Impact Of UK Government Strategies On Childhood Obesity: A Narrative Review

Causes of Childhood Obesity

Obesity is defined as the abnormal accumulation of fat resulting in health issues for people (Williams et al. 2015). Childhood obesity is one of the major concern for public health department currently as the issue is prevalent globally both in developed countries and many low and middle income countries (Patrick et al. 2013). Based on World Health Organization report, the global prevalence is understood from the fact that in 2016, more than 41 million children under the age of five were overweight (World Health Organization 2016). Apart from developed countries, the prevalence rate is also increasing in developing countries. Majority of obese children continue to be overweight during adulthood and they are most likely to suffer from chronic diseases like diabetes and cardiovascular disease in the future (Patrick et al. 2013). Hence, identifying the cause of childhood obesity and evaluating government strategies to tackle the epidemic would have long consequences.

The problem of weight gain and obesity mostly arise because of the imbalance between energy intake and expenditure. Although genetic background of an individual significantly increases the risk of childhood obesity, however child specific risk factors for obesity include sedentary behaviour, dietary intake and physical activity. These factors differ based on age and gender. Family characteristics such as parenting style and environmental factors such as free space and lifestyle also influence eating behaviour of children (Sahoo et al. 2015). Patrick et al. (2013) argues that parents facilitate positive eating patterns and their parenting style significantly influence risk factor of obesity. Reviewing parenting practices such as limiting screen time and focus on physical activity may help to evaluate the cause of obesity in children. Several government policies and strategies in different countries target the risk factors and implement interventions accordingly to deal with the problem of childhood obesity.

In UK, childhood obesity prevalence is going to epidemic levels.  Prevalence of obesity in UK has tripled in the last 30 years and the considering current rate, it is estimated that the prevalence rate may reach up to 11 million by 2030. Hence, obesity is one of the leading preventable diseases in UK and in Europe, it is the leading contributor of obesity epidemic with a contribution of about 24.9% (Renewbariatrics. 2017). As this may have long term consequences on the health of UK population and increase the burden of the health care system too, evaluating government’s action taken so far in UK may help to identify the future action that can resolve the issue of childhood obesity. The main aim of the dissertation is to conduct a narrative literature review to understand the impact of UK government policies related to childhood obesity and understand the strength and weakness of government’s action to deal with obesity. This may help to identify gaps in current policies and future amendment needs to efficiently deal with challenges of obesity.

Childhood obesity is turning out to be an epidemic in developed countries. UK is also one of the countries that are currently experiencing childhood obesity. This is evident from the fact that about one in every five children in primary schools is obese (Royal Society for Public Health (RSPH) 2017). The health survey data for childhood obesity prevalence in England revealed that one in every five children were obese in 2015/2016. The prevalence is also linked with level of deprivation as children living in the most deprived areas were most likely to be obese than in the least deprived areas. Difference in prevalence rate also differs based on ethnic diversity as the health survey data for England revealed high prevalence rate for Black/Black British children (15%) compared to Chinese children (7%) (National Statistics 2017). In the long term, such prevalence rate can have significant impact on the long-term future of the NHS (National Health Services) and physical and mental health consequences for affected children. The burden for NHS will increase due to prevalence of a number of physical health issues associated with obesity such as cancer, asthma, respiratory problem and diabetes. It may also increase risk of psychological problems such as anxiety, poor self-esteem and poor body image among children (Sahoo et al. 2015).

Prevalence in the UK

Obesity is one of the preventable diseases has that increased the burden of the health care system in UK too.  Due to the increased diagnosis of childhood obesity and its long term impact on physical health, UK government has spend about 48 billion pounds a year to take preventive action against obesity. With the increase in rate each year, the NHS cost may double to 10 billion pound a year by 2050 (Royal Society for Public Health (RSPH) 2017). To save the extra expense spend of health issues related to obesity, implementation of effective intervention to lower the rate of childhood obesity would be needed. Diagnosis of obesity increases many risk for affected individual compared to a healthy individual. For example, obese people are five times more susceptible to type 2 diabetes and two time more likely to develop blood pressure compared to healthy individuals (Toplak et al. 2016). This in future can increase the likelihood of cardiovascular disease and reduce life expectancy of the population. Hence, to increase the life expectancy rate of the UK population, decreasing BMI can reduce life expectancy, promote health and reduce health care associated cost too.

