritional status and opportunities to increase levels of physical activity. Public health practitioners, such as health visitors and school nurses, are uniquely positioned to lead the utilisation of children's rights discourse to effect change in how the issue of childhood obesity is addressed. The resulting change of attitudes and perspectives could facilitate a change in the approaches encapsulated in public health policies. These new public health policies could provide a more effective positive impact on the issue of childhood obesity through a broad range of integrated strategies pertaining to child nutrition, food advertising, transport options and safe play facilities. In order for this to happen, it is essential that public health practitioners understand the principles of children's rights, so that they can use the convention as a tool to facilitate advocacy for children.

Further research should seek to discover how rights discourse could be applied to deliver preventive interventions to address the issue of childhood obesity at all levels from individual, family, school, local community and national levels. Environmental as well as individual interventions could result from policies and strategies developed by embracing children's rights. The adoption of a children's rights discourse should therefore be utilised by public health practitioners in order to help achieve significantly improved results in the prevention of childhood obesity.

References

(1) Mulvihill C, Quigley R. The management of obesity and overweight: an analysis of reviews of diet, physical activity and behavioural approaches (evidence briefing). London: Health Development Agency, 2003.

(2) Cole TJ, Freeman JV, Preece MA. Body mass index reference curves for the UK, 1990. Archives of Disease in Childhood, 1995; 73: 25-9.

(3) Health Survey for England 2006. CVD and risk factors adults, obesity and risk factors children. Volume two: obesity and other risk factors in children. Leeds: The Information Centre, 2008.

(4) Goran MI, Ball GDC, Cruz ML. Obesity and risk of type 2 diabetes and cardiovascular disease in children and adolescents. Journal of Clinical Endocrinology & Metabolism, 2003; 88(4): 1417-27.

(5) Nead KG, Halterman JS, Kaczorowski JM, Auinger P, Weitzman M. Overweight children and adolescents: a risk group for iron deficiency. Pediatrics, 2004; 114(1):104-8.

(6) Hesketh K, Wake M, Waters E. Body mass index and parent-reported self-esteem in elementary school children: evidence for a causal relationship. International Journal of Obesity, 2004; 28(10): 1233-7.

(7) Janssen I, Craig WM, Boyce WF, Pickett W. Associations between overweight and obesity with bullying behaviours in school-aged children. Pediatrics, 2004; 113(5): 1187-94.

(8) Friedlander SL, Larkin EK, Rosen CL, Palermo TM, Redline S. Decreased quality of life associated with obesity in school-aged children. Archives of Pediatrics and Adolescent Medicine, 2003; 157(12): 1206-11.

(9) Wardle J, Cooke L. The impact of obesity on psychological wellbeing. Best Practice and Research: Clinical Endocrinology and Metabolism, 2005; 19(3): 421-40.

(10) Office for National Statistics. National diet and nutrition survey: young people aged four to 18 years. Volume one: report of the diet and nutrition survey. London: Stationery Office, 2000.

(11) Ludwig D, Peterson K, Gortmaker S. Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective observational analysis. The Lancet, 2001; 357(9255): 505-8.

(12) Department of Health, Health Check. On the state of the public health: annual report of the chief medical officer 2002. London: Department of Health, 2003: 36-45.

(13) Ryan M, BBC News. Have family meals gone out of fashion? BBC News 24 (10 February 2006).

(14) Sustain. TV Dinners: what's being served up by the advertisers? London: Sustain: the alliance for better food and farming, 2001.

(15) Hastings G, Stead M, McDermott L, Forsyth A, Mackintosh AM, Rayner M, Godfrey C, Caraher M, Angus K. Review of research on the effects of food promotion to children. Glasgow: Food Standards Agency, 2003.

(16) Livingstone S. A commentary on the research evidence regarding the effects of food promotion on children. London: Ofcom, 2004.

(17) National Audit Office. Tackling obesity in England: report by the comptroller and auditor general. London: Stationery Office, 2001.

(18) PSA Delivery Agreement 12. Improve the health and wellbeing of children and young people. Indicator three: levels of childhood obesity. London: HMSO, 2007.

(19) Department for Education and Skills. Every child Matters. Norwich: Stationery Office, 2003.

(20) Department of Health, Department for Education and Skills. The National Service Framework for children, young people and maternity services. London: Department of Health, 2004.

(21) Department of Health. Choosing health: making healthy choices easier. London: Department of Health, 2004.

(22) Department of Health. Choosing a better diet: a food and health action plan. London: Department of Health, 2005.

(23) Department of Health, Department of Culture, Media and Sport. Choosing activity: physical activity action plan. London: Department of Health, 2005.

