Key learning points:
– Childhood obesity potentially leads to a host of long-term conditions in later life
– The teasing, discrimination and stigma encountered by children who are overweight or obese is socially destructive and can lead to poor mental health
– Managing childhood obesity needs collaboration and co-operation to provide sustainable policies to tackle the obesogenic environment and provide focused, family-based solutions
The rise in rates of childhood obesity has become a major public health concern. Managing this crisis is a medical and social priority; childhood obesity is a visible precursor of the chronic, debilitating and pre-morbid disease that is adult obesity. In later life it can lead to a plethora of conditions, including type 2 diabetes, obstructive sleep apnoea and ischaemic heart disease. Paediatric type 2 diabetes may even increase the risk of diabetes complications, which imparts a new urgency to the prompt diagnosis and treatment of this complex condition.
Solutions are not yet apparent but collaborative, multiagency working with children and families from an early age is paramount. Issues to tackle include altering access to cheap, energy-dense foods and encouraging parents to engage with a long-term health-conscious focus. This article will review the causes of childhood obesity, examine the current trends and offer practical advice on how to manage the burgeoning crisis.
Current trends in childhood obesity
Britain is now dubbed ‘the fat man of Europe’. About one-in-five mothers are estimated to be either overweight or obese.1 Rates of obesity in adolescent children are currently 15 to 17%.2 Hospital admissions for obesity-related conditions in five-to-15-year-olds have increased fourfold in the past decade.3 Data from the National Child Measurement Programme suggest that rates of overweight and obesity may be stabilising, although there are no clear reasons for this shift.4
Root causes
Modern life has become more affluent for some, but not necessarily healthier, with a widening gap between the poorest and the richest. The truth about prosperity is not palatable; a report suggests that people born in the 1970s will be the first generation who are unlikely to outlive their parents.5 Unravelling the causes of ill-health in later life necessitates an examination of the early years. Maternal obesity seems to be associated with lifelong obesity and related co-morbidities in offspring, and there is a direct association between maternal pre-pregnancy weight and fetal growth. Babies are now heavier, longer and have larger head circumferences; higher gestational weight gain can then be associated with higher weight for height in infancy.6
Rapid weight gain in the first few months of life may also be linked to the development of obesity.7,8 Even more insidiously, the origins of obesity occur pre-conception because of epigenetic influences, which can extend into the early postnatal weeks of life, a crucial period for determining childhood adiposity.
Society finds it hard to identify what a child’s weight actually signifies. Obese parents who have children with weight problems can exist in a spiral of unhealthy, overweight family life. Parents may rationalise excess weight in their child as ‘puppy fat’ when the truth is that their child is overweight or obese. Letters from the school nurse about a child’s weight are often not well received,9 and studies increasingly demonstrate the mismatch between parental and clinical perception of weight and levels of obesity.10 Obesity services for children can include one-to-one consultations, nutrition workshops, training camps or minimal interventions with an ongoing measurement programme.
Stigma
Children who are overweight or obese are especially vulnerable to stigmatisation, and negative attitudes about weight are evident even in very young children. During childhood and adolescence, the formation of social relationships is particularly salient so obesity can affect later development at school. Teasing, discrimination and exclusion from peer activities at a young age can harm academic, physical and psychological development.11 Some parents and even teachers believe that the incessant recording of the child’s body mass index (BMI) encourages this stigmatisation of overweight children and is highly corrosive. Furthermore, children who suffer from abuse such as neglect, or who are depressed, are also at substantially increased risk for obesity both during their childhood and in later life.9
Beneficial early start
It has long been established that breastfeeding is both beneficial and protective for babies, so increasing breastfeeding prevalence is essential to reduce health inequalities and improve health outcomes. Breast milk is the best form of nutrition for infants and an extensive research base demonstrates that it reduces the rate of gastroenteritis and respiratory disease.12 Studies also show that babies who are breastfed for more than six months were protected against type 2 diabetes and had lower overall central adiposity at six to 13 years of age.6 Breastfeeding must remain the choice of the mother. Education, empowerment and practical support are the key to increasing breastfeeding rates in the UK.
