Childhood obesity rates have been causing alarm to experts for over a decade, but data released within the last year has indicated that the situation is escalating. NHS Digital revealed that childhood obesity rates have seen the largest rise since records began in 2006, with current rates amongst Reception and Year 6 children remaining higher than pre-pandemic levels. Increasingly, reports are showing that it is the children living in the most deprived areas of England that are the most affected by these rising rates.
‘What we believe in public health is that children should have the same chance to a be a healthy weight wherever they live, but from the data we can see that isn’t the case,’ says Bethan Page, public health speciality registrar at the Health Foundation. ‘Children who live in the most deprived areas of England are more than twice as likely to be living with obesity than those living in the least deprived.’
In late 2022 leading health think tank, The Nuffield Trust released a report showing the strong association between deprivation and obesity in children. It found that local authorities with the highest percentage of children living in low-income families had 6.9% more overweight or obese Year 6 children. Similarly local authorities with the highest percentage of reception-aged children living in areas with poor access to passive green space were 1.8% more obese or overweight.
Health inequalities in England are widening as the prevalence of the most deprived children living with obesity has increased while the prevalence in the least deprived children has stayed the same. Senior fellow Liz Fisher from the Nuffield Trust says: ‘Across my work I am struggling to find measures that we look at where we don’t see inequalities. There are wide inequalities within health outcomes in England and its persistent as well.’
Health inequality
There are various factors that contribute to widening health inequalities, one of them being accessibility. The COVID-19 pandemic prevented children from accessing weight management services, recreational facilities and going to school. ‘There is evidence to suggest that schools provide what is described as an obesogenic protective environment. This means schools provide an environment that prevents children from potentially becoming obese,’ says Dr Fisher. Schools closing would have reduced a child’s ability to take part in physical activity, having a hot school meal, as well as limiting the access to services provided by school nurses such as, health promotion sessions, assemblies and coffee mornings.
Phoebe Kalungi, community child healthy weight and infant feeding team lead and Amelie Gonguet, community child healthy weight advisor for Tower Hamlets GP Care Group, highlight the importance of school nurses in helping to support those who are affected by inequalities. ‘We might support a family who is struggling financially to access healthy food by connecting them to a local food pantry or a food bank, or by referring them to a local financial adviser so they can maximise their income,’ they say. Therefore, families not being able to access these services because of the pandemic would have affected those who rely on it the most.
The Nuffield Trust report highlights that currently access to passive green space for children is still an issue for the most deprived communities, as well as having safe access to these types of spaces. The report revealed that amongst Year 6 children, areas with higher levels of road traffic accidents had lower levels of obesity. ‘Our hypothesis was that where children were being more active, they were more likely to get into road traffic accidents,’ says Dr Fisher.
Lecturer in CYP nursing and school nursing at the University of Salford, Miriam Collett explains that the current system is stretched, as reductions in public spending coupled with the increasing demand for public services is causing inequalities to continue to widen. ‘The current cost of living crisis is leaving families to choose whether to eat or heat their home in winter. Where people are already living with very small margins , their health is bound to worsen,’ says Ms Collett.
She adds: ‘Similarly the strain on the NHS currently means that accessing health care in an appropriate timeframe is becoming increasingly more difficult and for those living in areas of deprivation, where their health outcomes are already at the lower end of the scale, delays in accessing healthcare push their health even lower.’
Access to healthy food
The affordability and availability of healthy foods can be limited for lower income families, particularly in the current cost of living crisis. ‘People live difficult lives and they have to make difficult choices and they’re making those choices based on the environment that they live in,’ says Dr Fisher.
The Obesity Health Alliance (OHA) a coalition of over 50 of the largest health charities, feel that the current environment does not support those on lower incomes to eat healthily because of availability, affordability and the marketing of unhealthy food. Alfred Slade, public affairs manager at OHA, describes how supermarket shelves stocking healthy products are smaller in more deprived areas as well as healthy food being more expensive than unhealthy foods. Similarly, food promotions such as ‘buy one get one free’ tend to be offered more on unhealthy foods which are then purchased in bulk because it is cheaper.
Similarly the Food Foundation, a charity focusing on creating a sustainable food system, released a report showing that the richest fifth only have to spend 7% of their disposable income to eat in line with the NHS’s Eatwell guidance. Meanwhile, those in the poorest fifth have to spend 40%. Mr Slade discusses how there is a higher prevalence of unhealthy food outlets in deprived communities. Scarborough has approximately 20 times more outlets per person compared to wealthier communities.
The OHA also strongly believe that exposure to advertising and marketing highly influences people’s choices and therefore unhealthy food marketing is aimed at low income families. Not only on TV and online but outdoors as well. Mr Slade explains: ‘If you go to Twickenham, or Richmond, you don’t see many junk food ads, potentially on the side of a bus coming from a poor area, but you don’t see them lining the streets, while in Hastings, parts of Ealing, or Mile End, the entire street is coated in ads, on buses, bus stops, phone booths, billboards, everywhere.’
