In addition, in the most deprived areas levels of obesity were more than double those in the least deprived.
There are few developed countries that are reducing childhood obesity, but world health experts have highlighted the success that France has had in tackling the problem. They point to the EPODE programme as being instrumental in that success.
EPODE (Ensemble Prevenons l'Obesite Des Enfants - which translates as Together Let's Prevent Childhood Obesity) began in the towns of Fleurbaix and Laventie in northern France in 1992. It takes a holistic, whole-system approach that aims to identify and address all the causes of childhood obesity and get everyone working together to tackle the causes - parents, schools, health professionals, communities, businesses, central and local government.
"Everyone - from the mayor to shop owners, schoolteachers, doctors, pharmacists, caterers, restaurant owners, sports associations, the media, scientists, and various branches of town government - joined in an effort to encourage children to eat better and move around more," said Dutch nutritionist Martijn Katan. "Towns built sporting facilities and playgrounds, mapped out walking itineraries and hired sports instructors. Families were offered cooking workshops, and families at risk were offered counselling."
Each town appointed an obesity champion to lead the initiative and who understood the needs of the local community. It appeared to work: by 2005, obesity in children had dropped to 8.8 per cent, while in similar neighbouring towns it had risen to 17.8 per cent.
The approach has subsequently been rolled out across France and other countries have adopted it.
- France has one of the lowest child obesity rates in Europe
- A key factor has been the development and expansion of the EPODE project
- EPODE draws together the resources of all community agencies
- It is funded by local authorities and business, with central government support
- The programme aims to tackle the contributory factors of obesity in children
- Analysis shows EPODE towns have lower levels of childhood obesity
SOCIETY AND CULTURE
Obesity levels in France among children aged 9 to 10 have remained steady, even falling in some cases, according to a recently published study by the Statistics Bureau of the French Ministry of Health.
The study of 8,000 French school children in 2014/15 found 18.1 per cent were overweight, and 3.6 per cent obese. These rates are significantly less than the European average, and show a consistent drop since 2008.
However, the ministerial report found that 10-year-olds from working class and lower income backgrounds were twice as likely to be overweight and four times more likely to be obese than 10-year-olds from higher income families. This translated into 1.4 per cent of children of professional parents registering as obese compared with 5.5 per cent of children of non-professional parents.
France has a long-held reputation for fine cuisine, but its traditional food tends to be high in fat and sugar - think croissants, cheese and pastries. This, combined with an increasingly fast-food culture and sedentary lifestyle, had contributed to the rise in obesity levels.
The Ministry of Social Affairs, Health and Women's Rights is responsible for defining national health strategy. In addition, the responsibilities of the central government include allocating budgeted expenditures among different sectors and, with respect to hospitals, among regions. The ministry is represented in the regions by the regional health agencies, which are responsible for population health and health care, including prevention and care delivery, public health and social care.
POLICY AND LEGISLATION
Following a five-year pilot study of EPODE in 10 towns, it was found that the prevalence of overweight and obese children in pilot towns was 9.1 per cent lower than the levels of similar towns.
In addition to rolling out EPODE, the other measures taken by the government banned fizzy drink and snack machines in state schools, and misleading television and print food advertising. France also put in place a 1.5 per cent tax on the advertising budgets of food companies that do not encourage healthy eating.
To be involved in the EPODE programme, areas contact the central co-ordination team (CCT) which is government funded. In addition to promoting the programme, the CCT trains and coaches a local project manager nominated in each EPODE community by local authorities.
The local project manager is also provided with tools to mobilise local stakeholders through a local steering committee and local networks. Its critical components include political commitment, sustainable resources, support services and a strong scientific input - drawing on the evidence-base - together with evaluation of the programme.
In addition, mayors of the first 10 French pilot towns have created an independent group called "Club des Maires EPODE" (EPODE mayors' club), which meets twice a year to share experiences as well as to raise awareness of the EPODE methodology with other mayors.
Epode costs two euros a day per child to run, which is borne equally between councils and businesses, such as Coca-Cola, which have been keen to participate due to the positive publicity surrounding the scheme.
PRACTICE AND IMPACT
EPODE relies on a clear methodology in order to bring about results and employs a multiple stakeholder approach both at a central level - ministries, health groups, voluntary groups and private partners - and at a local level in the community: political leaders, health professionals, families, teachers, local charities and businesses.
The main four pillars of the methodology are
- Gain formal political commitment from leaders of the key organisations, which influence policies both on a national and local level.
- Ensure sufficient resources are available to fund both central support services and local implementation.
- Provide social marketing, communication and support services for community practitioners.
- Evidence-based approach to implementing and evaluating the programme.
Activities undertaken through EPODE include:
- Social marketing campaigns on different topics (the importance of hydration, a balanced diet, physical activity through play, and sleep).
- Development of tools for educators.
- Activities for the whole community (for example, a Vitality day - an opportunity for families to spend a fun day being physically active).
- Introduction of a "Vitality pass" to encourage families to participate in healthy events.
- Action on fruits - a kindergarten programme where children are introduced to different types of seasonal fruit.
- The installation of sport and recreational facilities in the communities.
Experts highlight that key to the project's success is that these activities do not take place in insolation, but as a combined effort within the community, with strong support from local authorities, both political and financial.
Over the past 25 years, EPODE has expanded to more than 500 communities worldwide, including in Belgium, Spain, Greece, Australia and Mexico. An International Network was created in 2011 to provide support and resources to overseas sites.
In addition to contributing to lower obesity levels among French children, further analysis has found that EPODE can encourage children from poorer backgrounds to adopt healthier lifestyles.
A 2016 study by Borys showed that children from lower socio-economic backgrounds increased their fruit and vegetable consumption and cut intake of sugar and screen exposure as a result of participating in EPODE interventions.
By Dr Max Davie, health improvement officer, the Royal College of Paediatrics and Child Health
The EPODE programme displays many of the features needed in a good local programme. It has clear leadership, supportive local community buy-in, material changes to the environment such as the building of sports facilities and targeted attention to a wide range of contributory factors.
Very few cities have been able to cut childhood obesity, but recent initiatives in Amsterdam and Leeds have also been effective.
In 2013, the Amsterdam Healthy Weight Programme introduced a range of activities across schools and the community, with the prevalence of combined overweight and obesity among under-19s in the city falling from 21 to 18.5 per cent between 2012-15.
Meanwhile in Leeds, the proportion of children starting primary school obese fell from 9.4 per cent in 2009/10 to 8.8 per cent in 2016/17. One contributor to this success is the Health, Exercise, Nutrition for the Really Young (Henry) programme, which is based on interventions involving children from birth to five years.
The Leeds, Amsterdam and French models all have elements in common, but also differ in various respects. With EPODE, some of the benefits may well be specific to the French context, with elements of the programme matching French culture and lifestyle.
It seems unlikely that any particular model will be applicable to all areas in the UK or elsewhere. Instead, programmes need to be carefully tailored to individual areas, incorporating the general principles of successful models, in order to have the best chance of success. But alongside these locally driven programmes, more needs to be done centrally.
We know factors such as advertising influence what we eat and quick changes to legislation that prevent advertising of products high in salt, sugar and fat on television and online before 9pm will benefit all communities in the fight against obesity.
That's why we are calling on the government to implement this proposal alongside fewer price promotions on unhealthy food and the reformulation of products to reduce sugar.