Impact of UK Government Strategies on Childhood Obesity

This study evaluates the impact of UK government policies implemented to reduce the rate of childhood obesity, identifies gaps and strengths in past government strategies, and recommends innovative solutions to improve the efficacy of government strategies to prevent obesity.

Impact of UK government strategies to deal with childhood obesity
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Acknowledgement
Performing this particular research has been most knowledge gaining experiences of my
academic life. This research is sure to increase my knowledge base and analytical skill. It also
provided me the opportunity to experience the new challenges in research work. All this, would
be impossible without the dedicated support that I have received from my professors, seniors and
friends. I would like to take this opportunity to thank my supervisor ----------------------- for his
constant guidance and support and encouragement. Moreover, I liked to extend my gratitude to
library staffs for their kind help and support.
Lastly, I would like to thank the health and social care staffs who gave idea regarding various
obesity prevention campaigns launched in UK. The constant support received from all these
persons has been extremely inspiring. It has enlightened me with the thought process of the
research.
Warmest wishes,
Yours Sincerely,

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Abstract:
Introduction and background:
Obesity is a major public health burden and health care of UK has been facing great
burden due to obesity epidemic. Obesity prevalence rate has tripled in last 30 years and it is
estimated to reach 11 million by 2030. With the increase in prevalence rate, despite
implementation of several policies by the UK government, evaluating the strength and weakness
of past government strategy is essential.
Aim:
The main aim of the study is to evaluate the impact of government policies implemented
in UK to reduce the rate of childhood obesity, identify gaps and strength in past government
strategies and recommend innovative solutions to improve efficacy of government strategies to
prevent obesity.
Method:
Narrative review method has been used to explore past strategies and campaigns in an
effective manner. Thematic review method has been used to present research findings.
Results:
The narrative review of research articles gives idea about the strength gaps in government
strategies like social marketing campaigns, population based strategy, food marketing and food
tax policies, nutritional strategies and school related obesity prevention programs. The narrative
review describes results of each campaign.
Conclusion:
On the whole, majority of past strategies were found to be ineffective in reducing the
prevalence of obesity. Apart from various environmental factors, gaps in implementation process
were also found. Increasing the scope of advertising restrictions and narrowing focus of social
marketing campaigns were some recommended actions to have wider impact in the future.

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Table of Contents
Chapter 1: Introduction....................................................................................................................2
Chapter 2: Background and Rational...............................................................................................3
Chapter 3: Methodology..................................................................................................................5
Chapter 4: Presentation of main findings from the literature review:.............................................8
Chapter 5: Discussion and conclusion:..........................................................................................21
References:....................................................................................................................................28

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Chapter 1: Introduction
Obesity is defined as the abnormal accumulation of fat resulting in health issues for
people (Williams et al. 2015). Childhood obesity is one of the major concern for public health
department currently as the issue is prevalent globally both in developed countries and many low
and middle income countries (Patrick et al. 2013). Based on World Health Organization report,
the global prevalence is understood from the fact that in 2016, more than 41 million children
under the age of five were overweight (World Health Organization 2016). Apart from developed
countries, the prevalence rate is also increasing in developing countries. Majority of obese
children continue to be overweight during adulthood and they are most likely to suffer from
chronic diseases like diabetes and cardiovascular disease in the future (Patrick et al. 2013).
Hence, identifying the cause of childhood obesity and evaluating government strategies to tackle
the epidemic would have long consequences.
The problem of weight gain and obesity mostly arise because of the imbalance between
energy intake and expenditure. Although genetic background of an individual significantly
increases the risk of childhood obesity, however child specific risk factors for obesity include
sedentary behaviour, dietary intake and physical activity. These factors differ based on age and
gender. Family characteristics such as parenting style and environmental factors such as free
space and lifestyle also influence eating behaviour of children (Sahoo et al. 2015). Patrick et al.
(2013) argues that parents facilitate positive eating patterns and their parenting style significantly
influence risk factor of obesity. Reviewing parenting practices such as limiting screen time and
focus on physical activity may help to evaluate the cause of obesity in children. Several

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government policies and strategies in different countries target the risk factors and implement
interventions accordingly to deal with the problem of childhood obesity.
In UK, childhood obesity prevalence is going to epidemic levels. Prevalence of obesity
in UK has tripled in the last 30 years and the considering current rate, it is estimated that the
prevalence rate may reach up to 11 million by 2030. Hence, obesity is one of the leading
preventable diseases in UK and in Europe, it is the leading contributor of obesity epidemic with a
contribution of about 24.9% (Renewbariatrics. 2017). As this may have long term consequences
on the health of UK population and increase the burden of the health care system too, evaluating
government’s action taken so far in UK may help to identify the future action that can resolve the
issue of childhood obesity. The main aim of the dissertation is to conduct a narrative literature
review to understand the impact of UK government policies related to childhood obesity and
understand the strength and weakness of government’s action to deal with obesity. This may help
to identify gaps in current policies and future amendment needs to efficiently deal with
challenges of obesity.
Chapter 2: Background and Rational
Childhood obesity is turning out to be an epidemic in developed countries. UK is also one
of the countries that are currently experiencing childhood obesity. This is evident from the fact
that about one in every five children in primary schools is obese (Royal Society for Public Health
(RSPH) 2017). The health survey data for childhood obesity prevalence in England revealed that
one in every five children were obese in 2015/2016. The prevalence is also linked with level of
deprivation as children living in the most deprived areas were most likely to be obese than in the
least deprived areas. Difference in prevalence rate also differs based on ethnic diversity as the

