Overweight/obesity during childhood is a major public health issue with more than 200,000 Australian children between 2-18 years now obese (Booth et al, 2003). It has significant health implications across the life span. This Policy brief reviews the effectiveness of prevention and intervention strategies and highlights the importance of adopting a multi-faceted approach to decrease the prevalence of overweight/obesity in children.

Why is this issue important?

With around 25% of school-aged children (Booth et al, 2006; Booth et al, 2003) and 20% of preschoolers now overweight or obese (Wake et al, 2006), Australian children are heavier and less fit than ever before. Overweight doubled and obesity tripled in prevalence between 1985 and 1997, and continues to rise at a rate of about 1-1.5% per year (Booth et al, 2006; Sanigorski et al, 2007). Though Australian children are in ‘the middle of the pack’ internationally, their rate of rise is among the steepest (Lobstein et al, 2004).&nbsp

Centre for Community Child Health

English

Analysis and Policy Observatory (APO)

 
 
No 7 2007 
 
Initiative of: Supported by: 
POLICY BRIEF 
Translating early childhood research evidence to inform policy and practice 
 
Overweight and obesity in childhood  
Overweight/obesity during childhood is a major public health issue with more than 200,000 
Australian children between 2-18 years now obese (Booth et al, 2003).  It has significant health 
implications across the life span. This Policy Brief reviews the effectiveness of prevention and 
intervention strategies and highlights the importance of adopting a multi-faceted approach to 
decrease the prevalence of overweight/obesity in children. 
Why is this issue important? 
With around 25% of school-aged children 
(Booth et al, 2006; Booth et al, 2003) and 
20% of preschoolers now overweight or obese 
(Wake et al, 2006), Australian children are 
heavier and less fit than ever before. 
Overweight doubled and obesity tripled in 
prevalence between 1985 and 1997, and 
continues to rise at a rate of about 1-1.5% per 
year (Booth et al, 2006; Sanigorski et al, 
2007). Though Australian children are in ‘the 
middle of the pack’ internationally, their rate of 
rise is among the steepest (Lobstein et al, 
2004). 
 
Obesity is an all-inclusive epidemic, affecting 
rural and urban Australian children from all 
states, all age groups, and all socioeconomic 
levels (Booth et al, 2001). Nonetheless, there 
are disparities. In the Longitudinal Study of 
Australian Children: 
• culturally and linguistically diverse (CALD) 
and indigenous communities, and other 
disadvantaged backgrounds, are risk factors 
for heavier BMI status (especially for boys),  
• preschoolers in the lowest fifth of the 
population for social disadvantage have 
nearly 50% higher odds of being in a heavier 
body mass index (BMI) category compared to 
those in the top fifth of the population (Wake 
et al, 2006).   
 
Being overweight/obese has short term and 
long term consequences for physical and 
psychosocial health. Whilst most 
overweight/obese pre-school and primary 
school children appear healthy and well-
 
adjusted, many experience weight-related 
problems including: 
• Physical problems - joint and mobility 
problems, sleep apnoea and the early 
biochemical precursors of later diabetes, heart 
and liver disease (Ebbeling et al, 2002).  
• Psychosocial problems - exposure to 
teasing, bullying and social exclusion, which 
can lead to withdrawal from participation in 
activity, and in turn, increased weight gain due 
to lack of physical activity (Batch and Baur, 
2005; Williams et al, 2005). 
 
Overweight/obesity at adolescence, regardless 
of later BMI, are also associated with poorer 
health and employment outcomes for males, 
and poorer social and economic outcomes for 
females (Must, 1992). The most significant 
long-term concern is the increased risk of adult 
overweight/obesity, and the associated serious 
health problems (Summerbell et al, 2003). In 
addition to the implications for the individual 
and their family, overweight/obesity has 
substantial economic ramifications and places 
an enormous burden on the health and welfare 
system (Access Economics, 2005). 
 
There have been many prevention and 
intervention programs employed to address 
the obesity epidemic, but no one program has 
provided ‘the answer’ for successful outcomes 
(ACE, 2006). The need to evaluate ‘what has 
been done’ as well as ‘the next steps forward’, 
is critical given that it appears difficult if not 
impossible to reduce the average weight of 
populations once obesity is entrenched. 
 