The main rational for reviewing and critically evaluating UK policies related to childhood obesity by means of a narrative review is the increase in childhood obesity prevalence each year and little evidence of cost reduction due to implementation of policies or campaigns to prevent obesity. Jebb, Aveyard and Hawkes (2013) states that obesity as health threat to the nation was identified long back by the Conservative government in England. Since, then formal government strategies were implemented in 2008 and 2011 to prevent childhood obesity. These targeted active sports participating in schools, fruits and vegetable intake in children, eating habits, diet status, park use and walking levels in children. Many new government policies for marketing restriction in foods high in fats, sugar and salt, nutritional standards in schools, weight management and sport programs were also developed. Annual surveys shows reduction in obesity rates in recent years, however the problem has not been reversed. Hence, review of research papers investigating about the impact of different government policies in UK may help to determine gap in current child obesity prevention initiative and find out more about ways to reduce issues found in past government strategies related to childhood obesity. It may help to improve the implementation process and other challenges found in implementing government strategies.

The main aim of the study is to evaluate the impact of government policies implemented in UK to reduce the rate of childhood obesity and other challenges associated with childhood obesity.

• To identify and evaluate different policies implemented in UK to prevent and control childhood obesity
• To identify gaps and strength in past government strategies related to childhood obesity prevention
• To recommend future action to improve the efficacy of government strategies and campaigns to reduce childhood obesity and other health concerns for the affected population

 As the main aim of the research is to critically evaluate UK government policies related to childhood obesity prevention, narrative literature review method has been chosen as the research design for the study. Narrative reviews critically evaluates different primary studies specific to the research topics and focus on holistic interpretation based on current theories practice. Narrative reviews are suitable research design when the purpose of the research is get comprehensive information related to a research (Hart 2018). This research design may help to individually evaluate different policies in the area of food marketing, food and nutrition, physical activity and school programs in UK to prevent childhood obesity. In contrast to systematic review, a narrative review presents findings of a research in a condensed format that summarizes and critiques each study (Green, Johnson and Adams 2006). Therefore, narrative review method can help to present broad perspective related to the obesity prevention policies in UK and identify improvements needed in current policy initiative.

Impact on Finance and Healthcare

Search strategy is the process used to organize the search process and find relevant articles related to the research topic and research objective. A comprehensive search for relevant literature is guided by specific search terms, selection criteria, critical assessment or evaluation and data analysis process. Keywords and eligibility criteria forms the basis of searching articles from relevant databases. Apart from key words, several phrases, Boolean operators and subject headings also helps to retrieved relevant articles for reviewing the literature. For this research wide variety of key words were used to find articles as the aim was to evaluate diverse range of UK government policies related to obesity prevention. The search for articles were done from PubMed, Medline and CINAHL databases and the key search terms included in the search includes ‘childhood obesity’, ‘child obesity in UK’ and UK policy related to childhood obesity. This was the primary search terms. Based on the identification of different UK policies, other secondary search terms were also used to find relevant literature related to the topic. Boolean operators like ‘AND’ and ‘OR’ was also used for searching articles from CINAHL databases. The Boolean operators helped to separate different phrases and arrange key terms similar in meaning. Hence, use of ‘AND’ narrowed down the search process to get more information on policies and the use of ‘OR’ broadened the search hits by including all studies that is relevant to childhood obesity.

Setting eligibility criteria in a literature review supports a researcher in the search process and selection of articles for research. To find research articles relevant to the impact of UK government policies on dealing with childhood obesity, the following inclusion criteria where developed:

• All research articles must critically evaluate UK policies related to obesity
• The article should give detail on research findings from UK
• All research articles must be published within 2008 to 2018
• Articles published in English language should be included in the literature review

To get relevant research articles and segregate those which are not specific to the research question, the following exclusion criteria were taken:

• Articles published before 2008 will be excluded from the review
• Articles published in other language other than English will not be taken in the review
• Articles which gives details on strategies implemented in other countries other than UK will be excluded
• Articles discussion about adult obesity will be excluded

Different qualitative research has different techniques for conducting and documenting data analysis process. Thematic analysis is one of the data analysis methods that enable developing sensitive and rich research findings. The advantage of thematic analysis method is that it can be utilized to answer different types of research questions and epistemiology. Thematic analysis has a flexible research approach and the findings presented in the form of themes helps in easy grasp of research findings. A clear and organized report can be easily produced through thematic analysis research methods (Nowell et al. 2017). However, the common challenge in writing a thematic analysis is that it often contributes to many inconsistency and lack of coherence while developing themes for research findings. However, consistency can be improved by making explicit epistemiological position.

After selection of research articles based on inclusion and exclusion criteria and by setting search limits, articles were analysed in two stages. In the first stage, the title and abstract were analysed to find its suitability to answer research question. In the second stage, the full text articles were read to critically appraise research findings and identify strength and weakness of UK policies related to childhood obesity. The findings were presented in the form of themes according to thematic analysis of research literature. Thematic analysis is a method of data synthesis, where the focus is to identify patterned meaning across wide range of data and analyse research findings based on the identified themes (Braun, Clarke and Terry 2014). Thematic analysis supports a researcher to find meaning in unrelated research materials and systematically gain knowledge phenomenon or topic of interest. Thematic analysis is also a useful research method when the purpose is to review large number of qualitative data (Braun and Clarke 2014). Therefore, thematic analysis can yield useful research for this narrative review too.

