Obesity in adults is defined as having a body mass index (BMI) of 30 or more, while overweight stands for BMI between 25 and 30 (Baker, 2017). BMI, adjusted for age and gender, is used to measure obesity in children, taking into account different growth patterns among boys and girls for each age group. The British 1990 growth reference (UK90) serves as the growth standard. The threshold is 85th percentile for overweight and 95th percentile for obese. The increase in BMI was observed in both genders (The Health and Social Care Information Centre, 2013). At present, nearly a third of UK children are either overweight or obese. Children with excess weight are more likely to become overweight adults and suffer from a range of related ailments such as type-2 diabetes, heart disease, and depression. Excess weight is linked to academic underachievement and economic deprivation, as well as increased costs on the public social and welfare systems (Department of Health, 2017). https://aretezoe.com/

1. Childhood obesity
August 2017
Obesity in adults is defined as having a body mass index (BMI) of 30 or more, while
overweight stands for BMI between 25 and 30 (Baker, 2017). BMI, adjusted for age and gender,
is used to measure obesity in children, taking into account different growth patterns among boys
and girls for each age group. The British 1990 growth reference (UK90) serves as the growth
standard. The threshold is 85th percentile for overweight and 95th percentile for obese. The
increase in BMI was observed in both genders (The Health and Social Care Information Centre,
2013). At present, nearly a third of UK children are either overweight or obese. Children with
excess weight are more likely to become overweight adults and suffer from a range of related
ailments such as type-2 diabetes, heart disease, and depression. Excess weight is linked to
academic underachievement and economic deprivation, as well as increased costs on the public
social and welfare systems (Department of Health, 2017).
Epidemiology
The current prevalence of adult obesity in England is 27%, and another 36% of people are
overweight. The number of overweight people has been steadily growing over the past decade.
Men suffer from higher obesity rates than women; however, the percentage of overweight people
is equal for both genders. The worst affected regions include Northern England, Yorkshire and
Midlands. The highest obesity rates are in the age group between 55 and 64 years of age. About
9% of children in England become obese by the age of 4-5. Of every hundred children aged 4 and
5 years, 77 are of normal weight, 13 are overweight, and nine are obese. By the age of 10-11, the
number of children with healthy weight falls to 65, and the number s of overweight and obese
children increases to 14 and 20, respectively. In the age group of 10-11-year-olds, the highest rate
of obesity can be found in the most deprived regions in England, where the obesity rates reach
26% compared to 15% in the least deprived areas. In Scotland, 71% of children 12-15 years of
age are of healthy weight, while 14% are overweight, and 15% are obese. Obesity drug
prescriptions have fallen in all UK countries since 2008. With 26.6% of the population obese, the
UK follows the USA (38.2%) and Australia (27.9%) but ahead of Germany (23.6%) and France
(16.9%) (Baker, 2017).
The examination of trends shows a worrying development. In 2015, about one in five
first-graders and one in three 10-year-olds were overweight or obese, and it is estimated that if
the current trend continues, the number of children with excess weight will increase to 50% by
2020. The numbers of overweight and obese children are higher in urban areas and lower in rural
areas where people, including children, tend to spend more time outdoors. Children born after
1980 are three times more likely to have excess weight by the age of 10 than generations born
before them, partly because half of them do not meet the target of at least 60 minutes of physical
activity a day (RCPCH, 2015).
Ethnic background also affects the risk of becoming overweight or obese. The highest
prevalence of childhood obesity at school reception is among those who self-identify as Black or
Black British (>30%). By school grade six (10-11 years of age), the prevalence of excess weight,

2. overweight and obesity combined, reaches 30% and more for ethnic groups except for Chinese,
Black British being the worst affected (>40%) (Hanson, 2015).
Obese and overweight children are more likely to live in low-income households,
especially boys, while girls from the highest income backgrounds were least likely to be obese.
