Images of Amputated Limbs on your Child’s KitKat ?

When you walk through the packed aisles of a local Tesco or a Sainsbury’s you notice two things – that London real estate is expensive, and the dazzling colors of chips, candies, chocolate bars and all things sugary jostling for your attention. If your shopping run happens to be at the same time as the start or end of the school day, you cannot miss the happy cacophony of school children running up and down the aisles. 

One more thing you would notice, if you are paying at the counter, is the modesty of tobacco brands – sitting coyly behind the sliding doors or the curtains. Display of tobacco is currently banned in several countries, including the UK. The cigarette packs not only sit behind the modesty curtain, they also carry morbid visual warnings – for e.g. images of cancerous lungs. It took governments ages to arrive at these extraordinary measures. I suspect we are at the dawn of a similar movement with regards to sugar and processed foods.

Here is a classic bit of Sir Humphrey Appleby from 1986, followed by a real-life exchange in the House of Commons in 2019!

Fiction: Yes, Prime Minister[1]

Prime Minister Hacker: When cholera killed 30,000 people in 1833, we got the Public Health Act. When smog killed 2,500 people in 1952, we got the Clean Air Act. A commercial drug kills half a dozen people and we get it withdrawn from sale. Cigarettes kill 100,000 people a year and what do we get?

Sir Humphrey: ￡4 billion a year. 25,000 jobs in the tobacco industry, a flourishing cigarette export business, helping our balance of trade, 250,000 jobs related to tobacco - newsagents, packaging, and transport. It will be pointed out that the tobacco companies are great sponsors of sport.

Where would the sports programmes be if cigarette companies couldn't sponsor the events that they televise?

Prime Minister Hacker: We're talking about 100,000 deaths a year.

Sir Humphrey: Yes, but cigarette taxes pay for a third of the cost of the National Health Service. We're saving many more lives than we otherwise could because of those smokers who voluntarily lay down their lives for their friends. Smokers are national benefactors!

-----x-----

Real life: Excerpts from the Health and Social Care Committee Proceedings, House of Commons[2]

Anne Marie Morris, MP, Conservative:  Forget for a minute what the Government have promised to do. In an ideal world, what should we do in terms of advertising to change the pressure on children to eat more, worse food, if I can put it like that?

Professor Susan Jebb, Professor of Diet and Population Health, University of Oxford: We have to strip much of the advertising for unhealthy food out of our environments, whether that is on television, on billboards or in sports stadiums. We have to avoid this constant repetitive stimulus to eat, which is what it essentially amounts to

 Andrew Selous, MP, Conservative:  I think Anne Marie is really on to something here. This might be a bit shocking, but we have no compunction at all. You put pictures of someone’s tar-stained lungs on a pack of cigarettes, so what about pictures of amputated feet on a pack of jam doughnuts or something? Is that going too far? You are calling for bold action, but this is ultimately the consequence. There were 26,000 amputated lower limbs last year through type 2 diabetes. That is the bit that the public do not really see, and they do not associate, do they?

 Professor Dame Sally Davies, Former Chief Medical Officer:  We will end up there. After all, when I was a young doctor, type 2 diabetes was called “adult onset”. We started to see it in children in 2000. We get an extra 100 a year. If you look at what is happening with obesity and the impact on children, it shortens their lives by two and a half years, it dramatically impacts their life chances, and it impacts our economy, as the OECD said only a couple of weeks ago, by 3.4% of GDP.

-----X----

The above excerpt from the committee proceedings highlights the painful truths of childhood obesity. Sugar or diet alone is not responsible and there are multiple contributing factors to childhood obesity[3].

