In September 2015, the WHO Commission on Ending Childhood Obesity (ECHO) released a draft of its final report( 1 ) ahead of its presentation to the World Health Assembly in May 2016. This was closely followed by the inaugural World Obesity Day on 11 October which called for serious action to reduce obesity, because it is projected that 2·7 billion adults and 70 million children will be overweight or obese by 2025( 2 ). Achieving the WHO target in 2025 of no rise in adult, adolescent and childhood obesity above 2010 levels, adopted by all Member States, will not be possible without major actions. The world’s children really need the ECHO report to catalyse those actions. So how robust is this report and can it make a difference?
A robust report needs to balance several things: the complexity of the problem and solutions with the simplicity of strategies and communications; the precautionary approach for protecting children with the evidence-based approach on effectiveness of strategies; and the boldness and inspiration needed to mobilise society with the practicality and feasibility needed to shift governments and the food industry from their current positions of inadequate or token efforts. This is a big ask of the Commission and, in essence, it has created a very good report. Indeed, the recommendations are both feasible and, if all implemented, could make an enormous contribution to reducing childhood obesity. But that is a big ‘if’.
The report distils the complexity of childhood obesity into three broad strategic areas for action: (i) policies to reduce obesogenic environments; (ii) education and guidance at critical life-course periods; and (iii) treatment for children with obesity. The feedback during the consultation period following the release of the interim report in March 2015 has clearly strengthened the current report.
The Commission judged that the rationale and available evidence warranted the introduction of taxes on sugar-sweetened beverages, which would have spill-over benefits for reducing dental caries. This is an important recommendation because of industry opposition, and therefore political reluctance, to implement such a cost-saving intervention.
There had been an expectation from experts and advocates around the world that restricting unhealthy food marketing to children would be one important area in which the ECHO Commission could propose a bold new plan through a strong global instrument such as a code or convention. Children and parents are bombarded with sophisticated and effective integrated marketing communications for the very foods and beverages that are driving the unhealthy weight gain in children. The response to decades of advocacy to protect children from these powerful, predatory and unethical corporate behaviours has been little or no effective action from governments and multinational food industries.
Thus, many people will be disappointed that the ECHO report only echoes (sorry!) the existing sets of WHO recommendations.
No doubt the Commission was reading the political tea-leaves when it decided not to push for a stronger code on food marketing to children, but it does leave child health and child rights advocates with no added leverage above the status quo.
Perversely, at the same time as WHO is sticking with its weakest available instrument (i.e. recommendations for voluntary implementation) to protect children, multinational corporations are using the strongest available instrument (i.e. massive multilateral trade and direct foreign investment treaties converted into national laws) to cement the protection of their profits against government policy or regulatory action.
The guiding principles for addressing childhood obesity as set out in the ECHO report are, however, very strong and lead with children’s right to health. The other principles include: government leadership; whole-of-government approach; equity; integration with existing initiatives; accountability; integration into a life-course approach; and universal health coverage for the treatment of obesity. The inclusion of systems approaches would have strengthened these principles and this is a surprise omission given the potential for systems thinking and systems tools to deepen our understanding of the drivers of childhood obesity and create a step change in sustainable, at-scale interventions( Reference Carey and Crammond 3 , Reference Peters 4 ).
The potential value of the ECHO Commission is less in the newness or boldness of its recommendations, since most are repackaged from other reports, but more in the potential leverage that the Commission can achieve to accelerate the implementation of those recommendations. The ECHO Commission does have an Ad Hoc Working Group on Implementation, Monitoring and Accountability which is already considering this challenging question, but New Zealand has already provided the first litmus test of the Commission’s leverage to strengthen government action on childhood obesity. The Commission’s Co-Chair, Professor Sir Peter Gluckman, is also the New Zealand Prime Minister’s Chief Science Advisor and the Government had already signalled that reducing childhood obesity was one of its priorities for its current term of office. So with all these political alignments, what leverage has the ECHO report had in New Zealand?
The short and unfortunate answer is very little. The New Zealand Government’s Childhood Obesity Plan( 5 ) clearly cherry-picked the ECHO report’s soft policy recommendations on health education, sport and exercise participation and health system action for pregnant women and for pre-school children with obesity. All of the harder, more cost-effective, priority recommendations such as taxes on sugary drinks, restrictions on unhealthy food marketing to children and even healthy food-service policies in schools were disappointingly nowhere to be seen in the New Zealand plan. Perversely, there is even the possibility that the ECHO report’s emphasis on the biological and developmental determinants of childhood obesity gave the centre-right government the opportunity to seize on actions which are more at the individual level than the environmental level.
The ECHO report, however, is an excellent, authoritative report which draws some clear lines in the sand and it is hoped its influence will build over time to catalyse stronger government responses than was possible in New Zealand.
Several of the papers in this current issue of Public Health Nutrition relate directly to the work of the ECHO Commission and reinforce their recommendations. Carey et al.( Reference Carey, Caraher and Lawrence 6 ) discuss the powerful influence of industry groups in the development of a whole-of-government national food and nutrition policy in Australia. Mikkelsen et al.( Reference Mikkelsen, Engesveen and Afflerbach 7 ) call for the international frameworks of human rights to be invoked and translated into concrete strategies, policies, regulations and accountability mechanisms at national, regional, local and school levels. Two papers indicate that the implementation of policies to improve school food environments and to increase school meal uptake is essential. In Minnesota, USA, it was found that the average number of energy-dense, nutrient-poor snack foods and beverages available for purchase at school was inversely related to the strength of district wellness policies regulating vending machines and school stores( Reference Larson, Davey and Hoffman 8 ). In England, children having a school meal consumed a higher-quality diet over the whole day compared with children taking a packed lunch to school( Reference Evans, Mandl and Christian 9 ). In addition to the implementation of taxes on sugary drinks, as recommended by the ECHO report, there is still important work to be done on increasing nutrition literacy as well. As Munsell et al.( Reference Munsell, Harris and Sarda 10 ) show, many parents still believe that some sugary drinks are healthy options for children, particularly flavoured waters, fruit drinks and sports drinks.
This growing evidence base for action needs to be coupled with greater societal pressure to implement the ECHO report’s recommendations in a comprehensive, not cherry-picked, manner.
