Childhood obesity

Abstract

Almost a third of 2–15 year olds in the UK are classed as overweight or obese, with an estimated cost to the NHS of £4.2 billion a year. Although there has been a recent plateau in the rise of the prevalence of overweight and obese children, we cannot become complacent; it is estimated that by 2050, two-thirds of children will have an unhealthy weight. The causes of obesity are complex, and the majority of cases are linked to the obesogenic environment in which we now live. Most children who require help with weight management can be managed in primary care, with only a small number of children requiring referral to secondary care. This article will look at the UK and world trends in obesity and how we classify obesity. We will look at the challenges of treating childhood obesity and the best strategies in weight management to use in primary care.

The GP curriculum and childhood obesity

Clinical module 3.04: Care of children and young people lists the learning objectives required for a GP to manage childhood obesity. As a GP you should:

Recognise inappropriate eating habits such as morbid obesity and make appropriate referrals if specialist help is required

Have an awareness of disease prevention, well-being and safety in children and adolescents including healthy diet and exercise for children and young people

Promote physical health, mental health and emotional well-being by encouraging children, young people and their families to develop healthy lifestyles

Clinical module 3.17: Care of people with metabolic problems also lists the learning objectives required for a GP to manage a patient with obesity. As a GP you should:

Appreciate the health and medical consequences of obesity including malnutrition, increasing morbidity and reduced life expectancy, and have an understanding of the social, psychological and environmental factors underpinning obesity.

Global picture

The World Health Organization (WHO) regards childhood obesity as one of the main global public health challenges for the 21st century (WHO, 2015). Globally, in 2013, an estimated 42 000 000 children under the age of five were classed as overweight or obese. The worldwide prevalence is increasing rapidly and worldwide obesity has more than doubled since 1980 (WHO, 2015). Developing countries, which in the past had lower levels of obesity, are now catching up with developed nations, and the rate of their increase is much higher. In developing countries, there is now a double dilemma of children experiencing poor nutrition coupled with obesity, secondary to diets rich in low-cost energy-dense foods.

Trend in the UK

Numerous studies have shown an increase in the prevalence of obesity in British children. What has also been highlighted in these studies is the difference in prevalence between higher and lower socioeconomic classes. The Index of Multiple Deprivation (IMD) ranks every area of England from the most to least deprived. The list of rankings is divided into 10 groups to give deciles. The National Child Measurement Programme (NCMP) in 2014–15 found that when comparing obesity prevalence to the IMD deciles, the rates were 25% in the most deprived versus 11.5% in the least deprived (National Obesity Observatory, 2015). Differences are also seen between urban and rural areas. The greater the level of urbanisation, the greater is the odds of a child being classified as obese (Townsend & Riddler, 2009). The reason for this difference is likely to be multifactorial.

Childhood obesity has been rising in prevalence for a number of years (Fig. 1). The Foresight Report (Government Office for Science, 2007) predicted that by 2050, two-thirds of children will be overweight or obese, and this will cost the NHS £50 billion per year to treat the resultant complications.

Figure 1.

Prevalence of overweight and obese children between 1974 and 2003.

It is likely that the rise in obesity prevalence is multifactorial and is due to environmental and behavioural changes relating to diet and inactivity. Over the last 20 years, there has been a change in diet with a rise in consumption of processed foods and sugary drinks and an increase in portion size. Compared with previous generations, children in the UK now partake in less physical activity and have a more sedentary lifestyle. There is less general activity, such as walking to school and playing outdoor games, and children are spending more time indoors playing computer games. This change is partly fuelled by parents fearing that the outside world is now unsafe (Scottish Intercollegiate Guidelines Network (SIGN), 2010).

Definition of overweight and obese

There is no single agreed definition of ‘overweight’ and ‘obesity’ in children. This is primarily because there is no clear link between the degree of obesity and morbidity or mortality in childhood. In the UK, the thresholds are divided into two categories, based on whether the information is to be used for population statistics or to be used to define a clinical diagnosis. Overweight is defined as a body mass index (BMI) above the 85th centile for population studies and above the 91st for a clinical diagnosis. Obesity is defined as a BMI above the 95th centile for population studies and above the 98th centile for clinical diagnosis (National Obesity Observatory, 2011a).