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health survey data for England revealed high prevalence rate for Black/Black British children
(15%) compared to Chinese children (7%) (National Statistics 2017). In the long term, such
prevalence rate can have significant impact on the long-term future of the NHS (National Health
Services) and physical and mental health consequences for affected children. The burden for
NHS will increase due to prevalence of a number of physical health issues associated with
obesity such as cancer, asthma, respiratory problem and diabetes. It may also increase risk of
psychological problems such as anxiety, poor self-esteem and poor body image among children
(Sahoo et al. 2015).
Obesity is one of the preventable diseases has that increased the burden of the health care
system in UK too. Due to the increased diagnosis of childhood obesity and its long term impact
on physical health, UK government has spend about 48 billion pounds a year to take preventive
action against obesity. With the increase in rate each year, the NHS cost may double to 10 billion
pound a year by 2050 (Royal Society for Public Health (RSPH) 2017). To save the extra expense
spend of health issues related to obesity, implementation of effective intervention to lower the
rate of childhood obesity would be needed. Diagnosis of obesity increases many risk for affected
individual compared to a healthy individual. For example, obese people are five times more
susceptible to type 2 diabetes and two time more likely to develop blood pressure compared to
healthy individuals (Toplak et al. 2016). This in future can increase the likelihood of
cardiovascular disease and reduce life expectancy of the population. Hence, to increase the life
expectancy rate of the UK population, decreasing BMI can reduce life expectancy, promote
health and reduce health care associated cost too.
The main rational for reviewing and critically evaluating UK policies related to childhood
obesity by means of a narrative review is the increase in childhood obesity prevalence each year

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and little evidence of cost reduction due to implementation of policies or campaigns to prevent
obesity. Jebb, Aveyard and Hawkes (2013) states that obesity as health threat to the nation was
identified long back by the Conservative government in England. Since, then formal government
strategies were implemented in 2008 and 2011 to prevent childhood obesity. These targeted
active sports participating in schools, fruits and vegetable intake in children, eating habits, diet
status, park use and walking levels in children. Many new government policies for marketing
restriction in foods high in fats, sugar and salt, nutritional standards in schools, weight
management and sport programs were also developed. Annual surveys shows reduction in
obesity rates in recent years, however the problem has not been reversed. Hence, review of
research papers investigating about the impact of different government policies in UK may help
to determine gap in current child obesity prevention initiative and find out more about ways to
reduce issues found in past government strategies related to childhood obesity. It may help to
improve the implementation process and other challenges found in implementing government
strategies.
Aim and objectives:
The main aim of the study is to evaluate the impact of government policies implemented
in UK to reduce the rate of childhood obesity and other challenges associated with childhood
obesity.
The main objectives of the narrative review are
 To identify and evaluate different policies implemented in UK to prevent and control
childhood obesity

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 To identify gaps and strength in past government strategies related to childhood obesity
prevention
 To recommend future action to improve the efficacy of government strategies and
campaigns to reduce childhood obesity and other health concerns for the affected
population
Chapter 3: Methodology
Research design:
As the main aim of the research is to critically evaluate UK government policies related
to childhood obesity prevention, narrative literature review method has been chosen as the
research design for the study. Narrative reviews critically evaluates different primary studies
specific to the research topics and focus on holistic interpretation based on current theories
practice. Narrative reviews are suitable research design when the purpose of the research is get
comprehensive information related to a research (Hart 2018). This research design may help to
individually evaluate different policies in the area of food marketing, food and nutrition, physical
activity and school programs in UK to prevent childhood obesity. In contrast to systematic
review, a narrative review presents findings of a research in a condensed format that summarizes
and critiques each study (Green, Johnson and Adams 2006). Therefore, narrative review method
can help to present broad perspective related to the obesity prevention policies in UK and
identify improvements needed in current policy initiative.
Search strategy:
Search strategy is the process used to organize the search process and find relevant
articles related to the research topic and research objective. A comprehensive search for relevant

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literature is guided by specific search terms, selection criteria, critical assessment or evaluation
and data analysis process. Keywords and eligibility criteria forms the basis of searching articles
from relevant databases. Apart from key words, several phrases, Boolean operators and subject
headings also helps to retrieved relevant articles for reviewing the literature. For this research
wide variety of key words were used to find articles as the aim was to evaluate diverse range of
UK government policies related to obesity prevention. The search for articles were done from
PubMed, Medline and CINAHL databases and the key search terms included in the search
includes ‘childhood obesity’, ‘child obesity in UK’ and UK policy related to childhood obesity.
This was the primary search terms. Based on the identification of different UK policies, other
secondary search terms were also used to find relevant literature related to the topic. Boolean
operators like ‘AND’ and ‘OR’ was also used for searching articles from CINAHL databases.
The Boolean operators helped to separate different phrases and arrange key terms similar in
meaning. Hence, use of ‘AND’ narrowed down the search process to get more information on
policies and the use of ‘OR’ broadened the search hits by including all studies that is relevant to
childhood obesity.
Inclusion and exclusion criteria:
Setting eligibility criteria in a literature review supports a researcher in the search process
and selection of articles for research. To find research articles relevant to the impact of UK
government policies on dealing with childhood obesity, the following inclusion criteria where
developed:
 All research articles must critically evaluate UK policies related to obesity
 The article should give detail on research findings from UK