Effectiveness of UK Government Policies

Numerous initiatives were implemented by the UK government at school level to prevent risk of childhood obesity. The Change4Life (C4L) was one of the campaigns that focused on fulfilling the needs of physically inactive children. The research by Croker, Lucas and Wardle (2012) investigated about the impact of C4L campaign on preventing obesity in England. C4L targeted was a primary prevention approach launched in January 2009 in UK to prevent childhood obesity. The social marketing campaign emphasized on targeted message to raise awareness regarding long term consequences of overweight and obesity, developing healthier habits and reducing consumption of foods high in fat and sugars.  Families with children between 1-11 years and pregnant women were targeted and research participants were selected based on research on people exhibiting behaviour and attitude that can increase risk of children becoming obese. The main aim of the randomized controlled study design was to evaluate the impact of C4L on parent’s attitude towards children, activity and weight and diet and activity behaviours of parents and children. Targeting parent’s knowledge and attitude towards childhood obesity is a beneficial step as it promotes acquisition of correct attitudes and encourages good practices to manage obesity at family level (Mabiala Babela et al. 2015).

The C4L campaign included four phases to systematically educate parents regarding obesity and schools were randomized to intervention and control group. The main outcome measure included child behaviour, parent behaviour and attitudinal change after the campaign. The review of research findings revealed that 75% of families were aware of the campaign and awareness increased in both group at follow-up. Another significant finding was that near-significant association was found between socioeconomic status (SES) and rating of physical activity importance. Parent’s had varying views about the campaign and many reported that have already implemented the recommended behaviour or the recommendations are unrealistic. Hence, from these outcomes, it can be concluded that family information pack significantly (Croker, Lucas and Wardle 2012).  The intervention increased awareness about the campaign on parents, however very few positive influences on attitudes or behaviours of parents were seen. This is inconsistent with other social marketing campaigns which have achieved positive effects such as improved attitude towards preventing obesity. This points out to several limitations in the C4L campaign. Some limitations include not taking personalized feedback from parents and having a wide and complex focus. It targeted both complex diet and activity behaviours. Single interventions could have yield desirable results. The VERB was a campaign that focused on promoting physical activity in children and use of single intervention helped in achieving positive physical activity outcomes and also sustains the effect for longer time (Huhman et al. 2010).         

Preventing obesity requires population based approach as this helps to consider wide range of policy and environmental change strategies needed to target food access and food intake. Implementation of strategies in diverse setting is crucial to access whole population at risk (Brownson et al. 2017). Jebb, Aveyard and Hawkes (2013) reviewed all types of actions taken by the UK government to control obesity and strategies were implemented at various setting to target obesity prevention. Among early year interventions, the Family Nurse Partnership (FNP) was one of the interventions that were implemented by the UK government in 2007. It was a structured home visiting program that offered first-time mothers training stop smoking during pregnancy, increase breastfeeding and improve self-esteem (Owen-Jones et al. 2013).  The main rational for this type of intervention was that encouraging breastfeeding helps a child to develop healthy eating patterns. Yan et al. (2015) explains that breastfeeding babies are better able to regulate their food intake and prevent the risk of obesity. It reduces risk of non-communicable disease like obesity and diabetes in later life. Hence, breast feeding is regarded as factor that can protect children from weight gain and obesity.

Future Needs and Gaps in Current Policies

The review of research literature gave rise to two research articles that evaluated the impact of the Family Nurse Partnership programme for teenage mothers in England. Robling et al. (2017) evaluated the effectiveness of the FNP program on infant and maternal outcomes up to 24 months after birth. Non-blinded randomized trial was done in community midwifery setting in England and women aged 19 years or younger. Nurses received special training for the programme. The main primary outcome of the programme was tobacco use, birth weight and hospital admissions for the infant within 24 months of birth. Secondary outcomes included child health and development outcomes and parental life course post the programme. The analysis of research findings revealed no difference in smoking outcome between mothers in FNP and usual care group. The rate of emergency attendance within 24 months of child’s birth also did not differed between the two groups. This suggested limited or no positive impact of the FNP. However, for secondary outcomes, very minor positive effect was found in the area of child cognitive development and language development. On the whole, no positive effect of the program was found. The outcome also shows that FNP is not a cost-effective strategy implemented by the government. Hence, introducing FNP cannot reduce the burden of the UK health care system due to obesity.