Internationally, different thresholds are used. The International Obesity Task Force use an extrapolation of adult BMI definitions for overweight and obesity: greater than 25 kg/m² is overweight, greater than 30 kg/m² is obese and greater than 35 k g/m² is morbid obesity (National Obesity Observatory, 2011a).

How do we use growth charts?

In April 2006, the WHO published a new growth standard for children aged less than 5 years. This was produced from data collected in six countries: United States, Norway, Oman, Brazil, India and Ghana. The children used to compile these results were term infants from non-smoking, relatively affluent mothers, who had a healthy pregnancy. All the children had been breast-fed exclusively or predominantly for the first 6 months of life. After the publication of these growth standards, the Department of Health commissioned the Royal College of Paediatrics and Child Health (RCPCH) to design new growth charts (the UK-WHO chart), which amalgamated the data from the WHO study as well as information from the previous British Population Study (the UK 1990 chart) (Wright et al., 2010). These charts are now in use for all children aged 0–18 years.

Current growth charts do not allow for ethnic differences. The National Obesity Observatory published a report in 2011 looking at the differences in obesity in different ethnic groups. The prevalence of obesity is lower in children of white British parentage compared with children of Black African or Bangladeshi parentage (Boys: 18.9% versus 26% versus 29.1%, respectively). Studies have found that with the same BMI, Africans carry less fat, leading to overestimation of obesity, whereas South East Asians carry more fat, causing an underestimation of obesity (National Obesity Observatory, 2011b).

BMI: What is it?

BMI is accepted as the most practical and inexpensive way of assessing weight and can be used to compare populations. It is calculated by the following equation:

\frac{Weight (kg)}{Height (m^{2})}

In children, caution has to be in place when interpreting the result. In adults, the BMI is constant regardless of age, but in children the BMI varies with age, and growth patterns differ for boys and girls. A more meaningful approach is to use thresholds for BMI, which take into account the age and sex of the child. These thresholds are derived from reference populations and the data is frequently defined as a centile or specific z-score. Many countries have their own population-specific thresholds and in the UK we currently use the WHO-UK centile chart.

The WHO-UK growth charts, which are available from the Royal College of Paediatrics and Child Health (RCPCH) website (www.rcpch.ac.uk), now include a BMI centile chart. This provides centiles that are spaced at two-thirds standard deviation intervals from the mean (0.4th, 2nd, 9th, 25th, 50th, 75th, 91st, 98th and 99.6th centiles). A BMI above the 91st and 98th centile are classed as overweight and obese, respectively. The new charts also have a ‘look up’ tool that was designed to encourage calculation of the BMI centile. It enables the user to calculate the BMI centile using the height and weight centiles. The chart recommends that a BMI centile should be calculated if the weight is above the 75th centile or if the weight and height centiles differ.

How do we monitor obesity in the UK?

The Health Survey for England (HSE) is part of a programme undertaken by the Health and Social Care Information Centre. It was commenced in 1994 and was designed to monitor trends in the nation’s health. In 1995, children aged 2–15 years were included in the survey and under-2 year olds were added from 2002. Randomly selected addresses are chosen and in a household of more than two children, the data collected is restricted to the first two children. In 2013, 2185 children were interviewed (or parents interviewed about their child) and of these children, 1455 had a nurse visit. The results of the survey for 2013 are shown in Table 1.

Table 1.

Results of the HSE (2013).

	Overweight or obese (BMI greater than 85th centile) (%)	Obese (BMI greater than 95th centile) (%)
Boy	30	16
Girl	29	15

Source: Health & Social Care Information Centre (2014).

Since 2006, the NCMP has been collecting data from primary school children attending mainstream school in England. It measures the height and weight of around 1 000 000 school children in England every year at the points of reception class and year 6. The programme is not compulsory, but parents need to opt out if they do not want to take part. Parents are informed of their child’s results and the possible implication on their health. The results from 2013–14 are shown in Table 2.

Table 2.

Results of the NCMP 2013–14 survey.

	Overweight or obese (BMI greater than 85th centile) (%)	Obese (BMI greater than 95th centile) (%)
Reception class	22.5	9.5
Year 6	33.5	19.1

Source: National Obesity Observatory (2015).

Both the HSE and the NCMP provide important information about childhood obesity, but the HSE is limited by the small data set collected each year, whereas the NCMP includes only data from children in two school years. This information is used to plan local services, as well as raising the awareness of obesity for parents and professionals.

