There has been increasing public concern and awareness regarding adult obesity levels for some time, yet it is only relatively recently that the issue of childhood obesity has hit the mainstream headlines. With the number of overweight children having skyrocketed over recent decades, this issue is of medical concern and a political hot potato. Official figures quote a third of 2-15 year-olds being overweight or obese, with an increased prevalence in those from deprived backgrounds. Clearly, the causes of obesity are multiple and no single factor is solely to blame. The problem has crept up on the nation and requires a collaboration of government, industry, schools, medics and individuals to solve it.
GPs’ involvement in tackling the issue of childhood obesity is complex and controversial, and our responsibilities are often unclear. Many of us feel ill-equipped and lack the tools and resources to adequately support and encourage sustained weight management. However, as GPs, we undoubtedly have a unique opportunity to influence and support patients, particularly highlighting the links between obesity and health. The association between obesity and type 2 diabetes, heart disease and some cancers are often poorly understood by patients, and sadly these risks start to stack up in childhood. Perhaps, unsurprisingly, as children age, there is an increased chance their weight problems will persist into adulthood. Tackling weight-related problems early can help stop the progression to adult obesity and its associated co-morbidities.
Raising the issue of weight can be challenging, since obesity is not solely a medical issue. It has a raft of other emotional, social and psychological associations, and there can be a fear of offending patients. Obese children often have obese parents, and as a consequence norms become blurred. A child has a 20-40% chance of being obese if one parent is obese, and an 80% risk if both parents are.3 Raising the issue needs an assessment of parental and child awareness of the issue, while it will also require a degree of professional interpretation to
understand their willingness to change. The National Child Measurement Programme (NCMP) is a nationally mandated public health programme and was introduced by the government in 2006 in an effort to tackle the childhood obesity crisis. The Body Mass Index (BMI) of all children in reception class (aged 4 to 5 years) and year 6 (aged 10 to 11 years) is measured to assess overweight and obesity levels in children within primary schools. Information regarding each child is issued to parents and is sometimes a trigger to patients presenting to general practice. However, in many instances it is up to the GP to bring the topic to the fore.
Appearing judgmental or pejorative is often a worry when raising this issue, and a sensitive discussion is essential to aid parental cooperation. Open questions such as ‘How do you feel about you child’s weight?’ or ‘I see more children nowadays who are overweight. Could we check your child’s weight?’ may be helpful opening gambits. Adult BMI charts are not appropriate for children and paediatric charts should be used (http://www.rcpch.ac.uk/system/files/protected/page/GIRLS%20and%20BOYS%20BMI%20CHART.
pdf). A healthy BMI is typically between 25th and 75th centiles, with the 91st and 98th centile widely used as definitions for overweight and obese. As with all such tools, BMI can be a blunt instrument and a diagnosis of obesity should not be made on BMI alone. Sometimes plotting the child’s weight in front of the parents can be a useful tool in objectively demonstrating the problem.5 Unlike adults, the aim for most children is to maintain weight while they continue to grow in height, thus lowering their BMI. But, children with a BMI over the 98th centile with complications of obesity should aim for slow controlled gradual weight loss,5 and this is best done in a specialist setting. Obesity-related complications in children are similar to those in adulthood; type 2 diabetes, hypertension, hypercholesterolemia and sleep apnoea to name a few. Obese children are also at risk of premature puberty and menarche, and a host of psychological difficulties, including anxiety and depression.
Although rare, there are some medical causes of childhood obesity. Endocrine conditions such as hypothyroidism or Cushing’s syndrome are typically associated with faltering height, and chromosomal disorders such as Prader-Willi syndrome often have distinctive facial features.8 Clinical examination should also include assessment for obesity-related comorbidities such as hypertension, polycystic ovarian syndrome, dyslipidemia, joint pains, depression and type 2 diabetes. Secondary care referral would be indicated if any abnormalities were detected.
Once a diagnosis of obesity or overweight has been established, it is important to gauge how willing the child and the family is to make lifestyle changes. How involved the child is in such discussions depends very much on their age and maturity. It is generally accepted that unless there are significant associated co‑morbidities, interventions are not recommended unless all parties are in agreement. Offering initial advice regarding the links between health and weight with a suggested follow up in 6-12 months is often appropriate in such circumstances. In families who are keen to engage, it is important to encourage healthy lifestyle changes in the whole family rather than focusing on the child. It is important that parents act as role models for their children and take responsibility for what the whole family is eating. Statements such as ‘eat less and do more exercise’ are usually too broad and a specific tailored problem solving approach is usually required. Despite having been advocated by NICE, accessing local weight management pathways is extremely difficult. Despite this lack of widespread provision, there is simple information and support you can offer families.
Plenty of advice about ‘healthy’ diets exists, but more often than not it causes confusion and anxiety. Giving clear simple guidance to families is recommended, and calorie counting for the vast majority of children is inappropriate. Eating at the table and as a family, with parents leading by example, is crucial to help equip children with lifelong healthy eating skills.
Specific advice can include:
- Reinforcing the 5-day concept
- Encouraging children’s meals to include starchy foods
- Limiting sugary drinks and saving high calorie foods for treats.
Family-based psychological interventions that help break entrenched negative behaviour are hugely beneficial, yet not readily available in most areas. If psychological or parenting support is not accessible, simple techniques can be used to try to encourage lifestyle changes. Examples of this include exploring particular triggers for poor food choices, e.g. don’t keep crisps/fizzy drinks in the house if they are a favourite of the child, and negotiating ways to tackle negative behaviour, e.g. change route to school to avoid sweet shop or bulk cook and freeze food to avoid relying on fast food on busy days. Increasing physical activity is an important aspect of weight control. In general, children do not respond well to structured exercise programmes, so a more creative and individual approach should be sought.
Discussion points could include:
- What are their interests?
- Which family activities would appeal?
- Is there a safe place to play and run around in locally?
Many children associate exercise with ‘sports’, which may not appeal to all. Dancing, martial arts, roller blading, walking and so forth would all be suitable alternative activities. The child should aim to be moderately active for 60 minutes per day, and this can be broken down into shorter more manageable time slots if required.
The links between obesity and screen time are now widely accepted. Evidence supports the argument that both excess screen time (encompassing television, computers and games consoles) and having a bedroom TV increase the risk of obesity in children and adolescents, and these patterns of behavior extend into adulthood. Recommending no more than 4 hours of screen time per day may be a suitable starting point, since obesity rates double with screen time greater than this.
Follow up of these families every 3 to 6 months is important, and can be aided by the multidisciplinary team. Practice nurses, midwives and health visitors are vital in encouraging and reinforcing positive behaviour and can be helpful in supporting long-term management of patients.
Obviously, the answer to childhood obesity does not solely lie at the feet of general practitioners. Yet by discussing and promoting lifestyle changes, we have an opportunity to improve health outcomes for today’s young people and subsequent generations.
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