1. Children's nutrition: a global emergency Philip James IPA IDF IOTF IUNS WHF LSHTM and Chair of IOTF and the Presidential Council of the Global Prevention Alliance

2. Malnutrition: a continuing outrage TMRU, Kingston, Jamaica, Christmas 1966

3. Elimination malnutrition: a global deficit in policies and priorities UN Millennium report. James et al. Food & Nut Bulletin 2000, 21:Supplment 3 Potential response on the basis of Thailand's achievements % World Food Summit goal Desired UN response with major change in policies % underweight children in the world IFPRI Projections with free market mechanisms Millions of underweight & stunted schoolchildren

4. WHERE IS THE PRIORITY ?

5. Lifecycle: the proposed causal links Higher maternal mortality Reduced mental capacity Reduced capacity to care for baby Inadequate foetal nutrition Higher mortality rate Impaired mental development Untimely / inadequate Weaning Frequent infections Inadequate food, health & care Inadequate growth Woman Malnourished Pregnancy Low Weight Gain Adolescent Stunted Child Stunted Elderly Malnourished Baby Low Birth Weight Inadequate food, health & care Reduced mental capacity Inadequate food, health & care Epigenetic susceptibility to chronic diseases if diet becomes inappropriate Adapted from James et al. SCN Millennium Rep. Food & Nutrition Bulletin, 2000, 21, 3S.

6. British wartime feeding based on novel nutritional concepts Milk Cod liver oil Orange juice

8. The transformation of agriculture: an issue of fundamental national security

9. A quarter-pound cheeseburger, large fries and a 16 oz. soda provide: 1,166 calories 1,166 calories 51 g fat 51 g fat 95 mg cholesterol 95 mg cholesterol 1,450 mg sodium 1,450 mg sodium

10. 1900 – 2000: Prevalence of overweight and obesity for 5 - 15 yr old Australian children Norton K et al, Int J Pediatr Obes 2006

13. Projected overweight (incl. obesity) rates for school age children Wang and Lobstein, IOTF, 2006. e.g. China e.g. India % Prevalence e.g. US S.Arabia e.g. UK Global total Obese 74 mil. O/wt 287 mil. Global total Obese 74 mil. O/wt 287 mil.

15. Nutritional Contrasts

16. Childhood overweight & obesity 35 30 25 20 15 10 5 0 World Americas Near & Middle East Europe Asia-Pacific Sub-Sahara Prevalence % Overweight Obese Overweight Obese Lobstein et al., Obesity in Young Children. 2004, Obesity Reviews 5 (Suppl. 1), 4–85

17. The impact of inappropriate Western diets on most of the world's susceptible populations: health systems already overwhelmed Adapted from James et al. SCN Millennium Rep. Food & Nutrition Bulletin, 2000, 21, 3S. Early onset Type 2 Diabetes Reduced play and social isolation Reduced capacity to care for baby Disordered foetal nutrition Untimely / inadequate Early Weaning Frequent fast foods Inadequate physical activity Normal/high growth Woman o/w or obese Pregnancy Glucose intolerance/ diabetes Adolescent O/W-obese Child overweight Elderly Diabetes, strokes, heart disease, cancers arthritis Fat Baby High Birth Weight Poor school conditions Inadequate obstetric care Reduced job opportunities Inadequate health care system Abdominal obesity Rapid weight gain Reduced fertility; CVD, HT Cancers

19. The increasing risk of adult coronary heart disease if adults in childhood ( 7-13 yrs) had modest weight increases Copenhagen school children's study of 276,835 children measured from 1955 - 1960 with National Death and Hospital Discharge Registries. Hazard relates to one BMI Z score: linearly related to events at all ages but hazard ratio progressively increases with age during childhood. Baker, Olsen & Sorensen. NEJM 2007, 357: 2329-32

21. The keys to success in the food business and in obesity and chronic disease prevention PricePrice AvailabilityAvailability MarketingMarketing

23. Fundamental changes in physical activity: inevitable and optional changes Inevitable: Rural to urban transition Labour changes; Mechanisation/computerisation of standard work; also home duties e.g. cooking, washing, cleaning Optional: Urban building policies: high intensity or US style sprawl? Road and community design Office & supermarket location policies Car policies versus preference for cyclists/pedestrians Policies on free spaces for children's play; lighting for safety e.g. for older people Park/leisure/sports facilities/school PA lessons Ease of transport of perishable foods into towns/cities

