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Submission to the Senate Committee on the Obesity Epidemic in Australia

The following was written in 1.5 days for submission to the committee 11th July 2018 https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Obesity_epidemic_in_Australia

It is now published as Submission 122 here: https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Obesity_epidemic_in_Australia/Obesity/Submissions

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Thankyou for the opportunity to submit to the Committee into the Obesity Epidemic in Australia, especially among children.

We hope the information below may offer opportunity to reverse our obesity crisis, or is at least useful to illuminate some of its previously unexamined and cumulative causes.

Requested matters have guided the flow of our submission below, and we have attempted to report on each, though have changed headings.

 

Background, prevalence and causes of overweight and obesity in young children

The prevalence of childhood obesity in Australia began increasing in the 1970s, with overweight doubling, and obesity tripling between 1985 and 19951

By 2007-08 around 17% of 5 to 7 year old children were estimated to be overweight, and 8% were obese.2 This increased to 25% by 2014-153

But childhood overweight and obesity is a global problem.

According to landmark study comparing trends of 188 countries4 as of 2013, 23.2% of all children in developed countries worldwide are now overweight or obese, with peak obesity rates moving younger and no country recording success in any prevention or management initiatives in the last 30 years.5 Their results also record alarming increase in the rate of overweight and obesity of infants and children under four in developed countries worldwide6.

The commonality of such a severe lifestyle disease across so many different cultures with their different traditional foods and practices inspired Mashblox Pty Ltd to ask, what could we all be doing so wrong at such a young age?

Assuming that parents feeding their infants excessive obesogenic junk food are in the extreme minority, and that lack of exercise in children only just learning to walk is a non-issue, we hypothesised that the common factor was spoon feeding.

Mashblox Pty Ltd secured research partnership with the University of Canberra 2016 – 2017 when we identified the notion that no one could know an infant’s appetite better than the child themselves, and therefore spoon feeding ran chronic risk of overnutrition. We hypothesised that even slight overnutrition owing to lack of parent awareness of, or alertness to the child’s satiation cues, has a cumulative effect on the child’s Body Mass Index and potentially longstanding impact on their eating habits; all factors that are only exacerbated by current obesogenic conditions that are more commonly blamed.

This isn’t a new idea, only a new angle. Studies comparing breast-feeding and bottle feeding are well known to demonstrate reduced obesity both in infancy and later life7 8 9 10 11 12  owing to the child’s ability to regulate their own food intake appropriate to their needs by simply stopping suckling the breast. They have less opportunity to stop feeding when it’s a bottle teat in their mouth, and the child is dependent on the parent or caregiver’s observation of their cues to remove it, and their priority on doing so rather than ensuring the child finishes the bottle.

In both cases, these consumption habits last into childhood and beyond. 

 

Studies in the emerging field of baby led weaning13 lend further weight to the case, with an 11.1% reduction in overweight and obesity in infants that have been allowed to feed themselves after one year, regardless of other lesser correlates frequently examined in the space of infant obesity, namely: birthweight, breastfeeding duration, and age of introduction to solid foods14. The baby led weaning group also demonstrated a significantly lower preference for sweetened foods than the spoon fed group.

Further studies have been limited by documented increased risk of choking15 attributed to baby led weaning, as not all children are developmentally ready to safely consume most foods that are solid enough to grab, which also limits food options. Infant preferences for carbohydrates in baby-led weaning style feeding13 may be both representative of the ease with which these foods can be handled, and limiting of results given the low glycemic index of such foods (bread, toast e.g.) . Baby led weaning is also known to be particularly messy, and so may be difficult to recruit participants for, or quantify infant intake when practiced by traditional methods.

Studies continue to emerge around the world to explore this intriguing concept that how children are introduced to foods is significant for their long term relationship with it, and associated health outcomes including obesity prevention. Nevertheless, how children are introduced to foods remains an elusive risk factor on many well-known publications.

Impact of overweight and obesity to economy and wellbeing of Australian children

Estimates for the economic burden of obesity vary widely depending on source. Access Economics (via Australian Productivity Commission) posits costs to the Australian Economy at $58 billion for 2008 ($50 billion in lost wellbeing, and the balance in financial costs such as loss of productivity)16, an increase from their own reports of $21 billion three years prior in 200517. These costs relate to adults and are mostly born by the obese, but as the Australian Productivity Commission Economic Perspective on Childhood Obesity2 acknowledges, these figures can be thought of as “potential future costs for today’s obese children” – and their rate of increase should be alarming.

