Obesity remains as one of the most preventable diseases in the developed countries, and its prevalence continues to increase not only in affluent societies but also in developing countries (Segula 2014). The ease of accessibility and availability of food has contributed to the increasing prevalence of obesity and the obesogenic environment. The highest prevalence of obesity rates across Europe was recorded in the United Kingdom (U.K) (The Organisation for Economic Co-Operation and Development (2017). By 2030, approximately half of its population will be obese (National Health Service 2011).
The scale of the obesity problem is apparent by its statistics where approximately two-thirds of adults (63%) in England are classified as being overweight or obese. Furthermore, in a span of 22 years (1983-2015), the prevalence of obesity has risen from 14.9% to 26.9% (Public Health England 2017a). In terms of childhood obesity, a quarter of children aged 2 to 10 and one-third of 11 to 15 are obese or overweight. Obesity is of a growing public health concern due to its health implications associated with it which include diabetes, heart disease and stroke. This ultimately cause reduction in quality of life, poorer mental health and premature deaths worldwide (National Center for Chronic Disease Prevention and Health Promotion 2018).
Younger generation are becoming obese and are more likely to develop non-communicable diseases such as diabetes at younger age (Sahoo et al. 2015). According to Freedman et al. (2001), 80% of childhood obesity is likely to persist into adulthood, indicating how early life factors play a critical role for healthy development and reduced health risks in later life. This has caused the National Health Service (NHS) at least £5.1 billion and tens of billions to UK society annually and is expected to rise to £8.3 billion in 2025 and £9.7 billion in 2050 (Baker 2018).
Disparities in health can not only be seen in adults but also children despite advances in medical technology and global wealth, indicating those who are at a socioeconomic disadvantage will experience the greatest disease burden (Allen and Sesti 2018). Birmingham’s population is significantly diverse in terms of ethnic composition whereby one-third of ethnic minority groups account for the city’s population with Pakistanis being the largest ethnic minority group (10.6%), followed by Indians (5.8%) and Black Caribbean (4.4%) (Cangiano 2008). Evidence from research shows that, on average, individuals from minority ethnic backgrounds showcase greater levels of poor health compared to general population counterparts, indicating the greatest socioeconomic disadvantage groups will experience the greatest disease burden (Barry and Yuill 2011 and Strong, Maheswaran and Radford 2006). Therefore, giving children the best start in life is crucial in order to improve health and reduce health inequalities. Moreover, children at this age experience huge physical, psychological and behavioural changes as they mature and transition from children to young adults. This transitional period is critical as it allows unique opportunities for social determinants to affect health (Viner et al. 2012)
Hence, the target population is children of Asian ethnicity (includes Bangladeshi and Pakistani) aged 10-18 years old) in Birmingham. According to Birmingham City Council (2018), a rise in obesity at both Reception and Year 6 was recorded, with a growing gap between Birmingham and the national average whereas obesity prevalence is the highest at 24.4% at Year 6 among other ethnic groups. However, it should be noted that Body Mass Index (BMI) is not always an accurate predictor of fat distribution. Research has indicated for the same level of BMI, people of Asian ethnicity appear to carry more fat whereas people of African ethnicity carry less fat compared to the general population. This may lead to an overestimation of obesity among African and underestimation among Asian ethnicity (Harding et al. 2008).
For all these reasons, and in view of extremely high economic costs associated with obesity, the root of the problem has to be tackled by addressing the social determinants of health. These are referring to the conditions where people are born, grow, live and various wider set of forces and systems that eventually shape the quality of life outcomes (Daniel, Bornstein and Kane 2018). According to the Department for Work and Pensions (2018), the highest rate of persistent low income was found among people of Asian and Black households.
The association between poverty and children’s development has been well documented, beginning as early as the second year of life and extending to elementary and high school (Black, Hess and Berenson-Howard 2000). This includes, poor child development and worst health outcomes as children and adults, as well as lower socio-economic status as adults Duncan, Ziol-Guest and Kalil, 2010, Evans and Kim 2007). Readiness for school sets the trajectory for future success as it requires physical well-being, emotional health and adaptability to new experiences, appropriate social knowledge and cognitive skills (Kagan and Sharon 1992).
