Dr Sonia Saxena (left) and Dr Anthony A. Laverty share some useful tips on how to engage with families about weight problems in overweight and obese children

  • GPs should:
    • take an active role in tackling the current obesity epidemic, especially in supporting parents, who may not realise that their child is overweight or has a health risk
    • explore a parent's ideas, concerns, and expectations about food and exercise and build a picture of the home environment
    • exclude medical causes of overweight and plot height and weight on a growth chart
    • offer practical strategies, set achievable goals, agree follow up, and involve the multidisciplinary team for support.

Despite a recent levelling off of obesity among children in England, the numbers are still stark, with 14% of both boys and girls aged 2-15 years being classified as obese in 2012.1 The proportion of children who have weight problems doubles between the age of 5 years at primary school entry and 11 years old, when they begin secondary education. By the age of 11 years, 1 child in 3 is overweight and 1 in 5 is obese. Obesity prevalence is higher in London and urban areas and is twice as prevalent in deprived areas and among some minority ethnic groups, including south Asian and Afro-Caribbean children.1 A wealth of research emphasises that being overweight in childhood is detrimental to physical and psychological wellbeing, with a high risk of developing adverse cardiovascular profiles and musculoskeletal problems that impact into adulthood.2 Recent research has also highlighted a rise in children being admitted to hospital with obesity-related comorbid conditions, suggesting that the clinical burden and cost to the health service in treating obesity occurring during childhood itself is increasing.3 Bariatric surgery is becoming more common; in England, rates in children aged 13-18 years have increased 30-fold in the past 10 years and are likely to continue to increase3 but there is little data about the long-term outcomes of having this procedure in early life.

The role of primary care

General practitioners, and not specialists, are best placed along with other community-based primary care healthcare providers (including paediatricians, school nurses, practice nurses, and dietitians) to work with families to assess and manage the majority of children who are overweight or obese. Over 98% of children in the UK are registered with a GP,4 and general practice is where they most often come into contact with medical services. These contacts present an opportunity to assess a child's weight, intervene early, and monitor problems over time; however, the presentation of weight problems does not always manifest as an approach from concerned parents. In fact, one of the central problems in dealing with obesity in children is that many parents fail to recognise that their child may have issues with weight.

Parents' perceptions

While there is no systematic measurement of the weight of children in general practice, children in England are now weighed as part of the National Child Measurement Programme (NCMP). Established in 2006, the NCMP measures weight in children at Reception (aged between 4 and 5 years) and in Year 6 (aged between 10 and 11 years) and feeds this back to parents in writing (see www.hscic.gov.uk/ncmp).5 Recent research with parents of overweight children who took part in the NCMP found that 79% of them did not recognise their child as overweight.6 Among the minority of parents who did recognise their child was overweight, 41% did not consider this to be a health risk and therefore it is hardly surprising that only 15% of these parents seek help from their GP as a result of the feedback.7

It is clearly essential to get parents on board in addressing weight problems in their child because they are key players in determining environment and implementation of lifestyle and behavioural change. General practitioners are well placed to begin a sensitive and open discussion with families about weight problems in children; however, some practitioners say they are unsure about how to assess and tackle obesity in a child. Consultations with children in primary care are often time-limited and occur in the context of an acute illness, and many opportunities are missed.

This article aims to provide concise, practical guidance to help GPs give preventive advice to families and to assess and manage overweight and obese children. We consider three different scenarios reflecting common situations in which problems may present: primary prevention, opportunistic approaches, and assessing children who present with weight problems.

Primary prevention of obesity in children and families

Tackling overweight and obesity once the problem has set in is less effective, so opportunistic prevention is an important approach that benefits the whole population. General practitioners should take every opportunity to emphasise to prospective parents, pregnant women, and new parents the importance of core parenting skills of providing a good diet and opportunities for children to exercise in the early years.

Opportunistic approaches to addressing overweight in an unaware parent

Often, a child or young person will consult their GP for problems not directly related to weight, such as sleep apnoea or musculoskeletal problems, or for another reason unrelated to weight. The GP is faced with the awkward task of broaching the topic of weight when it is does not seem to be a priority or concern from the child's or parent's/carer's perspective. Even if it is clearly a health risk, many healthcare professionals may be put off raising a concern about a child's weight for fear of alienating parents or causing offence; however, there is good evidence that when doctors acknowledge to adult patients that weight problems need to be tackled, these adults initiate lifestyle changes,8 so a similar approach is likely to be effective in children.

Assessing children who present with weight problems

Parents frequently express direct concerns about their child's behaviour. Growth and development in children are so closely linked to their home environment that underpinning behaviours such as eating and physical activity inevitably impact on weight. For young children, this may include poor eating patterns with mealtimes being a 'battleground' or challenging behaviours in teenagers who might for example be pushing boundaries about screen times. A minority of parents openly present concerns about their child's weight or might be referred following concerns from a health visitor, school nurses, or social workers.