 Policy Brief No 7 2007: Overweight and obesity in childhood  2 
 
 
What does the research tell us? 
Why are children becoming obese?   
The interacting factors that determine whether 
or not a child becomes overweight are 
complex and multifaceted (Davison and Birch, 
2001). Children live within layers of extending 
influences: the family, the extended family or 
cultural group, the local community (childcare, 
school, local streets, recreational facilities), 
the wider community (television advertising, 
public transport) and the society. Obesity is 
driven by individual, environmental and social 
circumstances (Lobstein et al, 2004).   
 
Individual and family perspective    
Between 1985 and 1995, the energy density 
of food consumed by Australian children 
increased by about 13% (Cook et al, 2001). 
Children also became less fit (Tomkinson et 
al, 2003) and current daily physical activity is 
lower than recommended for general health 
(Reilly, 2005; Reilly et al, 2004). Even though 
the relative contributions to the obesity 
epidemic of overnutrition (large portions, high 
energy density) versus underactivity remain 
unclear, one emerging viewpoint is that 
although overnutrition may be the main driver 
of obesity, low physical activity may be 
responsible for many of its health 
consequences (Weiss and Raz, 2006). 
 
The critical question as to why some children 
become overweight, but others do not, can 
not yet be fully answered. While lifestyle 
choices play a part, many individuals appear 
to be genetically predisposed toward weight 
gain given the ‘right’ conditions (Popkin, 
1998). It takes many generations for the gene 
pool to evolve; however, it is possible to 
induce permanent changes in the way genes 
function (‘epigenetic’ changes) from one 
generation to the next. The most obese 
generation of young adults in history are now 
becoming parents, and having heavier babies 
and toddlers (Whitaker and Dietz, 1998). 
Epigenetic changes, due to exposures such 
as high glucose, high fat and/or high insulin 
during fetal life, could be programming 
individuals towards obesity even from before 
birth (Keith et al, 2006; Singhal et al, 2003).  
 
As well as their genes, families share lifestyle 
and local environment (Agras, 2005).  
Parental eating habits, feeding practices 
(Fisher, 1995) and duration of breastfeeding 
(Hediger et al, 2001) can all influence 
children’s weight. Children typically adopt their 
families’ meal patterns (such as high-fat food 
and fruit and vegetable intake) and practices 
(such as eating in front of the television) 
(Matheson et al, 2004). Children are also 
influenced by the family activity levels and 
parents’ ability to facilitate an active lifestyle 
for them (Reilly, 2005).  
 
Community perspective  
Environmental and societal changes have 
seen a reduction in incidental physical activity. 
• Perceptions about child safety, concerns 
about injury during active play at school and 
child care, and smaller families lead to less 
strenuous activity (Swinburn and Egger, 
2004).   
• People living in towns characterised by 
fewer green outdoor spaces and more rubbish 
and graffiti report lower physical activity and 
more obesity (Ellaway et al, 2005). 
 
In relation to food intake, a large proportion of 
the food supply is partially or fully prepared 
and cooked before purchase, and many 
meals are eaten away from home 
(Commonwealth Department of Health and 
Age Care, 1998). These items are often 
higher in fat, energy and portion size than 
home-prepared foods. High-sugar drinks and 
foods high in simple sugars, processed starch 
and fats are widely available, very palatable, 
and may specifically promote obesity. Poverty 
may impose a ‘double jeopardy’: energy-
dense food is preferentially purchased when 
money is tight, and this may compound the 
effects of poorer access to healthier nutrition 
options (Sausenthaler et al, 2007; Mendoza et 
al, 2006; Drewnowski et al, 2004). 
 
Approaches to effective prevention   
Attempts to develop evidence-based 
strategies need to take into consideration the 
individual and family perspective as well as 
the influence of the wider community. 
 
