Abstract
One in four children starting primary school and one in three children leaving primary school in England are overweight or obese. This article will explore the problem of childhood obesity and in particular the role of the GP and other members of the primary care team in preventing and managing this complex problem.
The GP curriculum and childhood obesity
Promote health on an individual and person-centred basis as part of the consultation Recognize and contend with the potential tension between the GP's health promotion role and the patient's own agenda Develop the skills to change patients' behaviour in health promotion and disease prevention Describe the effects of poor diet and obesity on the patient and his or her family Identify the patient's health beliefs regarding food and eating habits and reinforce, modify or challenge these beliefs as appropriate Recognize the stigma associated with being obese and the psychological and social effects these can have on the patient Understand the role of the GP and the wider primary health care team in health promotion activities in the community
Co-ordinate care with other primary care professionals, paediatricians and other appropriate specialists, leading to effective and appropriate care provision, taking an advocacy position for the patient or family when needed Develop and apply the primary care consultation to bring about an effective doctor, patient and family relationship to enable parents or carers, children and young people to participate in their own care planning and delivery Promote physical health, mental health and emotional well-being by encouraging children, young people and their families to develop healthy lifestyles
Be able to calculate body mass index (BMI) Understand that obesity is a risk factor for other conditions and that optimal treatment is preventative Recognize that non-concordance is common for metabolic conditions and respect the patient's autonomy when negotiating management Communicate the patient's risk of complications from obesity clearly and effectively in a non-biased manner Negotiate a programme of weight reduction sensitively with patients, giving appropriate health promotion advice regarding diet, exercise and pharmacological therapies Recognize that public health interventions are likely to have the largest impact on obesity and support such programmes where possible Understand the key government policy documents that influence health care provision for metabolic problems Recognize that stigma is associated with obesity Ensure that a patient's weight does not prejudice the information communicated or the doctor's attitude towards the patient
Definitions and policy
In children, being overweight is defined as having a BMI greater than the 85th centile and being obese is defined as having a BMI greater than the 95th centile (see Fig. 1). The National Audit Office (2006) estimates that obesity has a financial cost of £1 billion a year to the National Health Service (NHS) and a further £2.3–2.6 billion a year with regards its impact on the economy from indirect costs. This is because being obese is a risk factor for type II diabetes, hypertension, hyperlipidaemia, cardiovascular disease, osteoarthritis, sleep apnoea, gallstones and various cancers and reduces life expectancy by 9 years on average.
How to calculate and interpret BMI in children.
In 2004, the government launched a Public Service Agreement (PSA) to stop the yearly increase in obesity of children under the age of 11 years by 2010. The responsibility for this was split between the Departments of Health, Education and Skills and Culture, Media and Sport. National interventions included implementing healthier school meals, improving uptake of physical education lessons, encouraging local sports clubs to form links with schools and improving school playtime facilities. The public health initiative ‘Change 4 Life’ uses the simple slogan ‘eat well, move more, live longer’ and provides parents, children and schools with advice on healthier living (see Fig. 2).
Poster from the Change 4 Life Campaign.
By the age of 6 years, children are aware of the stigma attached to being overweight and are at risk of becoming isolated, rejected and of having distorted body images. Overweight children are twice as likely to become obese adults compared with normal weight children. Results from childhood obesity clinics have been generally poor (Bond et al., 2009). There is evidence that treating children for obesity at the same time as treating their overweight parents is more effective than treating children on their own (Edmunds et al., 2001).
The National Child Measurement Programme
The National Child Measurement Programme is a government run programme whereby all children starting primary school aged 4–5 years and finishing primary school aged 10–11 years have their height and weight measured and their BMI calculated (see Box 1). In some local authorities, letters are written to parents informing them of their child's BMI and whether or not they are overweight. Currently, there is no standard policy to provide GPs with this data.
