childhood obesity
TRANSCRIPT
Increasingly common problem in children Difficult to treat The adverse consequences of childhood obesity,
such as development of hypertension, hyperlipidaemia and type 2 diabetes, are under-recognised
The tendency for childhood obesity to persist into adult obesity
The prevention of childhood obesity is not adequately addressed despite a rapid rise in its prevalence
Treatments have only limited success, resulting in a negative approach to treatment strategies
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Obesity in children is different from obesity in adults - all children and adolescents need to grow; for example during puberty, a child’s weight will double and their height increase by 20%
Simple measures of obesity such as the body mass index (BMI) cannot be used in isolation, instead they should be expressed as a BMI percentile in relation to an age and sex matched population
In the prevention and treatment of childhood obesity, dietary energy restriction, increases in activity and decreases in sedentary behaviour must not compromise normal growth and development
weight maintenance is often a suitable goal, rather than weight loss
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The aetiology lies in deranged energy balance
In children, growth is only possible if energy intake (as food and drink) exceeds energy output (resting metabolic rate and activity)
Excess energy is stored in new tissue, excess adipose tissue will be formed and stored
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In UK, a rapid rise in the prevalence of obesity - due to environmental and behavioural changes relating to diet and inactivity
Particularly due to increased intake of high fat foods - they are readily available, very palatable and energy-dense, but may not satisfy the appetite as quickly as high carbohydrate foods
The marked rise in obesity prevalence has coincided with a major change in how children spend their time, resulting in both a decrease in physical activity and a rise in sedentary behaviour
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There has been a general reduction in activity during daily living (less walking, greater use of cars, more use of escalators and lifts), and also reductions in the amount of physical education and sport carried out at school and at home
The marked rise in sedentary behaviour -increased time spent watching television, playing computer games, surfing the internet and using the telephone
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Societal and political context to these changes loss of school playing fields lack of a safe environment in which to walk or
cycle to school or for physical play at the home transport policies that favour driving above
cycling or walking a food industry that targets children with
advertisements for high energy foods health promotion policies that fail to target
appropriate dietary change or address issues of health inequality
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Body Mass Index (BMI: weight in kilograms divided by the square of height in metres: kg/m2), obesity - BMI >30.0 kg/m2
For children and young people <18 years, BMI is not a static, varies from birth to adulthood, different between boys and girls
Interpretation of BMI values in children and young people therefore depends on comparisons with population reference data, using cut-off points in the BMI distribution (BMI percentiles)
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For clinical use:obese children are those with a BMI >98th
centile of the UK 1990 reference chart for age and sex
overweight children are those with a BMI >91st centile of the 1990 reference chart for age and sex
For epidemiological (research) purposes: overweight should be defined as BMI >85th
centile of the 1990 reference data obesity should be defined as BMI >95th centile
of the 1990 reference data for age and sex
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Increasing worldwide USA - one in five children are overweight UK - 11% of 6 year olds and 17% of 15 year
olds (Health Survey for England 1996) had a BMI >95th centile
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Cardiovascular Risk Factors, Metabolic & Endocrine Complications: increase in the prevalence of adolescent type 2
diabetes Atherosclerosis (level 3 evidence) Coronary artery diseases increased blood pressure adverse lipid profiles adverse changes in left ventricular mass Hyperinsulinaemia (evidence level 2)
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Psychological Consequences poor self esteem, being perceived as
unattractive, depression, disordered eating, bulimia and body dissatisfaction (level 2)
Other Medical Problems the risk of developing asthma and the
exacerbation of pre-existing asthma abnormalities of foot structure and function increased risk of type 1 diabetes (evidence level
2+)
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Long Term Morbidity & Mortality increased 32-year mortality risk (relative risk
1.95, confidence intervals 1.41 - 2.69) for men with BMI >26 at age 18 years (Evidence level 2++)
Socioeconomic associations Two good quality studies, one from the UK and
one from the USA show adverse associations between childhood obesity and educational attainment and income in women(evidence level 2+)
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Children at high risk of developing obesity: Syndromes like Prader Willi Hypothyroidism Socioeconomic status: relationship between
prevalence of childhood obesity and deprivation (defined by Townsend score), survey of 5 to14 year olds from 1994 to 1996 in Plymouth - found a significant relationship between degree of deprivation and increased prevalence of childhood obesity. (evidence level 3)
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GENDER - None AGE
Obesity was found to be more prevalent with increasing age in British children. Evidence level 2+,3
PARENTAL OBESITY No published, recent, UK study has evaluated the role of
parental obesity as a risk factor for childhood obesity in a cohort or cross-sectional survey
DIET No published UK study has evaluated the role of diet in a
cohort of children prior to the development of obesity. PHYSICAL ACTIVITY
No published UK study has evaluated the role of physical activity in a cohort of children prior to the development of obesity.