Whitaker (2003) suggests that, at the 
individual level, successful obesity prevention 
needs to include changes in parenting 
practices and access to information to support 
parents regarding:  
• increasing breast feeding rates and 
duration 
• developing a child’s fruit and vegetable 
acceptance, and inclusion in daily diet  
• developing a preference for lower fat foods 
and milk to reduce fat content and increase 
calcium content respectively to reduce 
potential weight gain and support healthy 
growth 
• drinking water in preference to sugary 
drinks to decrease kilojoule intake  
   
Policy Brief No 7 2007: Overweight and obesity in childhood  3 
young as possible, given that: 
• obesity clinics report the best results for 
younger children 
• obesity is already very stable by school 
entry 
• early treatment may avoid subsequent 
decline in physical and psychological health 
• young children can simply ‘grow into their 
weight’ (rather than having to actually lose 
weight) 
• even if children do not change their BMI 
trajectory, they may still benefit through 
improved fitness and glucose metabolism and 
relative increases in lean mass (Reinehr et al, 
2006). 
 
School-based interventions targeted to obese 
children have been successful (Sallis et al, 
1995), but are not currently popular because 
of fears of alienation and stigmatization. For 
children with established obesity, 
multidisciplinary hospital clinics have been 
shown to improve health outcomes in a large 
majority of referred children (Sabin et al, 
2007).  
 
The National Health and Medical Research 
Council (2003) guidelines recommended 
routine surveillance of BMI in primary care 
settings for all Australian children backed up 
with guidance, counseling, and treatment 
when needed. However, recent surveys show 
that community child health nurses (Wake et 
al, 2007), general practitioners (Gerner et al, 
2006), and paediatric hospitals (McLean et al, 
2006) do not routinely assess children for 
overweight, nor do parents themselves 
usually express concerns about overweight in 
their own young children. Even if 
professionals and parents could and did 
correctly identify obesity, few services are 
available, even for the children who are most 
obese and/or suffering other morbidities 
related to their obesity. Australia boasts only a 
handful of dedicated children’s obesity clinics, 
which tend to be poorly resourced, have long 
waiting lists, and see only a minute proportion 
of Australia’s severely obese children. An 
integrated service delivery approach across 
the primary, secondary and tertiary levels is 
needed so that there is adequate service 
provision to sufficiently reverse the trend of 
increasing levels of overweight/obesity (ACE, 
2006). 
 
Despite its current prominence, obesity is a 
relatively new public health issue, so that 
evidence about causal pathways and effective 
intervention strategies is still sparse. 
• establishing television viewing guidelines 
to limit sedentary activity  
• increasing outdoor play to increase 
physical activity. 
  
Parents can influence children’s physical 
activity and health practices through 
modeling, providing a healthy home 
environment and emphasizing behaviours 
more than weight. They can limit television 
and screen-based activities, particularly at 
times which compete with outdoor time and 
active play. Prevention programs aimed at 
supporting changes in parenting practices 
also need to include more intensive targeted 
strategies for families in communities at risk 
for higher rates of overweight/obesity (eg 
CALD, indigenous and socio-disadvantaged 
groups) (Harvey-Berino and Rourke, 2003).  
 
The community, including government, also 
plays an important role in prevention. A recent 
review demonstrated that the most cost-
effective obesity intervention included 
reduction in television advertising of high 
fat/sugar foods and beverages during 
children’s viewing hours, and a school-based 
nutrition education intervention to reduce 
consumption of soft drinks (ACE, 2006). 
Schools and child care centres, transport, 
urban design and infrastructure strategies can 
all encourage healthier nutrition as well as 
more and safer play. Strategies such as the 
‘Walking School Bus’ and ‘Active After School' 
programs have been found to have low cost-
effectiveness (ACE, 2006) in reducing 
prevalence rates of overweight/obesity, due to 
relatively low changes in the energy 
expenditure of those who participated in these 
programs, coupled with variable uptake 
across all communities. However, such 
strategies may have secondary benefits in 
community engagement. 
 