Insulin resistance conditions
Overweight and obese children are more prone to develop concomitant illness. Sleep apnoea, polycystic ovarian syndrome (PCOS) and acanthosis nigricans are all associated with insulin resistance later in life.13 Children are drawn to food that is dense in calories, and there is mounting evidence that the level of hyperglycaemia in children is rising.14
Low birth weight can be associated with the development of type 2 diabetes and early adiposity rebound. This is the decrease in BMI after the age of two years and the subsequent rise again around six years, often found more in western countries.15
Traditionally, the diagnosis of diabetes in children has long been associated with type 1 diabetes, characterised by an absolute lack of endogenous insulin and the need for replacement. Ketosis and hyperglycaemia are also features of this disease, which usually presents as an acute illness. The current increase in childhood obesity is now accompanied by an increase in diseases once exclusive to adulthood, such as type 2 diabetes, hypertension and atherosclerosis.15 Type 2 diabetes was first observed in children in 1979, when it was recognised to be a consequence of rising insulin resistance in ethnic minority groups. It is distinct from maturity onset diabetes of the young (MODY), a rare form of diabetes caused by a monogenetic defect in ß-cell function inherited in an autosomal dominant fashion.15 Type 2 diabetes results from an imbalance between insulin secretion and insulin resistance, and can present as early as puberty in overweight or obese children.16 There are some outstanding features of type 2 diabetes in childhood; glucose dysregulation progresses faster in obese youth, with a reduction in ß-cell function of about 15% per year, contrasted with a 7% reduction in adults.13
Methods of assessing childhood obesity
Waist circumference is not currently recommended as a means of diagnosing childhood obesity as there is no clear threshold at which waist circumference is associated with morbidity in this age group.17 Children grow at different rates so adult BMI tables (weight in kilos divided by height in metres squared) should not be used. With children’s growth charts, children are usually considered overweight if they are between the 85th and 94th centile, and obese if they are over the 95th centile.
Current controversies include the new classification for BMI in children. The new charts from the Royal College of Paediatrics and Child Health can place children in the overweight category, with accompanying distress for parents, when a year or so later it puts them in a ‘normal’ category. This situation has attracted criticism, alienating both parents and health professionals.
Treatment options for childhood obesity
There is sparse research on how to effectively prevent childhood obesity, although certain principles have emerged. A holistic approach is far more effective than focusing on diet alone. The way the message is delivered and the person delivering it is as important as the message itself. Modifying eating behaviour might provide additional benefits to the standardised lifestyle alteration offered to obese adolescents, according to one trial,18 which used a tool for retraining eating behaviour. Family-based therapy for childhood obesity also caused significant reductions in overweight.19
The involvement of family is a key feature of effective interventions. In an analysis of different approaches, such as behavioural camps and weight control programmes, a review concluded that treatment for childhood obesity should be delivered by teams encouraging increases in physical activity and changing dietary behaviour as a whole-family approach.20
There is also a strong evidence base of the early years prevention scheme (the HENRY approach),21 which supports families and recognises the enormous contribution made by increasing parenting skills, using strength-based and solution-focused approaches. HENRY combines an emphasis on key parenting skills with an approach that draws on the family partnership model. Children and their families learn about healthy eating habits combined with practitioners empathic approach to increasing physical activity and emotional wellbeing. Evidence from the Carnegie weight camps is also strongly correlative with positive weight reactions for overweight children. The solution-focused therapy service has provided a rich source of data using children’s interviews.22 EPODE, the large-scale, international multi-stakeholder involvement approach is also successful, fostering healthier lifestyles for children and families in a sustainable way. This monitoring and evaluation system combines a school-based obesity programme by placing community development, advocacy and collaborative working at the heart of the community to reduce childhood obesity.23
Addressing the obesogenic environment
It is easier to prevent or reduce obesity early in the life of a child when they are at their most impressionable.
Some primary care trusts (PCTs) and local authorities have been successful in curbing the plethora of fast-food outlets that tend to be located near schools.24 The caloric calculator is a metric for researchers and policy makers to estimate the effect of interventions to reduce childhood obesity and provides evidence for what interventions work and where to target the limited funding.25
Ensuring a healthy future for our children
Reducing the level of obesity in children is an enormous task. There are signs of recovery but clinical commissiong groups (CCGs) will need to be mindful of the rising burden of disease building up in communities. With the specific mandate from the Government to tackle childhood obesity, town planners, clinicians and health trainers will have to collaborate to help address this issue.
The government is committed to seeing a sustained downward trend in the level of excess weight in children by 2020.26 The national ambition is to decrease sedentary behaviour and increase physical activity. Funding of £150 million has been pledged to enable UK primary schools to improve the quality of sports provision and physical education. The School Food Plan, commissioned in 2012 as a national review of school nutritional policy, runs in parallel to this. The Department of Health has pledged more than £5 million to help encourage youngsters via schemes such as Change4Life, Street Play and walking initiatives.27
Combating childhood obesity starts with pre-pregnancy advice, followed by encouragement to breastfeed babies. Combined with sensible weaning, this will give children the best start in life. Better nutrition and increasing physical activity will make it easier for both parents and children to be healthy and mobile for as long as possible, as long as they are supported by changes to their local obesogenic environment. Altering social behaviour requires a change with the scientific, medical, educational and local authority sectors all pulling together to increase activity opportunities and decrease unhealthy food choices; these are vital tools in the fight to reverse childhood obesity.
