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• W2538274368 abstract "Childhood obesity is a complex, profound and intractable problem. The World Health Organization (WHO) states in its report Ending Childhood Obesity (WHO 2016) that ‘childhood obesity undermines the physical, social and psychological wellbeing of children’. It is predicted that without action, the increasing prevalence of obesity and the detrimental effects associated with excess adiposity will negate the health benefits contributing to improvements in life expectancy. This is particularly the case for low and middle income countries, where the absolute number of overweight and obese children is greater than in nations with higher incomes (Ng et al. 2013). Health inequalities are further compounded in developing countries where the ‘double burden’ of malnutrition and obesity is experienced (Prentice 2006). As nations develop, urbanisation and globalisation increase access to cheap, palatable, high-energy foods; so with greater affluence comes greater risk of overweight and obesity. However in high-income countries, a clear socio-economic gradient reveals greatest prevalence of obesity among the least affluent. WHO recognises that obesity in childhood tracks into later life and increases the risk of non-communicable diseases, such as cardiovascular disease and type 2 diabetes. Therefore, urgent action is called for to prevent overweight and obesity as early as possible to improve the life chances of the next generation. Key actions necessary to end childhood obesity according to WHO include promotion of healthy eating and physical activity to prevent excess weight gain and provision of family-based multicomponent lifestyle weight management services to treat those children and adolescents who are already obese. The report specifically identifies three critical times over the life-course to intervene, these are preconception and pregnancy; infancy and early childhood; and older childhood and adolescence. The importance of establishing healthy eating and activity habits in early life, in particular the first 1000 days from conception to the second birthday, cannot be overstated as it is much more effective and less challenging to intervene early on than to treat later in life. The UK government, in common with others globally, has undertaken consultations with relevant stakeholders in order to develop a plan for action to reduce levels of childhood obesity. In August 2016, the long awaited UK Childhood Obesity – A Plan for Action was published (Department of Health 2016). This has set out the context for England in relation to current prevalence of childhood overweight and obesity; the costs to the NHS of treating illness related to excess bodyweight; and from this a plan for action to reduce levels of childhood obesity within the next 10 years. This plan identifies 14 areas with wide-ranging implications for new initiatives, such as reformulation, as well as maintaining existing initiatives which support families. Many have criticised the Plan for Action as relatively weak compared to the recommendations from the Health Committee (2015); nevertheless, there are a number of action points which directly highlight the importance of nutrition in childhood within the context of high prevalence rates and enduring health inequalities. For example, figures for England reveal that approximately one-third of 2–15 year-olds are overweight or obese, that these children are likely to maintain their weight status into adulthood and that as adults with obesity, they are seven times more likely to develop type 2 diabetes (Abdullah et al. 2010) than those with a healthy bodyweight. In particular, children from poorer families are twice as likely to be obese as their better off peers at age 5 years, and by age 11 years, they are three times more likely to be obese as their more affluent counterparts. As 1 in 5 children are already overweight or obese before starting school, it is recognised in this plan and elsewhere that prevention during the early years is critical. To counter the obesity epidemic in children, the Plan for Action calls for a multiagency, multicomponent approach. This ranges from introducing initiatives such as a healthy rating scheme for schools to maintaining provision of Healthy Start vouchers for low-income families. Overall, this raft of actions has been mooted to improve the nutrition and activity of children and adolescents as a means to prevent the development of overweight and obesity. In particular, the plan focuses on reformulation of products; coordination of physical activity in and out of school; innovation to promote healthier products; improving public sector and school offerings; better food labelling; harnessing new technologies; providing support to families and early years settings. For example, a soft drinks levy directed at manufacturers has been proposed. This seeks to address the excess energy intake consumed by children and teenagers, and particularly intake of sugars. Teenagers in England are among the highest consumers of sugars-sweetened beverages in Europe. More generally, the Scientific Advisory Committee on Nutrition (SACN) has advised that intake of free sugars should be reduced to 5% of total energy intake (SACN 2015) and, as one 330 ml soft drink can exceed the recommended sugars intake for a whole day, the levy has been designed to encourage manufacturers to reduce the sugars content of their beverages, with 2 years to achieve this. Reformulation of other products containing sugar has also been proposed, with specific attention to the nine food categories contributing the most sugar to children's diets. According to the Plan for Action, ‘the sugar reduction programme will also work to reduce the sugar content of product ranges explicitly targeted at babies and young children’ (excluding breastmilk substitutes). As childhood obesity is a complex and challenging issue, targeting sugars consumption can be only one step towards the goal of improving nutrition in children. Indeed, it has long been accepted by scientists and clinicians that interventions to improve nutrition must begin preconception as maternal diet in pregnancy has profound effects on programming of health and disease, as well as providing an opportunity for flavour learning in utero (see Papadopoulou & Stanner 2014). Early life is the key period to establish healthy eating habits for wellbeing, growth and development (British Nutrition Foundation 2013). Exclusive breastfeeding for the first 6 months is recommended by WHO (2001), followed by continued breastfeeding and solid food introduction. During the period of complementary feeding, infants are provided with the opportunity to learn about a variety of