While children are acknowledged to suffer from lowered self-esteem most physical health problems arise later in life. However the prevalence of some obesity co-morbities such as type 2 diabetes, liver disease, impaired mobility, asthma, sleep apnoea, and risk factors for cardiovascular disease are increasingly being seen in children.2 The World Health Organisation’s Commission on Ending Childhood Obesity additionally recognises increased risks for osteoarthritis, and particularly endometrial, breast and colon cancers later in life for children who are overweight or obese.18

Efficacy of initiatives to date to combat overweight and obesity

Government and community initiatives seeking to influence activity levels of Australians to counter overweight and obesity started as far back as the 1980s’ “Life. Be in it” campaign. However, any such campaigns targeting older children and adolescents have had limited success anywhere in the world19

The Australian Productivity Commission’s 2010 paper “Childhood obesity – An economic perspective” suggests that this is because "Behavioural limitations can influence how people use available information about preventing obesity - even when it is available - and their responses to incentives.” In other words, habits are very difficult to break once set.

They continue, that “Children are particularly susceptible [to behavioural limitations] and have difficulty taking into account the future consequences of their actions”2 The International Journal of Obesity (IJO) argues that the “first years of life … may provide opportunities for preventive interventions … as these periods are characterised by high plasticity and rapid transitions”20, including high potential to influence epigenetic processes and predisposition to obesity21. However, they acknowledge that few early interventions have been attempted.

Besides previously referenced scattered emerging studies in baby led weaning, they still haven’t.

While we acknowledge that significant growth is undertaken between ages 0 – 3 in normal and healthy development, the Australian National Health Survey supports IJO’s identification of these peak early intervention periods of high plasticity with their own findings that ages 0 – 3 are one of two peak risk periods for rapid weight gain.22 The World Health Organisation additionally points out in their 2016 Report of the Commission on Ending Childhood Obesity, that “children with obesity are very likely to remain obese as adults and are at risk of chronic illness.”18

Impact of nutrition awareness campaigns could also be said to be negligible as an obesity prevention tactic, as evidenced by the continual increase of obesity globally compared to the wealth of readily available public education campaign materials sponsored by government.

Proposed Interventions to childhood obesity

We propose that an effective, low-risk obesity intervention is just as simple as supporting infants to self-feed.

The Australian Productivity Commission implies that there is hope in “influenc[ing] children’s eating behaviours… which might reduce obesity over time”2 and we propose that this is easiest to achieve in initial introduction to foods.

Baby-self feeding is proposed by Nancy Ripton and Melanie Potock as a “flexible feeding model that encourages limited purees mixed with finger foods.” The book reassures parents that “Babies get all the proven benefits of baby-led weaning without the increased gagging and fears of choking”.14

Mashblox Pty Ltd offers the solution of a simple, versatile infant feeding aid supporting age appropriate textures including soft lumps and chunks that encourage children to accept savoury foods including vegetables, but our mission to turn the tide of infant obesity extends beyond simply selling product – as evidenced by the research underpinning this submission and previous initiatives.

Mashblox Pty Ltd’s intended involvement with University of Canberra was to provide Mashblox® hollow silicone cube infant self-feeding aids as part of a suite of self-feeding tactics to be used for a pilot study exploring the receptivity of children to the concept through local Canberra childcare centres. This pilot was intended to inform broader longitudinal trials of self-feeding in a first for Australian Universities.

While this pilot has not yet happened with any University (and may end up being first conducted overseas), several local childcare centre chains expressed interest in participation, and market reception of the product has since provided anecdotal evidence for many hypothesised short term benefits, including improved infant receptivity to certain foods that are otherwise rejected including certain fruits (avocado, banana), vegetables (spinach, peas) and complex carbohydrates (porridge).

 

Roles and contributors to childhood obesity

This submission does not attempt to recommend practices to manage or reverse existing obesity, but to draw attention to emerging research identifying some of its early causes, and hence advise on its prevention in infants and young children under four.

We propose that culprits of excessive high density, low nutrient foods, excessive screen time and inadequate exercise that are typically identified as contributing to overweight and obesity paint an incomplete picture. Since these influences only come into strength later in childhood, we further propose that they are inappropriate considerations for obesity prevention as they only serve to compound underlying causes established in infancy.