The Health Weight, Healthy Lives (HWHL) was one of the population based strategy implemented in England to reduce the burden of obesity. The government published the HWHL strategy to deal with obesity and it focuses on five themes. The five streams included health growth and healthy weight for children, promoting healthier food choices, personalized advice and support and building physical activity. The HWHL ran till March 2010 and it was replaced with a new strategy by Novermber 10 (Jebb, Aveyard and Hawkes 2013). Hawkes, Ahern and Jebb (2014) aimed to investigate about the impact of HWHL strategy on bringing changes in action to address obesity in England. Qualitative research method with the use of semi-structured interview method wasdone to evaluate perspective of 40 stakeholders involved in the development and implementation of obesity strategy. Purposive sampling strategy helped to recruit target population for the study and evaluate wide range of perspective related to the success or failure of HWHL. The interview results revealed that all respondents had clear perception regarding the development of the strategy. The most dominant finding was that it was perceived the Strategy led to many positive outcomes and it facilitated cross-government engagement with the strategy. Special focus on child also facilitated relationship building. However, the strategy failed to get desired results at all government departments because of poor evaluation of different programs due to wide range of interaction actors and setting. In future, there is a need for UK government to adopt a systematic process of aligning goals and implementing transparent system to report changes in obesity rates.

The mounting prevalence of childhood obesity in the UK has been a key concern for healthcare professionals. The rapid rise in the health condition is known to pose a great public health challenge. As highlighted by Willis et al. (2013) about one-quarter of children in the country suffer from obesity or overweight at the time when they attain admission to school. Different arguments have come forward regarding the preventive strategies implemented by the government that point out that initiatives are scarce in amount that target infants. Evaluations carried our earlier on HENRY (Health Exercise Nutrition for the Really Young) had indicated that improvement can be achieved in the manner in which practitioners work in collaboration with families for having a positive impact on their life style. HENRY is a distinct initiative widely implemented across UK. The aim of the program is to address childhood obesity at the early stages through provision of training for health practitioners. The primary objectives of HENRY are betterment of parenting, effective eating pattern, healthy eating, increased physical activity and uplifted emotional well-being (Willis et al. 2016).

Willis et al. (2013) carried out an investigation of the effect of a program designed for providing parents of children attending preschool with education that guide healthier lifestyle. A cohort of families were considered for the study across the 8 week HENRY parent course. The settings were nine different locations in England. A total number of 77 parents had given enrolment and 71 completed questionnaires that focused on eating behaviors, parental self-efficacy and dietary intake. 60 parents provided data before and after the course, and analysis was done with the help of repeated measures analysis. The results indicated significant changes which was sustainable even at the time of follow-up. There was an increase in self-efficacy and capability of encouraging good behavior (P < 0.001). Adults and children both reported increase in the consumption of vegetables and fruits. A positive change in terms of eating behavior was also reported. The study indicated that the HENRY intervention had been effective in bringing about a positive impact on preschool children and families. In addition, it was suggested that there is a possibility that the positive changes brought about can be sustained till a later period.

The paper of Poobalan et al. (2010) focused on analyzing the present UK recommendations on obesity with the help of a proposed framework. As per the researchers, experts have been continually attempting to identify, appraise and synthesize existing evidence on policies implemented so that recommendation for future practice can come into focus. The background to the study was that recommendations, though based on evidence, have not been always able to formulate strategies that can be readily implemented (Selbie 2018). Poobalan et al. (2010) considered two bibliographic databases, Embase and Medline, along with varied government websites, for researching for recommendations provided on obesity between the years 1996 and 2007. The relevant documents were assessed that considered obesity prevention and treatment recommendations in UK. Critical appraisal of the articles was done and results were summarized as per a framework. The chief result that emerged was that most of the recommendations that were present on obesity failed to meet the standards of implementation. The recommendations did not have a clearly outlined structure for monitoring, and further, no particular time frame was mentioned. In addition, the cost of implementing the same was not appropriately estimated along with the stakeholders for implementation. There was however some exemptions to it which are mainly locally implemented strategies.

Different types of policies have been developed over the time to deal with childhood obesity. This also involved UK government’s action to restrict advertising of certain foods to children. Public Health advocates in England started focussing on advertising restriction as marketing focused mainly on less healthy food products (Food Foundation 2017). In 2010, the World Health Organization proposed 12 recommendations on marketing food and beverage to children. This included recommendations to reduce exposure of children high fat, salt or sugar (World Health Organization 2016). New regulations related to the content for food advertising to children were announced in 2007 and the UK government implemented prohibition of advertisement for foods high in fat, salt and sugar (HFSS) (Adams et al. 2012).

