Guidance

Childhood obesity: a plan for action

Updated 20 January 2017

Introduction

Today nearly a third of children aged 2 to 15 are overweight or obese1 2 and younger generations are becoming obese at earlier ages and staying obese for longer.3 Reducing obesity levels will save lives as obesity doubles the risk of dying prematurely.4 Obese adults are seven times more likely to become a type 2 diabetic than adults of a healthy weight5 which may cause blindness or limb amputation. And not only are obese people more likely to get physical health conditions like heart disease, they are also more likely to be living with conditions like depression.6 7

The economic costs are great, too. We spend more each year on the treatment of obesity and diabetes than we do on the police, fire service and judicial system combined.8 It was estimated that the NHS in England spent £5.1 billion on overweight and obesity-related ill-health in 2014/15.9

The burden is falling hardest on those children from low-income backgrounds. Obesity rates are highest for children from the most deprived areas and this is getting worse.10 Children aged 5 and from the poorest income groups are twice as likely to be obese compared to their most well off counterparts and by age 11 they are three times as likely.11

Obesity is a complex problem with many drivers, including our behaviour, environment, genetics and culture. However, at its root obesity is caused by an energy imbalance: taking in more energy through food than we use through activity. Physical activity is associated with numerous health benefits for children, such as muscle and bone strength, health and fitness, improved quality of sleep and maintenance of a healthy weight.12 There is also evidence that physical activity and participating in organised sports and after school clubs is linked to improved academic performance.13 14

Long-term, sustainable change will only be achieved through the active engagement of schools, communities, families and individuals.

We aim to significantly reduce England’s rate of childhood obesity within the next ten years. We are confident that our approach will reduce childhood obesity while respecting consumer choice, economic realities and, ultimately, our need to eat. Although we are clear in our goals and firm in the action we will take, the launch of this plan represents the start of a conversation, rather than the final word.

Introducing a soft drinks industry levy

Our children are consuming too many calories - and, in particular, too much sugar.15 Teenagers in England are the biggest consumers of sugar-sweetened drinks in Europe.16 The Scientific Advisory Committee on Nutrition (SACN) recently concluded that sugar consumption increases the risk of consuming too many calories, the risk of tooth decay, and that consumption of sugar sweetened beverages is associated with increased risk of type 2 diabetes and linked to higher weight in children.17 A single 330ml can of a soft drink with added sugar (which can contain as much as 35g of sugar), may instantly take a child over their maximum recommended daily intake of sugar.

As a first major step towards tackling childhood obesity, we will be introducing a soft drinks industry levy across the UK. In England, the revenue from the levy will be invested in programmes to reduce obesity and encourage physical activity and balanced diets for school age children. This includes doubling the Primary PE and Sport Premium and putting a further £10 million a year into school healthy breakfast clubs to give more children a healthier start to their day. The Barnett formula will be applied to spending on these new initiatives in the normal way.

This is a levy on producers and importers, and not on consumers, and is designed to encourage producers to reduce the amount of sugar in their products and to move consumers towards healthier alternatives. We have given producers and importers two years to lower the sugar in their drinks so that they won’t face the levy if they take action. Many manufacturers have already taken steps to reduce the overall levels of added sugar in their drinks, but the levy will create stronger incentives for action.

Alongside this plan, HM Treasury are consulting on the technical detail of the soft drinks industry levy over the summer, and will legislate in the Finance Bill 2017.

Taking out 20% of sugar in products

Evidence shows that slowly changing the balance of ingredients in everyday products, or making changes to product size, is a successful way of improving diets.18 19 This is because the changes are universal and do not rely on individual behaviour change. We will therefore launch a broad, structured sugar reduction programme to remove sugar from the products children eat most. All sectors of the food and drinks industry will be challenged to reduce overall sugar across a range of products that contribute to children’s sugar intakes by at least 20% by 2020, including a 5% reduction in year one. This can be achieved through reduction of sugar levels in products, reducing portion size or shifting purchasing towards lower sugar alternatives.

