Table of Contents  

Adivi: Childhood obesity – a public health issue to be addressed in the Middle East for the health of future generations

Introduction

The prevalence of overweight and obese children has reached epidemic levels, with resulting profound impacts on health and the economy. Globally, at least 42 million children under the age of 5 years were overweight in 2013.1

Obese children carry health problems into adulthood, decreasing their life span and increasing disability. Type 2 diabetes mellitus, heart problems, high blood pressure, gallbladder disease and osteoarthritis are the major diseases associated with obesity. Depression, low self-confidence and decreased social interaction are the psychological dimensions correlated with increasing weight in children.

For populations in North America and South America, 50% of children are expected to be classified as obese or overweight by 2020. Regions such as the Middle East and South East Asia are also expected to have a higher prevalence of overweight/obese children in the near future; one in five children in China are expected to be classified as obese by 2020. Despite the prevalence of malnutrition in Africa, the number of individuals that are overweight or obese is rising. According to the study conducted by the Institute for Health Metrics and Evaluation at the University of Washington,2 the last three decades have seen a steady rise in obesity in the Middle East.

Determinants

Obesity is caused by complex issues that include genetic, cultural, behavioural, nutritional and biological factors. A lifestyle of physical inactivity and unhealthy eating habits is a major governing factor. Developing countries that already have to contend with the burden of malnutrition must also face the problem of obesity. Middle Eastern countries, especially the United Arab Emirates (UAE) and Saudi Arabia, must deal with the rising levels of obesity among adults and children. Nutritious and healthy foods are expensive and, in general, the increasing food prices are forcing low-income families to seek cheaper unhealthy foods. On the contrary, affluence has actually increased consumption of sugary drinks and energy-dense foods. The additional calories have a major impact on the weight and health of children who reduce their intake of milk, fruits and vegetables as a result of the feelings of satiety arising from energy-dense foods.3

In many countries, most of the advertisements on television are for unhealthy foods targeting children or adolescents.4 Food marketers are targeting preschool children and toddlers with advertisements as they have a persuasive influence on their parents.5 The marketing of junk food, the availability of cheap junk food and the assimilation of Western culture are all considered to be contributors to rising obesity levels. A study of food-related advertising in Mexico found that 22% of total advertising was food related, 50% of which was aimed at children. The majority of these advertisements were for high-energy foods such as potato crisps and tortilla chips, desserts and cakes, juices, sweetened cereals, sweets, cookies, fast foods and sweetened beverages.6 Television channels focusing exclusively on food can flaunt street food and other junk food that can further entice children to eat these types of food.

In India and Nepal, 60% of television commercials promote soft drinks or carbonated drinks and 21% promote snacks.7 The frequency with which people eat out is also increasing as income increases. The Gourmet Retailer states that the Asia–Pacific region leads the world in dining out, with 31% of consumers in Hong Kong eating out every day.8 In the UAE, the frequency with which people eat out or order from a takeaway varies from once a week to more than three times a week.9 The number of independent and chain fast food restaurants has multiplied following the introduction of global cuisine. Popular Western fast foods are now regular mealtime options for children and adolescents. Some of these restaurants are open around the clock to give customers the chance to eat out late.9 School canteen menus offer pizzas and burgers accompanied by chips and carbonated drinks. However, it is thought that few children eat food from school canteens on a daily basis.

Sedentary behaviour contributes to various illnesses, especially obesity. More and more children and adolescents do not achieve the required 60 minutes of daily physical activity. Reduced living space, lack of play areas, poor air quality and unsafe neighbourhoods can isolate children. Schools try to utilize most of the available space for classrooms and do not allocate appropriate play areas or equipment. The shrinking availability of physical education activities and focus on academic competence have reduced break times. Basketball, football, cricket and other games formerly taught during physical education classes are now extracurricular activities available at a cost. The cost prevents many children from attending these classes. Television viewing, surfing the internet, internet chat and video games are substituted for physical activities, making children lethargic. Reduced physical activity also leads to less social interaction. Weight gain hinders participation in recreational or leisure time sports as a result of fatigue and sleep apnoea.