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 All research articles must be published within 2008 to 2018
 Articles published in English language should be included in the literature review
To get relevant research articles and segregate those which are not specific to the research
question, the following exclusion criteria were taken:
 Articles published before 2008 will be excluded from the review
 Articles published in other language other than English will not be taken in the review
 Articles which gives details on strategies implemented in other countries other than UK
will be excluded
 Articles discussion about adult obesity will be excluded
Data analysis:
Different qualitative research has different techniques for conducting and documenting
data analysis process. Thematic analysis is one of the data analysis methods that enable
developing sensitive and rich research findings. The advantage of thematic analysis method is
that it can be utilized to answer different types of research questions and epistemiology.
Thematic analysis has a flexible research approach and the findings presented in the form of
themes helps in easy grasp of research findings. A clear and organized report can be easily
produced through thematic analysis research methods (Nowell et al. 2017). However, the
common challenge in writing a thematic analysis is that it often contributes to many
inconsistency and lack of coherence while developing themes for research findings. However,
consistency can be improved by making explicit epistemiological position.
After selection of research articles based on inclusion and exclusion criteria and by
setting search limits, articles were analysed in two stages. In the first stage, the title and abstract

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were analysed to find its suitability to answer research question. In the second stage, the full text
articles were read to critically appraise research findings and identify strength and weakness of
UK policies related to childhood obesity. The findings were presented in the form of themes
according to thematic analysis of research literature. Thematic analysis is a method of data
synthesis, where the focus is to identify patterned meaning across wide range of data and analyse
research findings based on the identified themes (Braun, Clarke and Terry 2014). Thematic
analysis supports a researcher to find meaning in unrelated research materials and systematically
gain knowledge phenomenon or topic of interest. Thematic analysis is also a useful research
method when the purpose is to review large number of qualitative data (Braun and Clarke 2014).
Therefore, thematic analysis can yield useful research for this narrative review too.
Chapter 4: Presentation of main findings from the literature review:
Social marketing campaigns implemented in UK had large focus and very few positive outcomes:
Numerous initiatives were implemented by the UK government at school level to prevent
risk of childhood obesity. The Change4Life (C4L) was one of the campaigns that focused on
fulfilling the needs of physically inactive children. The research by Croker, Lucas and Wardle
(2012) investigated about the impact of C4L campaign on preventing obesity in England. C4L
targeted was a primary prevention approach launched in January 2009 in UK to prevent
childhood obesity. The social marketing campaign emphasized on targeted message to raise
awareness regarding long term consequences of overweight and obesity, developing healthier
habits and reducing consumption of foods high in fat and sugars. Families with children between
1-11 years and pregnant women were targeted and research participants were selected based on
research on people exhibiting behaviour and attitude that can increase risk of children becoming

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obese. The main aim of the randomized controlled study design was to evaluate the impact of
C4L on parent’s attitude towards children, activity and weight and diet and activity behaviours of
parents and children. Targeting parent’s knowledge and attitude towards childhood obesity is a
beneficial step as it promotes acquisition of correct attitudes and encourages good practices to
manage obesity at family level (Mabiala Babela et al. 2015).
The C4L campaign included four phases to systematically educate parents regarding
obesity and schools were randomized to intervention and control group. The main outcome
measure included child behaviour, parent behaviour and attitudinal change after the campaign.
The review of research findings revealed that 75% of families were aware of the campaign and
awareness increased in both group at follow-up. Another significant finding was that near-
significant association was found between socioeconomic status (SES) and rating of physical
activity importance. Parent’s had varying views about the campaign and many reported that have
already implemented the recommended behaviour or the recommendations are unrealistic.
Hence, from these outcomes, it can be concluded that family information pack significantly
(Croker, Lucas and Wardle 2012). The intervention increased awareness about the campaign on
parents, however very few positive influences on attitudes or behaviours of parents were seen.
This is inconsistent with other social marketing campaigns which have achieved positive effects
such as improved attitude towards preventing obesity. This points out to several limitations in the
C4L campaign. Some limitations include not taking personalized feedback from parents and
having a wide and complex focus. It targeted both complex diet and activity behaviours. Single
interventions could have yield desirable results. The VERB was a campaign that focused on
promoting physical activity in children and use of single intervention helped in achieving

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positive physical activity outcomes and also sustains the effect for longer time (Huhman et al.
2010).
Population based strategies to deal with childhood obesity:
Preventing obesity requires population based approach as this helps to consider wide
range of policy and environmental change strategies needed to target food access and food
intake. Implementation of strategies in diverse setting is crucial to access whole population at
risk (Brownson et al. 2017). Jebb, Aveyard and Hawkes (2013) reviewed all types of actions
taken by the UK government to control obesity and strategies were implemented at various
setting to target obesity prevention. Among early year interventions, the Family Nurse
Partnership (FNP) was one of the interventions that were implemented by the UK government in
2007. It was a structured home visiting program that offered first-time mothers training stop
smoking during pregnancy, increase breastfeeding and improve self-esteem (Owen-Jones et al.
2013). The main rational for this type of intervention was that encouraging breastfeeding helps a
child to develop healthy eating patterns. Yan et al. (2015) explains that breastfeeding babies are
better able to regulate their food intake and prevent the risk of obesity. It reduces risk of non-
communicable disease like obesity and diabetes in later life. Hence, breast feeding is regarded as
factor that can protect children from weight gain and obesity.
The review of research literature gave rise to two research articles that evaluated the
impact of the Family Nurse Partnership programme for teenage mothers in England. Robling et
al. (2017) evaluated the effectiveness of the FNP program on infant and maternal outcomes up to
24 months after birth. Non-blinded randomized trial was done in community midwifery setting in