This programme will be led and run by Public Health England (PHE) and will apply to all sectors of industry – retailers, manufacturers and the out of home sector (for example,restaurants, takeaways and cafés) – and to all foods and drinks that contribute to children’s sugar intakes, including those aimed at very young children. The programme will initially focus on the nine categories that make the largest contributions to children’s sugar intakes: breakfast cereals, yoghurts, biscuits, cakes, confectionery, morning goods (for example, pastries), puddings, ice cream and sweet spreads.20 Work will then move on to cover the remaining relevant foods and drinks, including any products that may be out of scope of the soft drinks industry levy, for example, milk-based drinks. The sugar reduction programme will also work to reduce the sugar content of product ranges explicitly targeted at babies and young children.21

PHE will advise Government on setting sugar targets per 100g of product and calorie caps for specific single serving products. The 4-year, category-specific targets for the nine initial categories will be published in March 2017. Progress will be measured on the basis of reductions in the sales weighted average sugar content per 100 grams of food and drink, reductions in portion size so that these contain less sugar, or a clear sales shift towards lower sugar alternatives.22

To ensure that the achievement matches expectations, progress will be reviewed by PHE who will publish interim reports on progress every 6 months. This will include reviewing reductions achieved through analysis of sales data and food composition data along with plans for further reductions. Some companies have led the way in addressing sugar reduction and it is important that existing work is recognised. Therefore, PHE will use 2015 data as the baseline for this reduction programme.

PHE will provide an assessment at 18 and 36 months (September 2018 and March 2020) on the approach adopted by industry. Government will use this information to determine whether sufficient progress is being made and whether alternative levers need to be used by the Government to reduce sugar and calories in food and drink consumed by children. If there has not been sufficient progress by 2020 we will use other levers to achieve the same aims.

Sugar reductions should be accompanied by reductions in calories and should not be compensated for by increases in saturated fat. Work to achieve salt targets should continue alongside the sugar reduction programme. From 2017, the programme will be extended to include setting targets to reduce total calories in a wider range of products contributing to children’s calorie intake and across all sectors, including the out of home sector. Work on saturated fat will be further reviewed in light of SACN recommendations due in 2017.

Supporting innovation to help businesses to make their products healthier

We want to encourage the next generation of innovation in science and technology to allow industry to create healthier, more sustainable products. To support this, Innovate UK ran a collaborative research and development (R&D) competition worth £10 million for research to stimulate new processes and products to increase the availability of healthier food choices for consumers and open up new markets. The recently formed Agri-Food Technology Council provides leadership in areas such as health and nutrition and consumer acceptability, and the Food Innovation Network is bringing together food businesses, researchers, and innovation support to enable greater take up of world-leading R&D.

Developing a new framework by updating the nutrient profile model

To help families to recognise healthier choices, we need a new way to determine which food and drink products are healthier and which are less healthy. The restrictions on food and drink advertising that are already in place to protect children are based on a tool called a ‘nutrient profile’. Each food and drink is assigned a score based on working out how much sugar, fat, salt, fruit, vegetables and nuts, fibre and protein it contains.

The current nutrient profile is over 10 years old and does not reflect recent scientific advice such as the SACN report or new products introduced. Having a strong, effective model will be crucial for underpinning all areas of this plan: giving clear guidance on how products will be treated will encourage companies to make their products healthier so they can avoid potential sanctions. Therefore, PHE is working with academics, industry, health non-governmental organisations (NGOs) and other stakeholders, to review the nutrient profile model to ensure it reflects the latest government dietary guidelines. This should ensure that an updated profile focuses on the most unhealthy products, rather than adversely affecting products which are consumed as part of a healthy diet.

Making healthy options available in the public sector

We need to harness the true potential of the public sector to reduce childhood obesity. The public sector in England spends over £2 billion on food and catering services annually, with just under half, £1 billion, being the cost of food and ingredients.23 These buildings, services and spaces should set an example to children and families.

