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Childhood obesity: if they're fat by four we've failed

Tam Fry
Director
Child Growth Foundation
2 Mayfield Avenue
Chiswick
London W4 1PW
T:020 8995 0257/ 8994 7625
F:020 8995 9075
E:cgflondon@aol.com
W:www.childgrowthfoundation. org.uk
For further ­information about the CGF and its work, please send an SAE together with a convenient ­telephone number to the address below, or call on the numbers provided (Tue, Thurs or Fri between 9am and 3.30pm)

This spring a stream of reports have been or are about to be published addressing the issue of obesity. They will invariably concentrate on the urgent need to slim down adults who are already fat and, also invariably, admit that the medical profession is at a loss to agree how obesity might best be treated. They will all call for action but take no responsibility for it.
A prime example is the report Storing up Problems: The Medical Case for a Slimmer Nation, from two of the Royal Colleges, which adroitly passes the problem back to government and policymakers.(1) This, however, is not before admitting that doctors in general have done little other than suggest that obese patients do something about their weight, and, because too often health professionals ignore the obvious signs of a nutritional disorder, it is therefore not surprising that interventions are considered only after medical complications have become apparent. If ever there was a case of closing the stable door after the horse has bolted, obesity is it. If ever there was a need for prevention rather than cure in the future, it is to prevent obesity in preschool childhood.
This summer, hopefully, the Department of Health is to float a white paper that will address this need. It will be disastrous if it doesn't complement last July's directive from the Chief Medical Officer for England (CMO) that GPs and practice nurses identify early signs of obesity in children and offer interventions at an early stage.(2) That was the first really sensible salvo in government thinking in the war to curb the current epidemic of obesity in children, since it was directed at pure prevention as opposed to preventing children who are already, sadly, overweight or obese from becoming fatter. The CMO also required public health doctors to make regular reports tracking the prevalence of overweight and obesity in their regions and identifying areas where progress is being made.
This isn't such a tall order as it sounds. You could start implementing it from today. It would be worthwhile since prevention is so much better and easier to implement than cure, and, to be hardheaded, up to eight times cheaper too. To be entirely frank, out-of-control weight may be one of those conditions that will never be entirely soluble, and a hugely profitable slimming industry has built up on the fact that control rarely succeeds. Although the CMO obviously believes that there are effective, evidence-based interventions, he is under no illusion that preventive measures must come first.
Two tools to assist early identification are already available, are inexpensive, and you could be using them within days. "Breast from Birth" charts (see Figure 1), designed initially to monitor exclusively breastfed babies, may also be used to monitor weight gain in the first 6 months. The paediatric Body Mass Index (BMI) charts then take over. Both track the earliest signs of weight excess sufficiently easily to be able to offer meaningful intervention. In most cases, successful interventions involve the family and address eating habits and physical activity, but you may need to call in a paediatric dietician or, in extremis, a paediatrician or clinical psychologist to help you. The problem should preferably be resolved in the community, and the Royal College of Paediatrics and Child Health (RCPCH) and the GP-led National Obesity Forum have jointly produced an approach to weight management in children (2-18 years) for primary care.(3)

[[NIP15_fig1_26]]
 