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England and women aged 19 years or younger. Nurses received special training for the
programme. The main primary outcome of the programme was tobacco use, birth weight and
hospital admissions for the infant within 24 months of birth. Secondary outcomes included child
health and development outcomes and parental life course post the programme. The analysis of
research findings revealed no difference in smoking outcome between mothers in FNP and usual
care group. The rate of emergency attendance within 24 months of child’s birth also did not
differed between the two groups. This suggested limited or no positive impact of the FNP.
However, for secondary outcomes, very minor positive effect was found in the area of child
cognitive development and language development. On the whole, no positive effect of the
program was found. The outcome also shows that FNP is not a cost-effective strategy
implemented by the government. Hence, introducing FNP cannot reduce the burden of the UK
health care system due to obesity.
The Health Weight, Healthy Lives (HWHL) was one of the population based strategy
implemented in England to reduce the burden of obesity. The government published the HWHL
strategy to deal with obesity and it focuses on five themes. The five streams included health
growth and healthy weight for children, promoting healthier food choices, personalized advice
and support and building physical activity. The HWHL ran till March 2010 and it was replaced
with a new strategy by Novermber 10 (Jebb, Aveyard and Hawkes 2013). Hawkes, Ahern and
Jebb (2014) aimed to investigate about the impact of HWHL strategy on bringing changes in
action to address obesity in England. Qualitative research method with the use of semi-structured
interview method wasdone to evaluate perspective of 40 stakeholders involved in the
development and implementation of obesity strategy. Purposive sampling strategy helped to
recruit target population for the study and evaluate wide range of perspective related to the

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success or failure of HWHL. The interview results revealed that all respondents had clear
perception regarding the development of the strategy. The most dominant finding was that it was
perceived the Strategy led to many positive outcomes and it facilitated cross-government
engagement with the strategy. Special focus on child also facilitated relationship building.
However, the strategy failed to get desired results at all government departments because of poor
evaluation of different programs due to wide range of interaction actors and setting. In future,
there is a need for UK government to adopt a systematic process of aligning goals and
implementing transparent system to report changes in obesity rates.
The mounting prevalence of childhood obesity in the UK has been a key concern for
healthcare professionals. The rapid rise in the health condition is known to pose a great public
health challenge. As highlighted by Willis et al. (2013) about one-quarter of children in the
country suffer from obesity or overweight at the time when they attain admission to school.
Different arguments have come forward regarding the preventive strategies implemented by the
government that point out that initiatives are scarce in amount that target infants. Evaluations
carried our earlier on HENRY (Health Exercise Nutrition for the Really Young) had indicated
that improvement can be achieved in the manner in which practitioners work in collaboration
with families for having a positive impact on their life style. HENRY is a distinct initiative
widely implemented across UK. The aim of the program is to address childhood obesity at the
early stages through provision of training for health practitioners. The primary objectives of
HENRY are betterment of parenting, effective eating pattern, healthy eating, increased physical
activity and uplifted emotional well-being (Willis et al. 2016).
Willis et al. (2013) carried out an investigation of the effect of a program designed for
providing parents of children attending preschool with education that guide healthier lifestyle. A

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cohort of families were considered for the study across the 8 week HENRY parent course. The
settings were nine different locations in England. A total number of 77 parents had given
enrolment and 71 completed questionnaires that focused on eating behaviors, parental self-
efficacy and dietary intake. 60 parents provided data before and after the course, and analysis
was done with the help of repeated measures analysis. The results indicated significant changes
which was sustainable even at the time of follow-up. There was an increase in self-efficacy and
capability of encouraging good behavior (P < 0.001). Adults and children both reported increase
in the consumption of vegetables and fruits. A positive change in terms of eating behavior was
also reported. The study indicated that the HENRY intervention had been effective in bringing
about a positive impact on preschool children and families. In addition, it was suggested that
there is a possibility that the positive changes brought about can be sustained till a later period.
The paper of Poobalan et al. (2010) focused on analyzing the present UK
recommendations on obesity with the help of a proposed framework. As per the researchers,
experts have been continually attempting to identify, appraise and synthesize existing evidence
on policies implemented so that recommendation for future practice can come into focus. The
background to the study was that recommendations, though based on evidence, have not been
always able to formulate strategies that can be readily implemented (Selbie 2018). Poobalan et
al. (2010) considered two bibliographic databases, Embase and Medline, along with varied
government websites, for researching for recommendations provided on obesity between the
years 1996 and 2007. The relevant documents were assessed that considered obesity prevention
and treatment recommendations in UK. Critical appraisal of the articles was done and results
were summarized as per a framework. The chief result that emerged was that most of the
recommendations that were present on obesity failed to meet the standards of implementation.