Every public sector setting, from leisure centres to hospitals, should have a food environment designed so the easy choices are also the healthy ones. Therefore, we will continue to work with local authorities and the Local Government Association to support them to tackle childhood obesity. This will include encouraging local authorities to adopt the GBSF standards, particularly in leisure centre vending machines. We will also ensure that there is full uptake of the Government Buying Standards for Food and Catering Services (GBSF) in central government departments

Ukactive, whose members manage a large proportion of the fitness and leisure centres in England, are committed to making the environment in those places healthier by considering ways to provide and promote healthy options and restrict the sale of unhealthy food and drink.

The Department of Health is building on this requirement by collaborating with PHE, NHS England and the Behavioural Insights Team to trial behavioural interventions in NHS hospitals. These interventions will measure changes in purchasing behaviour and the impact on revenue from sales.

Continuing to provide support with the cost of healthy food for those who need it most

We are re-committing to the Healthy Start scheme, which provided an estimated £60 million worth of vouchers to families on low income across England in 2015 to 2016. These can be exchanged for fresh or frozen fruit or vegetables and milk. The scheme also provides free vitamins to support intake during pregnancy and early years. Last year over 1.7 million vouchers were issued every four weeks and an average of 480,000 children in low income families were benefiting from the scheme in each month of the year.

Helping all children to enjoy an hour of physical activity every day

There is strong evidence that regular physical activity is associated with numerous health benefits for children.24 The UK chief medical officers recommend that all children and young people should engage in moderate to vigorous intensity physical activity for at least 60 minutes every day. Many schools already offer an average of two hours of PE or other physical activities per week. However, we need to do more to encourage children to be active every day. Every primary school child should get at least 60 minutes of moderate to vigorous physical activity a day. At least 30 minutes should be delivered in school every day through active break times, PE, extra-curricular clubs, active lessons, or other sport and physical activity events, with the remaining 30 minutes supported by parents and carers outside of school time.

Given the considerable new funding that the soft drinks industry levy will make available for school sports, the Government is keen that schools are supported as much as possible in how they spend the available funds for maximum impact. During inspections, Ofsted assess how effectively leaders use the Primary PE and Sport Premium and measure its impact on outcomes for pupils, and how effectively governors hold them to account for this. Physical activity will be a key part of the new healthy schools rating scheme, and so schools will have an opportunity to demonstrate what they are doing to make their pupils more physically active.

Schools will continue to have the freedom to consider spending the Primary PE and Sport Premium on specific interventions but to help schools understand what help is available, PHE will be developing advice to schools for the academic year 2017/18. This will set out how schools can work with the school nurses, health centres, healthy weight teams in local authorities and other resources, to help children develop a healthier lifestyle.

Furthermore, we will make available a new interactive online tool which will help schools plan at least 30 minutes of physical activity every day. This will help schools identify gaps in the existing opportunities for children to be active and will recommend a number of solutions they can choose, for example after school clubs, initiatives such as the daily mile, creating an active playground or having an active lesson.

Improving the co-ordination of quality sport and physical activity programmes for schools

We have asked the County Sports Partnerships to work with National Governing Bodies of sport, the Youth Sport Trust and other national and local providers to ensure that from September 2017, every primary school in England has access to a co-ordinated offer of high quality sport and physical activity programmes, both local and national. As part of this, national governing bodies will offer high quality sport programmes to every primary school.

While children spend a significant amount of time in school, keeping children active is a shared responsibility and parents and carers need to play their part. The Sport England Strategy ‘Towards an Active Nation’ (2016) has already set out a major new investment of £40m into projects which offer new opportunities for families and children to get active and play sport together. This investment will focus on helping children acquire a basic level of competence in sport and physical activity as well as supporting them to have fun, regardless of their level of ability.

We will continue investing in walking and cycling to school. Walking or cycling to school provides a healthy way to start the day. The government has committed to producing a Cycling and Walking Investment Strategy. The first strategy will set out plans for investing £300m to support cycling and walking. It will set a clear target to increase the number of children walking to school as well as continued support for Bikeability cycle training for children.

