The UK has been called the ‘fat man of Europe’ but could better health support early on be the key to change? by Caroline Green
The statistics on childhood obesity in the United Kingdom make for grim reading. Around one-quarter of children aged four to five and one-third of 10-11 year olds are overweight, according to research from the University of Nottingham. Children who are overweight at the age of five are more likely to be obese in adulthood. According to the charity Association for the Study of Obesity, rapid weight gain in the first twelve months of life lead to an increased risk of obesity at age seven.
That obesity goes hand in hand with a wide range of diseases, from cardiovascular disease, diabetes, musculoskeletal disorders and certain cancers (endometrial, breast, and colon, according to the World Health Organisation) is no longer in any doubt. The health risks are more immediate too, with obese children more prone to breathing difficulties, increased risk of fractures, hypertension, insulin resistance and psychological effects.
It is now clear that nutrition choices in the early years of life can have both an immediate and a long term effect on health. According to a paper by Professor Atul Singhal at the Institute of Child Health, University College Hospital, ‘More than 20 per cent of adult obesity might be caused by over-nutrition, or other early excessive weight gain in infancy.’
In terms of prevention, ‘There is good evidence that breast feeding offers some protection against childhood obesity,’ says Cris Glazebrook, Professor of Health Psychology, University of Nottingham. Atul Singhal adds, ‘Lots of data shows that babies breastfed for a month have lower cardiovascular disease later in life.’ The problem with formula milk, he explains, is that it has a much higher protein content – about 30% - than breast milk. Formula manufacturers have tried to reduce this as much as they can, but can only go so far as this process has a detrimental effect on the amino acids present in the milk.
Despite the wide ranging benefits of breast feeding, UK figures on this don't make for happy reading either. Over 25% of women with newborns don’t breastfeed. Over 50% of women aren’t breastfeeding at six weeks and less than 1% of UK babies are breastfed exclusively at 26 weeks.
Along with the breast/formula choice, the timing of weaning and early nutrition is also believed to have a direct effect on the chances of a child becoming obese.
Data from the Millennium Cohort Study, a multi-disciplinary research project following the lives of around 19,000 children born in the UK in 2000-1, showed that more than one in four (26 per cent) babies given solids before four months were overweight aged three compared with 22 per cent of those fed solids later on. The same held true when the youngsters reached five, with 24 per cent of those given solids before four months being overweight compared with 20 per cent of those given solids after four months. ‘
It is clear that the foundations for good health are built at a very young age. Basically, ‘By the time they get to school age it is too late,’ warns Singhal.
In the first year of a child’s life, health visitors are the medical professionals parents tend to see the most often. Sarah Redsell, Professor of Public Health at Anglia Ruskin University says, ‘Health visitors, community nursery nurses and children’s centre staff all have a role to play in advising parents about healthy infant nutrition.’ Singhal goes further and says the health visitor’s role is ‘crucial’, citing a recent study in Australia in which health visitors focused on obesity prevention in the first year. As reported in the British Medical Journal, the key intervention messages were ‘breast is best,’ ‘no solids for me until 6 months,’ ‘I eat a variety of fruit and vegetables every day,’ ‘only water in my cup,’ and ‘I am part of an active family.’ The result was clear: ‘For the 497 completed cases, the mean BMI at age two years was significantly lower for the intervention group.’
He believes that, ‘breastfeeding is probably the most important intervention there is. This is not a radical statement. If we could get the exclusive breastfeeding rate in this country anywhere near that of Scandinavia, then I think it will have a major impact.’
So should health visitors here be doing more to help parents make the right choices in feeding babies and young children?
Health visitors currently offer advice on a very wide range of issues, from family health and minor illnesses, to providing physical and developmental checks, to offering families specific support on subjects such as post natal depression. Giving advice and support on feeding and weaning is just one of the many roles they have in the community. At present, this support isn’t targeted to those who may need it the most.
Sarah Redsell and her team looked into the role of health visitors in identifying and intervening with infants at risk of developing obesity. A paper in the journal Maternal Child Nutrition concluded that, ‘A need for training and guidance was identified together with strategies to overcome system barriers. Health visitors do not currently target parents of infants at risk of obesity largely because they do not perceive they have appropriate guidance and skills to enable them to do so.’ And, ‘There is an urgent need for tools and training to enable all health care professionals to recognise and manage infants at risk of developing obesity without creating a sense of blame.’
