Childhood Obesity Status in Australia: A Recent Perspective

 

Kamrun Nahar1*, Tanveer A. Khan2, Md Kamal Hossain1*

1Vetafarm Pty Ltd, Wagga Wagga, NSW, 2650, Australia

2Faculty of Pharmacy, Al-Jouf University, Al-Jouf, Saudi Arabia.

*Corresponding Author E-mail: Hossain_238@yahoo.com

*Equally Contributed Authors

 

ABSTRACT:

Overweight and obesity is an important public health issue in Australia and around the world. Childhood obesity is becoming an increasing concern worldwide and Australia alone recognizes that 1 in 4 children are either overweight or obese. In Australia, as in many other countries, the community has become increasingly concerned about the rising prevalence of childhood obesity. The raft of health consequences for obese children now, and particularly when they are adults, has provided impetus for increased interest in the role for government in obesity prevention strategies. Children should therefore be considered the priority population for intervention strategies. Prevention may be achieved through a variety of interventions targeting built environment, physical activity, and diet. Some of these potential strategies for intervention in children can be implemented by targeting preschool institutions, schools or after-school care services as natural setting for influencing the diet and physical activity. All in all, there is an urgent need to initiate prevention and treatment of obesity in children.

 

KEYWORDS: Childhood, Obesity, Overweight, Prevention, BMI, economic cost, well being.

 

 

 

1. INTRODUCTION:

The world is undergoing a rapid epidemiological and nutritional transition characterized by persistent nutritional deficiencies, as evidenced by the prevalence of stunting, anaemia, and iron and zinc deficiencies. Concomitantly, there is a progressive rise in the prevalence of obesity, diabetes and other nutrition related chronic diseases (NRCDs) like obesity, diabetes, cardiovascular disease, and some forms of cancer. Obesity has reached epidemic levels in developed countries. The highest prevalence rates of childhood obesity have been observed in developed countries; however, its prevalence is increasing in developing countries as well1. Females are more likely to be obese as compared to males, owing to inherent hormonal differences2.

 

There has been a phenomenal rise in proportions of children having obesity in the last 4 decades, especially in the developed world. Childhood obesity is one of the most serious public health challenges of the 21st century. Childhood obesity is a worldwide epidemic that, in 2009, effected 155 million (1 in 10) 5-17 year olds3. In regards to The International Association for the Study of Obesity, figures collected in 2013 highlight that Greece held the highest values for both overweight and obese boys and girls (44% and 38% respectively)4  Twenty four percent of Australian girls, according to the Organization for Economic Co-operation and Development  (OECD), were considered obese, ranking in at 10th out of 40 countries4,5.  Both Spain and Canada reported the same statistical findings of 24%. In regards to obese and overweight boys, Australia is ranked 18th, showing an identical figure of 22% to that of the United Kingdom4,5. The lowest ratings of obesity were displayed by Indonesia showing values of 11% and 8% respectively for boys and girls6. In 2013, the World Health Organization estimated that over 42 million children under the age of five were obese with 31 million of these living in developing countries7.

 

Childhood obesity has been a consistent health burden throughout the entirety of Australia’s history with close regard placed on genetics and an energy imbalance between calorie consumption and expenditure. Between 1985 and 1995 the number of obese children increased dramatically from both perspectives of boys (10.7% to 20.5%) and girls (11.8% to 21.1%) aged 7–15 and 5-17 in the two respective year brackets (Fig 1)4. In the 10 years that followed, until 2008, figures continued to rise from 21% to 25% resulting in a similar percentile for both males and females8,9. In the 2011/12 Australian Bureau of Statistics- Australian Health Survey, statistics reiterated the lack of substantial preventative methods, highlighting a 1% increase and therefore a total of 26% of children aged between 5–17 years as being either overweight or obese10.

 

Fig: 1 Number of obese children between 1985 to 1996

 

For Australians aged between 4 and 17 years, obesity is a very concerning condition as once gained it is favorably harder to be liberated from. Short-term effects on children can mean a decrease in their psychological well-being 11 as well as physical deteriorations such as sleep apnea, breathlessness and cardiovascular disease11,12.  With an increase risk of adult obesity being associated with childhood obesity there are numerous long-term effects that can ultimately hinder the life expectancy of individuals including the development of serious diseases 13. In order to combat the worldwide epidemic of childhood obesity it is imperative that the issue is addressed in its early stages. The main preventative measures to be implemented include increasing physical exercise, dietary knowledge and decreasing sedentary behaviours12. In this review article emphasis was given to give a brief overview on its causes, socioeconomic impact, effect of obesity and its management.