Childhood obesity was found to be most prevalent in households where the parents were
overweight or obese as well. There was also a positive correlation between a sedentary lifestyle
and BMI for both boys and girls (The Health and Social Care Information Centre, 2013).
Health Impact
The health impact on child development starts in the womb. Although two-thirds of
pregnancies in the UK are planned to some degree, only a small minority of women change their
lifestyle prior to conception, including the efforts to lose weight. In 2013, over one-third of
British women aged 16-24 years and 50% of women aged 25-34 years were overweight or obese.
Multiple risk factors in early childhood increase the probability of being overweight or obese
later in life 4-fold. The most relevant risk factors are maternal obesity and pre-pregnant BMI >30,
excess gestational weight gain, smoking during pregnancy, low maternal vitamin D status, and
short duration of breastfeeding (Hanson, 2015).
Obesity is a significant public health problem that is associated with cardiovascular
disease. Hyperlipidemia, type 2 diabetes, and hypertension further increased the risk of
developing cardiovascular complications, such as peripheral artery disease and coronary artery
disease, and increases the risk of other conditions such as cancer, osteoarthritis, or gallbladder
problems. The National Audit Office (NAO) estimated that the number of deaths attributable to
obesity is about 6% of all deaths a year, or 30.000 deaths in total (The Health and Social Care
Information Centre, 2013).
The costs of the treatment of obesity are steadily increasing. The total cost of obesity is
about £27 billion per year, of which £19 billion accounts for NHS care, including obesity
medications. Many weight loss approaches result in short-term weight loss that is often regained
once the intervention stops. Multicomponent interventions recommended by NICE combine
lifestyle guidance, improvement of diet quality, decrease in calorie intake, increase in activity
levels. Weight Action Program (WAP) aimed at the loss of 5% bodyweight that was expected to
have health benefits. It was encouraging that 41% of the participants achieved this goal (NIHR
Centre, 2017).
Obesity increases the risk of numerous diseases later in life and all-cause mortality. The
Health Survey for England (HSE 2011) analyzed the relationship between BMI, waist
circumference, and the prevalence of specific diseases and the use of anti-obesity drugs.
Sibutramine (Meridia, Reductil), an appetite suppressor, was withdrawn from the market because
of a higher risk of stroke and heart attack. The market authorization for rimonabant (Acomplia)
had to be suspended because of the serious psychiatric side effects of the drug (The Health and
Social Care Information Centre, 2013).
Obesity in children is becoming a problem for pediatricians as well because of the lack of
guidance from NICE on how to manage the condition and associated ailments. Expert advice by
the Obesity Services for Children and Adolescents (OSCA) Network Group provides
pediatricians with assessment guideline, guide how to identify underlying causes of obesity, how

3. to recognize significant co-morbidities and assist with the choice of appropriate treatments. The
guideline primarily deals with cases that require referral to specialized care. A referral shall be
considered in children with BMI > 98th percentile and at least one risk factor. Risk factors
include short stature or dysmorphic signs, hypertension, sleep apnea, abnormal glucose or insulin
metabolism, issues with mobility or joint problems, dyslipidemia, signs of non-alcoholic liver
disease, polycystic ovarian syndrome, psychiatric co-morbidities such as eating disorders, family
history of type 2 diabetes and early-onset cardiovascular disease. The examination should include
screening for glucose and lipid metabolism, liver function, endocrinopathies, genetic obesity
syndromes and concomitant drug use, sleep problems, and behavioral and cognitive problems
(OSCA (Obesity Services for Children and Adolescents) Network Group, n.d.).
