**6. Interventions to tackle obesity in school children**

The plateauing of BMI of children and adolescents in high-income countries may be due specific initiatives by governments, community groups, schools and individuals and increased public awareness about the hazards of childhood obesity. Findings from the i3C study identified obesity, hypertension and dyslipidaemia as the three key modifiable factors in childhood that result in high cIMT in adulthood. All can be addressed effectively by lifestyle modification and medication. Obesity is easily apparent but difficult to treat on a sustained basis due to a variety of reasons. Hypertension and dyslipidaemia are more difficult to identify due to confusing cut-offs and multiple guidelines. Lifestyle modification is easy to suggest but difficult to implement. Care-givers and parents lack sufficient knowledge about dietary modifications and exercise programmes to advise children. Depression, low self-esteem, lack of peer and parental support and rebellious nature of adolescents make implementation of lifestyle changes difficult. Thus, a multi-modal approach to childhood obesity is required. Even modest loss of weight can lead to significant reduction in TG levels and increase in HDL-C levels. Even without weight loss, regular exercise training can have the same effect on serum lipids [105].

The WHO has included tackling childhood obesity as one of its priority areas. It has suggested a three-pronged strategy: reducing the risk of obesity by addressing critical elements in the life course, tackling obesogenic environment and norms and lastly treating obese children to improve their current and future health.

There is enough evidence to support the fact that undernutrition during pregnancy, excessive weight gain during pregnancy, hyperglycaemia during pregnancy and smoking and exposure to other toxins increase the risk of obesity in the child during infancy and childhood. Even obesity in fathers can increase risk of obesity in the child through epigenetic factors. Ensuring good health during pregnancy and a safe delivery are both important for the child's health. The WHO guidelines include dietary advice to prospective parents before conception and during pregnancy, avoidance of smoking, alcohol and other toxins. Early detection of gestational diabetes and hypertension, monitoring and managing gestational weight gain are other important measures suggested. Ensuring that the baby is exclusively breast-fed during the first 6 months of life and that breast feeding is continued even after complementary feeding is started are important to prevent malnutrition and deposition of excess fat in the baby. The magnitude of the gap between policy and implementation can be gauged from the Indian NFHS 2015–2016 data which show that despite recommendations for exclusive breast feeding up to an age of 6 months, only 55% of Indian infants were actually exclusively breast-fed. Many children in this age group were given other foods like plain water (18%), other milk (11%) and complementary foods (10%). Breast feeding can be encouraged by educational programmes for pregnant women, legislation and regulations to provide feeding rooms and time for breast feeding in work places, and by giving new mothers maternity leave. Nations should implement the International Code of Marketing of Breast-milk Substitutes and other World Health Assembly resolutions to promote breast feeding. During infancy and childhood, parents and care-givers should be given guidance and support to encourage consumption of a variety of healthy foods, avoidance of sugarsweetened milks and juices and energy-dense nutrient-poor foods. Enforcing regulations on marketing of complementary foods and beverages and subsidising healthy foods are other measures [5, 12].

Further, there should be government regulations on the types of foods and beverages that can be served in school meals. Provision of safe potable drinking water in schools is another basic requirement. Teaching children and parents about healthy eating and having an active lifestyle should be an integral part of school curriculum at all stages. Cookery class in schools is another way of teaching both children and parents about healthy food options. Making time in school schedules for play-time, encouraging sports by providing space and facilities both at schools and in communities will enable children to be physically active. A mandatory physical education programme is another good option. The government's role also includes enforcing ban of sale of HFSS foods and sweetened drinks in schools and around school premises.

Regular health check-ups and growth monitoring should also be an integral part of school life. Children who are overweight or obese should have easy access to treatment including psychotherapy, medications for hypertension, diabetes and dyslipidaemia and even bariatric surgery in extreme cases. Treatment of children should include parents or care-givers. This will provide the much needed emotional and psychological support these children will require to lose weight and change their lifestyles. Multi-specialty teams are required for a successful child-health programme. Successful programmes to tackle childhood obesity usually involve parents, teachers, community members, non-governmental organisations and private players. Some of the more successful international programmes are listed below:

	- a.Project Healthy Schools: This is a project set up by University of Michigan in collaboration with middle schools, community organisations and donors. It aims to educate and encourage children to eat healthy and lead healthy lives. The programme comprises of 10 health education activity modules that focus on eating more fruits and vegetables, consuming less sweetened drinks and sugary foods, eating slowly and eating less fatty food, being more active every day and spending less time in front of the screen [106].
	- a.Pick a tick initiative: This was started in 1989 by the Australian National Heart Foundation. Healthy food packets could be distinguished from others by presence of a symbol along with the nutrition panel. Apart from helping people select healthy foods, the programme also championed vigorously against excessive salt intake [107].

