For these strategies to have an impact, there is a need for a broader evidence base of their efficacy in different settings (especially in low-resource settings) and for them to be implemented at scale so that they reach those who require it the most. However, experience of converting evidence into policy and practice is not well documented for childhood obesity. There is good reason to believe that conversion of evidence to policy will be particularly difficult for combating changes in childhood diet and physical activity. Critical drivers of the childhood obesity epidemic, such as the marketing of high-fat foods, poor provision of facilities for physical activities and the increasing popularity of sedentary activities are intimately bound with modern development and globalization.¹ In this sense it shares many of the challenges of other non-communicable diseases that are also increasing rapidly in both developed and developing countries.

This chapter aims to learn from the experience of attempting to scale up the response to non-communicable diseases especially in resource poor settings. What are the strategic lessons to be learnt from the experience of responding to other non-communicable diseases?

Despite a continual struggle to move from non-communicable diseases being regarded as the problems of the rich, and having to confront the interests of some powerful private industries, there have been significant policy developments even in low- and middle-income countries. China and India have started to pull together the various initiatives around smoking, cardiovascular disease, diabetes and so on, into coherent national plans that go beyond individual level education or warnings on cigarette packets. Pakistan launched a National Action Plan on Non-communicable Diseases in 2003, which is now being scaled up as a major public health programme; and Vietnam, using the WHO recommended approach, has invested in the stepwise approach to the surveillance, prevention, and control of non-communicable diseases. The lifelong treatment of HIV/Aids is now being scaled up across a number of resources-poor settings and is giving rise to a number of innovations with respect to the way long-term care is to be delivered.

A comprehensive approach to childhood obesity shares many of the challenges that have been faced by other non-communicable disease epidemics, such as tobacco control, cancer control, diabetes and HIV/Aids. This chapter does not aim to re-state the control strategies being employed or go into details of specific interventions. Rather, it seeks to identify essential principles that have been critical for scaling up approaches to the various non-communicable disease epidemics in order to suggest some priority actions for addressing the childhood obesity epidemic.

In no particular order they are as follows:

Traditional responses to the control of non-communicable disease arose from the results of large longitudinal studies of men in places such as Framingham in the United States.² These studies followed up thousands of middle-aged men in order to isolate a number of important risk factors for heart disease and other non-communicable diseases. The control strategies that arose from such an approach focused on isolating individuals with risky lifestyles or risk factors and prescribed relevant behavior changes through health education to the population and, possibly, treatment for those at “high risk”. However, this approach has been very expensive and in itself had limited impact. In particular, it has been the realization that a large number of people at a small risk may give rise to more cases of disease than the small number who are at high risk,³ that shifted attention to interventions that could make a difference at a population level as exemplified by this insight into controlling blood pressure: “ … a 2% reduction in of mean blood pressure … has the potential to prevent 1.2 million deaths from stroke (about 15% of all deaths from stroke) and 0.6 million from coronary heart disease every year by 2020 in the Asia Pacific region alone … and could be readily achieved in many populations by reducing the salt content of manufactured food”.⁴

Analysis of large-scale examples of significant reversals in the prevalence of risk factors or reductions in mortality from non-communicable diseases from places such as Norway, Poland and Mauritius^5–7 has identified important structural interventions. Such interventions include a combination of selective agricultural subsidies, price manipulation, retail regulations, and clear labeling. For example, in the case of Norway this was based on a wide range of measures that included:⁵

• public and professional education and information;
  
• setting of consumer and producer price and income subsidies jointly in nutritionally justifiable ways;
  
• the adjustment of absolute and relative consumer food price subsidies, ensuring low prices for food grain, skimmed and low-fat milk, vegetables and potatoes;
  
• the avoidance of low prices for sugar, butter and margarine;
  
• the marking of regulations to promote provision of healthy foods by retail stores, street vendors and institutions; and
  
• the regulation of food processing and labeling.

Traditionally, international public health approaches have viewed national governments as the primary agents and locus of control for public health. Global threats are primarily conceived of as problems of border control and dealt primarily through cross-border cooperation between governments. The legal instruments are confined to national legislation and regulations. The scope of activities is also mostly focused on targeting risk factors in prevention programmes based in the Ministry of Health.⁸

However, experiences from global efforts to control tobacco consumption or restrict the marketing of breast-milk substitutes suggest that such an approach is not sufficient.⁹ In both cases attempts to influence the production, marketing and distribution of these products through general education, national campaigns or appeals to industry have been found to be necessary but not sufficient to have a real impact.¹⁰ The accelerating pace of globalization has resulted in many health determinants being constituted beyond national or even regional boundaries.⁸

Quite clearly, the de-linking of many health determinants from national space, requires a much broader response than that traditionally associated with the international approach. A wider range of actors and stakeholders, both governmental and non-governmental, need to be involved. It also suggests that a wider range of tools and approaches are required. One approach has been the development and adoption of codes of conduct that specify the control of marketing and trade of goods felt to damage public health.¹¹ Perhaps the most famous example is that of the International Code of Conduct on Breastfeeding Substitutes. This is a non-binding recommendation adopted by the World Health Assembly in 1981, with the purpose of promoting breastfeeding and regulating the marketing of breast-milk substitutes. However, this example also illustrates the limitation of voluntary codes with numerous documented transgressions of the Code by the breast-milk substitute industry.¹² This has led to the recognition of the need to develop more binding instruments.

In terms of binding instruments, the International Health Regulations were adopted by the Assembly in 1948 in order to control the international spread of communicable diseases. Most recently, the Framework Convention on Tobacco Control (FCTC), is a binding international convention, which aims to circumscribe the global spread of tobacco use and tobacco products (Box 2.1).

Legally binding instruments have the distinct advantage that State Parties tend to comply, and the disadvantage of a drawn-out process and the need for global political support for a single solution. Approaches which endorse binding international instruments on food-related health issues have been limited to food safety and security and, more recently, discussions of rights-based approaches to undernutrition. The non-binding intergovernmental resolution has the advantage of flexibility. Potential international standards and instruments in this area might address issues such as marketing restrictions for unhealthy food products, restrictions on the advertising and availability of unhealthy products in schools, standard packaging and labeling of food products, and potential price or tax measures to reduce the demand for unhealthy products. There is also the advantage of the public attention surrounding the drafting of such an instrument and the fact that it may set general standards for corporate conduct without actually being passed through legislation.