A small minority of obese children may require referral to a specialist, including some who fall outside of the highest percentile of weight or those who on blood testing are found to have evidence of cardio-metabolic disturbance. Eating disorders are beyond the remit of this article but are likely to require referral and specialist input. See Box 1 for some suggested steps in assessing an overweight child and when to refer to a specialist.9

History

The main aims of a focused history are to:

  • rule out an underlying disorder that may need referral to a specialist (1%-2% of cases, see Box 1)
  • identify the presence of comorbidities
  • assess the risk of developing comorbidities. This applies to the majority of children, who often have a mixture of predisposing genetic factors and live in an obesogenic environment; these children may benefit from repeated, brief, focused interventions to tackle weight problems.

Physical examination to assess weight

Assessment of weight in children is more difficult than with adults. This is because all children and adolescents need to grow: the body mass index (BMI) of children changes naturally with time and the patterns are different in boys and girls. For example, during puberty, a child's weight may double but their height only increase by 20%, so simple measures of obesity such as BMI cannot be used to define overweight and obesity cut-offs. Instead, they should be expressed as a BMI centile in relation to a national ageand sex-matched population. The correct method is to measure height and weight and plot these against a growth reference chart such as the BMI centiles of the UK 1990 population reference chart, and to base assessments on the BMI Z score.10

Similarly, waist circumference should be measured at the narrowest point of expiration between the ribs and iliac crest and ideally plotted on a reference chart.10

Setting realistic goals

A range of interventions have been tried in order to address obesity in children, and many of these were assessed in a recent Cochrane review.11 While overweight or mildly obese children are growing, aim for weight maintenance rather than weight loss. Dietary restriction, increases in activity, and decreases in sedentary behaviour must not compromise normal growth and development. For some children with more severe weight problems, sustained gradual weight loss may be an appropriate target. Drastic, rapid weight reductions have a very poor success rate in the long term. Lasting lifestyle changes are a much better investment.

For some post-pubertal teenagers with extreme obesity, aiming for a weight loss of 1-2 kg per month may be worthwhile. Be aware that changes in body composition, such as a reduction in waist circumference or increasing fat-free mass, is increasingly a goal for many young people who aim to be 'fat but fit' and improve their metabolic profile. Be alert to the possibility of underlying eating disorders in some young people, particularly those who report vigorous efforts to lose weight through excessive exercise. Commitment from a GP to regular review and continuity of care underpin an effective doctor-patient relationship and can flag problems as they emerge. Pointing families to community-based services that are available can alleviate the burden on individual GPs and provide valuable support to families.

Box 1: Assessing an overweight child9

History

  • Ask parents for information on when their child eats, what they eat, and how they eat. Too fast or too slowly? What are the portion sizes? How does this fit with the parent's expectations?
  • Ask about the family eating environment-do they eat together at a table, or in front of the TV?
  • Ask about the child's and family's activity levels. How much screen time do they have? Ask how they travel to school, for example active travel including walking, or taking the bus or train or being driven. Ask them to how much time they spend in each physical activity. As a minimum, 60 active minutes per day is recommended
  • Ask about developmental milestones. Developmental delay in an obese child may suggest hypothyroidism, Prader-Willi syndrome etc. Ask about family and environmental factors, including children's size in relation to parents and siblings, or any family history of obesity, thyroid disease, or diabetes
  • Review systems to detect comorbid medical problems (e.g. snoring, nocturnal bingeing, orthopaedic problems, mood assessment)
  • Ask how the child fits in socially at nursery or school. Being overweight may result in social discrimination and may in turn impact negatively on the child's self-esteem.

Physical and laboratory examination

  • Plot body mass index on a growth chart.6 This provides an objective way of demonstrating to parents where their child lies on the bell curve. Repeat after 3 months. If parents do not accept that their child is overweight, do not jeopardise a good relationship. Perhaps the health visitor could broach the subject again at a later opportunity. Assess waist circumference6
  • Baseline (fasting) blood tests are worthwhile and should include a full blood count, which may pick up iron deficiency anaemia. Children who have clinical suspicion of complex obesity, medical problems arising from obesity, impaired glucose tolerance, diabetes, dyslipidaemia, or abnormal liver function should be referred to a specialist. Similarly, refer on to specialist services if there is a concern about mental health, including eating disorders.

Parental role

General practitioners should emphasise that practical advice is aimed at the entire family and not solely at the child. Parents are responsible for food shopping and preparing meals and should be made aware that they are role models for their children. They should support and encourage their child and provide positive feedback. Some families are at particular risk, for example those where the parents themselves have weight problems. For them, a major lifestyle change may be worthwhile because prevention of obesity is much more effective than treating obesity itself.

Practical advice for behaviour change

See Box 2 for some practical advice for parents/carers and their overweight child, and Box 3 for some useful resources for practitioners, parents/carers and children.