**233**

*Obesity in School Children in India*

cence [108].

support [109].

3.Promoting a more active lifestyle:

4.Government policy initiatives

organisations.

*DOI: http://dx.doi.org/10.5772/intechopen.89602*

b.Ensemble-prévenons-l'obésité-des-enfants (EPODE): This literally translates as: 'Together Let's Prevent Childhood Obesity'. This was a community initiative in which intervention were done in 10 French towns in France for children aged 5–12 who were overweight or at risk of weight gain. The approach was 'positive, concrete and stepwise' learning process with no stigmatisation of any culture, food habits, overweight and obesity. It targeted sales of healthy foods in schools, advertisements with respect to food and drinks on TV, internet and schools, mandatory nutritional information on nutrition label, subsidy on healthy foods through agricultural reforms and training for health professionals so that they were able to recognise and diagnose obesity risks in infancy, childhood and adoles-

c.Healthy weight, Healthy lives: An initiative in England to tackle childhood obesity and hence later reduce obesity in adults. It was launched by the government in 2008. The various initiatives in this programme were promoting healthy growth and development of children, promoting healthier food choices, encouraging a more active lifestyle, incentivising good health and offering personalised help and

a.US White House Task Force on childhood obesity: This task force gave support to parents, adherence to limits on screen time and quality child care settings with nutritious food and ample opportunity for young children to be physically active. It also emphasised labels on food so that parents can make healthy food choices, improved school environment and lowered price of healthy foods. It improved access to safe parks, playgrounds and

b.Tri-Policy initiative: This was done in Canada by creating a supportive environment to increase physical activity in children, early action to detect risk of overweight and obesity and promote availability and accessibility of nutritious foods and decrease the marketing of foods and beverages

a.New South Wales initiative in Australia: It focused on restoring the energy balance for the population, with a specific focus on children, young people, and their families by reducing the factors that give rise to an 'obesogenic' environment. It emphasised coordination between governments initiatives to tackle obesity along with industry and non-profit

b.Regulations regarding food advertisements: Brazil prohibits advertisements which are intended to influence children or adolescents to consume HFSS foods. Ireland has strictly banned using celebrities, icons and personalities to promote food products which target children. Norway prevents food advertisements on channels for children under 18 and South TV permits advertising for specific food categories only before, during

and after programmes shown between 5 and 7 pm.

indoor and outdoor recreational facilities for children.

high in fat, sugar and/or sodium to children.

*Public Health in Developing Countries - Challenges and Opportunities*

healthy foods are other measures [5, 12].

around school premises.

screen [106].

2.Promoting better dietary choices:

exclusively breast-fed. Many children in this age group were given other foods like plain water (18%), other milk (11%) and complementary foods (10%). Breast feeding can be encouraged by educational programmes for pregnant women, legislation and regulations to provide feeding rooms and time for breast feeding in work places, and by giving new mothers maternity leave. Nations should implement the International Code of Marketing of Breast-milk Substitutes and other World Health Assembly resolutions to promote breast feeding. During infancy and childhood, parents and care-givers should be given guidance and support to encourage consumption of a variety of healthy foods, avoidance of sugarsweetened milks and juices and energy-dense nutrient-poor foods. Enforcing regulations on marketing of complementary foods and beverages and subsidising

Further, there should be government regulations on the types of foods and beverages that can be served in school meals. Provision of safe potable drinking water in schools is another basic requirement. Teaching children and parents about healthy eating and having an active lifestyle should be an integral part of school curriculum at all stages. Cookery class in schools is another way of teaching both children and parents about healthy food options. Making time in school schedules for play-time, encouraging sports by providing space and facilities both at schools and in communities will enable children to be physically active. A mandatory physical education programme is another good option. The government's role also includes enforcing ban of sale of HFSS foods and sweetened drinks in schools and

Regular health check-ups and growth monitoring should also be an integral part of school life. Children who are overweight or obese should have easy access to treatment including psychotherapy, medications for hypertension, diabetes and dyslipidaemia and even bariatric surgery in extreme cases. Treatment of children should include parents or care-givers. This will provide the much needed emotional and psychological support these children will require to lose weight and change their lifestyles. Multi-specialty teams are required for a successful child-health programme. Successful programmes to tackle childhood obesity usually involve parents, teachers, community members, non-governmental organisations and private players. Some of the more successful international programmes are listed

a.Project Healthy Schools: This is a project set up by University of Michigan in collaboration with middle schools, community organisations and donors. It aims to educate and encourage children to eat healthy and lead healthy lives. The programme comprises of 10 health education activity modules that focus on eating more fruits and vegetables, consuming less sweetened drinks and sugary foods, eating slowly and eating less fatty food, being more active every day and spending less time in front of the

a.Pick a tick initiative: This was started in 1989 by the Australian National Heart Foundation. Healthy food packets could be distinguished from others by presence of a symbol along with the nutrition panel. Apart from helping people select healthy foods, the programme also championed

1.Focus on school health education and changing lifestyle:

vigorously against excessive salt intake [107].