(24) Department for Education and Skills, Department of Health. Food in schools programme. London: Design and Technology Association, 2005. Available at: www.foodinschools.org (accessed 16 April 2008).

(25) Department of Health. National school fruit and vegetable scheme. London: Department of Health, 2002.

(26) Food Standards Agency. Food Standards Agency agrees action on promotion of foods to children (press release on action plan and consultation document, 5 July 2004). London: Food Standards Agency, 2004.

(27) Cross-Government Obesity Unit, Department of Health, Department of Children, Schools and Families. Healthy weight, healthy lives: a cross-government strategy for England. London: Central Office of Information, 2008.

(28) Food Standards Agency. Consumer attitudes survey 2003: summary for enforcement officers. London: Food Standards Agency, 2004.

(29) Thomas G, Thompson G. A child's place: why environment matters to children: a Green Alliance/Demos report. London: Green Alliance, Demos, May 2004.

(30) Simpson C, Simpson B. Childhood obesity and the importance of rights discourse: a way forward for public health practitioners. Environmental Health, 2004; 4(1): 53-61.

(31) Goldhagen J. Children's rights and the United Nations Convention on the Rights of the Child. Pediatrics, 2003; 112(3): 742-5.

(32) Fortin J. Children's rights and the developing law (second edition). London: Butterworths, 2003.

Julie Greenway MA, BSc, RGN, RHV

Doctoral student, University of Bristol
Table 1. Government strategies relating to children's welfare

 Policy document Summary of aims relevant to the
 issue of obesity

 1 Every child matters: * To encourage integrated
 change for children (19) planning, commissioning and
 delivery of services

 * To improve multidisciplinary
 working and increase accoun-
 tability to improve outcomes
 for children

 2 National Service * To enable children and young
 Framework for children, people to make informed choices
 young people and about healthy lifestyles, thus
 maternity services (20) empowering them to improve their
 own health

 3 Choosing health: making States halting the growth in
 healthy choices childhood obesity as a prime
 easier (21) objective. Actions to improve
 Choosing a better diet: nutrition in the early years
 a food and health of a child's life include:
 action plan (22) * Healthy Start Scheme
 * Healthy Schools Programme
 * Food in Schools Programme (24)
 * National School Fruit and
 Vegetable Scheme (25)

 Choosing activity: a Actions to improve levels of
 physical activity action physical activity include:
 plan (23) * Safe active travel to school
 * Physical education and sport:
 investment in school sports
 facilities and promotion of
 physically-active lifestyles

 4 Food Standards Agency * Schools should provide healthy
 action plan on food meal options and vending
 promotions and machines should promote
 children's diets (26) healthier options

 * Government and Ofcom should only
 endorse promotional campaigns
 that encourage children to eat
 healthier options

 * Advertising Standards Authority
 should review arrangements for the
 regulation of food advertising
 to children

 * Food manufacturers, retailers
 and the food service sector should
 agree targets for uptake of best
 practice advice on reducing the
 amounts of fat, sugar and salt in
 product ranges aimed at children

 5 Healthy weight, healthy Identifies five areas for action:
 lives: a cross-government * Children, healthy growth and
 strategy for England (27) healthy weight

 * Promoting healthier food choices

 * Building physical activity into
 our lives

 * Creating incentives for better
 health

 * Personalised advice, diet
 support, activity and health
 issues

Table 2. Convention articles relevant to the issue of
childhood obesity

Article 24 State parties recognise the right of the child to the
 enjoyment of the highest attainable standard
 of health. (Article 24 (1))

 State parties shall pursue full implementation of this
 right and, in particular, shall take appropriate
 measures (Article 24 (2)):

 * 'To combat disease and malnutrition ... through the
 provision of adequate nutritious foods and
 clean drinking-water' (Article 24 (2c))

 * 'To ensure that all segments of society, in
 particular parents and children, are informed, have
 access to education and are supported in the use of
 basic knowledge of child health and nutrition, the
 advantages of breastfeeding ...' (Article 24 (2e))

Article 27 State parties recognise the right of every child to a
 standard of living adequate for the child's physical,
 mental, spiritual, moral and social development
 (Article 27 (1)) and:

 * '... shall in case of need provide material
 assistance and support programmes, particularly with
 regard to nutrition, clothing and housing'
 (Article 27 (3))

Article 31 State parties recognise the right of the child to rest
 and leisure, to engage in play and recreational
 activities appropriate to the age of the child

Article 36 State parties shall protect the child against all other
 forms of exploitation prejudicial to any
 aspects of the child's welfare
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Title Annotation:PROFESSIONAL
Author:Greenway, Julie
Publication:Community Practitioner
Geographic Code:4EUUK
Date:May 1, 2008
Words:4144
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