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The recommendations did not have a clearly outlined structure for monitoring, and further, no
particular time frame was mentioned. In addition, the cost of implementing the same was not
appropriately estimated along with the stakeholders for implementation. There was however
some exemptions to it which are mainly locally implemented strategies.
Impact of UK government action related to food marketing and food tax to prevent obesity:
Different types of policies have been developed over the time to deal with childhood
obesity. This also involved UK government’s action to restrict advertising of certain foods to
children. Public Health advocates in England started focussing on advertising restriction as
marketing focused mainly on less healthy food products (Food Foundation 2017). In 2010, the
World Health Organization proposed 12 recommendations on marketing food and beverage to
children. This included recommendations to reduce exposure of children high fat, salt or sugar
(World Health Organization 2016). New regulations related to the content for food advertising to
children were announced in 2007 and the UK government implemented prohibition of
advertisement for foods high in fat, salt and sugar (HFSS) (Adams et al. 2012).
The research article by Adams et al. (2012) explored the consequences and impact of the
2007 UK food advertising restrictions on children’s purchase request and consumption pattern. A
cross-sectional study design was used to evaluate all advertisements broadcast in the Tyne Tees
region of the week for one week before and after the regulation. The HFSS status of advertised
food was also calculated. The analysis of research findings revealed gave data on exposure to
HFSS food advertising before and after the HFSS advertising restriction. In the period between
six months before and after the restriction, the exposure to HFSS advertising for children above 4
years was found to increase. This also happened despite adherence to the scheduling restriction.

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Hence, the scheduling restriction could not achieve the desired results. However, this result was
obtained because of a number of limitations in collecting data. Firstly, the research was
dependent on secondary data as it was not possible to view all the advertisements. Hence,
analysis of all types of food products being advertised could not be done. Another major
limitation of the study was that it did not evaluated impact of the restriction on purchasing and
consumption pattern and bodyweight. However, this was necessary because use of attractive
media character is brand advertising has a powerful impact on children’s food choices and
buying behaviour (Kraak and Story 2015).
The study by Adams et al. (2012) also gave the insight that the UK HFSS food
advertising restriction did no worked despite even though advertised adhered to the restrictions.
This result indicates that children are exposed to wide range of television than programmes
targeted only for children. The report by the Food Foundation (2017) also argues that UK
government implemented highly focused restrictions within regulated advertising challenges.
Children were exposed to HFSS advertising because children and young people watch other
programmes without restriction too. For example, certain programmes like X Factor and the
Simpsons at not targeted for children. However, these attract large attention of children and
young adults. The results gives implication for future improvement in policy and the need to
consider wide range of advertising to control unhealthy consumption pattern among UK
children. Hence, in future also, controlling the harmful role of marketing on children’s food
preference and obesity is important. Kraak and Story (2015) explains that children prefer foods
high in sweets and salts because of their current food environment and their understanding of
food brand logos further increase the craving and preference for fast food and sugar sweetened

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beverages. Kotler, Schiffman and Hanson (2012) argues that media character branding promote
use of energy dense foods among children and increases their purchase request too.
The research by Briggs et al. (2017) is considered relevant in relation to the
research topic and the theme of food marketing legislation as it conducts health impact
assessment of the UK soft drinks industry levy. The advertising restriction targeted reduction in
consumption of high fat, sugar and sweet foods. In addition, the research focused on analysis of
the UK soft drinks industry levy. The main rational for the research was the introduction of
tiered levy on sugar sweetened beverage by the UK government. In 2016, the UK government
imposed high taxes for drinks which have greater than 8 g of sugar per 100 ml, moderate tax for
5-8 g and no tax for less than 5 g sugar/100 ml. To maximise the health gain due to the soft
drinks levy, the main goal of the intervention was to evaluate the impact of various industry
responses on health. A risk assessment model was developed to estimate the effect of soft drink
price changes of obesity, dental caries and type 2 diabetes in UK. The evaluation of different
industry responses revealed that health effect is sensitive to the way the soft drink industry
responds to the levy. In accordance with this result, the results give the implication to constantly
monitor the implementation strategies taken by the industries to estimate long term effect on
health and obesity. Ma et al. (2016) gives the implication that such actions have the potential to
gradually reduce sugar in soft drinks and reduce health issues such as obesity and type 2
diabetes.
Impact of nutritional strategies on childhood obesity in UK:
Rayfield at et al. (2015) explored the relationship between breastfeeding support and
breastfeeding among late preterm in 34–36 weeks of gestation and term infants in ≥37 weeks of

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gestation. The positive impact of breastfeeding on decreasing childhood obesity has been
acknowledged by the UK government since long. Breastfeeding support has been initiated across
the country at different levels so that women can consider appropriate breastfeeding for the
newborns. A number of healthcare units offer support sessions to new mothers that includes
breastfeeding counsellors (Yan et al. 2014). A growing pool of literature suggests that
breastfeeding is effective in combating non-communicable diseases in later stages of life that
includes protection against obesity and overweight in childhood. Different plausible mechanisms
that support the concept have come forward. Breastfeeding preludes complementary feeding
practices that contribute to weight gain in an unhealthy manner. Intake of total energy is found to
be higher in those who have been formula-fed (Bider-Canfield et al. 2017). The article by
Rayfield at et al. (2015) aimed at understanding the effectiveness of breastfeeding support on
rate of breastfeeding in UK. The researchers carried out a secondary analysis of the UK 2010
Infant Feeding survey which aims at monitoring breastfeeding prevalence. They considered
carrying out logistic regression for determining the association of breastfeeding support with
breastfeeding at 10 days as well as 6 weeks in late preterm and term infants. The study
considered 14,525 term and 579 late preterm infants. 11,729 infants were initiated with
breastfeeding of which 81.8% were term and 79.4% were late preterm infants (p=0.425).
Mothers who stated that they were provided with contact details of breastfeeding support groups
demonstrated more chances of breastfeeding later preterm and term infants at 10 days and term
infants at 6 weeks. Mothers reporting that contact information about breastfeeding support
groups were not given to them had less chances of breastfeeding late preterm at 10 days and term
infants at 10 days and 6 weeks when comparison was done with mothers receiving the
information.