References
1. Hastie K, Yates P. Strategic High Impact Changes National Childhood Obesity Support Team. Department of Health, 2011.
2. Garton L. Managing Obesity Experiences from the US and the UK. Complete Nutrition 2013;13(3):64-66.
3. Neilsen J, Laverty A. Rising obesity-related hospital admissions in England among children and young people in England: National time trends study. journals.plos.org/plosone/article?id=10.1371/journal.pone.0065764 (accessed 25 April 2016).
4. HSCIS. National Child Measurement Programme – England, 2011-2012. hscic.gov.uk/catalogue/PUB09283 (accessed 25 April 2016).
5. Lee J. International Journal of Obesity, 2010.
6. Dabelea D, Crume T. Maternal Environment and the transgenerational cycle of obesity and diabetes. Diabetes 2011;60:1849-1855.
7. Hunt C. The Henry Approach. Primary Health Care 2009;19(4):21-14.
8. Baird J, Fisher D, Lucas P, Kleijnen J, Roberts J, Law C. Being big or growing fast: systematic review of size and growth in infancy and later obesity. British Medical Journal 2005;331:929.
9. Ebbeling C, Pawlak D, Ludwig D, Pawlak D, Ludwig D. Childhood obesity: public-health crisis, common sense cure. The Lancet 2002;360:473-82.
10. Black J. Child obesity cut-offs as derived from parental perceptions; cross-sectional perceptions. British Journal of General Practice 2015;65:180-181
11. Puhl R, Latner J. Stigma, Obesity and the health of the nations children. Psychological Bulletin 2007;133(4):557-580.
12. Geddes J. Breastfeeding-how to increase prevalence. Nursing Times 2012;108:12-14.
13. Schwartz M, Chadha. Type 2 diabetes mellitus in childhood; insulin resistance. Journal American Osteopath Association 2008;108(9):518-524.
14. Erikson J, Forsen T, Tuomolito. Early adiposity rebound in childhood and risk of type 2 diabetes in later life. Diabetoliga 2003;46:190-194.
15. Ehtisham S, Hattersley A, Dunger D, Barrett T. First UK survey of paediatric type 2 diabetes and MODY. Archives of Diseases in Childhood 2004;89;526-9.
16. Santoro N. Childhood Obesity and Type two diabetes; the frightening epidemic. World Journal Paediatrics 2013;9(2):101-102.
17. Griffiths C, Gately P, Marchant PR and Cooke CB. Cross-Sectional Comparisons of BMI and Waist Circumference in British Children: Mixed Public Health Messages. Obesity 2012;20(6):1258-1260.
18. Ford A, Bergh C. Treatment of childhood obesity by retraining eating behaviour. British Medical Journal 2010;340:5388.
19. Croker H, Viner R, Nicholls D, Haroun D, Chadwick P, Edwards C, Wells J, Wardle J. Family-Based behavioural treatment of childhood obesity in a UK national health service setting: randomised controllled trial. International Journal of Obesity 2011;36:16-26.
20. Staniford L, Breckon J, Copeland R. Journal of child and Family studies 2012;21;545-564
21. The HENRY Approach. What is HENRY? henry.org.uk (accessed 21 February 2016).
22. Hester J, McKenna J, Gately P. Discussing lifestyle behaviours with obese children. Education and Health 2009;27(3):362-663
23. Borys J-M, Le Bodo Y. EPODE approach for childhood obesity prevention: methods, progress and international development. Obesity Reviews 2012;13(4): 299-315.
24. Local Government Association. Waltham Forest- banning hot food takeaways to reduce health inequalities, 2010. local.gov.uk/web/guest/health/-/journal_content/56/10180/3511421/ARTICLE (accessed 25 April 2016).
25. Wang C, Hsiao A, Orleans T, Gortmaker S. The Caloric Calculator: Average Caloric Impact of Childhood Obesity Interventions. American Journal of Preventive Medicine 2013;47(1):104.
26. PHE. Reducing Obesity and Improving diet. gov.uk/government/policies/obesity-and-healthy-eating (accessed 21 February 2016)
27. Department of Health. Healthy Lives, Healthy people: A call to action on obesity in England, 2011. gov.uk/government/uploads/system/uploads/attachment_data/file/213720/dh_130487.pdf (accessed 25 April 2016).