While Mashblox Pty Ltd shares opinion with World Health Organisation that aggressive marketing of convenient, low-nutrition, calorie dense foods targeted at young children (or their parents) are unhelpful, we propose that habits established at home are more damaging.

These include:

  • Chronic overnutrition starting with spoon feeding,
  • Pressures to “finish your plate”
  • High calorie treats used as reward for good behaviour – or for special occasions
  • High calorie treats used to reward or incentivise consumption of other foods (that may also be in excess of energy requirements)
  • Feeding encouraged as a pacifying measure
  • Feeding encouraged regardless of the absence of hunger

(As reinforced by various references including IJO20, WHO18)

Related Matters

The current environment poses many significant challenges to the prevention of early childhood obesity. Two of the most significant factors are parent convenience, and the availability of inexpensive high calorie, nutrient poor foods.

Nothing yet surpasses “pouch and spout” baby food packaging for convenience, but while they also support infant self-feeding, problems with their contents are already being popularly identified.23 24 25 Overreliance on liquid foods encourages mindless eating without registering calorie intake, particularly when used as a pacifier, and criticisms of excessive portion sizes for recommended age ranges have been raised by TV programs such as ABC iView in 201724, and more recently by the New York Times.25

Additional concerns relate to the development of early sweet tooths through contents excessively sweetened to ensure palatability at a fine puree consistency. The Times points out that even pouches containing trendy nutrient dense superfoods (such as kale or quinoa e.g.) aren’t teaching kids to eat these things as they are unrecognisable from their original form.

 

Mashblox® assists these concerns by supporting broader textures: the food contents are still recognisable enough through the translucent silicone walls for the child to be accultured to, but novel enough to overcome barriers to eating such as are widely acknowledged as typical for vegetables. International Journal of Obesity again suggests that “early experience with these foods could potentially offset such neophobia and encourage childhood diets that are healthier and lower in energy density.”20

Recent parent feedback on our suggestion to experiment using Mashblox® to encourage green foods shows promise that translucent Mashblox can even be used to overcome aversions to the colour.

“We have had success!!” Kat, the Mum of 14 month old Madelyn reports.  “Tried spinach, green peas & a little bit of coconut yogurt (Madelyn is dairy intolerant). She is still so curious and loves to investigate the mashblox & explore what is inside. Very excited that she was so happy to eat green veg. The mashblox really makes it fun.”

She clarifies that Madelyn usually avoids peas and spinach and more often feeds any servings to the dog over the side of the high chair.

While this is only one example, we believe it’s significant given its evidence of infant receptivity to Mashblox® and support for early hypotheses that they will encourage consumption of healthy foods that are otherwise rejected. We suggest that further experimentation with green vegetables on wider scale may be particularly important, given comments by the International Journal of Obesity “Vegetables are initially rejected by young children; early experience with these foods could potentially offset such neophobia and encourage childhood diets that are healthier and lower in energy density.”20 as quoted above.   They further express concerns that “ In the current environment, the availability of inexpensive palatable foods high in sugar, salt and fat can limit children's opportunities to learn to like and accept healthy foods, resulting in diets high in added sugar, fat and salt”.

The International Journal of Obesity laments traditional practices exacerbating obesogenic conditions, “Many traditional child-feeding practices used today evolved in response to environmental threats of food scarcity, which prevailed until recently” contributing to wide-spread values that “a fat baby is a healthy baby” which may encourage overfeeding in critical periods.20 The concern is echoed by the World Health Organisation “longstanding cultural norms (such as the widespread belief that a fat baby is a healthy baby) may encourage families to over-feed their children.”18

IJO acknowledges that, “Traditions, by definition, are slow to change, and altering them will be a major challenge.”20

Proposal and recommendations

While we recognise that government initiatives cannot be seen to favour a privately held company, we propose that the marketing power and flexibility of such, alongside practical feeding alternatives (such as Mashblox provides) may be precisely what’s needed to change longstanding cultural traditions.

We would also like to draw attention to the opening for a Non-For Profit research entity deliberately created within the Mashblox Group company structure specifically for purpose of research into child obesity prevention.  We humbly request your consideration and help setting it up to initiate trials.

