policies that protect their business
practices.

44
It also offers lessons on

how to bring about change, highlighting
what can be achieved by a global move-
ment linking international and domestic
action, involving national coalitions,
NGOs, the media, and mobilisation of
the public to create sustained pressure
for change.

45

It is possible that success might be
achieved without global regulation but
it is essential that the option is not
ruled out. Some elements of the food
industry have adopted policies that are
likely to be beneficial but there is still a
very long way to go. The global public
health community might usefully recall
Theodore Roosevelt’s advice to ‘speak
softly but carry a big stick’.

46

The views expressed here are not neces-
sarily those of the authors’ organisations.
The authors report no competing interests.

References

Full list of references appears as online

supplementary data accompanying the online

publication of this paper.

2 IOTF. Overweight and obesity in the European

Union. Briefing Paper for the European

Commission Platform on Diet, Physical

Activity and Health, Brussels, 15 March 2005.

Available at: http://europa.eu.int/comm/

health/ph_determinants/life_style/nutrition/

documents/iotf_en.pdf.

3 Lobstein T, Baur L, Uauy R. Obesity in children

and young people: a crisis in public health.

Obes Rev 2004;5 Suppl 1:4–85.

21 WHO/FAO. Diet, nutrition and the prevention

of chronic diseases. Report of a joint

WHO/FAO expert consultation. WHO

Technical Series, No. 916. Geneva: World

Health Organization, 2003.

43 Yach D, McKee M, Lopez A, et al. Improving

diet and physical activity: 12 lessons from

controlling tobacco smoking. BMJ

2005;330:898–900.

1
Research Fellow, European Centre on Health
of Societies in Transition, London School of
Hygiene and Tropical Medicine, London, UK
2
Childhood Obesity Coordinator, International
Obesity TaskForce, London, UK
3
Professor of European Public Health, European
Centre on Health of Societies in Transition,
London School of Hygiene and Tropical
Medicine
Correspondence: Cécile Knai, Research Fellow,
European Centre on Health of Societies in
Transition, London School of Hygiene and
Tropical Medicine, London, UK e-mail: cecile.
knai@lshtm.ac.uk

doi:10.1093/eurpub/cki215

Curbing obesity: prevention and treatment
Caroline Braet and Myriam Van Winckel*

This viewpoint is written by two middle-
aged women who have been working
with obese children and their families
since �20 years, one as a psychologist
and the other as a paediatrician. As we
have been treating obesity in children,
our focus has not been prevention. The
thoughts that follow originate not only
from what we have been studying and
observing in our contacts with obese chil-
dren and their parents, but also from
what we have been learning as mothers
of our now teenage children.
Obesity develops when a genetically

sensitive person comes in a favourable
environment. Our genes are not changing
rapidly, whereas obesity has emerged as a
frequent and growing problem, from
young age on, everywhere in the
world. The United States is on top of
the list, followed by those developing
countries that are making the transition
to more wealth. But also in Europe the
same evolution is observed. When
reflecting on what has changed in our
environment and how to curb this evolu-
tion, one ends up with thinking politics.
Our thoughts, described below, are 3-

fold. On a macro-level, politicians will
have to invest in new rules and regula-
tions as well as in large programs which
will be the only way to streamline society
with all its different and conflicting pres-
sure groups. Secondly, serving healthy
food and facilitating a healthy life style
should be mission statements in socialis-
ing agencies like schools, sport clubs, and
summer camps. Finally, on a micro-level,
all of us can model a healthy living
attitude which can influence the people
and especially the parents and their

children in the near environment. We
will give now some examples below.

Move more

It is clear that an active lifestyle is as
important as healthy eating in the
prevention of obesity. Together with
modification in food consumption pat-
terns sedentarism has increased dramati-
cally. Reasons to explain this evolution
are obvious. When we were children,
we could bike alone to school and back
home from the age of 6 or 7 years. Our
parents did not worry to let us play
outside. Now, there are at least 10 times
more cars, which are also a lot faster and
make roads unsafe, and children cannot
be allowed to bike independently.

In primary and in secondary school
standard programmes offer only 2 ·
50 min of sport per week. A lot of sport-
ing facilities are available and affordable.
Unfortunately, our patients tell us far too
often that they stopped attending sport
clubs because they were not competitive.
If we want our children to retain the joy
of moving till adulthood, more recreative
and less competitive sporting facilities are
needed. Epstein et al.