Health consequences of obesity

There has been a four-fold increase in children admitted to hospital with obesity or obesity-related conditions. These include Type-2 diabetes, asthma and sleep apnoea. Obese children are more likely to become obese adults. Once established, obesity can be difficult to treat and there are immediate as well as long-term complications (SIGN, 2010).

Diabetes

The incidence of Type-2 diabetes in children is increasing in the UK and some children are being diagnosed as young as 7 years old. A surveillance programme published in 2007 (Haines, Chong Wan, Lynn, Barrett, & Shield, 2007) found that in under-17-year olds, 95% of those with Type-2 diabetes were classed as overweight and 83% were classed as obese. There is also an increased risk of diabetes in minority groups, in particular Black and South Asian populations, with an increase in incidence of 3.9 and 1.25 per 100 000, respectively, in comparison with 0.35 per 100 000 in those defined as Caucasian.

Obesity is strongly associated with insulin resistance. This coupled with the transient decrease in insulin sensitivity seen during puberty (due to increased growth hormone secretion) makes adolescence a particular risky time to develop Type-2 diabetes (D’Adamo & Caprio, 2011). Poor glycaemic control can be seen in adolescence, due to difficulties with social acceptance and stigmatisation. With the onset of early diabetes and the difficulties with poor glycaemic control, earlier onset of complications, including progressive neuropathy, retinopathy, nephropathy and atherosclerotic cardiovascular disease are seen.

Asthma

In a recent meta-analysis, it was found that children classed as overweight or obese have a 40–50% increased risk of developing asthma (Egan, Ettinger, & Bracken, 2013). Some parents falsely believe that their child with asthma should not exercise for fear of exacerbating their asthma. This causes an increase in weight, leading to the child having the spiraling effect of not exercising and further increasing their weight gain. Although the anxiety of parents and children with asthma should be acknowledged, there is no need to avoid exercise if there is a clear management plan in place.

Musculoskeletal

Being overweight or obese puts a strain on the musculoskeletal system. Compared with healthy weight children, obese children have more pain in their lower limbs and also have more functional changes in their lower limbs (Public Health England, 2016).These changes in function and the perception of pain discourages children from exercising, further fuelling an increase in the child’s weight.

Psychological

Obese children are more likely to experience psychological or psychiatric problems than non-obese children, with low self-esteem and behavioural problems being particularly common (SIGN, 2010). This is important to bear in mind when talking to children about their weight, which should be undertaken in a sensitive way.

Obstructive sleep apnoea

Obesity increases the risk of obstructive sleep apnoea (OSA) by approximately 5-fold (Obesity Services for Children and Adolescents (OSCA) Network Group, 2009). Symptoms include significant snoring, paradoxical chest movements and frequent awakenings, which lead to daytime sleepiness, cognitive and behavioural problems. Sleep can be assessed using the Chevin Paediatric Sleep Questionnaire, and a score of eight or more positive answers indicates a high risk for sleep abnormality. Diagnosis is confirmed with polysomnography.

Cardiovascular disease

A number of studies have consistently shown associations between obesity and major cardiovascular risk factors. The Avon Longitudinal Study (Lawlor et al., 2010) of 5235 children found that with an increase in one standard deviation of BMI above the mean at age 9–12 years, there was an increase in the odds for developing cardiovascular risk factors aged 15–16 years (Table 3). The odds ratio quantifies how strong the presence of obesity is associated with cardiovascular risk factors. An odds ratio greater than one increase the odds of an association. Children who are obese or overweight have a risk of developing multiple cardiovascular risk factors, which has a significant implication on future health as the child enters adulthood.

Table 3.

Odds ratio of cardiovascular risk factors derived from data from the Avon Longitudinal Study.

Risk factor	Odds ratio for girls	Odds ratio for boys
Systolic blood pressure greater than 130 mmHg	1.23	1.24
Raised low-density lipoprotein cholesterol	1.19	1.30
Raised triglycerides	1.43	1.96
Raised insulin levels	1.45	1.84

Source: Lawlor et al. (2010).

