Obesity in Children
Childhood obesity is a significant and growing public health concern in the UK, with the prevalence of overweight and obese children increasing. Being overweight or obese can lead to significant health risks, both in childhood and later in adulthood. A thorough and sensitive approach is essential to identify the underlying causes and manage the condition effectively.
Aetiology and Risk Factors
While overeating and a sedentary lifestyle are the most common causes, a holistic approach is needed to identify other contributing factors.
Endocrine Causes: Although rare, these should be considered, especially if weight gain is rapid or atypical. Causes include hypothyroidism, Cushing’s disease, and growth hormone deficiency.
Syndromes: Certain genetic syndromes are associated with obesity, such as Prader-Willi syndrome and Down’s syndrome.
Medications: Some medications can cause weight gain as a side effect, including valproate, risperidone, and corticosteroids.
Clinical Assessment
History
A detailed history should be taken to understand the context of the weight gain and assess for complications.
Onset: When did the weight gain begin? Was it associated with a specific event or change in lifestyle?
Dietary Habits: A detailed history of food intake, including portion sizes, types of food, and frequency of snacks.
Physical Activity: Assess the amount, intensity, and variety of physical activity.
Associated Symptoms: Enquire about co-morbidities such as obstructive sleep apnoea (snoring, poor sleep), joint pain, or symptoms of diabetes. Also, ask about psychosocial issues like bullying.
Examination
Growth Metrics: Plot the child’s weight, height, and BMI centile on a growth chart. A BMI above the 91st centile is considered overweight, and above the 98th centile is considered obese.
Physical Signs: Look for signs of underlying conditions, such as Acanthosis nigricans (a sign of insulin resistance), stretch marks, or any dysmorphic features.
Blood Pressure: Record blood pressure at each visit, as hypertension is a common comorbidity.
Investigations
Routine investigations are generally not required for simple, generalised obesity of dietary origin. Investigations are reserved for children with a BMI above the 98th centile with associated comorbidities or a suspected underlying cause.
Metabolic Syndrome: Tests may include HbA1c, fasting lipids, and a glucose and insulin profile.
Endocrine: If an endocrine cause is suspected, tests for thyroid function and cortisol levels may be ordered.
Genetics: Genetic testing may be considered in children with dysmorphic features.
Referral to Secondary Care
A referral to a specialist paediatric service is recommended if:
The child’s BMI is above the 99.6th centile.
The child’s BMI is above the 98th centile with associated comorbidities, such as hypertension or type 2 diabetes.
There is a suspected underlying endocrine or genetic cause.
Management
Management is a long-term process that requires a multi-faceted approach.
Non-Drug Management of Childhood Obesity in the UK
The non-drug management of childhood obesity in the UK is a crucial, long-term process that requires a multi-faceted approach. It focuses on lifestyle changes, education, and behavioural support to promote a healthy relationship with food and physical activity.
1. Education and Family Engagement
A crucial first step is to engage the entire family and provide clear, understandable education. Parents and caregivers are key to successful management.
Understanding BMI: Explain what body mass index (BMI) is and what the centile charts mean for the child’s age and sex. This helps families understand the severity of the issue and its potential health risks.
Health Risks: Inform the family about the possible complications of obesity, such as obstructive sleep apnoea, joint pain, and an increased risk of type 2 diabetes.
Set SMART Goals: Work with the family to set realistic and achievable goals for diet and physical activity. SMART goals are Specific, Measurable, Achievable, Relevant, and Time-bound.
2. Dietary Changes
Dietary interventions should focus on making sustainable, healthy eating a part of the family’s routine.
Food Types: Encourage a balanced diet rich in fruits, vegetables, and whole grains. Advise on reducing the intake of sugary drinks, high-fat snacks, and processed foods.
Portion Control: Help the family understand appropriate portion sizes for their child’s age. A dietitian can provide a personalised plan to manage total calories and portion sizes.
Structured Meals: Promote regular mealtimes and discourage grazing or eating in front of screens.
3. Physical Activity
Increasing physical activity should be a gradual process to ensure it is enjoyable and sustainable.
Moderate Intensity: Encourage children to engage in at least 60 minutes of moderate-intensity physical activity per day, which can be broken up throughout the day.
Variety: Encourage a variety of sports and activities to keep the child motivated. This could include local sports clubs, swimming, or active play in the park.
4. Psychological and Behavioural Support
Motivation: Help the child and family find their own motivations to make changes.
Addressing Emotional Issues: A psychologist can help the child and family manage emotional difficulties related to their weight, such as emotional eating or bullying. They can also work on strategies to help families adopt new, healthier behaviours.
Pharmacological and Surgical Management of Childhood Obesity in the UK
Pharmacological and surgical interventions for childhood obesity in the UK are reserved for severe cases that have not responded to lifestyle and behavioural changes. These options are considered last-line treatments due to potential side effects and the need for long-term follow-up.
Pharmacological Options
Drug therapy for childhood obesity is not widely used and is only considered in specific circumstances, under the guidance of a paediatric obesity specialist.
Orlistat: This is a lipase inhibitor that works by reducing the absorption of dietary fat. It is the only drug currently approved by the National Institute for Health and Care Excellence (NICE) for the management of obesity in children and adolescents.
Indications: Orlistat is recommended for adolescents aged 12 and older with severe obesity (BMI >98th centile) who have not responded to lifestyle changes and who have significant weight-related co-morbidities.
Side Effects: Common side effects include gastrointestinal issues such as fatty stools, faecal urgency, and flatulence.
Metformin: While not licensed for obesity, metformin is a drug used to manage prediabetes and type 2 diabetes. It may be used in adolescents with insulin resistance and obesity to improve glycaemic control.
Surgical Options
Bariatric surgery is a drastic measure and is only considered in a very small number of cases.
Indications: Bariatric surgery is reserved for adolescents with a BMI of 40 kg/m² or more (or >99.6th centile) or a BMI of 35 kg/m² or more with significant co-morbidities (e.g., type 2 diabetes, obstructive sleep apnoea) that have not responded to conventional weight management programmes.
Patient Selection: The decision for surgery is made by a multidisciplinary team and requires a comprehensive assessment. The adolescent must be physically and psychologically mature enough to understand and adhere to the life-long commitment and follow-up required after surgery.
Types of Surgery: Common bariatric procedures include the Roux-en-Y gastric bypass and sleeve gastrectomy, which work by reducing the size of the stomach or altering the digestive system to limit calorie absorption.
Both pharmacological and surgical interventions for childhood obesity are highly selective and require a specialist multidisciplinary team approach. They should only be considered after a comprehensive assessment and when all other non-drug management strategies have failed to produce significant and sustained results.