Childhood Obesity

Dr Aoife Kelleher

Journal Club

30th April 2015

• ‘Brian’• 9 year old boy• Weight >>99.6th centile• Height 75th centile• BMI >4SD above • Upset about his weight, bullied at school• ‘We’ve tried everything’

Why this topic?

• Always a big boy• ‘All his Dad’s side of the family are tall’• ‘Doesn’t eat all that much really’• No cardiovascular activity but he ‘does PE at school and

he loves swimming’• Parents both larger than average• Dad has type 2 diabetes diagnosed at 38 years

Further Information

• Born at term• Mum had gestational diabetes• Always at the top end of the centile charts• Significant increase in weight over the past 2 years• No medications, No allergies• No siblings

Background

• Centiles as described, no concern re growth velocity• No dysmorphic features• BP acceptable• Central adiposity• No acanthosis nigricans• No striae• Systemtic examination normal

Examination

• TW3 bone age• LFTs, U+Es• TFTs• Lipids• Fasting glucose and insulin• HbA1c• Molecular genetics (genetics of obesity study)• Leptin• OGTT

Investigations

• ‘Something must be done’• Serious discussion re dietary intake, portion size, healthy

choices• ?Dietitian referral• Increasing cardiovascular exercise, incorporating into

usual routine• Review in 6 months

» And ...........

What to do now?

• Weight increased by 7 kg.....

• ‘But we’ve tried everything....’

• ‘There must be a hormone problem....’

6 months later

WhyWeight Sheffield based at the Zest centreFormerly Zest for Health

Formerly Watch It

Free service for overweight and obese children

Children aged 7 – 15 years

Support healthy lifestyles, encourage healthier eating habits, increase physical activity, improve emotional wellbeing

2 hours per week for 12 weeks

Community based weight management services

Shine Health Academy

Manor based

Young people aged 10 – 17 years

Not for profit limited company

Healthy eating, exercise, cooking, emotional wellbeing, outdoor pursuits

Clinical question:

– In children who are overweight or obese, does participation in a community based weight management programme lead to sustained weight reduction or other benefits as compared with conventional management??

Try a community based weight management programme!

• Ane Kokkvoll, Sameline Grimsgaard, Silje Steinsbekk, Trond Flaegstad, Inger Njolstad

• Arch Dis Child 2015;100:441-448

Health in overweight children: 2-year follow-up of Finnmark Activity School – a randomised trial

• To compare a comprehensive lifestyle intervention for overweight children performed in groups of families with a conventional single family treatment

• Two year follow-up data on anthropometric and psychological outcome

Objective

• 97 overweight and obese children aged 6-12 years with BMI corresponding to >27.5kg/m2 in adults

• 2009-2013• Hammerfest Hospital• Randomised in a parallel design

Methods

Content of the intervention Single-family intervention Multiple-family intervention

Who is the target Parents and child Parents and child

Responsible for the intervention Community and hospital Community and hospital

Start Outpatient clinic 1 day Inpatient clinic stay for 3 days

Who delivers the interventionProject nurse, paediatrician and nutritionist at the hospital. Public health nurse in the municipality

Multidisciplinary team at the hospital. Public health nurse, physiotherapist and coach in the municipality

How Every family individuallyFamilies both individually and in groups

Physical activity for children Not arranged 2 hours a week in groups

Camp for families No camp 4 days 6–8 months from baseline

Solution-focused counselling Yes Yes

Follow-up intervals1, 2, 3, 5, 7, 10, 12, 18, 24 and 36 months

Equal intervals as the single-family group

Hours of contact first 12 months 8 36

Organised physical activity first 12 moths

0 38

Hours of contact 12–24 months 2.5 6.5

Organised physical activity 12–24 months

0 38

Characteristics of the two intervention programmes of Finnmark Activity School

• Prescheduled hospital visits at baseline, 3, 12, 24 and 36 months

• Anthropometric measurements, bloods, bioelectric impedance analysis and clinical examination

• Nurses blinded to group allocation preformed primary outcome measures

• Questionnaires at baseline, 6, 12, 24 and 36 months

Outcomes and blinding

• Powered to detect a between-group difference in mean change of 0.5kg/m2 BMI with SD of 0.8 from baseline to 2 years

• 80% power

• No difference between groups at baseline

• All data analysed by intention-to-treat

Sample size and statistical methods

Flow of participants* through 24 months of treatment: Finnmark Activity School. *Siblings are not included in the analysis. †Longitudinal analyses include all available data from every

subject through withdrawal or study completion.