Behavioral factors
Overweight and obesity have a significant impact on young peoples’ lives. The
Association for Young People’s Health worked with a group of 12-19-year olds who have been
involved in the PROMISE study for the treatment of obesity that was funded by NIHR and
carried out by UCL and partners and surveyed people from across the UK. Young people’s views
on weight loss vary between age groups. Teenagers love online engagement and mobile apps and
appreciate incentives such as gym passes. The barriers perceived by young people include denial,
fear of bullying, stigma, and shame. For parents, the main issue is the timing of discussions that is
crucial for young people to engage in any communication at all. Self-assessment tools, incentives
vouchers, gym membership, and access to information are perceived as essential by parents of
overweight children. For many parents, the obesity of their children represents a significant
stigma. Health professionals may also require some additional training that would help them
understand the impact of stress and bullying on weight gain and facilitate effective
communication with young people. Nutrition education is perceived as one of the most critical
gaps. Flawed self-assessment is an essential part of any solution: most overweight children
viewed their weight as normal. Yet, most believed they are supposed to find out that they are
overweight by themselves. The majority of young people would expect others to inform them that
they are overweight, should it be their family, teachers, health professionals, or youth workers.
For many, the problem of weight is ignored long enough to become unmanageable (Rigby &
Perrow, 2015).
School-age children who become obese before ten years of age tend to carry the extra
weight for the rest of their lives. Embarrassing holiday experiences with overweight children are
often the first impulse than forces parents to join healthy eating and activity programs. For
children, the concern is the food choices their families make, eating out and takeaways, and treats
and sweets often used as a reward for good behavior. The location of fast-food restaurants within
reach of children is a significant risk factor some communities have to tackle (ITV Tonight,
2015).
Obesity is a complex condition caused by a combination of biological, environmental,
behavioral, and commercial factors. In obesogenic environments, it is much more challenging to
make healthy choices that are either less convenient or more costly. Healthcare professionals
need to educate their patients about the impact of obesity and make every contact count. Other
actions to be taken by healthcare professionals include the provision of weight management
services that should be given the same priority as smoking cessation programs, and
implementation of nutritional standards comparable to those used in schools shall soon apply in
all UK hospitals. Support for new parents should include elementary food preparation skills to

4. promote breastfeeding. The obesogenic environment can be improved by the implementation of
nutritional standards in schools, reducing the presence and accessibility of fast food outlets in the
proximity of schools, and a ban on advertising of fatty and sugary foods before 9 pm. It is equally
important to make the healthy choice the natural choice by taxing sugary drinks, labeling food,
and building an environment that facilitates active travel (Academy of Royal Medical Colleges,
2013). The higher prevalence of obesity among disadvantaged groups is well known; however,
the early life factors that attenuate the effect are unclear. A study on more than 11.700 children
explored risk factors for childhood obesity thoroughly. Children of mothers with academic
qualifications were better off than those whose mothers did not have any academic degrees,
despite the same socio-economic status. The highest impact risk factors were maternal pre-
pregnancy weight, smoking during pregnancy, and low maternal qualifications (Massion et al.,
2016).
Nutrition
Eating behavior and food choices have a profound impact on the development of
overweight and obesity in children. Most importantly, the size of the average portion increased
substantially. While in the 1960s, the diameter of an average dinner plate was 9 inches, half a
century later its size increased to 12 inches. Making portion sizes smaller would reduce the total
calorie intake in the UK by 8% in children and by 16% in adults (Marteau, 2015).
Potter et al. (2017) argue that children’s future BMI can be predicted from the portions
their parents consider normal. The researchers studied parental and children’s beliefs about the
ideal and maximum portion size appropriate for their children. While children’s own beliefs
about how much food is appropriate did not predict their future BMI, their parents’ beliefs did.
Both children and adults tend to consume more food if given the opportunity to do so. Portion
size is an ideal opportunity to decrease the total consumption of food. Children who self-select a
larger portion size tend to be overweight. However, not all studies found this relationship. Higher
tolerance for large portions may lead to the selection of large portions due to gastric capacity that
is higher in obese individuals. Child-parent pairs were presented with a series of 50 images of
seven main meals they were familiar with. The pictures varied by portion size, varying by 20 kcal
increments. Children were asked to select their ideal and maximum portion size and how much
they like the meal. Parents were asked to indicate their own ideal portion size, their child’s ideal
and maximum portion size, own maximum portion size and familiarity with the food. Parents,
who overestimated their child’s ideal and maximum portion size, were more likely to have an
overweight or obese child (Potter et al., 2017).