The Government has delayed the introduction of a 9pm watershed ban on junk food advertising on TV which the OHA believes would have been vital in helping to reduce children’s exposure to unhealthy food marketing. Mr Slade explains this is because unhealthy products in supermarkets are bought as impulse buys and that is because they are so widely advertised, put near checkouts and also discounted. In Iceland, supermarkets decided to put fruit and vegetables near the front of their shops rather than the back which resulted in the sale of those products going up. The government have currently delayed the implementation of ‘location’ and ‘multibuy’ restrictions on products in supermarkets until October this year, which would help reduce the exposure that people have to unhealthy products when shopping. The OHA are campaigning for the policy to be implemented earlier.
As well as being less able to afford healthy food, people in deprived areas are more likely to live in inadequate accommodation. This means that they might not be able to prepare and cook healthy food at home. Ms Collett recalls working with a mother who was trying to improve her child’s nutritional intake but didn’t have the means to be able to do it. ‘She didn’t own a sharp knife or chopping board and had never prepared vegetables before. We started with some frozen peas in a mug, in the microwave, which felt like a manageable step for her and the child.’ Living in deprivation and poverty can impact many choices that families make, who may not have the capability and resources to have a healthy lifestyle.
Physical and mental health
Living with obesity can affect a child both physically and mentally in their childhood and later in life. It can increase a child’s risk of developing Type 2 diabetes which has been on the rise in young people, with Diabetes UK reporting last year that childhood obesity rates have seen the largest rise since NHS records began in 2006. Children living with obesity are five times more likely to be adults living with obesity therefore the likelihood of developing diabetes is high.
Data from the NHS for 2019/2020 found that there were 122,780 children and young adults under the age of 40 years with the disease. Commenting on the findings at the time, Diabetes UK chief executive Chris Askew warned of ‘a perfect storm’ of rising obesity levels leading to ‘an even greater increase in children with type 2 diabetes in the coming years, a crisis fuelled by longstanding health inequalities and made worse still by impacts of the cost of living crisis’.
Previous governments have made a commitment to reduce childhood obesity by 50% by 2030. However, Ms Kalungi and Ms Gonguet, highlight that things are not moving in the right direction for this commitment to be met. ‘There have been many policies and strategies published in the last decade, but many are not following through to implementation, and most of the recommendations tend to focus on individual responsibilities and individual behaviour change as opposed to focusing on modifying the obesogenic environment,’ they say.
Ms Kalungi and Ms Gonguet suggest extending the school fruit and vegetable scheme or implementing universal free school meals as good practical solutions which could help children to have healthier choices when it comes to food.
The Health Foundation’s public health speciality registrar, Bethan Page says that cuts in public health spending since 2015/16, have hit the most deprived areas the hardest.
‘That is essentially due to those cuts being poorly designed and not quite taking into account the different levels of need in different local areas,’ she explains. Ms Page points out that the fundamental building blocks of a decent life – such as good nutrition, secure employment, education – are often not considered within the health sphere, but are vital for people to stay healthy. ‘Sometimes those building blocks can be missing for some people or need repairing,’ she says.
In the short term, some experts believe there is mileage in using so-called ‘sin taxes’ on unhealthy foods. The existing Soft Drinks Levy has raised approximately £300 million which has been used to fund school breakfast and school sports programs. Mr Slade believes initiatives like these should be continued to help improve access to nutrition and deal with food insecurity. The OHA advocates extending the Soft Drinks Levy to other products with high fat, sugar and salt content. ‘Revenue has got to be invested back into measures to make healthy food more accessible, such as expanding free school meals, having healthy start vouchers and increasing the number of health visitors,’ explains Mr Slade.
In terms of improving access to healthier food and services, Ms Page proposes that local authorities use their planning powers to limit the number of takeaways near schools, thus reducing children’s exposure to junk food. Ms Collett believes that more needs to be invested into social prescribing and community-based support such as school nursing services, youth clubs, early help and leisure facilities. As well as trying to change the stigma around obesity which is the real barrier to improved health. ‘I’m not denying that for some children in a bigger body there are potential negative effects on their health, however this is also the case for some children in smaller bodies, and the stigma surrounding bigger bodies is often what prevents children engaging in those health promoting behaviours that could counteract that negative impact,’ says Ms Collett.
And here’s the rub, because it isn’t just a child’s external environment, which can trap them in a cycle of obesity and poorer life chances. It can be their inner life as well. Weight stigma can be one of the biggest impacts of a child living with obesity or being overweight. ‘The negative associations with the work ‘fat’ are unacceptable, and for many children in bigger bodies, the experiences of being called names or bullied at school can have a significant impact on them’, said Ms Collett.
Conclusion
Children may feel reluctant to seek out help, take part in PE lessons, struggle to make friends or suffer from poor mental health, which can affect their educational attainment and prevents them from fulfilling their potential, career wise. ‘The child may not necessarily be able to achieve as much as they possibly could do which means potentially living in poverty again because they’re not having the income they could have been earning,’ says Dr Fisher.
This can become an intergenerational issue as the individual continues to live in poverty during adulthood which potential children will also be subject to. Perhaps a cultural shift is just as important as a socioeconomic one in finally breaking this cycle, to help narrow the widening health inequalities or risk circumstances becoming worse. ‘Very soon, healthy weights will be a luxury for the wealthiest communities,’ warns Mr Slade.