Issue 126 childhood obesity

PAEDIATRIC

CHILDHOOD OBESITY Maeve Hanan Registered Dietitian, City Hospitals Sunderland

Maeve works as a Paediatric Dietitian in City Hospitals Sunderland. She also runs a blog called Dietetically Speaking.com which promotes evidencebased nutrition and dispels misleading nutrition claims and fad diets.

Childhood obesity is becoming an increasingly worrying issue.1 In 2014, an estimated 41 million children worldwide under the age of five were either overweight or obese1 and UK figures from 2015 revealed that almost a third of all children were overweight or obese.2 It may be surprising that, in absolute figures, there is more childhood obesity in developing countries compared to high-income countries; for example, in Africa 10.3 million children are classed as overweight or obese, which has almost doubled in the past 25 years.1 There is also an economic motivation for tackling this issue as it is estimated that the NHS in England spends roughly ÂŁ5 billion per year on treating conditions related to obesity.3 POTENTIAL CONSEQUENCES

Endocrine disorders Childhood obesity has been shown to increase the risk of developing diabetes as an adult more than adultonset obesity does.9 Furthermore, children as young as seven have been diagnosed with Type 2 diabetes in the UK.4,6 UK data also shows that 95% of children diagnosed with Type 2 diabetes were overweight and 83% were obese, 7 which is supported by similar data from the US.8 Premature puberty is also associated with childhood overweight and obesity, which can impact on growth and behaviour.

Respiratory disorders A recent systematic review found a 40-50% increased risk of asthma in children who are overweight or obese.10 Specifically, a rapid increase in BMI in the first two years of life is associated with an increased risk of developing childhood asthma11 and a higher BMI may be associated with a more severe form of asthma.12 Research suggests that obstructive sleep apnoea rates may be as high as 60% in obese children and adolescents.13 Overweight and obesity can also reduce exercise tolerance and increase fatigue levels.

Cardiovascular disorders As well as increasing the risk of developing cardiovascular disease in adulthood, childhood obesity can result in cardiovascular damage in childhood.14 Studies have found that 62-70% of those with childhood obesity present with cardiovascular risk factors such as hyperlipidaemia and hypertension.15-16. A study from the US reported that children in the obese category had a fourfold increased risk of developing hypertension as an adult.17 Musculoskeletal disorders Overweight and obesity can add excess pressure to the musculoskeletal system www.NHDmag.com July 2017 - Issue 126

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PAEDIATRIC Figure 1: Prevalence of excess weight among children

which can result in Blount’s disease (where the lower leg becomes bow-shaped due to interference with the tibial growth plate), hip disorders, back pain, knee pain, ankle and foot issues and more restricted activity levels.4

Worryingly, it has also been reported that obesity can double the risk of premature death,3 which could potentially take three to seven years off an obese adult’s life.5

Gastro-intestinal disorders Childhood obesity can increase the risk of developing non-alcoholic steatohepatitis (NASH), where fat can accumulate in the liver causing inflammation and damage.5

There is ongoing research into the numerous factors which contribute to obesity; but, overall, this is a complex area. Energy imbalance is an important part of this picture, but there is ongoing research into areas such as physiological, gastrointestinal, hormonal and metabolic risk factors. The obesogenic environment has a big role in encouraging an energy imbalance, with the increased availability of cheap high energy foods and an increasingly sedentary lifestyle; which often includes a lot of ‘screen time’ when it comes to childhood obesity.1 Genetic and epigenetic responses have an impact on childhood obesity risk, as maternal malnutrition and undernutrition in early childhood have been shown to increase the risk of obesity in later life. Conversely, maternal and paternal obesity can also increase the risk of childhood obesity.1 In developed countries, the highest risk of childhood obesity in seen in lower socioeconomic groups and also within minority

Psychological issues Evidence shows an increased risk of: low selfesteem, reduced quality of life, behavioural issues, poor social skills, being bullied, body image dissatisfaction and eating disorders in children and adolescents who are in the obese weight category.4,18-19 These issues may contribute to the observed association between childhood obesity and reduced educational attainment.1 Chronic diseases in adulthood Childhood obesity often leads to adult obesity and related chronic conditions1 such as: heart disease, stroke, Type 2 diabetes, dementia, certain cancers (e.g. breast, colon, endometrial) and liver disease.1,5,20 22

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CAUSES OF CHILDHOOD OBESITY

Table 1: Summary of the UK Government Childhood Obesity Plan Soft drinks industry levy

Producers and importers of sugary drinks have two years to lower the amount of sugar in their products, otherwise they will face an increased levy.

20% reduction in sugar content of products

Challenging the food and drinks industry to reduce the sugar in products frequently consumed by children (e.g. breakfast cereals, yoghurts, cakes, biscuits, confectionery) by 5% in year one and 20% by 2020.

Support research and innovation

Working with Innovate UK, the Agri-Food Technology Council and the Food Innovation Network to create healthier products.

Updating the nutrient profile model

Products have a score to represent how healthy they are which affects what foods can be advertised to children. However, these need to be updated to represent the current evidence base.

Healthy options in public sector settings

Setting an example in all public sector buildings (e.g. schools, hospitals, leisure centres, etc) by providing healthy food options and restricting junk food.

Supporting the cost of healthy options where needed

Ongoing ‘Healthy Start’ scheme which provides vouchers for fruit, vegetables and milk to those who need financial support.

Encouraging an hour of physical activity per day for all children

Every primary school child should get at least 30 minutes of physical activity in school via ‘active break times, PE, extra-curricular clubs, active lessons or other sport and physical activity events’. The remaining 30 minutes should be provided outside of school.