School meals account for a significant portion of children’s diet and contribute to forming
healthy dietary behavior. Lucas et al. (2017) compared school meal policies in the UK, Australia,
and Sweden. In the UK, the system of regulation of school meals is varied and decentralized, and
the policies are inconsistently applied. In the UK, foods provided in schools are categorized as
starchy, dairy, fruits, vegetables, and non-dairy protein, while in Australia, the federal guidelines
employ a traffic light approach. The researchers focused on existing standards and their practical
implementation and impact on children’s health. The chronological age of children in preschool
and primary school, therefore, may vary depending on standards that apply to them. In the UK,
children in nurseries receive 1/3 pint (189 ml) of milk a day, and fruit and vegetables three times
a week under the Nursery Milk Scheme and the Free School Fruit and Vegetable Scheme. Some
standards only apply in Wales and Northern Ireland but are voluntary in England. Guidelines
inconsistently apply to packed lunches, although some schools impose restrictions on sweet

5. drinks, sweets, and savory snacks. Because of the part-time attendance of primary schools, it is
impossible to know how many preschool children eat lunches that conform to the mandatory
preschool standards. The widespread use of packed lunches and additional food sources such as
vending machines, bake sales, and tuck shops make it impossible to measure the health benefits
of the implementation of school meal standards. The health impact of the provision of
nutritionally sound meals to disadvantaged groups is difficult to assess due to complex policies.
Moreover, these policies are inconsistently applied and enforced across the country (Lucas,
Patterson, Sacks, Billich & Evans, 2017).
Physical activity
The levels of physical activity of adolescents aged 13-15 years fell between 2008 and
2012. In 2008, only 28% of boys and 14% of girls met the recommended daily target of physical
activity. By 2012, these numbers fell to 14% for boys and 8% for girls (Hanson, 2015).
According to the Health Survey for England (HSE), the overall activity of children aged 4
to 15 has been steadily declining. The survey used self-reported activity and accelerometer data.
Other studies that measured school PE and Sports programs were included in the assessment.
Young people and children should spend 60 minutes every day performing moderate or vigorous
physical activity, as recommended by the Chief Medical Officer (CMO) of England. The children
were categorized into subgroups meet recommendations, some activity, and low activity by their
level of activity. In 2008, one-third of boys and one-quarter of girls reported they engage in the
recommended activity levels every day. The proportion of girls meeting the physical activity
recommendations decreased from 35% at the age of 2 to 12% among 14-year-olds.
Accelerometer data confirmed the self-reported data for boys (33%) but corrected the
number of girls who exercised at the recommended level from 21%. The results significantly
varied by age: of boys aged 4 to 10, 51% exercised at the recommended level, while only 7% of
boys from 11 to 15 met the standard; only 34% of girls aged 4 to 10 met the recommended
physical activity standards. However, in the age group from 11 to 15, none of the girls included
in the study met the recommended target of 60 minutes a day. Achieving physical activity targets
has been a challenge for most children. One way how to achieve this goal is to travel to and from
school on foot or by bicycle. In 2011, 43% of children walked to school, and 32% got a ride in
their parents' car and only 2.4% rode a bike. The main activities children engaged in were
walking, formal sports, and informal activities (The Health and Social Care Information Centre,
2013).
The level of activity also varies with ethnic background. According to a study published
by Smith, Aggio, and Hamer (2017), children of South Asian descent are less active than their
Caucasian counterparts are, even though all were British born. The researchers investigated the
change in activity levels of children based in central London concerning ethnicity using the
Actigraph accelerometer. The data from 281 children (64% Caucasian or mixed, 18% Black and
18% South Asian) showed that the life of children of South Asian descent was significantly more
sedentary at a 1-year follow-up than the lives of children of Caucasian or mixed descent.