Challenges in childhood obesity management

Childhood obesity differs from obesity in adults. Children still have a period of growth and on average, during puberty, children will double their weight and increase their height by 20% (SIGN, 2010). This is important, as any intervention needs to take into account the need for adequate nutrition for healthy growth and development while trying to manage weight. Depending on the age and physiological maturity of the child, the treatment goals may differ. In children who are pre-pubertal, the goal is weight maintenance or a decrease in the rate of weight gain while the child grows in height. In more seriously obese children and those who have stopped or almost stopped growing, the goal is to lose weight.

Another challenge encountered in weight management is that it involves working with the whole family, some of whom do not perceive their child’s weight as being a problem. A study performed in Wisconsin (Wald et al., 2007) looked at parents’ perceptions of their child’s weight and found that only 49% of parents recognised their overweight children as being overweight. Other surveys, including the HSE, have had similar results. If we think about the model of change, these families are on the pre-contemplation phase of change and they first need to realise the problem before change can be made. Health professionals can find this conversation hard to start, for fear of upsetting the family. Without the whole family recognising the problem, changes within the household are difficult to make and maintain.

Treatment of obesity

The first hurdle in treatment is recognising the child’s weight problem – this includes health professionals, as well as the family. There is no systematic weight assessment in general practice, so opportunistic encounters with children, when they are brought for other conditions, need to be utilised. There are many missed opportunities to review childrens’ weight and this has been recognised by the Measuring Up report (Academy of Medical Royal Colleges, 2013), which aims to increase training to make every contact count. Once a child’s weight problem has been recognised, families need to be introduced to the idea that changes need to be made, and ideally changes to the whole family. One way to tackle this is to slowly introduce the idea to the family. In the first consultation, the idea of the child’s health can be explored and the family can be given written information about good health. In a follow-up clinic, when the family may have moved on to the next stage of change, you can discuss their readiness to change.

The important aspects of treatment are to provide a healthy diet and promote exercise. A 2011 joint report (Chief Medical Officers, 2011) by the four nations’ Chief Medical Officers made a recommendation that all over-5 years in age should be doing 60 minutes of moderate-intensity activity a day and those under-5 years should do at least 180 minutes physical activity spread throughout the day. Only 2.5% of 11 year olds do the recommended 60 minutes of exercise a day. This is higher in younger children, with up to 51% of 4–10 year olds regularly exercising (NICE, 2009). It is recommended that sedentary behaviour should be reduced to no more than 2 hours a day or 14 hours over the week. It can be a daunting task to think about exercise, but the emphasis should be for families to do fun activities together and to increase daily activities.

There is no evidence to support the use of a diet that uses any particular dietary or macronutrient manipulation e.g. low carbohydrate or high protein. The mainstay of treatment is to eat a healthy nutrient-balanced diet that is lower in calories. This may require the help of a dietician to ensure that growth and development are not compromised. For many children the aim is weight stabilisation, but for some weight loss is required. The aim is to lose no more than 0.5–1 kg per month (SIGN, 2010).

Parents need to be taught about the importance of their lifestyle and parenting style on their child’s weight. Parents should be supported and encouraged to be a role model for their child.

In some areas of the UK, there are local weight management programmes aimed at children. A referral to these programmes is beneficial to children and families, as it provides the support needed to make consistent changes. In areas where these programmes are not available, a regular appointment with a member of the primary care team would be beneficial to provide encouragement and advice. Box 1 is a summary of the guideline from SIGN for parents to help with weight management.

The wider community can also play a vital role in weight management. Health visitors can support families with young children, and school nurses and teachers can actively encourage good lifestyle choices by school-aged children. In children where weight gain or eating may be linked to emotional or psychological difficulties, counsellors and psychologists can provide a way for the child to deal with the cause of their weight difficulties.

Is there a safeguarding issue?

Childhood obesity alone is not a safeguarding concern, but the consistent failure of a family to change lifestyle and engage with outside support indicates possible neglect. Viner, Roche, Macguire, and Nicholls (2010) suggested that this is of particular concern when the child is at imminent risk of OSA, hypertension and Type-2 diabetes. When child protection concerns are raised, there is likely to be a concern about welfare, so it is essential that all aspects of the child’s well-being are reviewed.

When to consider referral to secondary care

Obesity is now endemic, and it is not sustainable for it to be managed in secondary care. However, there are children that need the specialist management provided by a secondary care team. The OSCA network group (OSCA, 2009) has produced a consensus statement on recommendations for choosing those children that need to be referred from primary to secondary care (see Box 2). Table 4 outlines the risk factors for childhood obesity that if present should prompt that referral to secondary care.