The research article by Adams et al. (2012) explored the consequences and impact of the 2007 UK food advertising restrictions on children’s purchase request and consumption pattern. A cross-sectional study design was used to evaluate all advertisements broadcast in the Tyne Tees region of the week for one week before and after the regulation. The HFSS status of advertised food was also calculated. The analysis of research findings revealed gave data on exposure to HFSS food advertising before and after the HFSS advertising restriction. In the period between six months before and after the restriction, the exposure to HFSS advertising for children above 4 years was found to increase. This also happened despite adherence to the scheduling restriction. Hence, the scheduling restriction could not achieve the desired results. However, this result was obtained because of a number of limitations in collecting data. Firstly, the research was dependent on secondary data as it was not possible to view all the advertisements. Hence, analysis of all types of food products being advertised could not be done. Another major limitation of the study was that it did not evaluated impact of the restriction on purchasing and consumption pattern and bodyweight. However, this was necessary because use of attractive media character is brand advertising has a powerful impact on children’s food choices and buying behaviour (Kraak and Story 2015).

The study by Adams et al. (2012) also gave the insight that the UK HFSS food advertising restriction did no worked despite even though advertised adhered to the restrictions. This result indicates that children are exposed to wide range of television than programmes targeted only for children. The report by the Food Foundation (2017) also argues that UK government implemented highly focused restrictions within regulated advertising challenges. Children were exposed to HFSS advertising because children and young people watch other programmes without restriction too. For example, certain programmes like X Factor and the Simpsons at not targeted for children. However, these attract large attention of children and young adults. The results gives implication for future improvement in policy and the need to consider wide range of advertising to  control unhealthy consumption pattern among UK children. Hence, in future also, controlling the harmful role of marketing on children’s food preference and obesity is important. Kraak and Story (2015) explains that children prefer foods high in sweets and salts because of their current food environment and their understanding of food brand logos further increase the craving and preference for fast food and sugar sweetened beverages. Kotler, Schiffman and Hanson (2012) argues that media character branding promote use of energy dense foods among children and increases their purchase request too.

The research by Briggs et al. (2017) is considered relevant in relation to the research topic and the theme of food marketing legislation as it conducts health impact assessment of the UK soft drinks industry levy. The advertising restriction targeted reduction in consumption of high fat, sugar and sweet foods. In addition, the research focused on analysis of the UK soft drinks industry levy. The main rational for the research was the introduction of tiered levy on sugar sweetened beverage by the UK government.  In 2016, the UK government imposed high taxes for drinks which have greater than 8 g of sugar per 100 ml, moderate tax for 5-8 g and no tax for less than 5 g sugar/100 ml. To maximise the health gain due to the soft drinks levy, the main goal of the intervention was to evaluate the impact of various industry responses on health. A risk assessment model was developed to estimate the effect of soft drink price changes of obesity, dental caries and type 2 diabetes in UK. The evaluation of different industry responses revealed that health effect is sensitive to the way the soft drink industry responds to the levy. In accordance with this result, the results give the implication to constantly monitor the implementation strategies taken by the industries to estimate long term effect on health and obesity. Ma et al. (2016) gives the implication that such actions have the potential to gradually reduce sugar in soft drinks and reduce health issues such as obesity and type 2 diabetes.

Rayfield at et al. (2015) explored the relationship between breastfeeding support and breastfeeding among late preterm in 34–36 weeks of gestation  and term infants  in ≥37 weeks of gestation. The positive impact of breastfeeding on decreasing childhood obesity has been acknowledged by the UK government since long. Breastfeeding support has been initiated across the country at different levels so that women can consider appropriate breastfeeding for the newborns. A number of healthcare units offer support sessions to new mothers that includes breastfeeding counsellors (Yan et al. 2014). A growing pool of literature suggests that breastfeeding is effective in combating non-communicable diseases in later stages of life that includes protection against obesity and overweight in childhood. Different plausible mechanisms that support the concept have come forward. Breastfeeding preludes complementary feeding practices that contribute to weight gain in an unhealthy manner. Intake of total energy is found to be higher in those who have been formula-fed (Bider-Canfield et al. 2017). The article by Rayfield at et al. (2015) aimed at understanding the effectiveness of breastfeeding support on rate of breastfeeding in UK. The researchers carried out a secondary analysis of the UK 2010 Infant Feeding survey which aims at monitoring breastfeeding prevalence. They considered carrying out logistic regression for determining the association of breastfeeding support with breastfeeding at 10 days as well as 6 weeks in late preterm and term infants. The study considered 14,525 term and 579 late preterm infants. 11,729 infants were initiated with breastfeeding of which 81.8% were term and 79.4% were late preterm infants (p=0.425). Mothers who stated that they were provided with contact details of breastfeeding support groups demonstrated more chances of breastfeeding later preterm and term infants at 10 days and term infants at 6 weeks. Mothers reporting that contact information about breastfeeding support groups were not given to them had less chances of breastfeeding late preterm at 10 days and term infants at 10 days and 6 weeks when comparison was done with mothers receiving the information.

It was concluded from the study receiving help and support regarding breastfeeding in hospital is beneficial to a considerable extent, as increasing contact leads to higher rates of breastfeeding. The research considered many confounding factors and eliminated them during research process such as socioeconomic status, ethnicity, marital status and education level of mother. This was significant since breastfeeding is largely associated with varied socio-demographic factors (Onah et al. 2014).