Approximately 10% of children in the studied sample were obese. The authors observe that
children from minority ethnic groups are at higher risk of type 2 diabetes, central adiposity, and
hyperlipidemia compared to Caucasians and children of mixed heritage. There is increasing
evidence that British-born children of South Asian descent display signs of insulin resistance
already at the age of 10. Besides, there is growing concern that a sedentary lifestyle contributes to

6. the diabetes epidemic along with low levels of physical activity. Compared to 73% of Caucasian
10-year-olds, only 35% of children of South Asian descent meet the recommended 60 minutes of
moderate and vigorous activity (MVPA) a day. The Camden Active Spaces study examined
children’s physical activity before and after the renovation of a local playground. The children
were asked to wear the accelerometer around their waist when walking around and only take it
off during sleep or water-based activities such as swimming. Sedentary time was defined as 100
cpm, light exercise 100 – 3000 cpm, and MVPA as >3000 cmp. The measurements were
compared to self-reported activity time at school, watching TV, playing video games, or
studying. The combination of sedentary behavior and low level of activity promotes visceral
adiposity that is the highest risk factor for the development of type 2 diabetes. Children of South
Asian descent that display these behaviors early in life are particularly at risk (Smith, Aggio &
Hamer, 2017).
Environment
The environment is an essential part of the lifestyle. Two approaches to changing
behavior toward making healthier choices include resisting unhealthy environments where
calorie-dense food is plentiful and opportunities for exercise scarce, and the modification of
environment around us that make us eat healthier foods and move more. Subtle changes, such as
a standing desk can have a profound cumulative impact (Marteau, 2015).
Osei-Assibey et al. (2012) reviewed studies relating to the obesogenic environment and its
impact on childhood obesity. One of the causes of obesity is the fact that it is difficult to pursue
an individual healthy lifestyle in an environment that promotes diet rich in saturated fats and
sugar and a sedentary lifestyle. The obesogenic environment is the sum of the influences that the
surroundings, opportunities or conditions of life have on promoting obesity in individuals and
populations. Parental beliefs and behaviors become the prime target for intervention due to
associations between parental influences and children obesity. Early age interventions are
researchers because established obesity becomes more challenging to tackle, and tends to
continue to adolescence and adulthood. The main dietary drivers of obesity are the demand for
palatable, high-energy foods, ease of preparation, large portions, sugary drinks and availability,
and access, especially in schools and when eating out. The authors reviewed interventional
studies that focused on the exposure of children below the age of nine to dietary, environmental
influences, and the BMI outcome of such intervention. The included studies were from the USA
(23), the Netherlands (4), UK (4), Germany (3), and Sweden (1).
The Avon Longitudinal Study of Parents and Children in the UK showed that junk food
dietary pattern established at 38 months of age leads to overweight and obesity at age 7. The
effect of foods that are easy to prepare can be observed on working mothers, and especially those
of higher socioeconomic status who often work long hours. Five studies explored the impact of
food promotion on food choices and immediate energy intake related to exposure to food adverts.
Five studies explored the effect of portion sizes on food consumption and found a positive
correlation. Increasing portion size by adding vegetables was an effective way of reducing the
total energy intake. Restrictive feeding did not reduce total energy intake. Unsurprisingly, high-
energy snack foods were linked to obesity, especially when consumed frequently in front of a
TV. Four studies examined the effect of sugary soft drinks. Placing water fountains in schools
was an effective way to cut back sugar intake. Interventions in schools that aimed at the reduction
of the fat content of school lunches led to a decrease in serum cholesterol but not obesity.
Promotion of low-fat products, fruit and vegetables had short-term effects at best; complete

7. elimination of alternatives was required to achieve the desired outcome. The main limitation of
the reviewed studies was short duration, only between 4 weeks and six months. Besides, the data
derived from the study population may not be generalizable to the target groups (Osei-Assibey et
al., 2012).