Table 4.

Risk factors for obesity that require referral of the child to secondary care.

Risk factor	Detail
Possible underlying pathology
1. Relative short stature	Obese children are generally tall for their genetic potential
2. Dysmorphic signs and/or significant learning difficulties	For example, Prader–Willi syndrome, Down’s syndrome, Bardet–Biedl syndrome
Risk for co-morbidity	Any of the following: • Hypertension: Systolic or diastolic blood pressure greater than 98th centile for age using an appropriate sized cuff • OSA • Significant mobility or joint problems • Abnormal glucose or insulin metabolism • Acanthosis nigricans • Dyslipidameia • Alanine transaminase greater than 70 mmol is suggestive of non-alcoholic fatty liver disease • Features suggestive of polycystic ovarian syndrome
Evidence of psychological co-morbidity associated with obesity	• Significant family/individual distress related to obesity • Concerns about eating disorders • Safeguarding concerns
Family history of type-2 diabetes or premature cardiovascular disease in first- or second-degree relatives	• Early strong family history of cardiovascular disease before age of 60 years • Onset diabetes at less than 40 years of age

Adapted from OSCA consensus statement on the assessment of obesehildren and adolescents for paediatricians, with permission from Professor Russell Viner on behalf of the Obesity Services for Children and Adolescents (OSCA) Network Group.

Box 1.

SIGN advice regarding healthy lifestyle choices.

• Children should be encouraged to do at least 60 minutes of vigorous activity per day. For a child unused to exercise this should be built up gradually and can be done in short bursts

• Sedentary behaviour should be limited to a maximum of 2 hours a day

• Daily activities should be increased e.g. walking and cycling

• The choice of activity should be given to the child, as a more enjoyable sporty activity is more likely to be adhered to

• Increase activity as a family, such as going to the park

• Try to eat meals as a family and as a sociable activity without distractions

• Separate eating from other activities such as watching television

• Encourage children to listen to internal hunger cues and only eat when hungry

• Comfort children with attention, not food. Praise achievements with non-food items

• Avoid classifying food as good or bad and encourage a healthy diet (using the ‘Eat Well’ plate model)

• Keep foods that children should avoid out of the house

• Make the changes as a family and see them as a lifestyle change rather than a short-term fix

Source: SIGN (2010).

Box 2.

Criteria for the referral of obese children to secondary care.

1. Child with BMI greater than 98th centile who fulfil the following criteria:

• The child or family are seeking treatment

• The child has one or more risk factor(s) for possible underlying pathology or future morbidity as outlined in Table 4

2. Any child with extreme obesity (BMI greater than 3.5 standard deviations)

Source: OSCA Network Group (2009).

Secondary care management

Although medical and surgical treatment is not initiated in the primary care setting, it is useful to know the trends of management in secondary care. There is no anti-obesity medication licensed in the UK for children. A Cochrane report (Luttikhuis et al., 2009) concluded there is a small body of evidence that in adolescence (those aged over 12 years), orlistat used in combination with behavioural and lifestyle changes can have an effect on the BMI when compared with lifestyle modification alone. A SIGN guideline (SIGN, 2010) recommends that orlistat should only be considered in adolescents with a BMI above the 99.6th centile and with co-morbidities. Orlistat should only be used in specialist clinics where the effect and side effects can be monitored.

SIGN (2010) concludes in its guideline that there has been no random controlled trial of the effectiveness of bariatric surgery and a systematic review of 20 case studies has suggested that surgery should only be considered for post-pubertal adolescents with very severe to extreme obesity (BMI greater than 3.5 standard deviations) and severe co-morbidities. Surgery should only be carried out in a specialist centre.

Key points

Almost one-in-three children in the UK are overweight or obese and this number is expected to rise to two-in-three by 2050

BMI centiles are used to categorise weight, with overweight classed as a BMI centile greater than the 91st centile and obese classed as a BMI above the 98th centile

Being overweight or obese increases the risk of Type-2 diabetes, asthma, cardiovascular disease and OSA, as well as increasing immediate psychological disorders

The mainstay of treatment is promotion of a healthy diet, an increase in physical activity and a consequent decrease in sedentary lifestyle

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