Improving sport and physical activity programmes in schools

All primary schools in England should have access to good quality local and national sport and physical activity programmes.

Creating a healthy rating scheme for primary schools

A voluntary scheme for primary schools to be introduced in September 2017 to encourage healthier eating and physical activity.

Making school food healthier

Encouraging all schools, including academies to commit to new UK School Foods Standards (2015) and £10 million per year from the soft drinks levy to be used to support healthy breakfast clubs.

Clearer food labelling

Potentially distinguishing between the types of sugar in products to support healthier choices.

Supporting Early Years settings

Revised voluntary guidelines for menus in Early Years settings by the Children’s Food Trust.

Harnessing new technology

For example: Change4Life Sugar Smart app and digital innovations from Public Health England.

Health professionals to support families

Making ‘Every Contact Count’ with conversations on behaviour change, referrals for weight management support and signposting to reliable websites and resources.

groups who may be at risk of poor interaction with the health care system.1 For example, in the UK, children from the lowest income groups have double the risk of becoming obese compared to children from more affluent areas.3 However, the opposite is true in the developing world where higher obesity rates are seen in wealthier population groups; which may be related to the loss of traditional diets.1 The way society interacts with obesity can also exacerbate this issue; as the perceived

normalisation of obesity can reduce an individual’s motivation to make changes,1 but equally, the stigmatisation of obesity can hinder behaviour change due to psychological processes, especially when it comes to issues such as emotional eating and binge eating.

REDUCING CHILDHOOD OBESITY

It is often discussed that ‘no single intervention will cure childhood obesity’ due to its complex background as discussed above. For this reason, www.NHDmag.com July 2017 - Issue 126

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PAEDIATRIC Figure 2: Ending childhood obesity - recommendations from WHO

the World Health Organisation (WHO) have formed a ‘Commission on Ending Childhood Obesity’ which highlights the responsibility of all stakeholders (i.e. WHO, international organisations, national governments, NGOs, the private sector, charitable organisations and universities) in reducing the risk of childhood obesity to improve health and health equity worldwide.1 The main areas WHO has recommended to target are highlighted in Figure 2.

The UK government’s response to this call for action was the 2016 childhood obesity strategy which aims to reduce the rate of childhood obesity in England over the next 10 years.3 This has received a lot of criticism for being too weak in its proposals and the document itself states that ‘the launch of this plan represents the start of a conversation, rather than the final word’.

The main points of the UK’s ‘Childhood Obesity: A Plan for Action’ are summarised in Table 1.

From my experience of working in a childhood weight management setting, I feel that the way we interact with children and their families is key, especially ensuring that we focus on the positives, set realistic goals, boost the children’s self-esteem as much as possible and focus on ‘healthy choices’ and moderation rather than obsessing over a ‘healthy weight’.

It can also be useful to highlight the benefits of healthy changes without mentioning weight; for example, explaining the benefits of a healthy diet regardless of weight, or how physical activity is associated with healthy bones and joints, improved fitness, improved mood, better sleep and improved academic performance.3 CONCLUSION

Childhood obesity is evidently a crucial and topical issue worldwide which has far-reaching implications. Hopefully, in the next 10 years we will see an improvement in the prevalence of childhood obesity, but for this to happen large scale changes and cooperation between all key players is urgently needed.

References 1 World Health Organisation (2016). Report of the Commission on Ending Childhood Obesity (available at: http://apps.who.int/iris/ bitstream/10665/204176/1/9789241510066_eng.pdf) 2 Health and Social Care Information Centre (2015). Health Survey for England 2014 3 HM government (2016). Childhood Obesity - A Plan for Action (available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/546588/Childhood_ obesity_2016__2__acc.pdf) 4 Public Health England (2017). Health risks of childhood obesity (available at: www.noo.org.uk/NOO_about_obesity/obesity_and_health/health_risk_child) 5 Childhood Obesity Foundation. What are the Complications of Childhood Obesity? (available at: http://childhoodobesityfoundation.ca/what-is-childhood-obesity/ complications-childhood-obesity/) 6 Diabetes UK (2012). Key Statistics on Diabetes 7 Richardson et al (2012). Timing and duration of obesity in relation to diabetes: findings from an ethnically diverse, nationally representative sample 8 Li et al (2009). Prevalence of pre-diabetes and its association with clustering of cardiometabolic risk factors and hyperinsulinemia among US adolescents 9 Haines et al (2007). Rising incidence of Type 2 diabetes in children in the UK 10 Egan et al (2013). Childhood body mass index and subsequent physician-diagnosed asthma: a systematic review and meta-analysis of prospective cohort studies 11 Rzehak et al (2013). Body mass index trajectory classes and incident asthma in childhood: results from eight European birth cohorts 12 Black et al (2013). Increased asthma risk and asthma-related healthcare complications associated with childhood obesity 13 Kang et al (2012). Body weight status and obstructive sleep apnea in children 14 Cote et al (2013). Childhood Obesity and Cardiovascular Dysfunction 15 Freedman et al (2007). Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the Bogalusa Heart Study 16 Van Emmerik et al (2012). High cardiovascular risk in severely obese young children and adolescents 17 Watson et al (2013). Adult hypertension risk is more than quadrupled in obese children 18 Griffiths et al (2010). Self-esteem and quality of life in obese children and adolescents: a systematic review 19 Gatineau et al (2011). Is obesity associated with emotional and behavioural problems in children?

20 Pischon et al (2008). General and abdominal adiposity and risk of death in Europe

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