Many schools were also targeted by UK government to promote healthy eating habits in children. The School Fruit and Vegetable Scheme (SFVS) was launched in 2004 and in accordance with the scheme, each children between 4-6 years old were provided with a fruit and a vegetable every day. The main rational for implementing such scheme was that it could improve children’s diet and support a child in developing healthy eating habits (Jebb, Aveyard and Hawkes 2013). In accordance with the scheme, 440 million fruits and vegetable have been distributed in 18000 schools in recent years (Hughes et al. 2012). School can regarded as an ideal target to find solutions to a public health crisis like obesity. This can be said because school provides an ideal environment for physical activity promotion, nutrition education and nutritious offering. Implementing effective interventions at this stage facilitates building life-long health habits in children. While implementing school based obesity prevention intervention, proper consideration of research design and tailored intervention is useful to get the desired results (Ickes et al. 2014). This section provides review of school based intervention implemented in UK to deal with childhood obesity.

Hughes et al. (2012) investigated about the impact of the SFVS scheme on improvement in daily intake of fruit and vegetables across England. The main aim of the intervention was to support children to develop life-long healthy habits and reduce the prevalence of childhood obesity. The research in this area is important as it was a high scale intervention and evaluating the success of the scheme can have long-term implications on obesity prevention. The daily intake of fruits and vegetables were assessed from a cross-sectional sample of children aged 6-7 years. Dietary data was collected using the CADET (Child Diet and Evaluation Tool) and all types of food and drinks consumed by the children were recorded. Out of 3296 CADET distributed, 2709 were completed. The analysis of the CADET datasets revealed that 61.6% of the children ate at least one fruit or vegetable from the SFVS and 59.2% ate fruits and vegetables five times of the days. The assessment of fruit and vegetable intake was also done according to geographical areas. Frequency of consumption was found to be higher in South England and the participation rate was higher in Northern England. This indicates that the SFVS did not influenced intake of fruits and vegetables. However, the strength of the study is that it highlights the problem of poor diet in children in England as low levels of healthy foods were consumed by children. The intervention was also found to have greatest impact in more deprived areas. However, this is inconsistent with other research studies as Hollis et al. (2016) revealed little impact of school based intervention on adiposity outcomes.

Taking lessons from the result obtained for SFVS scheme, it can be said that SFVS might have been unsuccessful because of several reasons. For example, the SFVS targeted only one meal event which was the morning break. However, targeting more meals would have given more number of positive outcomes (Hughes et al. 2012). Hence, at school level, the UK government could have taken the initiative to target parents and educate them regarding providing healthy packed lunch to student. The benefits of such initiative is understood from a research study by Evans et al. (2010) that implemented a lunch box intervention to improve the quality of school children packed lunches. The cluster randomized controlled trial was done in 89 primary schools across UK. During the first phase of the intervention, all parents were provided a SMART lunch box cooler bag. In the second phase, all parents were given information leaflet on encouraging children to eat variety of nutritious foods. In the last phase, families were recipe books and menus. The main goal of the intervention was to increase consumption of nutrient rich food among children. The intervention led to small improvement in food and nutrient content of children’s packed lunches.  There were no significant limitations in research design except the fact that only one meal was assessed throughout the day. However, to have population level impact, large improvement is needed to tackle the obesity epidemic.

The article of Ransley et al. (2007) evaluated the impact of School Fruit and Vegetable Scheme (SFVS) on diet of children. Research had suggested that young people and children do not consume fruits and vegetables to an extent that can be beneficial for their health. National Diet and Nutrition Survey in England had pointed out that those in the age group of 4 and 18 years consume lesser amount of fruit and vegetable than the recommended amount. For addressing the health and dietary concerns of children in the country, the government had considered implementing the ‘5 A DAY program’ for raising awareness on the benefits on eating fruits and vegetables. A crucial aspect of the program is the School Fruit and Vegetable Scheme (SFVS) that had been articulated as a government strategy for addressing the low intakes of fruits and vegetables (Methner et al. 2017). It has been reported that the SFVS is the largest scale intervention in diet of children living in England after free school milk was introduced across the country. The scheme aimed at distributing 440 million pieces of vegetables and fruits annually to around two million school children across 18000 schools (Lucas et al. 2017).