Creating a new healthy rating scheme for primary schools

Schools are a vital part of our plan, and have opportunities to support healthier eating, physical activity and to shape healthy habits. Schools also have unique contact with parents and can signpost them to information and advice on keeping their children healthy. From September 2017, we will introduce a new voluntary healthy rating scheme for primary schools to recognise and encourage their contribution to preventing obesity by helping children to eat better and move more. This scheme will be taken into account during Ofsted inspections.

The scheme will help schools to demonstrate to parents that they are taking evidence-based actions to improve their pupils’ health. Building on existing schemes where appropriate, the criteria for the rating scheme will be developed in consultation with schools and experts but will cover the school’s approach as a whole. We will seek to actively involve parents in the rating process so they can be confident their children are attending schools which provide healthy food and opportunities for physical activity.

We are also keen to celebrate schools that can demonstrate healthy approaches towards tackling obesity amongst their pupils, and therefore we will run an annual competition to recognise schools with the most innovative and impactful projects.

Ofsted already evaluate a school’s success in promoting and supporting pupils’ knowledge of how to keep themselves healthy, including through exercising and healthy eating. Inspectors expect to see pupils making informed choices about eating and physical activity and the school’s culture promoting this aspect of pupils’ welfare. This evaluation informs inspectors’ judgement on pupils’ personal development, behaviour and welfare.

Once the new rating scheme is operational it will be referred to in the school inspection handbook, and Ofsted inspectors will be able to take account of the scheme as an important source of evidence about the steps taken by the school to promote healthy eating and physical activity.

In addition, in 2017, Ofsted will undertake a thematic review on obesity, healthy eating and physical activity in schools. The review will provide examples of good practice and recommendations on what more schools can do in this area.

Making school food healthier

We have already done a lot to improve school food: many school canteens are unrecognisable from those 20 to 30 years ago. The School Food Plan, published in July 2013, has helped bring about whole school improvements in food. The new School Food Standards came in to force from January 2015. They have been widely welcomed but since then new advice on sugar and nutrition has been published. Therefore the Department for Education (DfE), supported by PHE, will update the School Food Standards in light of refreshed government dietary recommendations

The majority of schools are subject to the School Food Standards. However, some academies and free schools are not. We are keen to encourage all academies to make a clear commitment as part of tackling childhood obesity. Therefore, the Secretary of State for Education will lead a campaign encouraging all schools to commit to the standards.

Breakfast clubs can contribute to improved attainment, attendance and overall health.25 This is why the government recently announced that £10 million a year of revenue from the soft drinks levy will fund the expansion of healthy breakfast clubs. This programme will ensure that more children benefit from a healthy start to their school day.

Clearer food labelling

In order to make healthier choices, families need to be presented with clear information about the food they are buying. The UK has led the way, working with industry to implement a voluntary front of pack traffic light labelling scheme, which now covers two thirds of products sold in the UK. However, an issue of increasing concern to families is understanding which sugars they should be cutting out of their diet. Current sugar labelling shows the total sugar content of foods but the new maximum intake recommendations are based on the specific sugars26 that are easily over-consumed, not all sugars.

The UK’s decision to leave the European Union will give us greater flexibility to determine what information should be presented on packaged food, and how it should be displayed. We want to build on the success of our current labelling scheme, and review additional opportunities to go further and ensure we are using the most effective ways to communicate information to families. This might include clearer visual labelling, such as teaspoons of sugar, to show consumers about the sugar content in packaged food and drink.

Supporting early years settings

The early years are a crucial time for children’s development. One in five children are already overweight or obese before they start school27 and only one in ten children aged two to four meets the UK chief medical officers’ physical activity guidelines for this age group.28 29 30

PHE have commissioned the Children’s Food Trust to develop revised menus for early years settings by December 2016. These will be incorporated into voluntary guidelines for early years settings to help them meet current Government dietary recommendations. This will include practical ideas and suggestions, alongside the sample menus.