PHYSICAL INACTIVITY AND TELEVISION VIEWING There is increasing evidence that physical inactivity,
particularly increased TV viewing, is a risk factor for the development of obesity in children and adolescents. There are currently no published studies on this topic from the UK.
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School, family and societal interventions to prevent obesity:
the child and family are perceived to be ready and willing to make the necessary lifestyle changes
Weight maintenance:healthier eating increasing habitual physical activity (brisk
walking) to a minimum of 30 mins day. In healthy children, 60 minutes of moderate-vigorous physical activity/day has been recommended
reducing physical inactivity (watching television and playing computer games) to <2 hours/day on average or the equivalent of 14 hours/week
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Possible approaches to implementing behavioural changes: encouraging children and their families to make
a few small, permanent changes in behaviour at a time
developing family awareness of eating, activity, and parenting behaviours
encouraging a family to improve their monitoring of their eating and activity habits
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When to refer:children who may have serious obesity-related
morbidity that requires weight loss (benign intracranial hypertension, sleep apnoea; obesity hypoventilation syndrome, orthopaedic problems and psychological morbidity)
children with a suspected underlying medical (endocrine) cause of obesity including all children under 24 months of age who are severely obese (BMI >99.6th centile)
all children with BMI >99.6th centile (who are at higher risk of obesity-related morbidity)
Suspect an underlying medical cause of obesity if a child is obese and also short for their age
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Role of secondary care: The primary purposes of referral - to exclude
underlying medical causes of obesity and to treat comorbidity
Most patients will not have an underlying medical cause and should be discharged back to management in the community
In patients with no underlying medical causes but with serious obesity-related comorbidity, treatment of the comorbidity may be indicated
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In secondary care, treatment should follow the principles, but weight loss, rather than weight maintenance may be the appropriate aim For obese children over the age of seven years, who can demonstrate prolonged weight maintenance and who are cared for by secondary care services, modest weight loss (no more than 0.5kg/month) advised
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Obesity in children is becoming more common
Obesity is due to an imbalance between energy consumption and energy expenditure. Obese children do not have low energy needs. They have high energy needs to support their high body weight
Obesity is a health concern in itself and also increases the risk of other serious health problems such as high blood pressure, diabetes and psychological distress
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An obese child tends to become an obese adult
There is no evidence that any drug treatment is effective in treating obesity in children Obesity in children may be prevented and treated by making lifestyle changes such as: increasing physical activity decreasing physical inactivity (eg TV watching)
Encouraging a well balanced and healthy diet
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Lifestyle change involves making small gradual changes to behaviour
Family support is necessary for treatment to succeed
The aim of treatment is to help children maintain their weight (so they can “grow in to it”)
A medical cause of obesity is more likely in the child who is obese and short for their age
Most children are not obese because of an underlying medical problem but as a result of their lifestyle
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Birth to 5 yrs: Breast milk food of choice Introduction of solid foods should be avoided
until infants are at least four to six months of age.
Weaning is best done gradually, starting with small amounts of pureed fruit or vegetables, or rice or other gluten free cereal
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From six months: full fat versions of dairy products recommended starchy foods very high in fibre should be avoided
From two years: gradual introduction of low fat dairy products so
that by the age of 5 most children are eating in accordance with the ‘Eating for Health’ plate model
Children from approximately one year would normally be expected to eat three meals a day and two between-meal snacks
Foods particularly high in fat and sugar are not necessary
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Over 5 yrs: One third of a child’s intake by volume should
comprise starchy carbohydrate foods, one third fruits and vegetables, with smaller amounts of foods from the meat, fish and alternatives group and low fat dairy products
fatty, sugary foods in small amounts can be part of a normal healthy diet
adequate fluid intake is also important (water, low fat milk, very well diluted low calorie diluting juices and diluted fruit juice)
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Eat regularly Include bread, pasta, cereals, rice or potatoes at
every meal Eat some form of fruit and vegetables at each
meal Limit foods high in sugar such as sweets and
chocolate Limit foods high in fat such as crisps, chips and
pastries Limit fried foods (including deep fried foods)
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Take plenty of exercise & limit time spent watching TV or playing computer games
Provide meals and snacks at regular times; avoid grazing all day long
Separate eating from other activities such as watching TV or doing schoolwork
Offer healthy options but agree one to two treats a week
Encourage the child to listen to internal hunger cues and to eat to appetite
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Instead of offering food as a reward to a child, try alternatives such as giving stickers, going to the cinema, a new book or toy, or having a friend to stay overnight
Comfort with attention, listening and hugs instead of food
Ask for help from friends and family in supporting behaviour changes
Keep foods that the child should be avoiding out of the house
Avoid classifying foods as good or bad The approach a parent takes to a child’s
behaviour should always be consistent
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More physical activities (30 min/day) walking instead of taking the bus using stairs instead of escalators or lifts going for walks, visits to parks and playgrounds swimming, cycling, rollerblading team activities such as football, dancing,
Brownies/Cubs and Guides/Scouts attending PE lessons/outdoor education.