Ransley et al. (2007) carried out a non-randomized controlled trial with infant and primary schools situated in northern part of England. A total number of 3707 children took part in the study whose age was between four and six years, studying at reception, year 1 and year 2. The intervention was that each child was provided with one portion of fruit or vegetable on every school day for eleven months. The primary outcomes to be measured were intake of nutrients in the form of fruit and vegetable consumption. The results indicated that there was an association between the SVFS and increased intake of fruits across year 1 and reception students 0.6 portions (95% confidence interval, 0.4 to 0.9), and of 0.4 portions (0.2 to 0.5) respectively. In year 2 there was an association with increase of 0.5 portions (0.2 to 0.7) of fruit at three months. On the whole, at seven months, no changes were evident in consumption of vegetable. Further, no association was evident between fat, salt or energy intake, and SFVS. In addition, small changes were evident in intake of Vitamin C or carotene. The main inference drawn from the research was that the SFVS was effective in promoting increase in intake of fruits among children after three months. At seven months there was a reduced effect of the scheme but the same was significant. Overall, the impact on the nutrient intake was considerably small across the gamut of children surveyed. It was therefore recommended that future interventions would be crucial for preventing the waning of the impact brought about by SVFS.

Childhood obesity has been recorded as a significant public health concern at the contemporary era, increasing the healthcare costs of the country and the burden on healthcare providers. As per the report of UK government, about one third of children with age between two and fifteen years were obese or overweight in the year 2016. It was also reported that the younger generation is increasingly becoming obese at an earlier stage. Reduction of level of obesity at the primitive stage is essential since obese children are more likely to remain obese as adults. Children are also at a risk of developing poor health conditions such as type 2 diabetes and hypertension as a result of their obese condition (Selbie 2018). The economic costs related to childhood obesity are also high, and every year the UK government is compelled to spend a considerable amount of money for combating childhood obesity and adult obesity. The NHS in UK had to spend about 5.1 billion on obesity-related ill-health conditions in the year 2014-15. According to Perry, Thurston and Arch (2015) childhood obesity is to be considered as a complex health problem that has varied drivers, including environment, behaviors, culture and genetics. The UK government in the past few decades has attempted continually to bring significant improvement in the prevalence of childhood obesity and reduce the economic burden of the condition. The strategies take up the government had been articulated with confidence to bring reduction in childhood obesity while giving respect to the economics of the country. The different strategies had strived to be clear in the goals and objectives so that firm actions could be taken (Braillon 2018).

The results of the present review indicated that HENRY (Health Exercise Nutrition for the Really Young) holds the potential to bring improvement in the way in which healthcare practitioners work with families to educate them and augment their lifestyles. It is therefore to the stated that there is an urgent need of similar initiatives in the future that can consider changing parenting patterns, healthy eating patterns and physical activity, all contributing to the wellbeing of children. As opined by Wilfrey et al. (2017) healthcare professionals are to be supported with training and resources so that they can guide parents regarding the eating patterns of their child. There is a need of health professionals to feel confident about discussing sensitive issues regarding child nutrition and weight issues of children with families. For supporting the ambition, different suites of resources are to be given for making every contact with the families effective. The resources are to be in the form of training that can overcome challenges in difficult conversation on behavior change (Rosemond et al. 2016). There is also a need of reviewing the existing materials about nutrition and childhood obesity that can encourage professionals to impart education (Sugiyama et al. 2016).

Moving on to breastfeeding strategies for curbing childhood obesity, it is already highlighted that breastfeeding support provided to mothers can augment the prevalence of breastfeeding that is directly linked with obesity prevention. As children grow older, the effects of breastfeeding are more evident which are exclusive. Breastfeeding cessation is a common problem among mothers across the globe and the contributory factors are diverse, including psychosocial, biophysical and socio-demographic factors and hospital practices (Wang et al. 2017). It is therefore highly relevant that healthcare professionals have a proactive approach in providing new mothers with instrumental and informational support interventions which aim at increasing breastfeeding rate. It can be pointed out from literature that in-person professional support would be more effective in place of remote support provided to mothers (Loiselle et a. 2016). In contrast, regular contact over the phone might be helpful in addressing the concerns of mothers after their discharge from the hospital on a regular basis. Support provided over the phone is more beneficial when there is a lack of other types of support (Fox, McMullen and Newburn, 2015). Fu et al. (2014) suggested that a combination of personal support in adjunct with telephone support would be ideal for increasing awareness level of mothers regarding breastfeeding. The rationale for a combination support provision would be that an in-person support provision might be economically and logistically challenging.

At this juncture it would be desirable to discuss about the School fruits and vegetable scheme (SFVS) that holds potential to increase healthy food consumption among children. Strategies aligned with the objective in tackling health conditions such as obesity, heart disease and cancer are noteworthy (Evans et al. 2012). Criticizing such scheme, Bere et al. (2015) highlighted that the government’s program for promoting fruits and vegetables in schools might be hit by any reduction on health spending. Such freezes on health spending on the government’s part might be a result of a thorough and accurate evaluation that such programs bring in negligible impact on consumption of fruits and vegetables on the long run. Staff managing for successful implementation of the same might also be challenging.