"Breast from Birth" charts
But why wait until the age of 2? There is enough literature now to suggest not only that unacceptable weight gain may begin even in the first months of life, but also that exclusively breastfed babies are less likely to develop into overweight toddlers if only we would leave them to their own devices. It is a sad fact that many babies are overfed in the UK because mothers are given unnecessary and damaging advice by health professionals. At a stroke they turn an otherwise normally proportioned infant into a potentially ungainly toddler. They stuff supplementary milk down the child when-ever its weight gain curve begins to fall away from the standard "Personal Child Health Record" (PCHR) 1st year weight centile lines, and the damage begins.
This fall is, however, exactly what breastfed children should be expected to have, since it is what nature intended. Society's fault is that we continue to use the current PCHR charts - compiled from a hotchpotch of breast-, mixed and bottle-fed babies - as the "norm", when actually we should recognise the weight gain curve of the breastfed infant as the norm and ditch the PCHR charts we have at the moment.
The "Breast from Birth" chart should be the new UK chart to aspire to, and, since it is already published, you don't need to wait for a national makeover to use it.(4) The chart reflects the weight pattern of the exclusively breastfed child, and the diagram shows how it differs from the child who is mixed- or bottle-fed (see Figure 1). The graphs show how the exclusively breastfed baby will not only lose less of its birthweight but also regain it faster than its formula or mixed feeding chums. By week 8 it should be substantially heavier but then begins to lose this distinction. The descent through the centiles begins and continues throughout the 12 months, so that by week 52 the 1 year old is substantially lighter than the rest. It does not follow that every breastfed baby will cling to any particular centile line - breastfed babies can be just as cussed as every other by veering up and down from the centiles - but it is much less likely to do so.
Why everyone is surprised that breastfed babies appear to be programmed to "lose" weight during their first year of life doesn't surprise Dr Tony Williams, a member of the Government's Scientific Advisory Committee on Nutrition. In his commentary accompanying the peer-reviewed paper announcing the "Breast from Birth" charts, he bemoaned the fact that this phenomenon is not universally recognised by health workers and therefore by parents. He even suggested that the accelerated growth in the first few weeks and the centile descent thereafter could be even greater than the diagram or the charts depict.
As mentioned above, the consequence of not understanding this natural pattern is often to advise unnecessary supplementary intake merely to keep the weight on. This inappropriate additional feeding will not only go towards making the baby fatter than nature intended, but also create additional - and unwarranted - growth cells, which in turn will need feeding.
It may be comforting for a mother to have a big, bonny, bouncing baby to show off to her friends, but if in retrospect the child is shown to have been overfed, the comfort may be short-lived.
Two additional advantages of making the "Breast from Birth" chart the default PCHR chart is not only that  it would be a powerful reminder that "breast is best" for both infant and mother, but also that any baby's weight gain can be plotted on it. It is useable with the erstwhile breastfed baby, should the mother decide to switch to formula or mixed feeding for whatever reason, and with the exclusively nonbreastfed infant. In both cases the weight curve should climb to, and follow, a higher centile.

Paediatric BMI charts
Unlike the adult BMI charts you may have pinned to your surgery wall, children's BMIs vary at every age of their childhood, are gender-specific, and any child whose overall weight gain needs to be monitored closely requires his/her personal copy (see Figure 2).(5)

[[NIP15_fig2_26]]

Paediatric BMI charts can be used from weaning onwards, but in practice the charts are better introduced following the child's first birthday. If you haven't successfully initiated prevention measures by then, BMI charts may better explain to parents how near their children's weight is verging to two important markers - the International Obesity Task Force (IOTF) cutoffs for overweight and obesity at age 2. This is also the age chosen by the RCPCH as the age by which progressive or severe obesity should be referred.
As with the 95% thrive lines, it might be helpful to get some training in BMI and adjusting for the fact that two quite differently built children can have the same index. Everything should be done not to refer for intervention the well-built child who happens to have the same high index score as an obviously overweight individual. The clincher is that the former will probably have a normal waist circumference measurement but the fat child won't. The first UK paediatric waist circumference centiles are printed on the back of the BMI charts.
Because intervention should be family focused, it is important that parents get an idea of what a healthy BMI is so that they can keep track of things at home. You should see from Figure 2 that the tinted area on the medical charts designates healthy BMI, but this may not be sufficient to coax the family into understanding that there is a "goal" to be achieved. Consequently, a more user-friendly "BMI goal" bedroom wallchart has been created for home use (see Figure 3). Provided with stick-on footballs, the aim is that the child gets as many as it can into the goalmouth every 6 months or so until it reaches school entry. The logic behind this is that the child will have discovered the benefit of eating healthily and being active by then and be less inclined to scoff "unhealthy" food. The family with daughters will, of course, be able to get a chart featuring a more feminine approach, and both charts will be published during 2004.

[[NIP15_fig3_27]]

References

  1. Royal College of Physicians and Royal College of Paediatrics and Child Health. Storing up ­problems:?the medical case for a slimmer nation. London: RCP/RCPCH; 2004.
  2. Department of Health. Chief Medical Officer's Annual Report 2002. London: Department of Health; 2003.
  3. Royal College of Paediatrics and Child Health and National Obesity Forum.An approach to weight ­management in children and adolescents (2-18 years) in primary care. London: RCPCH; 2002.
  4. Cole TJ, Paul AA, Whitehead RG. Weight ­reference charts for British ­long-term ­breastfed infants. Acta Paediatr 2002;91:1296-300.
  5. Cole TJ, Freeman JV, Preece MA.Body mass index ­reference curves for the UK, 1990. Arch Dis Child 1995;73:25-9.

Resources
Height Matters
Information and advice about growth disorders and their treatment
W:www.heightmatters.org.uk
Facts of Life
Website aimed at children, parents and teachers. Provides ­information on the biology behind growth
W:www.facts oflife.org.uk