foods, flavours and textures. This period is important as preferences established in infancy are known to track into later childhood (Venter & Harris 2009; Chambers 2016; Chambers et al. 2016). Breastfeeding may confer protective effects against obesity (discussed by Hardwick & Sidnell 2014) through a number of different mechanisms, including self-regulation of energy intake and appetite entrainment. Breastfeeding also promotes acceptance of new foods such as vegetables (discussed by Venter & Harris 2009). This is achieved in part via the diverse flavour profile of breastmilk, which permits a wide-ranging experience of different flavours, and if mothers themselves are consuming a healthy, varied diet, this will be transmitted both in utero and through breastfeeding. The introduction of solid foods provides a ‘window of opportunity’ when infants are most willing to accept new flavours and textures. Complementary feeding, whether achieved by traditional spoon feeding or baby-led weaning (see Cichero 2016), paves the way towards healthy eating. Liking and acceptance of foods that support good health are essential as children select and eat foods they prefer. Thus, initiatives such as healthy ratings for schools and making school food healthier, as mentioned by the Plan for Action, will fail unless children are already familiar with and prefer healthy options such as fruit and vegetables and wholegrain foods. Providing first foods such as vegetables during the weaning period (Cichero 2016), maintaining this food in the family diet as well as modelling intake of these foods by families (Venter & Harris 2009) together set the foundation for healthy eating habits. To make the most of this crucial period when babies are receptive to new foods, it has been suggested that offering vegetables exclusively for the first few weeks of complementary feeding with a ‘vegetables first’ approach enhances liking and facilitates acceptance of these foods (Chambers 2016; Chambers et al. 2016). Currently, as discussed by Cichero (2016), offering vegetables as a first food tends to be associated with baby-led weaning more than traditional spoon feeding. Indeed, UK survey data indicate that cereals are the most common first food whereas offering vegetables first is uncommon. Adopting a ‘vegetables first, frequently and in variety’ approach to complementary feeding is likely to steer children towards a healthier diet (Chambers 2016), and the consensus reached by the team assembled by the British Nutrition Foundation (BNF) has identified health visitors as key opinion leaders to guide families in offering tastes of a variety of vegetables when complementary feeding begins (Chambers et al. 2016). This could be an essential step in the transition from milk to solid foods, so that liking and acceptance are established. More complex textures and finger foods can then be introduced in response to readiness of the infant (Cichero 2016). As complementary feeding progresses, Hardwick and Sidnell (2014) identify the period after 12 months as a risky time for infant nutrition. They suggest that infants consume energy in excess of current recommendations, and protein intake in excess of metabolic requirements. It is known that rapid infant weight gain (with energy intake exceeding requirements) together with deteriorating dietary quality from 12 to 24 months contributes to risk of obesity (see Hardwick & Sidnell 2014). Therefore, intervention during this period is another opportunity to shape dietary choice and nutrient intake, for example by providing supplementation of vitamin D for all children (Alderton 2015). Healthcare professionals may lack the necessary skills or confidence to broach issues such as obesity risk with families. Yet, health visitors are ideally placed to provide prevention guidance during clinic visits and baby weighing sessions (Hardwik & Sidnell 2014) and this is recognised within the UK Childhood Obesity – Plan for Action. Here, resources for healthcare professionals and the wider workforce to ‘Make Every Contact Count’ are advocated. These materials provide training and information on how to tackle difficult conversations around health. For health visitors and school nurses, there is targeted training to identify weight issues in young children, given their privileged position working directly with families. In addition, the Plan for Action has announced the government's commitment to maintain Healthy Start vouchers for low-income families, to be used in exchange for milk and fresh or frozen fruit or vegetables as well as free vitamins during pregnancy and the early years. Given the observation that iron and vitamin D intakes decrease significantly beyond 12 months of age (Alderton 2015), maintaining these initiatives will help prevent vitamin D deficiency. For children, this is especially needed as there is a risk of compromised growth and development. Families more generally benefit from advice and guidance on what and how much to offer children. BNF has developed a food-based guide with clear visual examples for feeding 1–3 year-olds (Benelam et al. 2015). This is all the more important when it is known that mothers select amounts for their children based on what they serve themselves (Johnson et al. 2014; McCrickerd & Forde 2016). Therefore, if parents provide portions larger than recommended, children will learn to expect larger portions and this will contribute to overeating (McCrickerd & Forde 2016). Parents are confused about what and how much their children should be eating (Venter & Harris 2009); however, the BNF food-based guide specifically aimed at early years and other similar resources (e.g. Caroline Walker Trust 2006) have been well received if not yet fully evaluated. Overall, in line with the urgent action called for by WHO to end childhood obesity, the UK Plan for Action provides ‘the start of a conversation not the final word’. In the UK, it remains to be seen whether these proposed changes will have any discernible impact on overweight and obesity in children and young people. Nevertheless, there is a clear need to focus on the early years as a critical period to intervene. This is particularly illustrated by the window of opportunity for establishing food preferences during and beyond weaning, and laying the foundations of healthy eating during the first 1000 days of life. In particular, there is a clear need to recognise the privileged role of health visitors making every contact count to support families in providing the best start for their children." @default.
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• W2538274368 title "Nutrition in the early years - laying the foundations for healthy eating" @default.
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