WHO Commission on Ending Childhood Obesity presents final report and recommendations

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The World Health Organisation’s Commission on Ending Childhood Obesity, appointed by WHO Director-General Dr Margaret Chan in 2014, has now formally presented its final report.

The Commission was co-chaired by Sir Peter Gluckman, the Chief Science Advisor to the Prime Minister of New Zealand, and Dr Sania Nishtar, the founder and President of Heartfile, a health policy think tank based in Pakistan.

The Commission held hearings in all 6 WHO regions, and was supported by two technical working groups: the Ad Hoc WG on Science and Evidence, and the Ad Hoc WG on Implementation, Monitoring and Accountability.

In 2014, an estimated 41 million children under 5 years of age were either overweight or obese (this is defined as the proportion of children whose weight for height scores are more than 2 standard deviations, or more than 3 standard deviations, respectively, from the WHO growth standard median).

The Commission’s strategic approach rests on three categories of interventions:

  • interventions to tackle the obesogenic environment in order to improve the healthy eating and physical activity behaviours of children;
  • interventions targeting critical stages of the lifecourse; ie (i) preconception and pregnancy; (ii) infancy and early childhood; and (iii) older childhood and adolescence;
  • interventions to treat obese children in order to improve their current and future health.

A number of the Commission’s recommendations addressing the obesogenic environment, and critical stages of the lifecourse, in particular, confirm the role for law and regulation in improving the food and physical activity environment for children.

In a move sure to thrill the fizzy drinks industry, the Commission has called on countries to implement an effective tax on sugar-sweetened beverages, and noted that some countries may also consider a tax on foods high in fats or sugar.

Noting “unequivocal evidence that the marketing of unhealthy foods and sugar-sweetened beverages is related to childhood obesity”, the Commission has called on countries to implement the WHO’s Set of Recommendations on the Marketing of Foods and Non-alcoholic Beverages to Children.   It has also called for cooperation between Member States of the World Health Assembly to reduce the impact of cross-border marketing of unhealthy foods and beverages.

The Commission has called for a standardised global nutrient labelling system, as well as the implementation of interpretive front-of-pack nutritional labelling supported by public education to improve nutritional literacy.  Interpretive food labelling has consistently been a highly contested area of food law and policy.  For example, the European Food Industry reportedly spent 1 billion euro to ensure that front-of-pack traffic light labeling did not become a Europe-wide standard.  Traffic light labels interpret the quality of the nutrition of food by means of highly visible red, amber and green symbols that correspond to the amount of saturated fat, salt and added sugar in the product.

The Commission’s recommendation that schools, child-care settings and children’s sports facilities should be required to create healthy food environments may also require legislation or regulations for successful implementation in some countries.  The Commission has also specifically recommended that countries eliminate the sale or provision of unhealthy foods, such as sugar-sweetened beverages and energy-dense, nutrient-poor foods, in schools.

In the United States, the federal government subsidises the provision of breakfasts and lunches served at school to children from low-income families.  This has enabled the US Department of Agriculture to issue regulations  requiring schools that participate in the national school lunch and breakfast program to improve the nutritional quality of the foods that are served.   However, these standards have faced relentless opposition from the junk food industry and from Congress.  Mandatory standards to improve the nutritional quality of school food have been introduced in a number of jurisdictions, including England and Scotland.

Other recommendations that may require legislative or executive action include the enforcement of the International Code of Marketing of Breast-milk Substitutes and subsequent resolutions of the World Health Assembly (WHA).

The Commission’s report will be presented to the members of the WHA in May 2016, where further actions may be taken to support the implementation of the Commission’s recommendations.

Those with an interest in obesity should also keep an eye out for the report of the Lancet Commission on Obesity, co-chaired by Professor Boyd Swinburn (University of Auckland), and Professor Bill Dietz (George Washington University).  In this paper, Professors Swinburn and Dietz outline the work of their Commission.

 

 

Is your summer barbeque under fire? Chewing over the evidence on meat and cancer, and digesting the implications for regulation

Corned beef

The report

We’ve now had a few weeks to chew over the latest report linking food and cancer. Only this time it wasn’t a puff-piece in your Sunday newspaper, but an extremely comprehensive report from IARC, the World Health Organization’s International Agency for Research on Cancer. After a systematic review, IARC’s findings on the links between red and processed meat consumption, and cancer, were published in a press release and in The Lancet in late October (the full findings will be published later as a monograph).

In brief, red meat (“all mammalian muscle meat, including, beef, veal, pork, lamb, mutton, horse, and goat”) was classified as being probably carcinogenic to humans. Processed meat (“meat that has been transformed through salting, curing, fermentation, smoking, or other processes to enhance flavour or improve preservation”) was classified as carcinogenic to humans. This means that, based on epidemiological studies, IARC found “convincing evidence” that meat products like ham, sausages, corned beef and biltong cause colorectal cancer.

Is meat the “new tobacco”?

Despite widespread media reporting that red and processed meats were now “as big a threat as cigarettes”, IARC did not actually make this comparison. Rather, it rated the strength of the evidence for the link as “Group 1”, meaning that the evidence is strong. So, the evidence linking tobacco and lung cancer is equally persuasive (Group 1) but this does not mean that eating meat is as dangerous as smoking. (This classification system is widely used in systematic assessments of nutritional evidence, including in the Australian Dietary Guidelines.)

Among those who denounced the comparison between eating meat and smoking cigarettes was Australia’s Agriculture Minister, Barnaby Joyce. Clearly, Mr Joyce has an interest in dampening any concerns that might threaten Australia’s reputation as a nation of meat-eaters – but in this case his assessment of the evidence was correct.