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It was concluded from the study receiving help and support regarding breastfeeding in
hospital is beneficial to a considerable extent, as increasing contact leads to higher rates of
breastfeeding. The research considered many confounding factors and eliminated them during
research process such as socioeconomic status, ethnicity, marital status and education level of
mother. This was significant since breastfeeding is largely associated with varied socio-
demographic factors (Onah et al. 2014).
Impact of school related policy on preventing childhood obesity in UK:
Many schools were also targeted by UK government to promote healthy eating habits in
children. The School Fruit and Vegetable Scheme (SFVS) was launched in 2004 and in
accordance with the scheme, each children between 4-6 years old were provided with a fruit and
a vegetable every day. The main rational for implementing such scheme was that it could
improve children’s diet and support a child in developing healthy eating habits (Jebb, Aveyard
and Hawkes 2013). In accordance with the scheme, 440 million fruits and vegetable have been
distributed in 18000 schools in recent years (Hughes et al. 2012). School can regarded as an ideal
target to find solutions to a public health crisis like obesity. This can be said because school
provides an ideal environment for physical activity promotion, nutrition education and nutritious
offering. Implementing effective interventions at this stage facilitates building life-long health
habits in children. While implementing school based obesity prevention intervention, proper
consideration of research design and tailored intervention is useful to get the desired results
(Ickes et al. 2014). This section provides review of school based intervention implemented in UK
to deal with childhood obesity.

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Hughes et al. (2012) investigated about the impact of the SFVS scheme on improvement
in daily intake of fruit and vegetables across England. The main aim of the intervention was to
support children to develop life-long healthy habits and reduce the prevalence of childhood
obesity. The research in this area is important as it was a high scale intervention and evaluating
the success of the scheme can have long-term implications on obesity prevention. The daily
intake of fruits and vegetables were assessed from a cross-sectional sample of children aged 6-7
years. Dietary data was collected using the CADET (Child Diet and Evaluation Tool) and all
types of food and drinks consumed by the children were recorded. Out of 3296 CADET
distributed, 2709 were completed. The analysis of the CADET datasets revealed that 61.6% of
the children ate at least one fruit or vegetable from the SFVS and 59.2% ate fruits and vegetables
five times of the days. The assessment of fruit and vegetable intake was also done according to
geographical areas. Frequency of consumption was found to be higher in South England and the
participation rate was higher in Northern England. This indicates that the SFVS did not
influenced intake of fruits and vegetables. However, the strength of the study is that it highlights
the problem of poor diet in children in England as low levels of healthy foods were consumed by
children. The intervention was also found to have greatest impact in more deprived areas.
However, this is inconsistent with other research studies as Hollis et al. (2016) revealed little
impact of school based intervention on adiposity outcomes.
Taking lessons from the result obtained for SFVS scheme, it can be said that SFVS might
have been unsuccessful because of several reasons. For example, the SFVS targeted only one
meal event which was the morning break. However, targeting more meals would have given
more number of positive outcomes (Hughes et al. 2012). Hence, at school level, the UK
government could have taken the initiative to target parents and educate them regarding

23
providing healthy packed lunch to student. The benefits of such initiative is understood from a
research study by Evans et al. (2010) that implemented a lunch box intervention to improve the
quality of school children packed lunches. The cluster randomized controlled trial was done in
89 primary schools across UK. During the first phase of the intervention, all parents were
provided a SMART lunch box cooler bag. In the second phase, all parents were given
information leaflet on encouraging children to eat variety of nutritious foods. In the last phase,
families were recipe books and menus. The main goal of the intervention was to increase
consumption of nutrient rich food among children. The intervention led to small improvement in
food and nutrient content of children’s packed lunches. There were no significant limitations in
research design except the fact that only one meal was assessed throughout the day. However, to
have population level impact, large improvement is needed to tackle the obesity epidemic.
The article of Ransley et al. (2007) evaluated the impact of School Fruit and Vegetable
Scheme (SFVS) on diet of children. Research had suggested that young people and children do
not consume fruits and vegetables to an extent that can be beneficial for their health. National
Diet and Nutrition Survey in England had pointed out that those in the age group of 4 and 18
years consume lesser amount of fruit and vegetable than the recommended amount. For
addressing the health and dietary concerns of children in the country, the government had
considered implementing the ‘5 A DAY program’ for raising awareness on the benefits on eating
fruits and vegetables. A crucial aspect of the program is the School Fruit and Vegetable Scheme
(SFVS) that had been articulated as a government strategy for addressing the low intakes of
fruits and vegetables (Methner et al. 2017). It has been reported that the SFVS is the largest scale
intervention in diet of children living in England after free school milk was introduced across the