1
suggests an exer-

cise programme in which mainly aerobic
exercises of moderate intensity, such as
cycling, swimming, walking, jogging,
rope-skipping or rowing, are planned
for minimum 30 min a day. Schools
seem to be the best place to take respon-
sibility for organising these daily activ-
ities for all children.

Walking and biking are important
components of an active daily lifestyle.
The Amish people in North America

who refuse to use electricity and motor
cars have a low incidence of obesity (0%
in men, 9% in women). An average
Amish man walks twice as much as an
average European man.

2
It is of course

not realistic to ban modern comfort such
as cars and elevators. If we want,
however, to achieve the necessary lifestyle
change we will need to create car free
areas where people live enabling
children to play outside, and we need
reliable and timely public transport,
safe bicycle lanes between home and
school or work, shower facilities at
work, and strong incentives to diminish
the use of cars.

Reduce ‘screen’-time to
maximum 2 h a day

Research has clearly shown that obesity is
inversely related to the time spent watch-
ing television. Television was introduced
in our homes when we were 10 years old.
Until 6 p.m. only music and a fixed
abstract black and white box and line
pattern was shown. At 6 p.m. 1 h of chil-
dren’s programme would start. It was far
less difficult for our parents to restrict
television viewing than it is for contem-
porary parents. Now several clock-round
children’s programmes are available. In
order to restrict television viewing time,
parents need to set rules and control these
rules. This is a time-consuming and frus-
trating experience for parents, while in
the mean time they have their own
agenda and their own plans and duties.
Trying to streamline TV watching as
well as playing PC games is part of an

Curbing Childhood Obesity 561

http://europa.eu.int/comm/


educating process where more and more
the children seem to ‘win’ and reinforce
their parents by stopping with wining
when TV is on. Altering the so-called
coercive cycles asks for a strict conse-
quent approach, which is not in conflict
with a democratic, authoritative
educational approach by the parents. In
our opinion messages like ‘reduce TV
time’ are far more difficult to implement
than explicit unequivocal rules (e.g. TV
from 7 p.m. until 8 p.m. or ‘screen-time’
from 6 p.m. until 8 p.m.).

Can we stop the
bad habit of eating
in between?

Some children, from young age on, refuse
healthy food like vegetables and fruit.
When they are hungry they prefer
unhealthy snacks. Anxious parents do
follow the whims of their offspring.
Others are simply not hungry during
meals because they drink soft drinks or
eat sweets in between. By consuming
energy-dense snacks, it is not unusual
that children eat more than they need.
How to break through these bad habits?
First of all, it is advisable to develop
the habit of eating only at fixed hours.
The National Institute for Food

3
suggests

the following scheme: three standard
meals with balanced carbohydrates, pro-
teins, and fat as well as two (or three)
scheduled snacks. We also need clear
messages with regard to healthy snacks
(e.g. <100 kcal.) and beverages: drink
water during all meals, restrict milk
consumption to 500–700 ml/day, limit
consumption of soft drinks to once
weekly, and drink not more than one
fruit juice a day.

Second, children are strongly advised
to reduce the number of places where
they eat. Researchers assume that as
one eats in more situations there are
more and more environmental stimuli
reminding of food, whereas reducing
these situations extinguishes the remind-
ing value of an environmental stimulus.
It is also recommended to do nothing else
but eating during the meal and to avoid
other activities such as walking around,
reading, watching television, or making
telephone calls. For children it is helpful
to have fewer supplies in the house stored
in as few cupboards as possible. Probably,
it will be necessary to coach the shopping
culture of many parents. Some people
suggest to provide food in the market
with a green (healthy, not dense in cal-
ories), red (dense in calories, ‘empty’ cal-
ories, not containing vitamins or
minerals), or orange (not to use without
restrictions, but containing valuable
nutrients) sticker. If only parents have
healthy food in their house, discussions

about what or how much the child can
eat will be easily solved. As Satter

4
sug-

gests ‘parents decide what and when their
children eat, children decide how much
they eat’.

Financing preventive
programs in at-risk
groups

Obesity ‘runs’ in families. Overweight in
childhood is strongly affected by parental
fatness. These families will need more
specific help. Moreover, these families
are more situated in neighbourhoods
with low socioeconomic status, where
families have more financial problems
and often more stress and less free
space. It can be helpful to run specific
programmes together with these families
where ideas are shared regarding prepar-
ing healthy food, managing the costs of
healthy food, finding sport clubs, orga-
nising safe play grounds, and setting rules
and having them observed. However,
there is little incentive for counsellors
to set up programmes if no means of
financing them are provided.