24. Obesity: time watching TV overwhelms leisure activity in Australia Adapted from Salmon, Bauman et al IJO 2000;24:600-606 Adapted from Salmon, Bauman et al IJO 2000; 24:600-606 TV time Increasing TV time Leisure time sport & activity Average BMI for each group 28 27 26 25 24 23 22 21 Total daily physical activity High Moderate Low Inactive

25. e.g. Focus on Health Education; campaigns selectively help upper socio-economic groups Individual responsibility Changes to the "toxic" environment Adapted from Puska P, 2001 Progressively adapt all towns/cities to favour pedestrian/cycling as norm with car restrictions Nutritional standards for food in all government facilities/schools; eliminate trans fats; catering on Finnish scale: fruit + veg. within meal costs Limit/abolish all marketing to children Selectively increase costs of high fat/sugary products; soft drinks Social/employment/medical policies for breast feeding as the norm Complementary approaches to obesity & chronic disease prevention

26. Prevalence of obesity in schoolchildren in Singapore weight (kg) for height (m) >120% % 16 14 12 10 8 6 4 2 197619781980 1982198419861988199019921994199619982000 New growth charts used since 1994. Source: Ministry of Health, Singapore Dramatic response to intense focus on obese children's diet and physical activity

27. Marketing to Children

28. Food industry promotions: Food industry promotions: Can confuse nutritional knowledge, e.g. whether fruit is in product Can confuse nutritional knowledge, e.g. whether fruit is in product Change food preferences Change food preferences Change purchasing behaviour Change purchasing behaviour Influence choice and consumption by brand Influence choice and consumption by brand Alter balance of food categories eaten Alter balance of food categories eaten Manipulating children's behaviour: evidence from the UK government's systematic analysis Hastings Report, UK Food Standards Agency, 25th September, 2003.

29. The most cost-effective community (not national) interventions in Australia Victoria State Analyses: Sept 2006 InterventionCost in Australian $ for each DALY saved Restrict TV advertising4 Soft drink intervention at school3,000 Walking buses to school770,000 Cycling (travel SMART schools)260,000 After-school community programmes.90,000 Doctors targeting the overweight children32,000 School multiple interventions, but no physical education14,000 Add Add Physical Education7,000 School education to reduce TV viewing3,000 Family-based program for obese child4,000 School program targeting overweight & obese children3,000 Medical treatment with drugs, e.g. Orlistat14,000

30. Strategies for combating childhood obesity Protecting children at least up to 12 yrs: Breast feeding Breast feeding Proper weaning practices Proper weaning practices Regulated child minders: food and play Regulated child minders: food and play Legislate on all forms of marketing: TV, radio, text messages, internet, food product labelling, games etc. Legislate on all forms of marketing: TV, radio, text messages, internet, food product labelling, games etc. School environment : major changes needed School environment : major changes needed Supermarket practices Supermarket practices Pricing policies : affect school aged children Pricing policies : affect school aged children Policies on density of available fast foods outlets in town centers Policies on density of available fast foods outlets in town centers

31. The interest and influences of different stakeholders INFLUENCE -10 -5 0 5 10 INTEREST Children Health professionals Advocacy orgs. Scientists Parents Ministry of Health Parliament Farmers Media Church Ministries of Transport & Agriculture Retailers Treasury President Advertising industry Food/drink industry Food inspectors Ministry of Education Teachers 0510 Ministry of Trade Lobstein T : Analyses based on UK Food Commission's experience and new EU policy work.

32. Five Practical Priorities Major drive to increase/ sustain breast feeding Major drive to increase/ sustain breast feeding: facilities at work important; maternal leave + cultural change Marketing restrictions Marketing restrictions (not just TV advertising) - statutory for children & adolescents: rights of child extend to 18 yrs Control of food Control of food in nurseries, all school facilities and school environment: avoid choice - all foods of high nutritional quality + facilities to allow spontaneous play - not TV Fruit and vegetable availability Fruit and vegetable availability routine in canteens and restaurants (within main cost) Transformation of physical facilities for spontaneous & leisure time activity Transformation of physical facilities for spontaneous & leisure time activity: urban design changes with novel traffic policies; pedestrian only areas immediately adjacent to houses/apartments