1. Health Diplomacy: Science, diplomacy, human values and childhood obesity Sir Peter Gluckman FRS Chief Science Advisor AAAS San Jose 2015 OFFICE OF THE PRIME MINISTER’S CHIEF SCIENCE ADVISOR NEW ZEALAND

2. OFFICE OF THE PRIME MINISTER’S CHIEF SCIENCE ADVISOR NEW ZEALAND Overweight & obesity in children <20 yrs, 2013: Developed countries Data from Ng et al. (2014) Lancet 384: 766

3. OFFICE OF THE PRIME MINISTER’S CHIEF SCIENCE ADVISOR NEW ZEALAND Data from Ng et al. (2014) Lancet 384: 766 Overweight & obesity in children <20 yrs, 2013: Developing countries

4. OFFICE OF THE PRIME MINISTER’S CHIEF SCIENCE ADVISOR NEW ZEALAND Trends in overweight in children Data from WHO Global Status Report on Noncommunicable Diseases 2010 Low-income High-income Upper-middle income Lower-middle income

5. OFFICE OF THE PRIME MINISTER’S CHIEF SCIENCE ADVISOR NEW ZEALAND The epidemiological problem The rates of childhood overweight and obesity in many developed countries now exceed 40% of all children and have risen dramatically over the past two decades In some developing countries similar rates have been observed Many children who are not yet obese are on the pathway to obesity The rates of rise in childhood obesity in lower-middle income countries are rising faster than in developed countries Childhood obesity can co-exist with under-nutrition (eg stunting)

6. OFFICE OF THE PRIME MINISTER’S CHIEF SCIENCE ADVISOR NEW ZEALAND The health and economic problem Childhood obesity is the fore-runner of adult obesity and its co-morbidities (heart disease, hypertension, diabetes) Childhood obesity is associated with childhood morbidities including stigmatization, behavioral and learning disorders, asthma, musculoskeletal disorders and early onset metabolic disease There are powerful intergenerational influences such that maternal obesity/diabetes begets offspring obesity

7. OFFICE OF THE PRIME MINISTER’S CHIEF SCIENCE ADVISOR NEW ZEALAND The biological problem Childhood obesity is the product of biological determinants extending from before conception (in both parents) through pregnancy and infancy, interacting with behavioral and contextual factors operating in childhood Prenatal and early infant experience induce epigenetic and other biological processes that sensitize the offspring to the postnatal obesogenic environment Effective intervention to prevent childhood obesity requires consideration of the life course dimension as well as the obesogenic environment

8. OFFICE OF THE PRIME MINISTER’S CHIEF SCIENCE ADVISOR NEW ZEALAND Multifactor solutions Life course focused – Preconception nutrition – Pregnancy weight gain, health, management of gestational diabetes – Breast feeding, appropriate weaning foods – Sleep and exercise behavior in infancy and childhood – Societal attitudes to infant weight gain/body image – Healthy school environment, nutritional literacy Obesogenic environment focused – Role of Industry (voluntary, regulated) – Role of Government (regulation, fiscal controls, labeling of food, social marketing etc)

9. OFFICE OF THE PRIME MINISTER’S CHIEF SCIENCE ADVISOR NEW ZEALAND The policy problem Adult obesity has dominated in considerations of non- communicable disease and the policy dialogues have been dominated by a focus on lifestyle (diet and exercise) – and this has led many governments to see this solely as a matter of individual responsibility But childhood obesity cannot be seen as matter of individual responsibility. The child on a pathway to obesity is a product of its developmental history and an environment not of its making. This has critical implications for the policy response and is yet to be fully appreciated

10. OFFICE OF THE PRIME MINISTER’S CHIEF SCIENCE ADVISOR NEW ZEALAND The policy response The adult obesity community largely ignored childhood obesity until very recently The science of the life course approach first emerged in the 1980s but was first incorporated into any international policy statement in 2011 (UNGA Political Declaration) In 2014 the Director-General of the WHO established a Commission on Ending Childhood Obesity −First consultative report will be released in March A few countries are starting to develop national strategies

11. OFFICE OF THE PRIME MINISTER’S CHIEF SCIENCE ADVISOR NEW ZEALAND The policy challenge The solutions extend well beyond the health sector even within government – Education – Sports and recreation – Women’s and Children’s rights – Consumer affairs, agriculture and food – Transport and urban design – Trade The solutions involve multiple other stakeholders – Civil society – The private sector Food production, food processing, food marketing, retail, pricing Beverage and fast food sectors Sports sector

12. OFFICE OF THE PRIME MINISTER’S CHIEF SCIENCE ADVISOR NEW ZEALAND The barriers and tensions Solutions will vary according to national context Solutions cannot be left to individual responsibility Many governments fear the “nanny state” label But folk biology still assumes it is all about individual responsibility It has been positioned as removing attention from adult NCDs

13. OFFICE OF THE PRIME MINISTER’S CHIEF SCIENCE ADVISOR NEW ZEALAND The barriers and tensions (cont.) Solutions need the engagement of the private sector −Product development, knowledge of infant and child nutrition, child eating behaviors, effective marketing to mothers and children BUT: −Entrenched positions can limit effective dialogue. Dialogue is needed while protecting the distinct interests of the community and government and avoiding the private sector entering the policy space −Solutions will require a mix of changed behaviors, incentives and regulation (what is the role of marketing restrictions, fiscal measures?)

14. OFFICE OF THE PRIME MINISTER’S CHIEF SCIENCE ADVISOR NEW ZEALAND The “diplomatic” challenge The slate of stakeholders includes everything from multi- national corporations to children in low socio-economic circumstances and across nations of very different development status The matter is then intensified by issues such as food security, trade policy and the role of the private sector Science has shifted the focus of effort but resolving these issues is compounded by issues that extend well beyond health to political, economic, social and ideological considerations, and advocacy often becomes conflated with the evidential base A broad multi-stakeholder and multi-disciplinary approach is needed if effective solutions are to be reached