Examining the impact of cuts to local government spending on Sure Start Children’s Centres on childhood obesity: a commentary

Abstract

The adverse effects of childhood obesity are considerable, both during childhood and in the longer term. Children with obesity have a higher risk of psychological morbidity, and are more likely to be obese and have cardiovascular risk factors as adults. The importance of childhood conditions more generally (and social and geographical inequalities in these conditions) for population health is increasingly recognised and prioritised among both academic and policyoriented audiences. 3 The Sure Start Children’s Centres in England are a good example of initiatives that were designed to deal with this, with prevention of obesity and reduction of health inequalities being among the aims of the centres. 5 However, spending cuts may have threatened the capacity of the centres to achieve these aims, in the same way that spending cuts in other domains have had detrimental effects on health inequalities. 7 Mason et al have provided an excellent and meticulously presented analysis of the impact of cuts to local government spending on Sure Start Children’s Centres on childhood obesity in England. Using a longitudinal ecological approach, they found that cuts to Sure Start spending after 2010 were related to an increased prevalence of obesity in children at school reception, and that the spending cuts may have therefore contributed to obesity for thousands of children. In this commentary, I reflect on the findings and the approach of the paper, focusing on three main topics: (1) estimates of the number of children affected by the cuts, and implications of this for reinvesting in Sure Start; (2) involvement of target/reference groups; and (3) the implications of this study in light of the COVID-19 pandemic. To assess the impact of the spending cuts on obesity in children, and the implications of this for reinvesting in Sure Start, it is important to carefully consider the estimates of the number of children affected by the cuts. The authors estimated that each 10% cut in spending was associated with a 0.34% relative increase in the prevalence of obesity in the following year, and that an additional 4575 children were obese after the spending cuts. This corresponds to a relative increase of about 1.5–2% in obesity over the study period. This relative increase may appear to be modest, but in absolute terms the number of children affected is considerable, and given the longerterm impact of obesity the consequences are potentially life changing. In this light, it is also important that the authors no longer find significant effects of the spending cuts if they use a 2 year lag, rather than the 1 year lag in their main analyses. To fully assess the longerterm impacts of the spending cuts, as the authors acknowledge it will be important for future research to examine many longer time lags. This will also help to assess the balance between reinvestment in the Sure Start centres and the longerterm impact on the children who were affected by the spending cuts, bearing in mind that the consequences of increases in childhood obesity will also be felt by healthcare systems and society as a whole. Although not directly part of the study as such, it is also worth highlighting the role of the target/reference groups of the Sure Start centres in informing the focus of the paper. Under ‘Patient and public involvement’, the authors note that their study was informed by discussions with children and young people’s reference groups, which encouraged them to perform the analysis presented in the paper. This resonates with new programmes and initiatives that increasingly recognise the importance of involving people who are directly affected by health inequalities (eg, people living in deprived areas) in research that aims to examine and deal with these inequalities. For example, a new major funding programme by the main Dutch science funder that focuses on reducing socioeconomic inequalities in health has direct involvement of the target/reference group in the development of the research project as one of its key requirements. For these new initiatives, it would be valuable to gain further insight into how exactly studies such as that of Mason et al approach the discussions with reference groups to inform their analyses. Finally, what are the implications of the findings of this study in light of the COVID-19 pandemic? Several studies have already shown that the COVID-19 pandemic has further decreased physical activity and increased unhealthy food intake and sedentary behaviour among children with obesity. 11 Moreover, this pandemic will further increase social and geographical inequalities in the social determinants of health, and is therefore also likely to exacerbate obesity levels, especially among children living in the most deprived areas. In considering reinvestment in Sure Start, it will therefore be crucial to see the services provided here not just as components of multifaceted approaches to reduce childhood obesity, but as part of an urgent comprehensive response to an unprecedented syndemic.