2. CAUSES OF CHILD OBESITY:

It is widely accepted that increase in obesity results from an imbalance between energy intake and expenditure, with an increase in positive energy balance being closely associated with the lifestyle adopted and the dietary intake preferences. However, there is increasing evidence indicating that an individual’s genetic background is important in determining obesity risk. Research has made important contributions to our understanding of the factors associated with obesity. The ecological model, as described by Davison et al., suggests that child risk factors for obesity include dietary intake, physical activity and sedentary behaviour14. The impact of such risk factors is moderated by factors such as age, gender. Family characteristics parenting style, parents’ lifestyles also play a role. Environmental factors such as school policies, demographics, and parents’ work related demands further influence eating and activity behaviors.

 

2.1 Genetics:

A strong genetic basis exists for the development of obesity. Numerous genes have been linked with a predisposition to excess fat. At least six very rare mutations of single-genes causing severe early-onset obesity have been identified. In addition, there are also a number of rare syndromes that cause obesity, among other conditions, such as Prader–Willi syndrome and Bardet–Biedl syndrome15. In addition, an international review of twin and adoption studies found that genetics had a strong effect on Body Mass Index (BMI) variation at all ages, and the effect was stronger than that of environmental influences16. However, biological factors alone, including genetic composition, are unlikely to account for the rise in obesity that has occurred since the 1970s, as it has occurred too quickly to be explained in evolutionary terms17,18. It is more likely that the rise is due to changes in the social and Genetics, according to the Australian Health Survey plays a primary role in determining obesity19. In 2011/2012 it was recorded that 90% of the Australian population had inherited their obese tendencies due to the epigenetic modifications of their mothers during pregnancy19. Interchanging closely with the genetic factor, the environment and individual temptations are also highlighted as contributing causes to the worldwide epidemic. The genetic configuration influences the tendencies to become overweight, and diet and physical activity determines to what extent those tendencies are elaborated20.

 

2.2 Diet and parental influence:

Parents, guardians and teachers all play a key role in the mentality that children have towards certain types of foods as they develop. The first five years of a child’s life, when developing a familiarization with solids, can ultimately have a negative influence on the foods that they give preference to in the future21. “Treat” food consumption, which is a well- intentioned technique used by parents to reward their children, contributes to between 23- 24% of an individual’s total daily energy intake (aged between 2–16 years old)22. With no more than 20% being recommended daily it is visibly clear that adults may not be allowing their children to develop an intrinsic motivation for healthy foods, ‘rewarding’ them with energy dense snacks such as potato chips, muffins and lollies22. According to the Australian Dietary Guidelines 2013 a child aged between 4–8 years old should consume 1 ½ serves of fruit and 4 ½ serves of vegetable daily with individuals aged 9 and above recommended to consume “2 and 5”4, 23. Parents can help to positively influence their child’s diet by being an active role model and eating a wide variety of fruits and vegetables themselves. Encouraging children to eat a variety of different nutritional snacks and making fruits and vegetables visually appealing through changing their shapes can also help to entice and excite children about fruit and vegetable consumption15.

 

2.3 Impact of society:

In order for an individual (children) to remain healthy, there must be a balance between the amount of calories consumed and the amount of calories expend (through physical activity). Socio-environmental factors that disrupt this energy consumption/ expenditure balance include changes to the economy (food costs), an increased dependency on cars and sedentary behaviors and an increased marketing of poor nutritional foods3.