Physical Inactivity: Four in five 11- to 17-year-olds around the world are not taking enough physical exercise. The World Health Organization says children's health is being damaged as well as their brain development and social skills. It says failing to take the recommended hour a day of exercise is a universal problem in rich and poor countries

Recommended: Children aged 5- 18: 60 minutes of physical activity everyday. Adults aged 19-64: 150 minutes of moderate aerobic activity per week[4]

In India, where my young nephew and niece are, it is a luxury for a child to get 60 minutes of daily physical activity. Homework, school commute, TV/screen time and lack of safe open spaces in some cities make it extremely difficult. Like many OECD countries, the increasing prosperity among the urban middle class is enabling a high calorie diet among the kids.

Socio-economic Status: The effects of socio-economic status on childhood obesity are well researched[5]. For example, London Borough of Tower Hamlets, which houses Canary Wharf complex and Queen Elizabeth Olympic Park reports very high levels of child hood obesity. In Tower Hamlets, nearly 1 in 7 children in reception (4- to 5-year-olds) and over 1 in 4 of children in year 6 (10- to 11-year-olds) are obese. Tower Hamlets has the fifth highest proportion of obese 10- to 11-year-olds in London, and the sixth highest in the country[6]. An often-quoted statistic about Tower Hamlets: there are 42 fried chicken shops for every secondary school in the borough.[7]  

Where do we go from here? What’s in Our Tool Kit?

Childhood obesity is one of the issues NHS has promised to tackle in the NHS Long Term Plan. The government has pledged to halve childhood obesity and significantly reduce the gap in obesity between children from the most and least deprived areas by 2030[8].

There are interesting insights from the success the city of Leeds has had in lowering child obesity. To quote Tom Berry of HENRY[9], a charity that has helped Leeds in tackling this problem, “simply providing nutritional and activity guidance is unlikely to result in meaningful change – especially for families dealing with the multiple challenges associated with socio-economic deprivation.” We need more of these integrated programmes that address all aspects of the issue.

Wearables/ Fitness tracker:

Get people, particularly young adults to move. Would a fitness/steps tracker help?

• Fitness trackers are a good addition to an integrated plan that uses lifestyle changes, diet and exercise. But they are not silver bullets on their own. The IDEA randomized clinical trial reported that digital devices that monitor and provide feedback on physical activity might not offer an advantage over standard behavioral weight loss approaches[10].
• Health Education England has developed No Obesity apps. We need to wait and see if these apps have been effective. There are also a few other apps targeting obesity for adults in the NHS App Library

Educating the kids, parents and the public:

• Failures of Calorie Labeling at Fast Food Chains[12]: “It is rare for eating out and takeaway chains in the UK to provide point of choice kcal labeling and when labeling is provided it does not adhere to recommended labeling practices. Chains that previously volunteered to provide kcal labeling as part of an industry and public health partnership do so inadequately. Voluntary policies have not resulted in adequate kcal labeling in the UK eating out of home sector”.

Engaging content, not just facts on nutrition and diet

Peppa Pig is a great model for anyone trying to create engaging content for children. This globally popular cartoon show has captivated children, particularly preschoolers. The show itself has got some flak from bloggers for ‘fat shaming’ Daddy Pig[11]. Assuming we manage to take the body shaming (or other unacceptable) parts out. A show like this could be a great platform for instilling healthy eating from start.  Rajio taisō – radio calisthenics is an interesting template – in terms of content (no allusion to the politics!)

I would wager that the public information budgets of all the public health departments in the world put together will not match a global confectioner's advertising budget for a single brand. One could draw inspiration from campaigns like ‘Got milk’, and The National Egg Coordination Committee (NECC) India on promoting consumption of eggs. 

Park Run / Couch to 5K:

On analyzing the association between parent and child weight, NHS Health survey has found that 28% of children of an obese mother were also obese, compared with 8% of children whose mother was not overweight or obese. 24% of children of an obese father were also obese, compared with 9% of children where the father was not overweight or obese[13]. It might seem silly to mention Kevin Hart in this article, but deserves mentioning – comedian Kevin Hart has a YouTube series What The Fit; there is an episode on how your kids can actually double as one of the best workout partners you'll ever pair with[14].