24
country. The scheme aimed at distributing 440 million pieces of vegetables and fruits annually to
around two million school children across 18000 schools (Lucas et al. 2017).
Ransley et al. (2007) carried out a non-randomized controlled trial with infant and
primary schools situated in northern part of England. A total number of 3707 children took part
in the study whose age was between four and six years, studying at reception, year 1 and year 2.
The intervention was that each child was provided with one portion of fruit or vegetable on every
school day for eleven months. The primary outcomes to be measured were intake of nutrients in
the form of fruit and vegetable consumption. The results indicated that there was an association
between the SVFS and increased intake of fruits across year 1 and reception students 0.6 portions
(95% confidence interval, 0.4 to 0.9), and of 0.4 portions (0.2 to 0.5) respectively. In year 2 there
was an association with increase of 0.5 portions (0.2 to 0.7) of fruit at three months. On the
whole, at seven months, no changes were evident in consumption of vegetable. Further, no
association was evident between fat, salt or energy intake, and SFVS. In addition, small changes
were evident in intake of Vitamin C or carotene. The main inference drawn from the research
was that the SFVS was effective in promoting increase in intake of fruits among children after
three months. At seven months there was a reduced effect of the scheme but the same was
significant. Overall, the impact on the nutrient intake was considerably small across the gamut of
children surveyed. It was therefore recommended that future interventions would be crucial for
preventing the waning of the impact brought about by SVFS.
Chapter 5: Discussion and conclusion:
Childhood obesity has been recorded as a significant public health concern at the
contemporary era, increasing the healthcare costs of the country and the burden on healthcare

25
providers. As per the report of UK government, about one third of children with age between two
and fifteen years were obese or overweight in the year 2016. It was also reported that the
younger generation is increasingly becoming obese at an earlier stage. Reduction of level of
obesity at the primitive stage is essential since obese children are more likely to remain obese as
adults. Children are also at a risk of developing poor health conditions such as type 2 diabetes
and hypertension as a result of their obese condition (Selbie 2018). The economic costs related to
childhood obesity are also high, and every year the UK government is compelled to spend a
considerable amount of money for combating childhood obesity and adult obesity. The NHS in
UK had to spend about 5.1 billion on obesity-related ill-health conditions in the year 2014-15.
According to Perry, Thurston and Arch (2015) childhood obesity is to be considered as a
complex health problem that has varied drivers, including environment, behaviors, culture and
genetics. The UK government in the past few decades has attempted continually to bring
significant improvement in the prevalence of childhood obesity and reduce the economic burden
of the condition. The strategies take up the government had been articulated with confidence to
bring reduction in childhood obesity while giving respect to the economics of the country. The
different strategies had strived to be clear in the goals and objectives so that firm actions could
be taken (Braillon 2018).
The results of the present review indicated that HENRY (Health Exercise Nutrition for
the Really Young) holds the potential to bring improvement in the way in which healthcare
practitioners work with families to educate them and augment their lifestyles. It is therefore to
the stated that there is an urgent need of similar initiatives in the future that can consider
changing parenting patterns, healthy eating patterns and physical activity, all contributing to the
wellbeing of children. As opined by Wilfrey et al. (2017) healthcare professionals are to be

26
supported with training and resources so that they can guide parents regarding the eating patterns
of their child. There is a need of health professionals to feel confident about discussing sensitive
issues regarding child nutrition and weight issues of children with families. For supporting the
ambition, different suites of resources are to be given for making every contact with the families
effective. The resources are to be in the form of training that can overcome challenges in difficult
conversation on behavior change (Rosemond et al. 2016). There is also a need of reviewing the
existing materials about nutrition and childhood obesity that can encourage professionals to
impart education (Sugiyama et al. 2016).
Moving on to breastfeeding strategies for curbing childhood obesity, it is already
highlighted that breastfeeding support provided to mothers can augment the prevalence of
breastfeeding that is directly linked with obesity prevention. As children grow older, the effects
of breastfeeding are more evident which are exclusive. Breastfeeding cessation is a common
problem among mothers across the globe and the contributory factors are diverse, including
psychosocial, biophysical and socio-demographic factors and hospital practices (Wang et al.
2017). It is therefore highly relevant that healthcare professionals have a proactive approach in
providing new mothers with instrumental and informational support interventions which aim at
increasing breastfeeding rate. It can be pointed out from literature that in-person professional
support would be more effective in place of remote support provided to mothers (Loiselle et a.
2016). In contrast, regular contact over the phone might be helpful in addressing the concerns of
mothers after their discharge from the hospital on a regular basis. Support provided over the
phone is more beneficial when there is a lack of other types of support (Fox, McMullen and
Newburn, 2015). Fu et al. (2014) suggested that a combination of personal support in adjunct with
telephone support would be ideal for increasing awareness level of mothers regarding