 

2.4 Media and advertising:

Advertising is a common aspect of today's society and is strategically conducted and presented and conducted to persuade consumers to respond in a particular way. Approximately 30% of advertisements conducted during children's television viewing hours in Australia are directed on food intending to influence children towards unhealthy food products24. Companies such as “McDonalds”, in particular, have specifically created and designed their advertisements and commercials so that they are appealing and enticing to children. Through the use of bright alluring colors, the introduction of the ‘happy meal’, the strategic use of playgrounds and the Ronald McDonald character it is evident that children are the main target audience25. In a similar way, Australian sporting teams are often sponsored by companies who market unhealthy food products to children and young adults. Recent reports show that during a high- profile cricket match, the KFC (Kentucky Fried Chicken) logo was clearly visible for 61% of playing time and XXXX beer logo clearly visible for 75% of playing time in a similar event26. As a country dominated by sporting heroes, with a strong child based audience during televised times, the inclusion of unhealthy foods and alcohol sponsorship may indicate to children that even their most idolized sporting heroes support such unhealthy products.

 

Some children find it hard to grasp the concept of unhealthy products in the same way they have internalized the negative effects of smoking. Advertisements in Australia for tobacco smoking reflect the negative outcomes associated, through the use of graphic and gruesome images. Unhealthy food, in comparison, is not portrayed in the same light, despite the equality of consequences. Instead, commercials, billboards and television advertisements portray fast food and energy dense products with attractive colors and happy/ energetic staff members, persuading children to believe that high calorie junk food promotes a positive and rewarding experience27.

 

2.5 Cost and portion sizes:

In this same manner, to entice children, the value of energy dense products has also decreased making these products cheaper and more available to younger adults. Despite the prices of these items being reduced, the portion sizes coincidently have also risen, allowing individuals to pay less for more12,25.

 

2.6 Transport:

Australians have developed a reliance on cars as a means of transport instead of walking or cycling. As a result of the radical development of technology over the past 30 years, individuals have adapted a less active mentality becoming increasingly more reliant on cars as a means of transport and succumbing to more sedentary behaviors. Individuals are more inclined to use a vehicle, bus or train as transportation as a pose to physically walking or riding a bike. This idle perspective that Australians are adopting is a clear contributor to the obesity epidemic. A study carried out in 2008 showing the relationship between walking and obesity in Europe, North America and Australia highlights that the countries with the highest levels of active transportation generally had the lowest obesity rates 27. The lowest rate of active transportation was seen in the United States (only 8%) and they also, coincidently, had the highest rate of obesity (34.3%)28.

 

2.7 Sedentary behavior:

Another contributor to the epidemic of childhood obesity has been the increase in sedentary pursuits. Sedentary behaviour includes the time spent using electronic media as a means of entertainment. Examples include: television, seated electronic games (iPad

) and computer use, including educational or non educational pursuits. The Australian Governments Department of Health recommends that children aged between 5– 12 years should not be sedentary for more than two hours a day29.

2.8 Socio-economic factors:

The socio-economic status of individual families has also been said to be a related cause for overweight and obese individuals. Children who grow up in families who have a lower income are more likely to be obese compared to those who have a higher income and are therefore brought up in higher socio-economic environments30. Lack of playground equipment, dangerous roads, and unsafe neighborhoods are all factors that contribute to a lower level of physical activity27. The financial status of a family has also been reported to be a key influence in the physical well being of children, as parents may not have the funds to support children in participating in extracurricular activities and physical activity in general26. As a result of this, children are more inclined to spend their time partaking in sedentary activities such as watching television31. Economic status is also shown to be a major contributor to obesity, as families tend to buy more affordable foods, those of which are usually higher in fat and energy density26.

 

Researchers suggest that individuals with a low income are more likely to becoming obese and those who are more financially stable, less likely. Causation behind this issue is founded on the prices of nutritional based foods being more expensive thus directing funds towards cheaper and more calorie dense options such as fast food and take away. The minority of the costs of healthy eating, however, firmly outweigh the economical burden that is placed on both the individual and society caused by diet-related chronic disease 4.

 

2.9 School environment:

In order to decrease the prevalence of childhood obesity in Australia both parents and teachers must together develop techniques that best encourage healthy eating. In association to this, parents must also develop stronger understandings of the specific foods that will either benefit or prove unfavorable to their children’s health. The establishment of in school programs that urge children to participate in physical activity is also imperative, introducing children to fun methods of exercising such as interactive games26.