School readiness is critical to academic achievement later in life as differences in school entry have long-term consequences. In a study by Lee and Burkman (2002), students who start school significantly behind their peers can never close the readiness gap. Instead, the gap widens as they move through schools (Engle and Black 2018). The increased likelihood of truancy, drop-out rates and unhealthy or delinquent behaviours is the consequences of early school failure. Children from socially disadvantaged communities and families often do not receive the stimulation and the social skills required to prepare them for school. This is mainly due to parental inconsistency with regards to daily routines and parenting, lack of supervision, poor role modelling as well as lack of support from parents (Ferguson, Bovaird and Mueller 2007)
Results from a Canadian study concluded that children from low-income households score lower on measures of vocabulary and communication skills, knowledge of numbers and the ability to concentrate and cooperative play among children of wealthier households (Thomas 2006). Similar trends can be seen in regard to low school readiness associated with socially deprived neighbourhoods whereby target groups go on to complete less schooling, work less and earn less than others (Janus et al. 2007 and Duncan and Magnuson 2013). Thus, the evidence is clear and unanimous that children from low-income families will be at a cognitive and behavioural disadvantage. Although a rate of decline of obesity and its comorbidities is seen in White Europeans in the UK, the same could not be said for minority ethnic group. These inequalities have been attributed to issues regarding health care accessibility and cultural differences, which posed as major barriers medical advice and treatment (Latif 2010)
Poor living conditions, housing together with homelessness in particular constitutes a health risk especially to child development outcomes. For instance, respiratory conditions due to poor indoor air quality, lead and asbestos ingestion, overcrowding, accidents and injuries due to structural deficiencies (Evans 2006 and Leventhal and Newman 2010). Households in the lowest income groups are two times more likely to live in damp housing or housing that are of poor quality compared to households in the highest income group (Davies 2012).
Housing instability disrupts work, school and social networks between parents and children and over time, concerns over the stability of one’s housing situation and poor control over it result in distress and mental disorders (Hernandez and Suglla 2016). Physical and mental health conditions as a result of poor housing can have associated impacts on a child’s education, especially in children of minority groups (Chambers et al. 2015). This is due to children living in unfit and overcrowded housing often miss school due to illnesses and infections and as a result, experience delayed cognitive development (Rough et al. 2013). Housing indefinitely exert a strong influence towards a child’s development via influences on parental practices, especially young children who spend most of their time indoors, under parental supervision (Moore, Mcdonal and Mchugh-Dillon 2015). At the same time, managing the needs of children with health issues is a difficulty when housing is inappropriate or inadequate (Koenig 2007).
A balanced diet is a fundamental part of childhood nutrition. Health inequalities exist among the target group, as they tend to exhibit poor health outcomes, higher rates of obesity, type 2 diabetes and cardiovascular disease, compared to the general population (Leung and Stanner 2011). This is due to the dietary patterns for minority groups have changed drastically owing to migration and the adoption of Westernised convenience food, particularly among children, such as chips, burgers, carbonated drinks and food that are high in fat and sugar, contributing to high overall energy intake (Rawaf and Bahl 1998). Moreover, the nutrient composition of their traditional recipes has high-fat content (Kassam-Khamis 2000). This is further justified by Fieldhouse (1995), whereby cooking oil and meat are more affordable and easily attained after migration. Moreover, the intake of fruits and vegetables is low, whereby the proportion of eating the recommended 5 a day is lower among children from low-income households (All Party Parliamentary Group on Health in All Policies 2016). Dietary calcium is known to decrease gastrointestinal lead absorption which is critical for child development. Children of economically deprived areas are at risk of excessive lead exposure and low intake of dietary calcium. As previously mentioned, due to poor housing as well as the physical environment to which they are inevitably exposed (Bruening et al. 1999).
Ultimately the advancement of technology and ease of access to food have shaped an obesogenic environment, subsequently giving rise to health inequalities. The Obesity and the Food Environment is a policy that aims to tackle obesity by focusing specifically on what can be done in order to improve the food environment (Public Health England 2017a).
Takeaways are likely to contribute to health inequalities faced by people living in deprived neighbourhoods, especially children as they are highly price sensitive as their food choices are dependent on its price (House of Commons 2018). Studies have shown fast-food outlets are clustered around the school, enabling children to purchase energy-dense food (Caraher, Lloyd and Madelin 2014 and Ellaway et al. 2012). In a small longitudinal study involving 29 secondary schools in East London has found an increased in the number of takeaways and grocers within 800m of a school, giving rise to the negative effect on the adolescent diet (Smith et al. 2013). This is supported by a prospective study involving 944,487 children in a 6-year follow-up study, indicating the ease of accessibility to hot takeaway outlets is associated with increased odds childhood obesity (Hamano et al. 2017).