Approaches to effective intervention and 
treatment 
Treatment and intervention for those 
children already overweight and obese is as 
important a priority as prevention. Evidence 
shows that targeted family-based 
interventions are effective and cost-efficient 
(Barlow and Dietz, 1998). Older children 
need to be actively engaged, along with the 
family, to make necessary behavioural and 
lifestyle changes (Summerbell et al, 2003). 
For younger children, the most effective 
approach involves professionals working 
with the parents (Golan et al, 2006). It is 
also necessary for interventions to start as 
 Policy Brief No 7 2007: Overweight and obesity in childhood          www.rch.org.au/ccch/policybriefs.cfm 4 
 
What are the implications of the research? 
• Obesity is a multi-cause disease, and therefore requires multiple solutions. 
• Once obesity grips a population, it is difficult to lower its prevalence. 
However, it is possible to slow or even prevent further increases.   
• Prevention efforts need to continue even though it is not yet known exactly 
which aspects of behaviour drive which aspects of obesity and its 
consequences.  
• Obesity is a ‘pandemic’, needing effective responses for every community. 
‘At-risk’ communities require additional resources and solutions. 
• Effective population interventions must not only work for help-seeking 
individuals, but also reach all those in need, and be cost-effective. Multi-
faceted approaches with community-wide engagement have shown the 
most promise.  
• Within the healthcare sector, obesity treatment continues to rely on the 
traditional practice of presentation to a primary care practitioner followed by 
referral. Since neither parents nor practitioners routinely raise the issue or 
consider the overweight/obese child to be ‘sick’, the vast majority of obese 
children are not offered care. In any case, capacity to meet the demand for 
care is limited. 
• Primary and secondary health care professionals do not routinely conduct 
surveillance of BMI as recommended by the NH&MRC, therefore the issue 
is not raised with the parent/s. 
• There are significant gaps in the information available about effective 
strategies and delivery models for prevention and intervention. Research 
and rigorous data-monitoring is required to inform communities, 
practitioners and families. 
Considerations for policy and programs 
• Consider the child, family, and community, and use a genuine whole-of-
government collaborative approach, involving (but not limited to) the health, 
education, community services, sports, transport, food, agriculture, 
environment, primary industry and communications portfolios, to develop 
effective policy and programs. 
• Monitor trends through a national surveillance strategy for children’s BMI 
status, physical activity, nutrition and obesity-related morbidity.  
• Support parents with education and parenting skills to make healthy 
lifestyle choices for themselves and their children. The responsibilities of 
parents should be balanced by effective community and societal preventive 
strategies.   
• Limit the marketing/advertising of food for and to children. Although 
research on effectiveness is limited, policy and legislative approaches have 
worked in other areas such as tobacco control and bike helmets.   
• Involve primary health care as an effective player in all initiatives.   
• Develop multidisciplinary clinics funded not only to deliver needed services, 
but to continually evaluate and improve performance.  
• Support nationally-coordinated longitudinal, clinical, primary care and 
community child obesity research, to shorten the time frame from research 
to implementation and accurate monitoring.  
• Sustain, develop and determine the effectiveness of promising interventions 
through long-term support. It is crucial to evaluate all strategies for 
effectiveness, reach and cost.  
Policy Briefs aim to stimulate 
informed debate about issues 
that affect children’s health and 
wellbeing.  Each issue draws 
on current research and 
international best practice.  
A multi-disciplinary team from 
the Centre for Community Child 
Health produce these Policy 
Briefs.   
An advisory group of national 
and international experts in 
children's policy and service 
delivery provides advice and 
peer review. 
 
The Centre for Community Child 
Health is at the forefront of 
research into early childhood 
development and behaviour.  The 
Centre is committed to translating 
research to inform public policy, 
service delivery and practice.  
 
Tel:     +61 3 9345 5137 
Email: email.policy@rch.org.au 
Web:   www.rch.org.au/ccch 
 
Centre for Community Child Health 
The Royal Children’s Hospital  
Flemington Road 
PARKVILLE  3052 
Victoria  Australia 
 
References 
A full list of references and 
further reading used in the 
development of this Policy Brief 
is available from: 
www.rch.org.au/ccch/policybriefs.cfm
 
Next Policy Brief 
Policy Brief No 8 will address 
child development and 
learning. 
To receive Policy Brief e-alerts 
subscribe to:  
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Overweight and obesity in childhood

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Overweight and obesity in childhood

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