In accordance with the aim and objective of the research, strengths and gaps were identified in UK government’s action to restrict HFSS advertising to children. Targeting food marketing and advertising was a powerful strategy as it had the potential to address children’s food preferences and choices for energy dense and unhealthy foods. The strategy has the potential to change the obesogenic environment around UK children. Obesogenic environment can be defined as the combination of all factors that influence the surroundings and increase the opportunity for promoting obesity in a individual or a population. Television is a strong medium that increases children’s exposure to unhealthy food products and this could be targeted to reduce children’s preference for unhealthy food (Boyland and Whalen 2015). However, the review of the research study by Adams et al. (2012) revealed failure of the UK HFSS advertising restriction on food choices. Although there were many methodological limitations in the study that affected the generalisability of the research findings, however several loopholes in UK government strategy has also been found. The strategy was not successful because it targeted only programs for children, however in reality children were exposed too many other programmes too. Recognizing several loopholes in the HFSS advertising restriction strategy, Public Health England recommended implementing tighter restrictions on brand advertising and bringing sports and near-school marketing into the scope of the regulation. This can lead to positive impact if it is implemented in the right manner.

From then narrative review of research literature, social marketing has been identified as a powerful medium to change attitude of behaviour towards nutrition and physical activity. Social marketing has the potential to provide the right education to people to promote healthy living. The C4L can be regarded as a promising intervention as it targeted fostering healthy behaviour in population at risk of obesity. The idea is considered very effective as social marketing is one of the top health improvement strategies in many countries. Social marketing intervention for health promotion is favoured as it provides intelligent solution to social factors contributing to obesity (Gracia-Marco, Moreno and Vicente-Rodríguez, 2012). Hence, when applied in a systematic manner, social marketing campaign has the potential to apply the resources effectively and maximize the value of such campaigns. However, lack of consideration of a narrow aim and inclusion of many complex goal affected the success of the C4L campaign in UK (Croker, Lucas and Wardle 2012). According to Hubley and Copeman (2018), adopting value to user approach can help social marketing promoters to implement effective strategies.

To conclude, the narrative review summarized the strength and gaps found in various UK strategies to deal with childhood obesity. The narrative review gave insight into wide range of actions implemented by the UK government to deal with childhood obesity. This included implementation of social marketing campaigns to influence attitudes and behaviour of parents towards obesity, early years intervention such as FNP targeting pregnant women, population based approach such as HWHL, food advertising restrictions and food tax levy, school based interventions like SFVS scheme and many other. These interventions targeted various settings and various stakeholders in UK to deal with obesity. However, the narrative review clear indicates that majority of interventions or strategies implemented by the government were not effective in getting the desired results. Several errors or limitations were found in implementing the intervention. For example, in relation to C4L, the social marketing campaign could not change attitude or behaviour of parents towards healthy eating because of wide focus and poor campaign design (Croker, Lucas and Wardle 2012). It lacked inclusion of behavioural theory or psychological theory to improve outcome and promote behavioural change. The advantage of social marketing intervention in dealing with childhood obesity is that such campaigns have wide appeal and it has the advantage of reaching to a large audience. Hence, proper selection and dissemination of target message to target audience can promote achieving goal of such programs. Similarly, various processes related anomalies affected the fulfilment of UK government goals to reduce the rate of childhood obesity. There is a need to evaluate the strategies and identify future policy changes to achieve the goal of obesity prevention.

The review of UK government action indicates that many promising strategies were implemented by the UK government to tackle childhood obesity. The strategies applied powerful medium or wide range of setting to reduce the risk of obesity in children. However, most of the initiative failed due to poor implementation process. Hence, the main work of the stakeholders is to identify innovative approach to improve the delivery process.  It is recommended that UK government and policy makers focus on improving the following areas in the future to reduce the prevalence of childhood obesity:

• Expanding the scope of advertising restriction will be necessary so that restrictions are imposed for other programmes too. Imposing stricter restrictions of marketing and advertising of high fat, salt and sugar foods should also be done so that brand advertising of unhealthy food is completely omitted. This can play a significant role in addressing the obesogenic environment in UK.
• The social marketing campaigns have the potential to increase awareness about health issue and risk factor of obesity in target population. To increase the quality of social marketing campaigns in the future, it is recommended to have a narrow focus and to apply behavioural theories to influence the change process. This can involve focusing on reinforcing specific behaviours based by conducting behavioural analysis and using a theoretical framework to develop interventions (Larsen et al. 2015).
• There is also a need to consider partnership with other stakeholders who can provide valuable ideas relation to the implementation process. UK government can focus on encouraging voluntary partnership with private organizations such as NGO to positively influence the obesogenic environment. It can foster implementation of innovative and targeted actions to prevent obesity in populations vulnerable to risk of obesity (Jebb, Aveyard and Hawkes 2013).
• Implementing strict legislation to restrict marketing and sale of unhealthy foods can also play a role in addressing the obesity epidemic in UK.

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