 

3. EFFECTS OF OBESITY:

3.1 Psychological:

Short-term prospects for children in Australia suffering from a Body Mass Index (BMI) of more than 25 kg/m2include deteriorations in their physical health as well as a decreased psychological well-being3. Children who are obese or overweight by the time they reach their schooling careers are likely to become victims of discrimination, bullying and teasing in the playground 32. Individuals who are made to feel inferior for their physical appearance develop a self-conscious attitude towards their body image, leading them to foster feelings of depression, anxiety and incompetence12,29. Psychological detriments of this sort can also have a negative effect on children’s ability to form relationships and make friends with peers. The social stigma surrounding the “perfect body image” can also be extremely degrading to adolescents who feel they are unable to meet the expectations of such situations causing further damage mentally and physically (anorexia and bulimia)33.  From a long- term perspective obesity can also cause negative psychological effects on individuals who are discriminated and victimized in the work place. Food is also used as a psychological coping mechanism for overweight adults who indulge when they are feeling stressed, lonely and sad. The guilt felt as a result of this "mindless eating" can, in turn, cause people to feel anxious and distressed34.

 

3.2 Physical:

The physical implications of obesity in children include sleep apnoea, breathlessness, a reduced tolerance to exercise and orthopedic and gastrointestinal problems including non-alcoholic fatty liver disease4. Children who reciprocate these physical health disadvantages tend to struggle to concentrate more in- school and find it harder to fit in, being marginalized due to the inability to partake in physical exercise. According to the Dieticians Association of Australia 25-50% of overweight or obese children with turn out to be obese as adults 35. Long-term effects of obesity, therefore, include cardiovascular disease (hypertension and high blood pressure) and particular types of cancers in particular colon, kidney and breast cancer4,8. Non-alcoholic fatty liver disease (NAFLD) is one of the most common risk factors associated with obesity being characterized as a buildup of fat within the liver cells36. Musculoskeletal defects such as osteoarthritis are also said to have a strong link with obesity due to excessive amounts of weight being exerted on the joints4. Individuals who have a Body Mass Index (BMI) that is equal to or greater than 25 kg/m2 are also said to have an increased chance of premature morality8.

 

3.3 Economic costs and consequences:

As a result of the alarming statistics involving the number of obese children in Australia the consequences have also been extensive to the economy. Between the ages of 4–5 years the costs of childhood obesity, according to the Longitudinal Study of Australian Children, has incurred significantly higher medical and pharmaceutical bills4. The health system comprised direct health care, indirect health care, and burden of disease costs was estimated at $58.2 billion in 20088. Direct costs included 4 main medical conditions: cardiovascular disease, type 2 diabetes, osteoarthritis and specific forms of cancer with in-direct costs referring to productivity loss (premature morality and sick days) and burden of disease, financial and social costs. In particular cardiovascular accounted for $34.6 billion, cancer, $9.7 billion, type 2 diabetes $8.3 billion and osteoarthritis $5.7 billion8. The access economic has estimated the cost of obesity under two main categories as “Loss of wellbeing and financial costs”. Details of the cost structure have been explained in box 1.

 

 

Access Economics’ estimates of the costs of obesity, 2008

Access Economics estimated the total cost of obesity in Australia was $58 billion in

2008. This estimate encompassed two types of costs the ‘loss of wellbeing’ and financial costs.

The cost of the loss of wellbeing was measured as the dollar value of the burden of disease arising from disability, loss of wellbeing and premature death and was estimated to be approximately $50 billion in 2008. This accounted for 86 per cent of the total estimated costs of obesity. This estimate was derived by multiplying the burden of disease attributable to obesity (in terms of disability adjusted life years) by an estimate of the value of a statistical life. These costs are borne by obese individuals themselves.

The financial costs of obesity were estimated to be $8 billion in 2008, and included:

·         health system costs (such as hospital and nursing home costs, GP and specialist services, and pharmaceuticals)

·         productivity losses

·         carer costs

·         transfer costs (that is, the deadweight loss from the higher level of taxation)

·         other indirect costs (such as aids, modifications and travel).

·         Financial costs are borne, to differing extents, by obese individuals, their families and friends, governments, employers and society

 

 

 

4. TREATMENT AND MANAGEMENT:

The two most common forms of treatment that are crucial for individuals to carry out to combat obesity include changing to a healthier diet and increasing their physical exercise8. In extreme cases, if children are morbidly obese bariatric surgery may be carried out.