**232**

below:

	- a.US White House Task Force on childhood obesity: This task force gave support to parents, adherence to limits on screen time and quality child care settings with nutritious food and ample opportunity for young children to be physically active. It also emphasised labels on food so that parents can make healthy food choices, improved school environment and lowered price of healthy foods. It improved access to safe parks, playgrounds and indoor and outdoor recreational facilities for children.
	- b.Tri-Policy initiative: This was done in Canada by creating a supportive environment to increase physical activity in children, early action to detect risk of overweight and obesity and promote availability and accessibility of nutritious foods and decrease the marketing of foods and beverages high in fat, sugar and/or sodium to children.
	- a.New South Wales initiative in Australia: It focused on restoring the energy balance for the population, with a specific focus on children, young people, and their families by reducing the factors that give rise to an 'obesogenic' environment. It emphasised coordination between governments initiatives to tackle obesity along with industry and non-profit organisations.
	- b.Regulations regarding food advertisements: Brazil prohibits advertisements which are intended to influence children or adolescents to consume HFSS foods. Ireland has strictly banned using celebrities, icons and personalities to promote food products which target children. Norway prevents food advertisements on channels for children under 18 and South TV permits advertising for specific food categories only before, during and after programmes shown between 5 and 7 pm.

#### **6.1 Actions taken in India to reduce childhood obesity in school children**

Food Safety and Standards Authority of India (FSSAI) proposed a ban on sale of HFSS foods in school canteens in 2016. It also suggested categorisation of food items as 'green' or healthy foods constituting 80% of the food items, 'red' or common HFSS foods that should not be made available in schools; and 'yellow' category foods that should be eaten sparingly and could be made available in small portions and less frequently. In response to this, Maharashtra state government issued a notification instructing schools to stop serving HFSS food in their canteens. However, the same has not been implemented in other states. The Central Board of Secondary Education (CBSE) has also issued an advisory to all its affiliated schools to ensure that no HFSS food items are available in school canteens and within 20 m of their premises.

Ministry of Health and Family Welfare launched the School Health Programme in 2008 under the National Rural Health Mission (NRHM). The programme also aims to address physical and mental health needs of the children through nutritional interventions, yoga and counselling.

Food Safety and Standards Act, 2006 has provisions to prohibit advertisements that are misleading. These are monitored by the Advertisement Standards Council of India (ASCI). However, the advisories on misleading advertisements are not being strictly implemented. Kaushal et al. reported that the prevalence of misleading advertisements is about 60% [110]. A majority (90%) of these were for HFSS foods. The common methods of non-compliance included promotion of a food item with free gifts (57%), using celebrity endorsement on the food packaging (19%), making false claims (14%) and appealing with cartoons (10%). Apart from restrictions on food advertisements, we also need to strengthen nutrition labelling laws, and educate both parents and children about interpreting nutrient labelling. In India, food packages already have a labelling for vegetarian and non-vegetarian products. HFSS could also be labelled using colour codes as suggested above.

Family and parental guidance play an important role in preventing children from becoming obese. Family involvement can be pivotal in increasing physical activity, healthy eating patterns and decreasing sedentary time. Educating families and stakeholders about healthy eating pattern will help in cutting down on junk food in home and school, and increase healthy eating, thereby decreasing the risk of developing obesity.

Community level programs like CHETNA (Childrens' Health Education Through Nutrition and Health Awareness) and MARG (Medical education for children/adolescents for realistic prevention of obesity and diabetes and for healthy living) are a beginning. These programmes focus on building nutritional awareness and promoting increased physical activity, through pamphlets, lectures skits and group activities targeting both parents and children. They now cover 500,000 children in 15 towns/cities in North India [15]. Since children spend a significant amount of their day in schools, activities involving their peers in schools are smart ways of getting them interested. The government has recently introduced fitness test for all school children and compulsory physical activity during school hours. A 'Fit India' campaign has been announced by the primeminister and a number of sports and film celebrities are part of the campaign. But much more needs to be done.