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The Behavioural Health Centre, The Children's Hospital of Philadelphia and the University of Pennsylvania School of Medicine
498 participants 12 to 16 years of age with a body mass index (BMI) that was at least 2 units more than the U.S. weighted mean of the 95th percentile based on age and sex
CONCLUSIONS: Sibutramine added to a behaviour therapy program reduced BMI and body weight more than placebo and improved the profile of several metabolic risk factors in obese adolescents
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E Stamatakis, P Primatesta, S Chinn et al UCL & King’s College London Archives of Disease in Childhood, October 2005;90:999-1004
Individuals from lower socioeconomic strata have diets rich in low cost energy dense foods participate less in sports or physical activity have lower weight control awareness Lower SES is linked to lower control over one’s
life and this does not encourages the adoption of healthy lifestyles for a given individual and their children
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To examine the childhood overweight and obesity prevalence trends between 1974 and 2003
Assess whether these trends relate to parental social class and household income
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A school based and a general population health survey: the National Study of Health and Growth in 1974, 1984, and 1994, and the Health Survey for England, yearly from 1996 to 2003
Participants: 14587 white boys and 14014 white girls aged 5–10
years Ethical Approval:
by London Medical Research Ethics Council
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Physical Measurements:Exact ageHeight & Weight
Overweight and obesity prevalence:calculated using UK specific as well as
international age & sex specific body mass index cut-offs - Wt(kg)/Ht(m2)
Socioeconomic status:measured using the Registrar General’s social
class; household income (1997 onwards only) was adjusted for household size
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Total of 14587 boys and 14014 girls aged 5–10 years
The prevalence of obesity in boys increased from 1.2% in 1984 to 3.4% in 1996–97 and 6.0% in 2002–03
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In girls, obesity increased from 1.8% in 1984 to 4.5% in 1996–97 and 6.6% in 2002–03
Obesity prevalence has been increasing at accelerating rates in the more recent years
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Children from manual social classes had marginally higher odds (OR 1.14, 95% CI 0.98 to 1.33) and children from higher income households had lower odds (OR 0.74, 95% CI 0.61 to 0.89) to be obese than their peers from non-manual class, and lower income households
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03/02/15 43Copyright ©2005 BMJ Publishing Group Ltd.
Stamatakis, E et al. Arch Dis Child 2005;90:999-1004
Figure 1: Obesity prevalence trends from 1997 to 2002-03 by income category and sex (Lower income: bottom 50% of income distribution of each individual year; higher income: top 50% of income distribution of each individual year)
03/02/15 44Copyright ©2005 BMJ Publishing Group Ltd.
Stamatakis, E et al. Arch Dis Child 2005;90:999-1004
Figure 2: Obesity prevalence trends from 1997 to 2002-03 by income group and social class for boys and girls combined.
Results showed that the upward trends in overweight and obesity in children noted by other authors over the 1990s are continuing into the 2000s
Alarmingly, the rate of increase has accelerated over the last decade
15 fold increase in the average annual rate of change in boys and 5 fold increase in girls
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Family social class at birth & in infancy have a long term effect on BMI
Obesity among children from manual classes and children from lower income households seems to be increasing more rapidly than among children from non-manual classes and higher income households
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Both material deprivation and other early social influences such as parental occupation are closely related to the development of obesity in childhood
Social class and especially income inequalities should be tackled, and interventions aimed at relieving economic hardship may reduce the risk of behaviors damaging health from childhood
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Childhood obesity is increasing rapidly into the 2000s in England
These increases are more marked among children from lower socioeconomic strata
Considering the calamitous consequences of obesity, there is an urgent need for action to halt and reverse this rapid upward trend among English children,
especially among those from lower socioeconomic strata
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Cross References
Psychological consequences obese children are more likely to experience
psychological or psychiatric problems than non-obese children
girls are at greater risk than boys risk of psychological morbidity increases with age Low self esteem and behavioral problems were
particularly commonly associated with obesity 34% of obese (defined as BMI >95th centile), white,
13–14 year old girls had low self esteem (defined as <10th centile) compared to 8% of non-obese white girls
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Cardiovascular risk factors in childhood high blood pressure dyslipidaemia abnormalities in left ventricular mass and/or function abnormalities in endothelial function hyperinsulinaemia and/or insulin resistance
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Social and economic effects obesity in adolescence/young adulthood has
adverse effects on social and economic outcomes in young adulthood (income, educational attainment)
Persistence of obesity from childhood Impact of childhood obesity on adult
morbidity and risk of premature mortality Cardiovascular risk factors in adulthood
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the promotion of active lifestyles the restriction of television viewing the promotion of fruit and vegetable
consumption the restriction of energy dense and sugary foods
and drinks
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