 

4.1 Dieting:

It is important for parents and teachers to encourage children to consume more fruits and vegetables. In Australia, the “2 Fruit and 5 Veg” campaign is advertised to educate and encourage young children and adults of the necessary nutrients that are needed in a daily diet37. For adults who are entirely responsible for the foods that their children consume, it is important that they are aware of the key strategies of a healthy regime. Adults should provide their children with a moderate to low fat diet by limiting the amount of energy dense meals they feed them, reiterate the importance of eating breakfast and encourage children to eat their vegetables29. For young adolescents who have a BMI percentile of 80 or above, there are certain weight loss programs available that offer services specified in dietary advice and fitness coaching8.

 

It is also imperative that parents and guardians are well informed regarding healthy eating for their children. Developing strategies on how to encourage their children to eat more healthy foods and grasping the knowledge on how to distinguish between high and low calorie based pre-packaged snacks is crucial26.

 

The food industry also plays a huge part in promoting healthy foods as management from a dietary point of view. Methods include making wholesome foods widely available and affordable for their customers. Closely monitoring and managing the amount of fat, sugar and salt content that is in the foods that are sold is also important 3.

 

4.2 Physical exercise:

A key method of preventing obesity is physical exercise. The "Find 30" campaign reiterates the importance of exercising for at least 30 minutes a day in order to maintain a healthy lifestyle. Physical exercise, in order for a child to maintain a healthy lifestyle, must be considered a fundamental aspect of their daily regimen5. The environment including both school and local neighborhoods where children grow up are an important stimulus of physical activity. Sporting facilities, playgrounds and bike tracks are all encouraging features that influence the length of time a day that a child is physically active. The “Healthy Together Victoria” campaign run by St Pauls Primary in Mildura is a state government funded program that, according to World Health Organisation worker Timthoy Armstrong, is recognized worldwide with New Zealand, the United Kingdom and Canada all participating in similar exercises. The program in Victoria focuses on the health of its students by walking laps every morning and encouraging children to attend the healthy breakfast following, three times a week 13.

 

Another campaign that is run in Australia to educate and encourage individuals to regularly exercise is the “Find 30” initiative. Initially developed in 2008, the “find 30 every day” campaign encourages Australian candidates to participate in at least thirty minutes of moderate-intense physical activity as a bench mark for maintaining a healthy lifestyle 38.

 

4.3 Bariatric surgery:

Although there are many short- term preventative methods in place to combat childhood, there are some individuals who return to their initial base weight and therefore might turn to surgical measures to achieve a more lasting effect 8. Bariatric surgery is an effective procedure used to restrict the patient’s food intake and decrease absorption of food in the stomach and intestines 36. Procedures of this type are said to be able to reduce excess body weight of obese or overweight individuals by 50-75%, ultimately maintaining this weight loss for 16 years following 8.

 

5. AUSTRALIAN SUCCESSFUL INTERVENTIONS:

Australian interventions addressing childhood obesity are primarily of a targeted kind, focusing on providing information, increasing education and influencing physical activity37,38. Few interventions list reducing or preventing obesity in children among their stated objectives, although many seek to influence physical activity or dietary awareness or both. Given that some of these have measured body composition (such as BMI or waist circumference), they provide some insights into how well they work in terms of reducing or preventing obesity.

 

In general, the interventions studied have had mixed success in improving body composition. But in some cases they were successful in promoting other desirable outcomes, such as increasing the level of physical activity. The results from some other interventions were less positive. Further, long-term follow up to assess the sustainability of outcomes has not been undertaken for many Australian interventions.

 

5.1 Be Active Eat Well:

Be Active Eat Well was one of the first community-based interventions in Australia with an evaluation. Key strategies of the intervention included changing canteen menus, introducing daily fruit, reducing television watching and increasing activities after school. Be Active Eat Well delivered positive (short-term) results for most of the body composition measures (for example, waist circumference), though not Body Mass Index (BMI). Long-term results are yet to be reported.

 

5.2 Switch–Play:

Switch–Play focused on physical activity through two components behaviour modification (delivered in classrooms) and/or fundamental movement skills (delivered in physical activity facilities).

 

Switch–Play had a significant effect on BMI for the children participating in a combined behavioral modification and fundamental movement skills program, directly after the intervention and at the 6- and 12-month follow-ups. This group was also less likely to be overweight or obese between baseline and post intervention and at the 12-month follow-up. No significant change was reported in BMI for the other two intervention groups (one undertaking only behaviour modification and the other undertaking only fundamental movement skills).