### **7. Conclusion**

Obesity in Indian school children is a cause of concern. To tackle this menace, a sustained multi-pronged approach is required, where all stake holders join hands.

**235**

**Author details**

Vangal Krishnaswamy Sashindran1

provided the original work is properly cited.

*Obesity in School Children in India*

*DOI: http://dx.doi.org/10.5772/intechopen.89602*

programmes to target childhood nutrition and lifestyle.

The strategy starts at the pre-conception time, continues during pregnancy, infancy and childhood. Apart from promoting healthy eating and an active lifestyle, it also includes active case finding among overweight and obese children and aggressive management of diabetes, hypertension and dyslipidaemia apart from weight loss. Legislations targeting infant feeds, HFSS, artificially sweetened soft drinks, nutrient labelling and food advertisements are important. Government have to be serious about implementing these legislations and they should also formulate imaginative

\* and Puja Dudeja<sup>2</sup>

2 Colonel (Pensions), Office of Director General Armed Forces, New Delhi, India

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

1 Principal Medical Officer, HQ Central Air Command, Prayagraj, India

\*Address all correspondence to: vksashindran@gmail.com

### *Obesity in School Children in India DOI: http://dx.doi.org/10.5772/intechopen.89602*

*Public Health in Developing Countries - Challenges and Opportunities*

tional interventions, yoga and counselling.

**6.1 Actions taken in India to reduce childhood obesity in school children**

Food Safety and Standards Authority of India (FSSAI) proposed a ban on sale of HFSS foods in school canteens in 2016. It also suggested categorisation of food items as 'green' or healthy foods constituting 80% of the food items, 'red' or common HFSS foods that should not be made available in schools; and 'yellow' category foods that should be eaten sparingly and could be made available in small portions and less frequently. In response to this, Maharashtra state government issued a notification instructing schools to stop serving HFSS food in their canteens. However, the same has not been implemented in other states. The Central Board of Secondary Education (CBSE) has also issued an advisory to all its affiliated schools to ensure that no HFSS food items are available in school canteens and within 20 m of their premises.

Ministry of Health and Family Welfare launched the School Health Programme in 2008 under the National Rural Health Mission (NRHM). The programme also aims to address physical and mental health needs of the children through nutri-

Food Safety and Standards Act, 2006 has provisions to prohibit advertisements that are misleading. These are monitored by the Advertisement Standards Council of India (ASCI). However, the advisories on misleading advertisements are not being strictly implemented. Kaushal et al. reported that the prevalence of misleading advertisements is about 60% [110]. A majority (90%) of these were for HFSS foods. The common methods of non-compliance included promotion of a food item with free gifts (57%), using celebrity endorsement on the food packaging (19%), making false claims (14%) and appealing with cartoons (10%). Apart from restrictions on food advertisements, we also need to strengthen nutrition labelling laws, and educate both parents and children about interpreting nutrient labelling. In India, food packages already have a labelling for vegetarian and non-vegetarian products. HFSS could also be labelled using colour codes as suggested above. Family and parental guidance play an important role in preventing children from becoming obese. Family involvement can be pivotal in increasing physical activity, healthy eating patterns and decreasing sedentary time. Educating families and stakeholders about healthy eating pattern will help in cutting down on junk food in home and school, and increase healthy eating, thereby decreasing the risk of

Community level programs like CHETNA (Childrens' Health Education Through Nutrition and Health Awareness) and MARG (Medical education for children/adolescents for realistic prevention of obesity and diabetes and for healthy living) are a beginning. These programmes focus on building nutritional awareness and promoting increased physical activity, through pamphlets, lectures skits and group activities targeting both parents and children. They now cover 500,000 children in 15 towns/cities in North India [15]. Since children spend a significant amount of their day in schools, activities involving their peers in schools are smart ways of getting them interested. The government has recently introduced fitness test for all school children and compulsory physical activity during school hours. A 'Fit India' campaign has been announced by the primeminister and a number of sports and film celebrities are part of the campaign. But

Obesity in Indian school children is a cause of concern. To tackle this menace, a sustained multi-pronged approach is required, where all stake holders join hands.

**234**

developing obesity.

much more needs to be done.

**7. Conclusion**

The strategy starts at the pre-conception time, continues during pregnancy, infancy and childhood. Apart from promoting healthy eating and an active lifestyle, it also includes active case finding among overweight and obese children and aggressive management of diabetes, hypertension and dyslipidaemia apart from weight loss. Legislations targeting infant feeds, HFSS, artificially sweetened soft drinks, nutrient labelling and food advertisements are important. Government have to be serious about implementing these legislations and they should also formulate imaginative programmes to target childhood nutrition and lifestyle.