Conclusion:

Coming back to labeling - with regards to the tobacco, on reviewing the impact of warning images, the results revealed that threatening visual warnings with a high threat level are the most effective in increasing negative emotions (fear, disgust, valence, arousal) and behavioral intentions conducive to public health (desire to quit, etc.)[15].

Recent research has found that labeling food with "exercise calories" made it easier for people to understand what they were eating and nudge them into making better choices. For example your pizza box will have a label that you need to walk four hours to burn off the calories from a pizza or you need to run 22 minutes or walk 42 minutes to burn off the calories from a chocolate bar[16].

The Government of Singapore, which is famously interventionist, is considering a total ban on advertisement for drinks with high sugar content. While a ‘sugar tax’ passes the cost to consumer, a total ban can potentially push the manufacture to reform these goods[17]. Total ban on advertising of high sugar drinks might seem draconian and too paternal a move. It took several decades for the society and the tobacco industry to accept smoking as a public crisis, and to accept that the restrictions on smoking are not paternalistic but necessary for a healthy society.

While childhood obesity cannot be tackled by controlling sugar consumption alone, we need to throw all we have against the wall and see what sticks. Either we collectively find a solution that helps citizens live better, health systems less burdened, and the companies sell healthy treats (stay profitable) OR there may come a day, not too far down the line, where a Kit-Kat pack carries images of amputated limbs.

References:

[1] Yes Prime Minister, Season 1, Episode 3

[2] Oral evidence: Childhood Obesity follow-up 2019, HC 130, Tuesday 29 October 2019

[3] Weihrauch-Blüher, S. & Wiegand, S. Curr Obes Rep (2018) 7: 254. https://doi.org/10.1007/s13679-018-0320-0

[4] Public Health England

[5] David Bann, William Johnson, Leah Li, Diana Kuh, Rebecca Hardy, Socioeconomic inequalities in childhood and adolescent body-mass index, weight, and height from 1953 to 2015: an analysis of four longitudinal, observational, British birth cohort studies, The Lancet Public Health, Volume 3, Issue 4,2018,

[6] https://www.towerhamlets.gov.uk/lgnl/health__social_care/public_health/healthy_lifestyle,_children.aspx

[7] https://www.theguardian.com/society/2016/jan/28/chicken-shop-mile-britain-fat-cheap-food-obesity

[8] NHS Long Term Plan (Version 1.2)

[9] henry.org.uk

[10] Jakicic JM, Davis KK, Rogers RJ, et al. Effect of Wearable Technology Combined With a Lifestyle Intervention on Long-term Weight Loss: The IDEA Randomized Clinical Trial. JAMA. 2016;316(11):1161–1171. doi:https://doi.org/10.1001/jama.2016.12858

[11] OK, Can Peppa Pig Stop Fat-Shaming Daddy Pig All The Time? Poor Daddy pig! By Emily McCombs

11/01/2017, huffingtonpost.co.uk

[12] Robinson, E., Burton, S., Gough, T. et al. Point of choice kilocalorie labelling in the UK eating out of home sector: a descriptive study of major chains. BMC Public Health 19, 649 (2019) doi:10.1186/s12889-019-7017-5

[13] Health Survey of England 2017

[14] https://www.youtube.com/watch?v=T3fgGI-HjIw What The Fit, Season 1, Episode 15

[15] The influence of threatening visual warnings on tobacco packaging: Measuring the impact of threat level, image size, and type of pack through psychophysiological and self-report methods: Droulers O, Gallopel-Morvan K, Lacoste-Badie S, Lajante M (2017) https://doi.org/10.1371/journal.pone.0184415

[16] Daley AJ, McGee E, Bayliss S, et alEffects of physical activity calorie equivalent food labelling to reduce food selection and consumption: systematic review and meta-analysis of randomised controlled studies Epidemiology Community Health Published Online First: 10 December 2019. doi: 10.1136/jech-2019-21321

[17] Stefania Palma, FT.com, Asian Countries Watch as Singapore Expands ‘war on diabetes’, 1st Jan, 2020.