Hence, The Strategies for Encouraging Healthier Out of Home Food Provision A toolkit for local councils was introduced. It emphasised the importance of engaging with local authorities (LA) in using licensing powers to influence the provision of healthier food and reduce the proliferation of takeaways (Public Health England 2017b). This signify increased power for LA to respond to obesity challenges in terms of licensing, planning and place shaping fast food takeaways away from schools. PHE have built on this call, stating that interpretation regarding the extent to which existing powers can be used and enforced, and uncertainty surrounding best practice differs among local authorities (LA). Moreover, political and economic challenges may exist, whereby issues concerning public health in planning decisions may be of secondary concern (Public Health England 2017b). This signify that the policy and the council’s planning powers can do little to nothing to address the clustering of fast-food outlets that are already in place. Moreover, planning experts have pointed out that the current planning system tends to focus on how land is used and is not designed to deal with the detail of how a business is operated (The Local Government Association 2018). Moreover, the policy aims to improve the quality of the food environment around schools, as it has the potential to influence children’s food-purchasing habits, ultimately influencing their future diets (School Food Trust 2012). Emphasis has been placed especially taking actions on hot food takeaways. However, the policy fails to address the fact that sweets, sugar-sweetened drinks and other high-calorie food can be purchased in shops nearby school (Public Health England 2014).
Furthermore, studies have indicated that consumers tend to increase energy intake when eating out, usually due to them containing higher calories and fat and less fibre (Lin and Guthrie 2014). The policy encourages the partnership between LA and food operators to provide caloric information through menu labelling. This is to offer consumers a more transparent choice when eating out and with the significant increase in fast food outlets, they posed as a difficulty to resist them. (Tedstone 2018). In a poll conducted by Diabetes U.K (2018), 76% of British adults agree that calorie information should be displayed on their menu so that consumers can make informed and healthier food choices. In a cross-sectional study involving 648 diners, found that with calorie labelling, diners tend to purchase 151 few calories than those dining in restaurants without calorie labelling (Auchincloss et al. 2013). Furthermore, in order to conclude that consumers learn from exposure to energy content information, researchers examined transaction data from 884 card-holders after the implementation of menu labelling, who made food purchases in stores outside the city that were unlabeled. Results were consistent with a learning account, as reductions in energy content of transactions were recorded in unlabeled stores among customers who had previously been to stores with menu labelling (VanEpps et al. 2016).
However, other studies have found minimal, if any, effects of calories labelling whereby meta-analysis conducted before and after calorie labelling showed no association between labelling and meal calorie content in a small sample of children and adolescents (Dumanovsky et al. 2011 and Elbel et al. 2009). Results inconsistency may be due to diverse methods and settings investigated in studies result in high heterogeneity. For example, previous studies have also indicated taste, cost, accessibility and convenience are of higher relevance to consumers than nutritional concerns (Glanz et al. 1998 and Rydell et al. 2009). These factors are not observed in a laboratory setting as food offered are often free. Therefore, the ease of accessibility and convenience could not be evaluated (Cantu-Jungles 2017).
Unlike the U.S where food labelling laws are implemented nationwide, the UK has yet to implement mandatory calorie labelling. Therefore, it relies on the voluntary commitments of food businesses operators. The policy did not address a major gap in the potential benefit of meu labelling, which is the absence of long-term data. Hence, the efficacy of menu labelling at changing behavioural choices especially in communities where obesity prevalence is greatest, could not be explored, further widening the gap of health inequalities (House of Commons 2018). Although most menu labelling provide basic calorie information, however it requires mathematical manipulation, requiring higher levels of nutrition knowledge and literacy (Emrich et al. 2014 and Roberto and Khandpur 2014). The policy did not account for socially deprived individuals and children who lack higher education and may find it hard to conduct a comparison between what is considered ‘healthy’ and ‘less healthy due to this and unlike the ‘Traffic Light’ system that incorporates colours and symbols, to aid consumers to identify items that have ‘low’, ‘medium’ or ‘high’ nutritional quality (White et al. 2016).
In conclusion, the costs of obesity are considerable, especially when further complicated by other illnesses. Hence, tackling obesity requires a multifaceted approach as it is caused by various complex underlying factors. Addressing the social determinants of health is crucial in improving the health of the target population, and to reduce ethnic health inequalities. Halting its invasion and succeeding in maintaining healthy lifestyles in order to revert this situation is the responsibility of all agents involved. Therefore, the partnership between LA and food operators is critical in achieving health goals. The Health Matters: Obesity and the food environment policy managed to address issues surrounding obesity and the obesogenic environment. However, evidence in some areas of the policy is lacking, especially in socially disadvantaged groups. The policy acts as a stepping stone in drawing on existing evidence and focus on the collaboration among different sectors, community and local authorities-led project and filling in the gaps where service provision is lacking.
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