Prior to the introduction of the National Child Measurement Programme in 2007, a study by school nurses piloted the process and investigated how 11-year-old children felt about being weighed. It found that a quarter of participants did not like being weighed and measured and that girls were generally more negative about it than boys. Most negative comments came from children who were overweight but also from children who were shorter than average. More than half of the students (equally spread between girls and boys) ‘did not care’ about being weighed. Some students expressed relief at not being overweight (Duncan, 2007).
Interestingly, adolescents' perception of how overweight they are has been found to depend on how overweight their peers are. In a study by Maximova et al. (2008), overweight adolescents who had overweight peers were less likely to perceive themselves as being overweight. The concern is that as populations become more overweight, being overweight becomes the norm and is not perceived as being a problem. Health professionals may also find it difficult to identify overweight children, perhaps because they are more overweight themselves.
What do primary care health professionals think?
Primary care is viewed by many as an appropriate setting to tackle childhood obesity. Turner et al. (2009) interviewed 12 GPs, 10 practice nurses, 4 school nurses and 4 health visitors to find out about their experiences and views on managing this complex problem. Common themes from this study included:
Primary care as a treatment setting
Most of the participants felt that primary care was an appropriate setting because GPs treated whole families and understood their social situation, thus could provide holistic care. They also had good access to health visitors and school nurses. One of the health visitors felt that obesity needed to be tackled early on in a child's development and that they were best placed for this. Some participants felt that they had not been trained to manage childhood obesity and others felt that it was medicalizing a social problem and should not be their responsibility.
A difficult subject to broach
Participants felt that it would be difficult to bring up children's weight if they presented with a completely different problem, especially if their weight did not appear to be impacting on their health. A particular problem was time pressure and having to prioritize the problem that the child had come with in the first place.
Limited contact with obese children
None of the study participants had regular contact with primary school aged children. Health visitors' work was focused towards pre-school children and families in need. School nurses felt that helping children to lose weight was ‘down on the list’ compared to child protection issues and was therefore not a priority. One school nurse commented ‘health promotion is just like the icing on the cake’.
Working with parents
A common theme was that parents became defensive and did not acknowledge that their child was overweight or that it was a problem. Parents were described as not making the link between the child's weight and their unhealthy diet or sedentary lifestyle. Some parents used food as a sign of affection and did not want to deny their children food. It was also felt that poorer parents did not have the knowledge, money or time to prepare healthy food. Some practitioners felt that overweight families tended to believe that it was a genetic problem and this reduced their motivation to do anything about it.
Tips for the GP consultation
The National Institute for Health and Clinical Excellence (NICE, 2010) divides management of childhood obesity into:
general principles of care first steps to managing obesity when to consider referring a child to secondary care specialist management
The guidelines emphasize the importance of creating a supportive environment for children and their families to make lifestyle changes, tailoring management to the individual child and encouraging parents to take responsibility for their child, especially if the child is under the age of 12 years.
During consultations, children's and their parents’ ideas and beliefs about being overweight and what has led to their weight gain should be explored, asking in particular about diet and activity levels. It is useful to probe into what has been tried already and what they have learned from this. Readiness to making changes to lifestyle and confidence to achieve these changes should be assessed.
Prevention is better than cure
Identifying pre-school children who are at risk of becoming obese and implementing lifestyle and parenting changes early on may be key to halting the obesity epidemic. Reilly et al. (2005) identified eight factors in the first 3 years of life that were associated with an increased risk of obesity aged 7 years. These included:
high birth weight higher than normal weight gain in the first year parental obesity watching more than 8 hours of television per week and short sleep duration
Health visitors seem to be best placed to identify these children and to educate parents about healthy eating and healthy living.
History taking
The initial assessment of an overweight child must be done in a sensitive and non-judgemental manner. It should include gestational problems (e.g. gestational diabetes), birth weight, onset of obesity and onset of puberty. Family history is important. Ask about weight tendencies of family members and conditions associated with obesity such as diabetes or cardiovascular disease. Ask about symptoms related to co-morbidities, e.g. menstrual irregularities associated with polycystic ovarian syndrome; cold intolerance, fatigue and dry skin associated with hypothyroidism; night-time snoring or daytime somnolence related to sleep apnoea and hip or knee pain associated with slipped capital femoral epiphysis.