Obesity has a negative effect on mental health. Lack of self-confidence and low self-esteem are caused by a negative body image and social discrimination. Depression and anxiety are common mental health disorders in association with less social interaction and increased isolation. Obese children have low self-esteem and are highly prone to smoking, drinking and obsessive–compulsive disorder.10 Studies have been conducted to establish the effect of obesity on mental health in children and adolescents. These studies do state the negative psychological effect lacks evidence on gender and ethnicity.11 In a study by Schwimmer et al.,12 in 2003, it was found that overweight children rated their quality of life in an equivalent manner to young cancer patients on chemotherapy. In addition, diminished or impaired intellectual development is a risk factor for obese children.13

Cardiovascular disease is the most common cause of mortality followed by accidents and cancer.14 Type 2 diabetes, high blood pressure, heart ailments, osteoarthritis, certain types of cancer and other debilitating diseases are the lifelong risks associated with the increasing prevalence of overweight or obese children and adolescents. Health care costs are burgeoning and putting strain on already overburdened economies. The USA spends approximately $147 billion on obesity health care annually.15 As health insurance and social security in developing countries is not on a par with that in developed countries, medical expenses can be a burden on individual finances. Disability costs and reduced productivity overtaxes the financial budgets of nations. In the UAE, according to statistics provided by the World Health Organization (WHO), per capita health expenditure in 2012 was $1335, and the public health expenditure was 2% of the total gross domestic product.16,17

Strategies for prevention

Physicians are unable to treat obesity in children in the clinical setting alone. Support from family and teachers is also necessary. Food advertising aimed at children is expanding from television to mobile phones, the internet and video games. Fast food companies use toys and video games as a marketing strategy to entice children.

The Junk Food Trap: marketing unhealthy food to children in Asia Pacific, a Consumers International report released in 2008,18 revealed that multinational companies continued marketing unhealthy food in Asia despite signing pledges. As food marketing regulations differ between countries across Asia, multinational companies exploit the lack of regulation of marketing and advertising in some countries.18 Regulatory laws on advertising and marketing of food have been proposed but have not been enforced owing to legal, social and financial barriers.19 Television advertising during school hours or in late night programmes is advised. To address the obesity issue, the UAE government approved certain measures in December 2013, which included calorie content labelling on food packaging, reducing the size of carbonated drinks, regulations on food advertising and banning school canteens from selling unhealthy food.20 Schools in the UAE are now progressing towards implementing these regulations in their canteens.

Nutritional information, such as calorie and sugar and other additive contents, are now available on food packages in accordance with regulations. Unfortunately, this information is overlooked or disregarded in favour of how these foods taste.

Regulating food advertising is a good initiative to curb commercials that promote an unhealthy lifestyle and food products with high quantities of sugar, fat and salt. Scrutiny of endorsements and insistence on scientific evidence for health benefits is advised. Brands guilty of misinformation should be fined. Food advertising during school hours and late night programmes is suggested to prevent children from being targeted. School canteens should offer seasonal fruits, instead of fried snacks, and foods with colourful vegetables to tempt children and encourage them to develop better eating habits.

Physical activity should be encouraged from a very young age to prevent the risk of obesity. Schools are a good environment with the resources to increase physical activity and promote nutritious food choices. Panellists and experts at the International Obesity Task Force have agreed that various steps should be taken by parents, educators and community officials to adopt beneficial settings in the community.21

Successful strategies to combat child obesity include behavioural modifications such as:

  • walking to school, where applicable

  • taking the stairs

  • reduced television viewing and playing of video/computer games

  • increasing physical activity classes at school

  • encouraging leisure sports

  • family dinners in a specified dining area away from the television

  • promoting healthy food choices with nutritious food at school and in the home.

Green buildings and communities can ensure physical activity. Apartment blocks could include a floor exclusively for indoor games to promote physical activity. Including this at the design stage will appeal to families and is a good marketing strategy for builders.

Conclusion

Studies have to be conducted to record the outcomes of the new regulations on unhealthy food and other initiatives. Most lifestyle interventions to curb child obesity have been employed in North America and Europe rather than the Middle East and North Africa. The effectiveness of these interventions has, so far, produced varied results. Middle Eastern countries require more interventions to modify behaviour in school and family settings, and also the sustainability of these modifications must be verified in terms of their long-term health benefits. The interventions in the USA and Europe have indicated that the sustainability of these behavioural modifications is the issue of concern. Hence, it is important to reiterate the necessity of sustainable models. International organizations such as WHO and local non-governmental organizations should take assertive action to prevent and campaign against unhealthy lifestyles.

The European Court of Justice has ruled that obesity is a disability and should be covered under disability discrimination acts.22 The United States government used to consider obesity to be a disability when it physically or mentally impairs an individual until amendment in 2000.23,24 The Resources for Human Development Inc. settled a case of ‘termination based on discrimination’ for $125 000 in 2012.14 The ruling of obesity as a disability could burden companies and governments with the need to provide short- and long-term treatment of associated diseases and compensation for unemployment. Organizations and companies need to organize extra space and additional facilities, if any, to provide for obese employees and may enforce rules on weight gain for other employees. An increase in insurance premiums is also a possibility. Implementing a similar court ruling in other parts of the world could tax economies that are already burdened with their existing health care expenditure.

Lifestyle modification programmes that are proven to be effective for children have to be implemented regularly to prevent child obesity, thereby ensuring the health of future generations and a better economy.

References

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9. 

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18. 

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