In early 2017, we will launch a campaign to raise awareness of these guidelines among both early years practitioners and parents and we will update the Early Years Foundation Stage Framework to make specific reference to the UK chief medical officers’ guidelines for physical activity in the early years (including active play).

Harnessing the best new technology

Consumer power and choices are important drivers of the food environment and, potentially, in ending the childhood obesity crisis. We need accessible, simple information on how much sugar, fat and salt your weekly shop contains. We need to capitalise on the power of technology to support healthier choices. The uptake of Change4Life’s Sugar Smart app31 shows the potential of digital applications in this regard. We will therefore work with PHE, Innovate UK, the third sector and commercial players to investigate opportunities to bring forward a suite of applications that enable consumers to make the best use of technology and data to inform eating decisions. We will also ask PHE to build on work which is underway around digital based weight management support for adults and explore similar approaches for children and families.

We recognise that this is a fast-paced industry and advances are constantly being made. We want to provide a national forum to engage the country’s best innovators with the childhood obesity cause. To support this, PHE will hold an annual digital technology ‘hackathon’, bringing together leading developers and programmers to produce innovative solutions to address childhood obesity.

Enabling health professionals to support families

We are asking health care professionals to build on the good work they already do by always talking to parents about their family’s diet, working towards making it the default to weigh everyone, referring people to local weight management services, clubs and websites if they ask for more advice.

Health professionals should feel confident discussing nutrition and weight issues with children, their families and adults. To support this ambition, Health Education England (HEE) and PHE have launched a suite of resources aimed at supporting the health care and wider workforce to ‘make every contact count’. These resources include training on influencing behaviour change and initiating difficult conversations about health and wellbeing, as well as targeted training for health visitors and school nurses given their unique positioning which enables them to identify weight issues in children early on.

We will review where content on nutrition, physical activity, healthy weight messaging and weaning advice in materials for visits by midwives and health visitors can be strengthened so new families get the best advice to ensure a focus on healthy weight. We will also explore how evidence-based healthy weight messaging can be introduced at other contact points, such as childhood immunisation programmes.

HEE has also reviewed and updated the existing materials about obesity and nutrition available via the E-learning for Health platform and encourage all those working in the NHS to undertake relevant training as part of their continuing professional development, so that they feel confident about raising weight issues, nutrition and physical activity as an issue.

We will continue to explore what more can be done across the health sector and work with our partners to develop approaches to prevent and reduce childhood obesity.

Conclusion

With nearly a third of children aged 2-15 overweight or obese32, tackling childhood obesity requires us all to take action. Government, industry, schools and the public sector all have a part to play in making food and drink healthier and supporting healthier choices for our children. The benefits for reducing obesity are clear – it will save lives and reduce inequalities.

The actions in this plan will significantly reduce England’s rate of childhood obesity within the next 10 years. Achieving this will mean fewer obese children in 2026 than if obesity rates stay as they are.33 We are confident that our approach will reduce childhood obesity while respecting consumer choice, economic realities and, ultimately, our need to eat. Although we are clear in our goals and firm in the action we will take, the launch of this plan represents the start of a conversation, rather than the final word. Over the coming year, we will monitor action and assess progress, and take further action where it is needed.

  1. Health and Social Care Information Centre (2015) Health Survey for England 2014

  2. A child’s BMI is based on ‘weight for height’ defined as weight in kilograms divided by the height in metres squared (kg/m2). To take into account growth patterns by age and gender, a children’s BMI is compared with BMI centiles on published growth charts. Children with a BMI above the 98th centile are considered clinically obese. For population monitoring those above the 95th centile are classed as obese.

  3. Johnson W, Li L, Kuh D, Hardy R (2015) How Has the Age-Related Process of Overweight or Obesity Development Changed over Time? Coordinated Analyses of Individual Participant Data from Five United Kingdom Birth Cohorts. PLoS Med 12(5)

  4. T. Pischon, M.D et al. (2008) General and Abdominal Adiposity and Risk of Death in Europe. The New England Journal of Medicine. 359:2105-2120.