Involve children and their parents
When negotiating lifestyle changes, the child's preference, social circumstances and level of risk (based on BMI) should be taken into account. Children should be encouraged to problem solve and to set goals for themselves. Parents should be advised to make similar changes so that they act as role models for the children. Any success, however small, should be praised and rewarded.
Exercise
NICE (2010) advises that children should be doing 60 minutes of at least moderate activity (e.g. swimming, walking, cycling) each day. This can be done in one go or split into shorter sessions lasting 10 minutes or more. Sedentary activities such as watching television and playing video games should be reduced where possible. Emphasis should be put on the other health benefits of exercise including reduced risk of diabetes, and children should be encouraged to keep exercising even if they are not losing weight.
A thorough history of exercise and sedentary activities is needed, again probing to find out exactly how long the child spends watching television or playing video games. There may be barriers to doing exercise, for example, is the child embarrassed to wear a swimming costume or are the child's parents worried about the child being outdoors? These barriers must be identified and the parents and child should be encouraged to think of solutions, for example, doing other sports or indoor activities. It is essential to take into account the child's preferences. What sports does the child like doing? What sports are the child good at? Activities that involve the whole family are particularly effective (Plourde, 2006).
Diet
NICE (2010) highlights that dietary advice must only be offered alongside other lifestyle advice and not in isolation. Again, it should be individualized to each child and take into account food preferences and age. It should aim to be in line with current healthy eating advice (such as ‘5-a-day’), should be sustainable and should aim to reduce children's total energy intake to below their energy expenditure. Similarly, with exercise, children and their families should be advised to continue their healthier diet even if it does not result in weight loss as there are other health benefits. If a child or family seems unwilling to make lifestyle changes, information about the benefits of losing weight, eating healthily and being more active should be given, along with details of who to contact if they change their minds.
A detailed account of the child's diet must be taken. A good way of approaching this is to ask the child what they would eat during an average school day. This may require some probing to get a true account. For example, ‘How many grapes do you eat during the day? Do you have any other snacks between meals? Does your Mum give the same amount of food to the children and the adults?’ Also ask about eating behaviours. ‘Does the family eat the evening meal in front of the television? Who does the child eat his or her school lunch with?’
Any changes to a child's diet should either aim for gradual weight loss or, if the child is having a growth spurt, aim to maintain current weight, creating a plateau on the growth chart. Introduce small changes one at a time, e.g. taking a piece of fruit to school instead of a chocolate bar. Using food as a reward should be discouraged (Plourde, 2006). A previous InnovAiT article provides further advice on healthy eating for children (Dissanayake, 2010).
Referral to secondary care
The NICE (2010) guidelines are rather vague in terms of referral criteria to secondary care. Referral is advised if there is significant co-morbidity or if the child or family has complex emotional or social needs. Failure of treatment in the community should also warrant referral to secondary care.
Secondary care assessment should include blood pressure monitoring, fasting lipid profile, fasting insulin and glucose levels, liver function tests and endocrine investigations. Children attending obesity clinics will often have a shared care arrangement, e.g. the GP monitors blood pressure and BMI between clinic appointments. Specialist management includes drug treatment, such as orlistat, and in exceptional circumstances surgery. These treatments should only be initiated after dietary, exercise and behavioural approaches have been tried and evaluated and should be co-ordinated by a multidisciplinary team that can provide psychological, educational, family and social assessment.
Psychosocial assessment
Finding out about a child's social situation, parent's health beliefs about obesity and the family's readiness to make changes is essential. Is the family in a financial position to make changes to diet and lifestyle? Do they have other more pressing problems which mean that weight loss is just not a priority? It is also important to ask children how they feel about being overweight and to assess the psychological impact it is having on them. Do they have low self-esteem? Are they being bullied at school? Are they feeling depressed or low? These are clearly delicate areas to talk about and may need to be re-visited at a later stage once you have got to know the child and gained his or her trust.