27
breastfeeding. The rationale for a combination support provision would be that an in-person
support provision might be economically and logistically challenging.
At this juncture it would be desirable to discuss about the School fruits and vegetable
scheme (SFVS) that holds potential to increase healthy food consumption among children.
Strategies aligned with the objective in tackling health conditions such as obesity, heart disease
and cancer are noteworthy (Evans et al. 2012). Criticizing such scheme, Bere et al. (2015)
highlighted that the government’s program for promoting fruits and vegetables in schools might
be hit by any reduction on health spending. Such freezes on health spending on the government’s
part might be a result of a thorough and accurate evaluation that such programs bring in
negligible impact on consumption of fruits and vegetables on the long run. Staff managing for
successful implementation of the same might also be challenging.
In accordance with the aim and objective of the research, strengths and gaps were
identified in UK government’s action to restrict HFSS advertising to children. Targeting food
marketing and advertising was a powerful strategy as it had the potential to address children’s
food preferences and choices for energy dense and unhealthy foods. The strategy has the
potential to change the obesogenic environment around UK children. Obesogenic environment
can be defined as the combination of all factors that influence the surroundings and increase the
opportunity for promoting obesity in a individual or a population. Television is a strong medium
that increases children’s exposure to unhealthy food products and this could be targeted to reduce
children’s preference for unhealthy food (Boyland and Whalen 2015). However, the review of
the research study by Adams et al. (2012) revealed failure of the UK HFSS advertising
restriction on food choices. Although there were many methodological limitations in the study
that affected the generalisability of the research findings, however several loopholes in UK

28
government strategy has also been found. The strategy was not successful because it targeted
only programs for children, however in reality children were exposed too many other
programmes too. Recognizing several loopholes in the HFSS advertising restriction strategy,
Public Health England recommended implementing tighter restrictions on brand advertising and
bringing sports and near-school marketing into the scope of the regulation. This can lead to
positive impact if it is implemented in the right manner.
From then narrative review of research literature, social marketing has been identified as
a powerful medium to change attitude of behaviour towards nutrition and physical activity.
Social marketing has the potential to provide the right education to people to promote healthy
living. The C4L can be regarded as a promising intervention as it targeted fostering healthy
behaviour in population at risk of obesity. The idea is considered very effective as social
marketing is one of the top health improvement strategies in many countries. Social marketing
intervention for health promotion is favoured as it provides intelligent solution to social factors
contributing to obesity (Gracia-Marco, Moreno and Vicente-Rodríguez, 2012). Hence, when
applied in a systematic manner, social marketing campaign has the potential to apply the
resources effectively and maximize the value of such campaigns. However, lack of consideration
of a narrow aim and inclusion of many complex goal affected the success of the C4L campaign
in UK (Croker, Lucas and Wardle 2012). According to Hubley and Copeman (2018), adopting
value to user approach can help social marketing promoters to implement effective strategies.
To conclude, the narrative review summarized the strength and gaps found in various UK
strategies to deal with childhood obesity. The narrative review gave insight into wide range of
actions implemented by the UK government to deal with childhood obesity. This included
implementation of social marketing campaigns to influence attitudes and behaviour of parents

29
towards obesity, early years intervention such as FNP targeting pregnant women, population
based approach such as HWHL, food advertising restrictions and food tax levy, school based
interventions like SFVS scheme and many other. These interventions targeted various settings
and various stakeholders in UK to deal with obesity. However, the narrative review clear
indicates that majority of interventions or strategies implemented by the government were not
effective in getting the desired results. Several errors or limitations were found in implementing
the intervention. For example, in relation to C4L, the social marketing campaign could not
change attitude or behaviour of parents towards healthy eating because of wide focus and poor
campaign design (Croker, Lucas and Wardle 2012). It lacked inclusion of behavioural theory or
psychological theory to improve outcome and promote behavioural change. The advantage of
social marketing intervention in dealing with childhood obesity is that such campaigns have wide
appeal and it has the advantage of reaching to a large audience. Hence, proper selection and
dissemination of target message to target audience can promote achieving goal of such programs.
Similarly, various processes related anomalies affected the fulfilment of UK government goals to
reduce the rate of childhood obesity. There is a need to evaluate the strategies and identify future
policy changes to achieve the goal of obesity prevention.
The review of UK government action indicates that many promising strategies were
implemented by the UK government to tackle childhood obesity. The strategies applied powerful
medium or wide range of setting to reduce the risk of obesity in children. However, most of the
initiative failed due to poor implementation process. Hence, the main work of the stakeholders is
to identify innovative approach to improve the delivery process. It is recommended that UK
government and policy makers focus on improving the following areas in the future to reduce the
prevalence of childhood obesity:

30
 Expanding the scope of advertising restriction will be necessary so that restrictions are
imposed for other programmes too. Imposing stricter restrictions of marketing and
advertising of high fat, salt and sugar foods should also be done so that brand advertising
of unhealthy food is completely omitted. This can play a significant role in addressing the
obesogenic environment in UK.
 The social marketing campaigns have the potential to increase awareness about health
issue and risk factor of obesity in target population. To increase the quality of social
marketing campaigns in the future, it is recommended to have a narrow focus and to
apply behavioural theories to influence the change process. This can involve focusing on
reinforcing specific behaviours based by conducting behavioural analysis and using a
theoretical framework to develop interventions (Larsen et al. 2015).
 There is also a need to consider partnership with other stakeholders who can provide
valuable ideas relation to the implementation process. UK government can focus on
encouraging voluntary partnership with private organizations such as NGO to positively
influence the obesogenic environment. It can foster implementation of innovative and
targeted actions to prevent obesity in populations vulnerable to risk of obesity (Jebb,
Aveyard and Hawkes 2013).
 Implementing strict legislation to restrict marketing and sale of unhealthy foods can also
play a role in addressing the obesity epidemic in UK.

31
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