Baby steps towards a healthy society

SINGAPORE - In a bid to tackle rising childhood obesity, Singapore plans to ban advertisements on unhealthy food and drinks that specifically target children. It is holding an online public consultation this month to work out the details of the ban, which takes effect next year. The ban will start with TV ads and children's magazines.

At first glance, this is great news. Quebec, the Canadian province that since 1980 has banned such advertising to children under 13, has one of the lowest child obesity rates in Canada. But advertising is only one part of the equation - and tackling only childhood obesity may be barking up the wrong tree.

First, the ban should be implemented in more places, such as beyond television and print. Children are now spending more time on computers and in front of gadgets playing games, and these are avenues for advertising too.

What's more, is it the ads or the time spent being sedentary that is affecting children's health? You can limit advertising, but it will have a small impact without also limiting children's time spent studying or in front of the TV, iPad or computer.

What children eat also matters. Most schools here have limits, based on Health Promotion Board guidelines, on selling sugary drinks and fried food.

But when dining out with the family, children are on their own. So it's vital to remember that parents also play a role, and that children model their behaviour on their elders.

Besides advertising, there are other ways to curb unhealthy eating.

A study led by Duke-NUS Graduate Medical School health economist Eric Finkelstein, published online last month in the Journal of Health Economics, shows that a tax on sugary drinks that increased their price by 20 per cent would cut consumption by roughly 8 per cent to 10 per cent - and likely result in people taking in fewer calories.

For such a tax to work, it is important to understand what the biggest sources of unhealthy food in the Singapore diet are and tax those, whether they are fast food, fried food or rich food from other, high-end joints such as creamy pastas and buttery dishes.

Even apparently healthy beverages like flavoured milk, juices or probiotic drinks can be too high in sugar. And beyond healthy eating, more could be done to get children out and active.

Mercifully, the Ministry of Education stopped its Trim and Fit school exercise programme (which singled out overweight children, who then got the impression that exercise was a punishment) in 2008.

Instead, there could simply be more time for PE and play in school - tailored to each child's interests.

As a bookish child, I dreaded games day and spent more time running away from the ball than towards it. (Not till adulthood did it dawn on me that running was the only part I enjoyed.)

Why is targeting childhood obesity, defined here as having a body mass index (BMI) above the 97th percentile of a reference population, important?

Obese children are at higher risk of Type 2 diabetes, hypertension, sleep apnoea and other medical conditions, wrote National University Hospital (NUH) paediatrician Lee Yung Seng in a 2009 commentary. And their cardiovascular health may be affected later in life if they are obese for a longer time.

But targeting child obesity alone is not enough. For one thing, while obesity and poor health are closely linked, they are not exactly the same thing.

Associate Professor Chong Yap Seng, an NUH obstetrician-gynaecologist leading a major study of how metabolic diseases arise from early life conditions, points out that in the United States, the adult obesity rate is more than a third, but the diabetes rate is 8 per cent.

Here, the adult obesity rate is 10 per cent, but the diabetes rate is 11 per cent.

And, he said, there are those who eat whatever they want and don't gain a gram, but others who struggle to keep the kilos off. Science is still trying to figure that out, he said.

"Obesity is a complex subject, but the most important thing is not to treat it as an individual tendency or fault," he said.

Humans are very well-adapted, generally, for lean times. But a mismatch occurs when there is plenty of food to go around and little need for physical labour, as in a prosperous, developed country like Singapore.

And in fact, such a mismatch can begin in the womb, Prof Chong said.

For instance, Dutch mothers exposed to wartime famine conditions during World War II had smaller babies. But these children grew up during post-war boom times.

With their bodies prepared for lean times, they ended up with higher rates of metabolic and cardiovascular disease later in life than children and adults already alive during famine conditions.

The "Dutch hunger winter" is an extreme example but it demonstrates the importance of maternal health to a child's future well-being.

What is more, when a child is plump also matters. There are developmentally appropriate times to be plump, said Prof Chong, such as in infancy and between about four and six years old.

Being plump at a developmentally inappropriate time could be a sign that something is not right. (And here adults can play a role: An overfed toddler is not "cute".)

What does all this mean? Singapore, then, should work on creating a better match between its prosperous environment and what humans are adapted for.

Banning fast-food ads aimed at children is one way of doing so, and is a good thing as it targets all children rather than just the obese ones. Taxing the food and drink itself, or making healthier foods more readily available, could be another.

Encouraging physical activity and increasing access to recreational spaces, could be a third. (Public pools, community centres with basketball courts, and walking paths are a great first step.)

The real value of health promotion for children, including cutting back on fast-food ads aimed at them, is that it cultivates healthy behaviour, preferences and habits that, one hopes, persist into adulthood.

Even a mother's health while she is pregnant, due to the circumstances she faces or the choices she makes, has an impact on health throughout the child's lifetime.

And that extends to the choices parents make - to pacify children with ice cream, or to go cycling on a weekend - as their children grow up. It's not really about childhood obesity, which is really just convenient shorthand for the medical problems children are statistically more likely to face at present and in the future.

Instead, it's about improving the health of a society, and the health of Singapore's future - and in particular, the health of all children, across the board.

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