 

Recommendations

  • Broad promotion of infant self-feeding and the importance of setting healthy feeding habits alongside government nutritional recommendations. Feeding infants a perfectly balanced nutritional spectrum of foods is ineffective to teach them healthy habits if they’re still being fed any proportion more than their requirements. Mashblox Pty Ltd recognises that government recommendations supporting any particular self-feeding product are unlikely, regardless of early anecdotal benefits of improving young children’s receptivity to unsweetened vegetables.
  • Investment in and support for further longitudinal research of self feeding through Australian Universities and childcare centres. If desired, Mashblox Pty Ltd is committed to involvement in this.
  • Specific research into benefits of Mashblox as part of a suite of infant self feeding tactics
  • Phasing out of junk food marketing aimed at any age group, as this influence trickles down to children.
  • Phasing out of foods that are identified as high energy density, low nutrient value on display and easily available at supermarket “impulse bars” and petrol stations, as this promotes unhealthy eating that children will ultimately observe and absorb.

Thankyou again for the opportunity to be heard on this matter.

Yours Sincerely, 

Alix O'Hara, as Inventor, Founder, CEO Mashblox Pty Ltd. 

References

1 https://www.betterhealth.vic.gov.au/health/healthyliving/obesity-in-children-causes

2 Australian Productivity Commission: Childhood Obesity – An Economic Perspective (2010) Jacqueline Crowle, Erin Turner

3 Overweight and obesity rates across Australia, (2014-15) Australian Institute of Health and Welfare

4 Paulo A Lotufo, DrPH, Yuan Lu, MSc, Jixiang Ma, PhD, et Al (2014) Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013

5 http://www.healthdata.org/news-release/nearly-one-third-world’s-population-obese-or-overweight-new-data-show (Secondary source referencing (4))

6 http://vizhub.healthdata.org/obesity

7 Grummer-Strawn LM, Mei Z. Does breastfeeding protect against pediatric overweight? Analysis of longitudinal data from the centers for disease control and prevention pediatric nutrition surveillance system. Pediatrics 2004

8 Gillman MW, Rifas-Shiman SL, Camargo Jr CA, Berkey CS, Frazier AL, Rockett HRH et al. Risk of overweight among adolescents who were breastfed as infants. JAMA 2001

9 Arenz S, Ruckerl R, Koletzko B, von Kries R. Breastfeeding and childhood obesity—a systematic review. Int J Obes Relat Metab Disord 2004

10 Baird J, Poole J, Robinson S, Marriott L, Godfrey K, Cooper C et al. Milk feeding and dietary patterns predict weight and fat gains in infancy. Paediatr Perinat Epidemiol 2008

11 Harder T, Bergmann R, Kallischnigg G, Plagemann A. Duration of breastfeeding and risk of overweight: a meta-analysis. Am J Epidemiol 2005

12 Owen CG, Martin RM, Whincup PH, Davey Smith G, Gillman MW, Cook DG. The effect of breastfeeding on mean body mass index throughout life: a quantitative review of published and unpublished observational evidence. Am J Clin Nutr 2005

13 Townsend E, Pitchford N. Baby knows best? The impact of weaning style on food preferences and body mass index in early childhood in a case–controlled sample, 2012

14  Baby Self-Feeding, Nancy Ripton & Melanie Potock M.A., CCC-SLP, published 2016 ©Nancy Ripton publishing

15 Cameron, S; Taylor, R; Heath A-L; (2012) Parent-led or baby-led? Associations between complementary feeding practices and health-related behaviours in a survey of New Zealand families

16 Access Economics, 2018

17 Access Economics, 2015 http://www.abc.net.au/worldtoday/content/2008/s2343612.htm (I could not find primary sources for either)

18 Commission on Ending Childhood Obesity, World Health Organisation, 2017

19 Summerbell CD, Walters E, Edmunds L, Kelly SAM, Brown T, Campbell KJ. Interventions for preventing obesity in children, 2005

20 S L Anzman, B Y Rollins and L L Birch (2010) Parental influence on children's early eating environments and obesity risk: implications for prevention. International Journal of Obesity  

21 Gluckman P, Hanson M. Developmental and epigenetic pathways to obesity: an evolutionary-developmental perspective. International Journal of Obesity, 2008

22 Table: Prevalence of overweight and obesity by age, Australian National Health Survey 2011-2012

23 “Generation Suck could damage children’s development” ABC, 26th August 2016

24 ABC iView, 2017  (story no longer available)

25 “Rethinking baby food pouches” New York Times, 19th June 2018