NICE guidance

NICE issued guidelines on the identification, assessment, prevention, and management of obesity in 2006 and 2013 (an update to the 2006 guideline is due in November 2014), noting a need to improve care, particularly in primary care.13,14 NICE observes, however, that the problem of obesity is population-wide and affects us all: 'The clinical management of obesity cannot be viewed in isolation from the environment in which people live'.13 A multi-agency approach in the local community is advocated, involving local authorities and directors of public health. Schools also need to be involved, with adequately trained staff who have enough time to discuss ideas and concerns with children and their parents. NICE concerns itself mostly with the role that the NHS plays in preventing and treating health problems, but tackling the obesity epidemic is likely to need concerted public health action.

Nationally this will require commitment for changes from government, the food industry, and environmental bodies. Positive changes that are already part of new policies include a new school food plan which means all children in reception will receive free school meals and primary and secondary schools will be educating children about nutrition and health alongside core academic subjects such as literacy and numeracy.

Clearly, it is not possible for GPs to take on all the challenges of tackling the obesity epidemic in their registered child population alone. It is a good idea to take time to find out what is happening in the local area, and what other services and support are available. Signposting families towards local services will make more efficient use of available resources and alleviate the burden on individual GPs. The key points that NICE makes that are relevant for local commissioners of services are to ensure that staff are adequately trained and that they have enough time to discuss ideas with children and their parents. NICE highlights that clinical commissioning groups need to ensure that there are adequate facilities to support communities to tackle obesity. However, community-based services tackling obesity are lacking in many regions and commissioners vary in their approach to investing in these. Although NICE has clarified criteria for referral for weight management to community-based pathways and specialist services including bariatric surgery, a major mismatch exists between what is needed and currently available.15

Box 2: Practical advice for behaviour change in overweight children9

  • Advocate regular mealtimes with minimal snacking (on fruit or vegetables only) in between
  • Advise families to eat meals together at a table and not in front of the television or computer
  • Advise parents to exchange all the child's sugar-sweetened drinks for water
  • Promote:
    • the consumption of fruit, vegetables, and complex carbohydrates such as bread, pasta and rice
    • low fat levels in meals (including meat) and non-fried foods
    • physical activity (e.g. walking or cycling to school) for a minimum of 1 hour per day
  • Suggest social activities with parents or friends (e.g. walking, playing games where the child will be physically active)
  • Reduce sedentary activities (e.g. television or computer) to 2 hours of media time per day (!). Related to this, the quality of sleep can be improved by removing all electronic devices (e.g. mobile phones) from bedrooms.

Box 3: Useful resources for practitioners, children, and parents/carers

Figure 1: the eatwell plate12
The eatwell plate

Conclusion

There are very many challenges and problems facing GPs, and childhood obesity is only one of them. Although there is no silver bullet for childhood obesity, primary care has a uniquely important role to play and practical strategies used in the consultation room can help families to gain healthier life trajectories to break the cycle of obesity across generations.

Further reading

Poskitt E and Edmonds L. Management of Child Obesity. Cambridge: Cambridge University Press, 2008. ISBN:9780521609777. Available from the Royal College of General Practitioners.

Declarations

SS is funded by a National Institute for Health Research Career Development Fellowship (NIHR CDF-2011-04-048). AL is funded by the Department of Health Policy Research Programme. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

 

  • The key responsibility for the prevention of childhood obesity now lies with public health departments based in local authorities
  • Childhood obesity has multifactorial causes and its management requires a multiagency and multi-professional approach:
    • this makes it an ideal subject to be included in the local health and wellbeing plan, which can identify the parts to be played by each agency (e.g. health, education, and transport) in an obesity prevention strategy
  • Health services' responsibilities will include the identification and management of childhood obesity and require well-trained staff:
    • there are key roles here for health visitors and school nurses working alongside GPs, and the strategy should identify clear pathways for care and when specialist referral is required.
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  2. Friedemann C, Heneghan C, Mahtani K et al. Cardiovascular disease risk in healthy children and its association with body mass index: systematic review and meta-analysis. BMJ 2012; 345: e4759.
  3. Jones Nielsen J, Laverty A, Millett C et al. Rising obesity-related hospital admissions among children and young people in England: National Time Trends Study. PloS One 2013; 8 (6): e65764.
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  9. Parry L, Saxena S, Christie D. Addressing an overweight child and an unaware parent in the general practice consultation. London Journal of Primary Care 2010; 3: 42-44.
  10. The National Obesity Observatory. A simple guide to classifying body mass index in children. National Obesity Observatory, June 2011. See www.noo.org.uk/uploads/doc/vid_11762_classifyingBMIinchildren.pdf
  11. Waters E, de Silva-Sanigorski A, Hall B et al. Interventions for preventing obesity in children (review). Cochrane Database Syst Rev 2011; 12: CD001871.
  12. Heathy start website. The eatwell plate. www.healthystart.nhs.uk/food-and-health-tips/healthy-eating-eatwell-plate/ (accessed 1 September 2014).
  13. NICE. Guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. Clinical Guideline 43. NICE, 2006. Available at: www.nice.org.uk/guidance/CG43
  14. NICE. Managing overweight and obesity among children and young people: lifestyle weight management services. Public Health Guideline 47. NICE, 2013. Available at: www.nice.org.uk/guidance/ph47
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