Regulation of bacon: the next frontier for public health law?

All in all, you may want to consider throwing a few extra vegetable skewers on your next barbeque. But more interestingly for our purposes, what – if any – are the implications for law and regulation?

As countries such as India and China undergo rapid social and nutritional transitions, the demand for meat will only grow – worldwide, meat-eating is correlated with greater wealth. This has environmental as well as health implications. Together, these implications may eventually prompt countries to take regulatory action.

While there are currently no jurisdictions that regulate the consumption of meat, the following developments may be indicative of an early trend:

  • “Meatless Mondays” or “meat-free Mondays” campaigns have been springing up around the world since the early 2000s. These tend to be grassroots civil society initiatives aimed at making vegetarian food more acceptable and available.
  • In 2009, the Belgian city of Ghent became the first in the world to proclaim an official “Veggie Thursday”.
  • The most recent iteration of the US government’s dietary guidelines, “MyPlate”, refers to daily “protein” rather than “meat” consumption.
  • In the early 1990s, Ghana introduced food standards setting maximum fat limits for pork, beef, mutton and poultry, in response to concerns about diet-related NCDs. While not a curb on meat consumption per se, this regulatory response does speak to some of the concerns raised by IARC.
  • Perhaps most tellingly, the food industry has come to recognise the commercial potential of vegetarian foods, which are now said to have “gone mainstream” after decades on the hippie fringe.

This is where the comparison with tobacco control may be more salient. The evidence linking tobacco to cancer was recognised by some governments as early as the mid-1950s, but the WHO’s Framework Convention on Tobacco Control was not enacted until 2003. Biltong regulation will no doubt require a similar fermentation period. But the mix of voluntary, regulatory and commercial developments above suggests that the goal of curbing meat consumption is not far-fetched or conceptually unappealing. More controversial perhaps will be the methods of achieving that goal. Warning labels on a pack of sausages? A tax on bacon? A ban on quarter-pounders? We’ll get back to you in 30 years…

World Health Organisation publishes new report on overweight, obesity, diabetes and the law

Posted by Jenny Kaldor and Roger Magnusson

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This is the view when you look out the front gates of the World Health Organisation’s regional headquarters in Manila.

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A few blocks away, in the processed food aisles of the supermarket, parents are encouraged to purchase “nutrition power for kids”.

The Western Pacific Region, which includes Australia, is home to 138 million adults with diabetes, and includes a number of Pacific Island countries where more than one third of the population have diabetes, and around one half of the population are obese.  [See separate blog post]

In response to these issues in our region, Manila was the venue for a consultation on 9-11 April 2014, on overweight, obesity, diabetes and the law, co-hosted by the University of Sydney (Sydney Law School and the Boden Institute), and by the International Development Law Organisation (IDLO).  The consultation brought together public health practitioners, community leaders and academics from around the region, including Fiji, Singapore, New Zealand, Indonesia, Cambodia, South Korea, Mongolia, PNG, the Philippines and more.

The consultation was co-chaired by Professor Stephen Colagiuri (Boden Institute of Obesity, Nutrition, Exercise & Eating Disorders), Professor Roger Magnusson (Sydney Law School), and Mr David Patterson (IDLO).  The background paper and meeting report were written by the rapporteur for the consultation, Ms Jenny Kaldor, who is a PhD candidate at Sydney Law School.

The Western Pacific Regional Office of the World Health Organisation (WHO – WPRO) was the co-sponsor and convenor of the consultation, and has just published the meeting report, which is available below:

WPRO CONSULTATION ON OVERWEIGHT OBESITY DIABETES AND THE LAW – 9-11A APRIL 2014 – FINAL REPORT – RS_2014_GE_66_PHL_eng.

The report illustrates the variety of legal issues that overweight, obesity and diabetes are causing for countries within the Western Pacific WHO region, as well as how law might be used to improve health outcomes.  These include the problems of diabetes-related disability discrimination, discrimination in access to diabetes medications, and good practices in legislation to improve food environments and opportunities for physical activity, from across the region.  The report discusses the opportunities for, and obstacles to, using law effectively, as well as the challenge of ensuring that trade agreements and trade laws do not work at cross-purposes to health policies on obesity and diabetes.

The meeting report highlights several important conclusions:

  • There is a strong need to build the evidence-base on legal interventions relating to obesity, diabetes and population diets.  Case studies, feasibility studies, guidelines, summaries and other tools can assist countries to share their knowledge and experience with legal and regulatory interventions.  Researchers and academics have an important role to play.  Networks need to be built across the region to better facilitate information sharing.
  • Developing local expertise in public health law and in particular, law related to obesity, overweight and diabetes, is a priority.
  • In-depth technical advice is needed on promising interventions.  These include a tax on sugar-sweetened beverages; restrictions on unhealthy marketing of food and beverages to children; requirements for interpretive, front-of-pack labelling; and legislation to create environments that facilitate and encourage physical activity.
  • Civil society has a vital role to play in the development, implementation and enforcement of innovative legal approaches to overweight, obesity and diabetes.
  • Addressing the interference of the food and drinks industries in policy development and implementation in countries across the region is a priority.  Clear guidelines are needed to avoid conflicts of interest and to ensure that government interactions with the food industry are transparent and constructive, and do not jeopardise public health goals.
  • Law needs to be better integrated into the agenda of the World Health Organisation.  Law is central to advancing the goals of WHO, and can enable countries to protect, respect and fulfil the right to health.