  5. Asnawi Abdullah, Anna Peeters, Maximilian de Courten, Johannes Stoelwinder (2010) The magnitude of association between overweight and obesity and the risk of diabetes: A meta-analysis of prospective cohort studies. Diabetes Research and Clinical Practice.

  6. Health and Social Care Information Centre (2015) Health Survey for England 2014.

  7. Gatineau M, Dent M (2011) Obesity and Mental Health. Oxford: National Obesity Observatory.

  8. McKinsey Global Institute (2014) Overcoming Obesity: An Initial Economic Analysis.

  9. Estimates for UK in 2014/15 are based on: Scarborough, P. (2011) The economic burden of ill health due to diet, physical inactivity, smoking, alcohol and obesity in the UK: an update to 2006–07 NHS costs. Journal of Public Health. May 2011, 1-9. Uplifted to take into account inflation. No adjustment has been made for slight changes in overweight and obesity rates over this period. It’s been assumed England costs account for around 85% of UK costs.

  10. Health and Social Care Information Centre (2015) National Child Measurement Programme, England 2014/15

  11. Yvonne Kelly, Alice Goisis, and Amanda Sacker (2015) Why are poorer children at higher risk of obesity and overweight? A UK cohort study. The European Journal of Public Health.

  12. Start Active, Stay Active: A report on physical activity from the four home countries’ chief medical officers, July 2011.

  13. PHE (2014): The link between pupil health and wellbeing and attainment https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/370686/HT_briefing_layoutvFINALvii.pdf

  14. Chanfreau et al (2016): Out of school activities during primary school and KS2 attainment

  15. Public Health England (2015) Sugar Reduction: the evidence for action.

  16. Brooks, F. et al (2010) Health Behaviours in School-aged Children

  17. The Scientific Advisory Committee on Nutrition (2015) Carbohydrates and Health

  18. Department of Health (2012). Report on dietary sodium intakes 2012. Online. Available from: https://www.gov.uk/government/news/report-on-dietary-sodium-intakes cited in Public Health England (2015) Sugar reduction: the evidence for action

  19. Hollands G, Shemilt I, Marteau T, Jebb S, Lewis H, Wei Y, et al. (2015) Portion, package or tableware size for changing selection and consumption of food, alcohol and tobacco. Cochrane Database of Systematic Reviews. Issue 6. Art. No.: CD011045.

  20. Excludes soft drinks as these will be covered by the soft drinks industry levy.

  21. Excluding breast-milk substitutes.

  22. The sales weighted average refers to the average sugar levels across a food category, and is calculated by weighting the contribution of individual products according to volume sales.

  23. Smarter food procurement in the public sector, NAO report HC 963-I Session 2005-2006, 30 March 2006

  24. Start Active, Stay Active: A report on physical activity from the four home countries’ chief medical officers, July 2011.

  25. Public Health England (2013) Breakfast and Cognition

  26. Public health advice recommends limitation of ‘Free sugars’ consumption, which includes all refined sugar added to foods, plus sugars naturally present in ingredients such as honey, syrups and unsweetened fruit juices.

  27. Health and Social Care Information Centre (2015) National Child Measurement Programme: England, 2014/15.

  28. The recommended level of moderate to vigorous physical activity for children under 5 is 180 minutes a day, spread through-out the day. [CMO (2011) UK Physical Activity Guidelines]

  29. Health and Social Care Information Centre (2013) Health Survey for England 2012.

  30. chief medical officer (2011) Physical activity guidelines for under 5s, Factsheet 2.

  31. See: https://www.nhs.uk/change4life-beta/campaigns/sugar-smart/home

  32. Health and Social Care Information Centre (2015) Health Survey for England 2014

  33. There are 1.6 million obese children aged 2-15 in England: Health and Social Care Information Centre (2015) Health Survey for England 2014 Trend Tables