Treating obese children
is prevention of
later obesity

Overweight and obesity in childhood
have been shown to be predictive for
obesity in later adult life. If the over-
weight can reach stability during child-
hood, we can prevent this evolution.
Indeed, some evidence exists that effec-
tive management of childhood obesity is
possible, with long lasting effects on
lifestyle.

1
The treatment that shows to

be effective is family based and needs a
multidisciplinary approach focusing
on behavioural changes. Reimbursement
for these programmes will be necessary.
However, meta-analyses on treatment
programmes of childhood obesity indi-
cated that few randomised controlled
trials were available and long-term
follow-ups were scarce. Moreover, no
evaluation of tailoring treatment to spe-
cificcharacteristics ofthechildrenisavail-
able. It seems extremely urgent that the
evaluation of non-pharmacological treat-
ment programmes is provided by policy-
makers.

Afterthoughts. . ..

Research in developing and evaluating
prevention programmes of obesity
needs priority financing. The cost of
this research will only be a fraction of
what is now already spent in the treat-
ment of adult obesity. Drugs currently
available, such as those causing fat

malabsorption, are marginally effective
and cost �$170 a month for the patient.
Hospital costs for bariatric surgery in
the US increased more than 6-fold
between 1998 and 2002, from $157 mil-
lion to $948 million a year. In many
countries, over 50% of the adult popula-
tion is overweight and it is difficult
to reduce excessive weight once it is
established. Obesity prevention should
therefore focus on children in the first
place.
The Kiel Obesity Prevention Study

5
is

one of the few programmes demonstrat-
ing positive outcomes in 5- to 7-year-old
schoolchildren, by giving simple educa-
tional messages to all children and their
parents. These are (i) eat fruit and vege-
tables each day, (ii) reduce the intake of
high fat foods, (iii) keep active at least 1 h
a day, and (iv) decrease television viewing
to <1 h a day. School meetings were
combined with targeted programmes
for families with overweight and or/
obese parents. However, effective preven-
tion programmes are based on the
knowledge of risk factors and causes.
Even if most risk factors for the develop-
ment of obesity seem to be self evident,
little research is available on what to base
clear evidence based guidelines for effec-
tive prevention.
Most of the ideas presented here ask an

engagement of the parents of young chil-
dren. During adolescence young people
develop their own life style. A child is
highly dependent on its parents’ attitudes
and guidance, whereas adolescents are
strongly influenced by their peers and
idols. Here, popular media people can
use their influence in both directions
and model a healthier life style. Some
of them are already strongly involved
in different charity projects and others
have set up big campaigns for people
or animals all over the world who need
help. Because the obesity epidemic is one
of the biggest problems of modern
society, we must invite the media to
think about their status and its influence
on adolescents’ life style. The media,
together with the academic world can
be very influential on the policy to ask
for action programmes or for European
guidelines. Perhaps, we hope, this will
help develop a world-wide culture
where healthy choices are cool and
trendy.

References

1 Epstein LH, Myers MD, Raynor HA, et al.

Treatment of pediatric obesity. Pediatrics

1998;101:554–70.

2 Bassett DR, Schneider PL, Huntington GE.

Physical activity in an old order Amish

community. Med Sci Sports Exerc 2004;

36:79–85.

3 Available at: http//www.nutrition.gov.

562 European Journal of Public Health



A checklist for curbing childhood obesity
Claude Marcus*

The insight that childhood obesity is a
problem is spreading fast. Most
decision-makers involved in public
health are aware of the fact that obesity
early in life negatively affects self esteem
and increases the risk of future diabetes
and cardiovascular disease although the
effect of obesity on cancer risk is less well
known. Thus, childhood obesity is one of
our major threats to public health and
will cause a reduced life expectancy in
the future if we do not act now.
The prevalence of obesity and over-