Ane Kokkvoll et al. Arch Dis Child 2015;100:441-448Copyright © BMJ Publishing Group Ltd & Royal College of Paediatrics and Child Health. All rights reserved.

• BMI increased by 1.29kg/m2 in the MUFI group and by 2.02kg/m2 in the SIFI group (p=0.075)

• Mean decrease in the BMI SD score was 0.2units in the MUFI group and 0.08units in the SIFI group (p=0.046)

• Waist circumference increased by 0.21cm in the MUFI group and 2.6cm in the SIFI group (p=0.038)

• Pooled data showed a significant decrease in BMI SD score of 0.14 units

Results

• No between group difference in mental health, self worth or quality of life

• But...

• Pooled data showed a significant improvement in parent and self-reported SDQ problem scale and an increase in self-reported athletic competence

Results continued

• Mean treatment effect in the MUFI group did not reach >0.25 BMI SD score reduction – necessary to reduce CVS risk factors

• Waist circumference is considered a good marker of visceral adipose tissue in children

• No adverse effects in psychological outcomes in either group after two years

Discussion

• Randomised design

• Blinding of primary outcome assessors

• Sample size achieved

• Appropriate statistical models

• Moderate withdrawal

• Appropriate pilot study

Strengths

• Lower study power than anticipated due to larger variability in BMI

• Inclusion criterion of BMI 27.5kg/m2• Nurses measuring waist circumference not blinded• Different reference populations for the calculation of the

BMI SD score• Variability of BMI SD score depending on level of

adiposity• Same providers in both treatment arms

Limitations

• Can the cost of MUFI be justified?

• Effect of waist circumference reduction on CV risk factors needs further investigation

• Overall significant decrease in BMI SD score in both groups suggests increased awareness and minimal support is sufficient to succeed with lifestyle changes in some families

• Mental health and well-being in addition to other health outcomes should be examined

Implications

• No between-group difference for BMI or psychological outcomes

• Significant between-group difference in waist circumference in favour of the MUFI approach

• Pooled results showed significant improvement in reported mental health combined with a significant decrease in BMI SD score of 0.14

Conclusions

1. Did the trial address a clearly focused issue?» Yes

2. Was the assignment of patients to treatments randomised?

» Yes

3. Were all the patients who entered the trial properly accounted for at its conclusion?

» Yes

CASP screening questions

1. Were patients, health workers and study personnel ‘blind’ to treatment?

» Patients were not blinded» Nurses in the main were blinded save those doing

waist circumference measurements

2. Were the groups similar at the start of the trial?» Yes

CASP Detailed Questions

1. How large was the treatment effect?» Minimal!

2. How precise was the estimate of the treatment effect?» Reasonably

What are the results?

1. Can the results be applied to the local population?» Different health system» Cash strapped NHS» Similar population obesity levels

2. Were all the clinically important outcomes considered?» ~Yes

3. Are the benefits worth the harms and the costs? » Probably not!

Will the results help locally?

• 1 in 5 children in reception are overweight or obese

• Rises to 1 in 3 by year 6 (19.1% obese, 14.4% overweight)

» National Child Measurement Programme 2013/2014

Childhood obesity in the UK

'Two phases' of childhood obesity suggestedBy Nick Triggle Health correspondent

• 28 April 2015• From the section Health

Parents 'rarely spot child obesity'By James Gallagher Health editor, BBC News website 30 March 2015From the section Health

Parents hardly ever spot obesity in their children, resulting in damaging consequences for health, doctors warn.In a study of 2,976 families in the UK, only four parents thought their child was very overweight. Medical assessments put the figure at 369.The researchers, writing in the British Journal of General Practice, said obesity had become the new normal in society.Experts said the study showed the "enormity" of the obesity epidemic.Around one in five children in Year 6 is obese and a further 14% are overweight, the National Child Measurement Programme shows.

Doctors 'will not tackle' children's weight problemsA new study shows hospital doctors treating obese children are reluctant to raise the topic of their weight, or point them to help or advice

Doctors are turning a "blind eye" to child patients who are overweight or obese, researchers say. A study of children visiting an outpatients department over a 10-week period looked at whether doctors and nurses offered any intervention to those who were overweight or obese, such as advice, further investigation or further specialist support. While one in four children were overweight or obese, few were offered any such intervention - while in contrast, all underweight children were investigated and given follow-up support. The study found that of the 11 per cent of children who were obese, only a third of them (34 per cent) were offered anything like this. The study found that among the 14 per cent of children who were overweight, just two per cent were subject to any type of intervention. Latest national figures show one in 10 children are now obese before they start primary school, while more than one in 5 reaches this point by the age of 11.

Any questions?

• Thank you