 

5.3 Engaging Adolescent Girls in School Sport:

Engaging Adolescent Girls in School Sport aimed to increase physical activity by increasing enjoyment of physical activity, perceived competence and physical self-perception. The intervention (which did not measure body composition) succeeded in increasing the target group’s enjoyment of physical activity and body image, yet levels of physical activity reportedly declined.

 

6. EXPERT OPINION IN CHILD OBESITY:

The results of the global study into obesity rates, published in the medical journal The Lancet, show almost a quarter of the country's children and 63 per cent of the adult population is overweight. Australia's obesity levels are now on par with the United States, but slightly less than New Zealand.

 

The study has prompted health experts to call on the Federal Government of Australia to commit to a national anti-obesity strategy 35. (Childhood obesity exaggerated: expert). Childhood obesity rates in Australia, as well as in New Zealand, the US, China and many European counties, have barely budged in the past decade.

 

Many experts attribute much of the alarm surrounding the issue today to a sharp rise in childhood obesity in the 1980s and '90s, which was forecast to continue but had not materialised. In Australia, for example, just one per cent of boys and 0.8 per cent of girls were obese in 1985 and this increased to 5.4 per cent and 5.7 per cent respectively in 1996.More than a decade later, in 2008, obesity in Australian children was found to be 5.3 per cent for boys - a slight decrease - and 5.9 per cent for girls.

 

Expert explained "Because childhood obesity increased in the 1980s doesn't mean that it will continue, and in fact it hasn't, noting the childhood obesity rate appeared to have "levelled off" and a new balance had been reached 38. An obese person is generally considered to have a body mass index (BMI) calculation of 30 or above. Taking in those children near but not at this level, Australia's rate of overweight and obesity roughly doubled from 1985 to 1996 (from about 11 per cent to 23 per cent) but there was almost no movement to 2008 (24 per cent) (Fig 2).

 

Fig: 2 Rate of obesity between 1985 and 2008

 

While the evidence pointed to a plateau, it should be noted the data was not as clear cut as it seemed. Children went through periods of rapid growth, and those with more advanced muscle development could be deemed to be overweight. This often-included children from a Pacific Islander or Maori background and for many kids "overweight" was not the same as "unfitness". "Our children have got taller for generations. The multi cultural society in Australia is going to produce lots of children that are different and diverse. Dr O’Dea et al pointed in their research in 2000 that, in a nationwide study of nearly 5000 children and teens, found nine per cent of lower socioeconomic status children were obese compared to only five per cent of children from middle or higher income families. The expert added "It's really an issue of social class. "And that's where we need to be very careful to approach it as a social justice issue for these low income communities, and disadvantaged communities, where we see the most childhood obesity." Serving healthy breakfasts in schools - known to stabilise and improve a child's eating pattern throughout the day - was one key way to address the problem.

 

The expert team called for more of a focus on "assisting physical activity in safe neighborhoods, in school programs, in after school programs, in non-competitive physical activity where children can be encouraged to play".

 

7. CONCLUSION:

Obesity is a chronic disorder that has multiple causes. Obesity in childhood has significant impact on both physical and psychological health. In addition, psychological disorders such as depression occur with increased frequency in obese children. Overweight children are more likely to have cardiovascular and digestive diseases in adulthood as compared with those who are lean. It is believed that both over-consumption of calories and reduced physical activity are mainly involved in childhood obesity. A number of potential effective plans can be implemented to target built environment, physical activity, and diet. These strategies can be initiated at home and in preschool institutions, schools or after-school care services as natural setting for influencing the diet and physical activity and at home and work for adults. Both groups can benefit from an appropriate built environment. However, further research needs to examine the most effective strategies of intervention, prevention, and treatment of obesity. These strategies should be culture specific, ethnical, and consider the socio-economical aspects of the targeting population.

 

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Received on 29.06.2017          Modified on 31.07.2017

Accepted on 21.08.2017        © RJPT All right reserved

Research J. Pharm. and Tech. 2017; 10(8): 2727-2734.

DOI: 10.5958/0974-360X.2017.00500.5