weight has increased 3-fold or more in
most western countries during the last 25
years. It is generally accepted that the
changes in society involving eating habits
and physical activity are crucial. No other
factors are of equal importance for the
understanding of the childhood obesity
epidemic. Thus, it is quite simple. We
have to reduce the intake of sweetened
drinks, sweet, and fat snacks; go back to a
more regular eating pattern without
snacking between meals; and increase
the physical activity. However, although
simple, the realisation of such changes is
so difficult that we have to realise that we
have a lost generation of adolescents and
adults with habits so firmly rooted that it
is not possible to affect their behaviour
within a democratic society. Conse-
quently we have to focus on younger chil-
dren and start immediately when they are
beginning school, i.e. at 5–6 years of age.
Measures taken to handle the situation

are often too toothless. One reason seems
to be the general but erroneous fear that
tougher recommendations may lead to
increased number of eating disorders
especially among girls. There are no indi-
cations that recommendations regarding
good eating habits and physical activity
increase the risk of eating disorders.
Another problem is that short-sighted

economical considerations sometimes
are more important than long-term

efforts to reduce childhood obesity.
The European Union has difficulties
handling the overproduction of butter
and milk. In an attempt to both improve
children’s eating habits and reduce the
overproduction of milk products, school
lunches milk is subsidised. However the
benefits of this initiative are markedly
hampered by the fact that whole milk
is three times more subsidised than low
fat milk and consequently an unfortunate
intake of high animal fat among children
is stimulated by the EU.

The feeling of helplessness against the
commercial and marketing powers of big
companies such as Coca Cola and Mc
Donald’s also seems to reduce the will-
ingness to act. However, in my opinion, a
consequent use of the school as an arena
to influence children to adopt a healthy
lifestyle should not be underestimated.
Furthermore, if schools have a firm
attitude regarding sweet drinks and
snacks it will be much easier for parents
to have defined limits for their children
as well.

What is most important if we effec-
tively want to prevent childhood obesity,
is it to modify food intake or physical
activity? If we consider that a normal
10-year-old child weighing 30 kg has to
walk for 3 h or run 10 km to burn the
energy from an ice cream (300 kcal), it is
easy to realise that increasing physical
activity without a concurrent change of
eating habits will be almost without
effect. This is problematic both for
decision-makers and parents because
directions regarding restricted eating
and reduced snacking may be considered
more repressive and more negative than
increased physical activity. Therefore
most initiatives are aimed at physical
activity. Of course, despite this reasoning
we must not forget that there is a group of
both lean and overweight children today
who live an extremely sedentary life who

are in need of help to become more phy-
sically active.
My simple list of measures is not too

expensive and many things can be
launched without any long start-up time.

� Ban all sweets, sweetened drinks, ice
cream, and energy-dense snacks from
nurseries, schools, and after school
care centres. Inform parents about
healthier alternatives if the children
have packed lunch.

� Inform parents of their duty to ban all
sweets, sweet breakfast cereals, swee-
tened drinks, ice cream, and energy-
dense snacks from daily family life
and encourage them that they are
good care-taking parents if they reduce
irregular snacking to a minimum.

� Increase activity of daily living for chil-
dren. Teach them at a young age to
take a walk instead of taking the bus.
Use consequently the stairs instead of
an elevator together with children.

� Subsidise whole grain food and fresh
fruit and vegetables. This might pro-
vide a better and more functional
incentive than extra tax on unhealthy
foods.

� Reduce the subsidies on whole milk
and increase them on low fat milk in
schools

� Identify children with a pronounced
sedentary behaviour and develop
methods to increase their physical
activity.

�
Professor of Pediatrics, Karolinska Institute,
Head of National Childhood Obesity Centre,
Karolinska University Hospital, Stockholm,
Sweden
Correspondence: Claude Marcus, Professor
of Pediatrics, Karolinska Institute and Head
of National Childhood Obesity Centre,
Karolinska University Hospital, Stockholm,
Sweden e-mail: Marcusclaude.marcus@
klinvet.ki.se

doi:10.1093/eurpub/cki217

4 Satter E. How to get your kid to eat . . . but not too

much. Palo Alto: Bull Publishing Company,

1987.

5 Müller MJ, Asbeck I, Mast M, et al. Prevention

of obesity-more than an intention. Concept and

first results of the Kiel Obesity Prevention Study

(KOPS). Int J Obes 2001;25 Suppl 1:S66–74.

�
Ghent University, Belgium
Correspondence: Caroline Braet, Department

of Developmental, Personality and Social
Psychology, Ghent University, H. Dunantlaan
2, 9000 Ghent (B), Belgium e-mail: caroline.
braet@ugent.be

doi:10.1093/eurpub/cki216

Curbing Childhood Obesity 563