Family-based treatment
Interventions that have targeted parents and their children have been shown to be effective and weight loss of a parent has been shown to be a positive predictor for weight loss in a child (Plourde, 2006). One study comparing two interventions found that group sessions solely aimed at parents of overweight children were more effective than group sessions targeted at the children themselves (Golan et al., 1998). This illustrates two important factors: firstly, parents act as role models for their children, and secondly, children eat what their parents give them. Getting the child's parents on board is essential to the process.
Is childhood obesity the icing on the cake?
Childhood obesity is a complex problem influenced by psychological, social and biological factors. As such, a co-ordinated multidisciplinary effort between GPs, child obesity specialists, health visitors, school nurses, dieticians, teachers and practice nurses is paramount.
Parenting is key and identifying pre-school children at risk of becoming obese and educating parents early on about healthy eating and healthy living seems to be a logical first step. Health visitors and school nurses are best placed to deliver this intervention but, like many health professionals, are swamped by more urgent matters such as safeguarding of children.
GPs inevitably have a role to play in identifying overweight children opportunistically and by broaching the sensitive subject of their weight with children and their parents. GPs are well placed to help negotiate lifestyle changes and to signpost families to other health care professionals. The implications of childhood obesity on emotional and physical morbidity are reason enough to make its prevention and treatment a real priority.
Case study
Mrs P has brought her 10-year-old daughter, Jane, to the GP because she has received a letter from Jane's school saying that she has a BMI above the 85th centile and this means that she is overweight. Mrs P is angry at the school for saying this. Even if Jane is a bit overweight, Mrs P does not think that it is a problem and does not know what she can do about it. She has another child at home who has attention deficit hyperactivity disorder (ADHD) and takes up all her time. She is also struggling to pay the bills and cannot afford expensive healthy food.
This case highlights some of the challenges of treating overweight children in a primary care setting, as well as potential problems with current public health initiatives such as the National Child Measurement Programme. How might you feel if you received a letter telling you that your child is overweight? Embarrassed that other parents might find out? Worried about your child being teased about it at school? Clearly, Mrs P has other pressing problems, such as looking after her other child with ADHD. Is she in a position to make any changes to Jane's diet or physical activity? Is she motivated to help Jane to lose weight?
The fact that Mrs P has brought Jane to the GP in the first place suggests that it is important to them and reflecting on this could be a good place to start the consultation. It is of course essential to include Jane— perhaps start by asking her how she felt about being weighed and whether she's worried about her weight. Salient points in the history, such as diet and activity levels; family history of weight problems and what they have tried already, need to be covered. Taking a good social history is important and barriers to losing weight, such as healthier food being more expensive and time consuming to prepare, must be identified, encouraging Mrs P and Jane to think of practical solutions. Small lifestyle changes, such as changing to semi-skimmed milk or going swimming once a week, need to be negotiated.
There is a lot to cover in one consultation and Jane and Mrs P will need to come back for follow-up appointments. Information leaflets and websites, such as Change 4 Life, may be useful. Jane's weight should be monitored but it must be emphasized that even if she does not lose weight, she should persevere with the lifestyle changes. She may not lose weight because she is still growing and doing more exercise, but eating a balanced diet will make her healthier and fitter in the long run.
Key points
One in three children leaving primary school in England is overweight or obese Public health initiatives include the National Child Measurement Programme and Change 4 Life The child's BMI should be calculated and plotted on a growth chart Treating childhood obesity in primary care presents many challenges Seek children's and their parents’ ideas about their weight and why they are overweight, as well as what they have already tried Lifestyle interventions including diet and exercise are key and must be individualized for each child; any success, however small, should be praised
Footnotes
Acknowledgements
The author thanks Prof. Debbie Sharp, Prof. Julian Hamilton-Shield and Dr Barbara Laue for their help in proof reading the article. Case study 2 used in this article is completely fictional. Any similarities to the story of any real person are entirely coincidental.