Viewpoint - Management of childhood obesity

Investing in community prevention strategies is the key to fighting obesity, writes Dr David Haslam.

Primary care cannot possibly shoulder the responsibility for childhood obesity, when it is clearly a societal problem, caused by a harmful environment that allows children to consume food and remain inactive almost without limits.

The ultimate responsibility lies with the government to invest sufficient resources in importing community prevention strategies that have been shown to work, such as the French EPODE model (a programme aimed at facilitating the adoption of a healthy lifestyle in everyday life).

However, attempting to solve the problem of childhood obesity by preventing it is like summoning the health and safety officer to check the plugs, while the house is burning down.

The appropriate management, rather than mere prevention, of childhood obesity is paramount; therefore primary care must accept a share of the burden, even though the scenario still exists whereby politicians are entrusted with overseeing clinical arenas and targets about which they know very little. Successfully intervening for the benefit of an obese child is easier said than done.

A Cochrane review shrugged its figurative shoulders, concluding that 'there is a limited amount of quality data on the components of programmes to treat childhood obesity ... no direct conclusions can be drawn from this review with confidence'.

Not every PCT is blessed with a local childhood obesity programme (such as MEND, WATCH-IT or Carnegie; see Resources box).

Consequences of obesity
Seventy-five per cent of obese children become obese adults, but even the 25 per cent who do not cast a shadow over their adult health, due to the metabolic changes that start at an early age.

Specialist centres are now reporting co-morbidities including type-2 diabetes in obese children, up to a quarter of whom fulfil the criteria for the metabolic syndrome.

High BP and dyslipidaemia in children as young as nine and left ventricular hypertrophy are common, and 25 per cent of children between four and 10 with a BMI greater than the 95th centile have impaired glucose tolerance, with 4 per cent suffering from overt type-2 diabetes.

A quarter of children with a BMI over the 95th centile are hypertensive and postmortem studies on obese children dying of unrelated causes have revealed atherosclerosis and coronary artery disease.

Childhood obesity also leads to worsening of asthma, sleep apnoea, Blount disease of the tibia and gallstones, not to mention profound psychological repercussions and discrimination.

Parental impact
In treating childhood obesity, it is important to identify those individuals on whom time and resources should be spent.

Highly motivated 'worried-well-by-proxy' parents might bring their normal or overweight child, having read a newspaper report about the obesity epidemic, and eagerly consume every word of wisdom offered.

On the other hand, obese children may be lumbered with ill-informed and resentful parents who react badly to what they perceive as the implied criticism of their child's upbringing.

Epigenetics dictates that a child's gene expression is altered by its mother's behaviour during pregnancy. If her diet is inappropriate, the fetus will be predisposed to obesity before it has taken its first mouthful of milk.

Dietary suggestions for patients
  • A balanced, varied diet for the whole family.
  • Meals at regular times; avoid grazing and TV snacks.
  • Smaller portions.
  • Avoid using food/snacks as rewards or treats.
  • Healthy snacks (e.g. fruit) as alternatives to sweets, chocolates, crisps, nuts, biscuits, cakes.
  • Less energy dense food e.g. semi-skimmed milk, low fat spreads.
  • Whole foods that take time to eat e.g. fruits and wholemeal bread.
  • At least five portions of fruit and vegetables per day.
  • Low calorie drinks (preferably water).
  • Grill, boil or bake foods without added fat, rather than frying.

Assessment
Assessment of an obese child should include:

  • Personal and family history of obesity or other related conditions.
  • Physical activity and eating patterns within and outside the home, including drinks. Consider the possibility of secretive eating and vomiting.
  • Psychological factors; bullying, depression or bereavement.
  • Academic and social progress.

Examination should include height, weight and BMI. BMI charts are currently available showing the centiles for boys and girls, but also the levels of BMI at each age that correspond to the adult levels of >25 'overweight' and >30 'obese'.

It is unusual to advise weight loss in a child, except in extreme cases, although many adolescents are of adult proportions, and can be treated accordingly.

Management
Weight management goals are usually either:

  • No weight gain as height increases, or;
  • Weight gain slower than height gain.

Physical activity advice should suggest that any increase in activity will help. Aim for sustainable lifestyle activities such as walking, cycling and using the stairs instead of lifts. Develop an active lifestyle in the whole family. Walk or cycle to school. Decrease TV viewing and other sedentary behaviours.

Support and monitoring
Possibly the most important role of the primary care team is simply encouragement and regular monitoring of children and families, which in itself can bring about valuable changes in lifestyle and health.

Programmes such as MEND (see Resources) are successful, and based on robust evidence.

Pharmacotherapy and bariatric surgery have been positively appraised by NICE, but are only appropriate for seriously affected individuals, and are the domain of specialist centres.

One day, genetic engineering and nanotechnology may render primary care obesity services obsolete, but until then primary care must fight the fires of childhood obesity, while government policy fans the flames.

  • Dr Haslam is a GPSI in obesity and cardiometabolic disease in Hertfordshire, physician in obesity medicine at the Centre for Obesity Research at Luton & Dunstable Hospital, and clinical director of the National Obesity Forum.
  • Declaration of interest: none declared

WHEN TO CONSIDER REFERRAL TO A PAEDIATRICIAN

  • Serious morbidity related to obesity exists (e.g. sleep apnoea, orthopaedic problems, type-2 diabetes mellitus, hypertension).
  • Height below 9th centile, unexpectedly short for family or slowed growth velocity.
  • Precocious or late puberty - before eight years or no signs at 13 in girls, 15 in boys).
  • Significant learning disability.
  • Symptoms or signs of genetic or endocrine abnormalities - genetic or hormonal disorders may cause weight gain or behavioural changes leading to weight gain.
  • Severe and progressive obesity before two years of age.
  • Other significant concerns.

Resources


Recommended MIMS links

Have you registered with us yet?

Register now to enjoy more articles and free email bulletins

Register

Already registered?

Sign in

Before commenting please read our rules for commenting on articles.

If you see a comment you find offensive, you can flag it as inappropriate. In the top right-hand corner of an individual comment, you will see 'flag as inappropriate'. Clicking this prompts us to review the comment. For further information see our rules for commenting on articles.

comments powered by Disqus