The slow change in public perception of obesity as a problem corresponds with the shift
in reporting. A review of 2,414 articles published between 1996 and 2010 in 7 UK newspapers
showed increasing coverage of the topic of obesity and a trend toward a change in the obesogenic
environment with less focus on individual behavioral modifications. Most of the coverage was
based on information from the World Health Organisation that issued a global health warning
that obesity's impact is so diverse and extreme that it should now be regarded as one of the
greatest neglected public health problems of our time. UK prevalence of obesity is the highest
among the countries of Northern Europe and continues to increase among all age groups.
Commercial interests received widespread coverage as well (Hilton, Patterson & Teyhan, 2012).
Policies and Recommendations
Incentives that encourage people to change their behavior range from educational
programs to tax imposed on unhealthy foods such as fizzy drinks. Experience from Denmark
shows that taxing foods that contain more than 2.3% of saturated fat decreased the sales by 0.9%;
however, the change was only marginal in the most at-risk population. In Mexico, a 10% tax on
sugary drinks reduced sales by 10%. Other measures aimed at the decrease of consumption of
sugary beverages include the reduction of package size or regulation of the packaging shape,
location in the store elsewhere out of direct sight, and consumer education. The reduction of
package size and taxation has the highest impact and lowest acceptability by the public (Marteau,
2015).
In 2015, a report by the Royal College of Pediatrics and Child Health recommended a
series of measures aimed at the reduction of the prevalence of childhood obesity. The measures
included a pilot duty of at least 20% on sugary soft drinks, the expansion of food standards to all
schools, making personal, social and health education a statutory subject, and the ban on
advertising of fatty and sugary foods before 9 pm (RCPCH, 2015).
In August 2016, the UK government published its report Childhood Obesity: A Plan for
Action. The timing coincided with the Olympics, and the report received very little media
attention. The report fails to address stronger controls on advertising, reformulation of foods
available in schools, and nutrition education. The report recognizes that the causes of childhood
obesity are a complex combination of biological, behavioral, environmental, and commercial
factors. The problem of childhood obesity is especially prevalent in lower socioeconomic groups,
where the level of control people have over their environment is the lowest. Mark Hanson et al.
(2017) concluded that the cooperation of the UK government with international experts on the
topic would help develop more effective policies and standards (Hanson, Mullins & Modi,
2017).
In January 2017, the UK Department of Health, the Cabinet Office published guidance on
Childhood obesity: A plan for action. The policy outlines the most important factors that
contribute to the epidemic of childhood obesity, such as the introduction of a soft drinks industry
levy, a 20% sugar decrease in foodstuffs, making healthy options available in the public sector,
and improving conditions at schools to encourage physical activity. A substantial portion of
calorie intake consumed by British teenagers comes from sugary drinks, increasing their risk of

8. obesity, tooth decay, and type 2 diabetes. A single can of a sweet drink contains more than a
recommended daily intake of sugar. Soft drinks industry levy will be used to support physical
activity in schools. The change will be legislated in the Finance Bill 2017. More transparent food
labeling and reduction of sugar content per 100g of product, portion size, and total calorie content
will affect breakfast cereals, yogurts, biscuits, cakes, confectionery, pastries, puddings, ice cream,
and sweet spreads. More food categories will be added in 2017. Competition Innovate UK was
run to support research into new, healthier, processes and products. Update in the nutrient profile
will be used to assign a score to individual products that will be subject to advertising restrictions.
Physical activity is an integral part of healthy development. At least 60 minutes of moderate to
vigorous physical exercise every day are recommended for the healthy development of children.
Physical education offered in schools should be complemented by active breaks, active lessons,
sports, and other events outside schools and at home. The Sports England Strategy Towards an
Active Nation (2016) should contribute to these efforts by providing opportunities for families to
be active together. The government also supports projects of walking and cycling to school. A
new rating scheme should help schools to increase physical activity of children (Department of
Health, 2017).

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