One of the problems, it seems, is that health visitors feel ill-equipped to deal with parental defensiveness on this subject. Singhal believes the attitude that an overweight or ‘bonny’ baby is a healthy one, runs very deep. ‘The instincts were 100% right 40 years ago or longer, or in countries where there is a huge amount of maternal malnutrition.’
But in the wealthy West in 2013, those same instincts can be misguided. You could even say ‘dangerous.’
Karen Adams is the Course Leader of the MSc in Public Health Nursing Practice and Senior Lecturer in Primary Care at the University of Huddersfield. She trains health visitors and says that cuts in the workforce over the past ten years have made it very difficult for health visitors to, ‘ deliver the full package of what they previously could deliver. Their role has been eroded. Everything has been targeted towards vulnerability and child protection instead so that they haven’t been able to do that community and group based public health work.’
But change is afoot, thanks to the Health Visiting Implementation Plan, a government drive to increase the numbers of working health visitors by 4,700 by 2015. This, says Allen, has begun to come into force since the Redsell research was carried out.
The number of students on the training programme at Huddersfield alone has already doubled in recent times.
Allen is extremely positive about this increase in workforce, believing it will allow health visitors to offer more advice on nutrition and help parents with targeted support. Because all health visitors are trained nurses to begin with, she believes the multi disciplinary backgrounds they bring to the job can have a very positive effect in tackling these health care issues. For example, a health visitor with a mental health background will possibly have a deeper understanding of issues around attachment, depression and so on, which might have an influence on the nutritional choices made within the family.
‘You can’t isolate obesity as one factor,’ she says. ‘Health visitors can bring multi disciplinary skills to the complex issues surrounding it.’ Allen seems confident that an increased workforce will be able to broaden the areas of support and advice it offers, giving parents more targeted help on nutrition where it is needed.
But is this just a numbers game? Or could a more integrated, holistic approach to training allow health visitors to offer better support to the parents of young children?
The charity HENRY (Health Exercise and Nutrition for the Really Young) takes this broader approach. The HENRY model offers training for health and early years practitioners; information about food and activity that is easy to understand; support for parents, so they have the knowledge and skills to provide a healthy start for young children, and solution-focused strategies to help families change old habits.
Director Kim Roberts says, ‘Traditional approaches to tackling obesity have focused on giving nutritional advice. HENRY recognises that the messenger (i.e. the health visitor) is as important as the message – and that helping people to change depends to a very great extent on the attitude and skills of the practitioner. The HENRY approach is built on working in partnership with families – developing relationships based on trust and respect and doing things with families rather than to them – in order to develop motivation, confidence and support behaviour change.’ She adds, ‘Many health
visitors come to HENRY training courses feeling that they just aren’t getting anywhere – I remember a health visitor at one of our trainings saying (about her work with the mother of an obese three year old) “I sit there giving her advice and I know she’s not going to take any of it.” What HENRY does is help health visitors move beyond simply dispensing advice and get alongside parents to help them set their own goals and make a positive choice to change.’
Primary care trusts, public health departments, local authorities and universities commission HENRY to provide training courses locally. Health visitors don’t have to fund their own training. Roberts says that so far, HENRY has trained 7,000 practitioners in 55 local primary care trusts or local authorities. They have nine local training teams – locally employed health visitors and public health practitioners who they have trained to deliver HENRY training to other practitioners in their area.
A report commissioned by the NHS entitled Tackling obesity through the Healthy Child Programme: a framework for action, recommends the HENRY approach, saying that, ‘Where families are at higher risk of obesity, parenting programmes that focus on lifestyle, such as Let’s Get Healthy with HENRY, are particularly appropriate.’
With more health visitors working in the community and innovative new approaches to training, maybe the United Kingdom will one day shrug off the Fat Man of Europe label and help children enjoy a healthier start in life.
Caroline Green spent many years as a science and health journalist
and is an accomplished author of award-winning books for young adults.