NHD CPD eArticle Vol 9.12 by NH Publishing Ltd

NHD CPD eArticle Volume 9.12 10th Oct 2019

PRETEEN OBESITY: THE PARENT’S ROLE In this article, Farihah delves into the specific realms of preteen or childhood obesity and what role a parent might play in this. In developed countries, such as the United Kingdom, some of the largest public health problems stem from rising prevalence of non-communicable diseases, obesity being one. Childhood obesity in particular has increased steadily throughout the last decade and currently sits at a 40-year high globally,1 and although figures have almost plateaued in the last few years,2 prevalence has not diminished. It is well-elucidated now, that obesity and overweight are caused and exacerbated by multiple factors. Although it is easy to put the blame on one single thing, current research clearly demonstrates that overweight and obesity are, to various extents, caused by: • varying genetic dispositions; • metabolic conditions; • warped perceptions of portion size leading to greater consumption; • increase in consumption of high calorie food products and a decrease in consumption of fresh produce; • decreased physical activity due to an increase in the use of digital technology and a move away from labour-driven occupation and leisure; • appetite control mechanisms; • a variety of cofounding factors, including existing health conditions and lifestyle situations. Obesity and overweight lead to a heightened risk of comorbidities,

including, but not limited to, cardiovascular disease, Type 2 diabetes mellitus, many cancers, gallstones and sleep apnoea. The first case of noninsulin dependent diabetes mellitus was recorded in a child in 20023 and 715 young people under the age of 25 were diagnosed with Type 2 diabetes in the audit year, according to the Royal College of Paediatrics and Child Health National Paediatric Diabetes Audit 2016-17. This was an increase of 77 from the previous audit year.4 Clearly, there is a huge public health issue on our hands. However, children have limited agency in managing their health and symptoms, so in what capacity could parents be facilitating an obesogenic environment, or is it unfair to point the blame at parents alone?

Farihah Choudhury Masters Student, London School of Hygiene and Tropical Medicine Farihah is taking a MSc in Nutrition for Global Health. She is interested in public health nutrition, in particular lifestyle disease, including obesity as a product of changing food environments, food sustainability and food culture & anthropology.

THE PICTURE IN ENGLAND

The report from Public Health England (PHE), Patterns and Trends in Child Obesity (updated Feb 2019),5 profiles childhood obesity via the National Measurement Programme.17 Its findings illustrate that 1 in 10 Reception children (aged 4-5) is obese and 1 in 5 children in Year 6 (aged 10-11) is obese. See Figure 1. The Health Survey for England 20176 summarises that 30% of children aged 2-15 were overweight or obese, including 17% who were obese. Interestingly, the same survey revealed telling data about parents’ perception of their children’s weight. The report shows that parents of overweight

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NHD CPD eArticle

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Figure 1: BMI status of children by age, National Child Measurement Programme 2017/18, Public Health England.5

and obese parents often thought that their child was “the right weight”. Around half of parents of obese children said that their child “seemed about the right weight”.6 Does this perception lead to delayed or insufficient intervention? PARENTAL CONTROL, INFLUENCE AND ATTITUDES

A foetus gets used to the taste of the maternal diet during pregnancy and infants who are breastfed experience the maternal diet further through breast milk. This facilitative experience provides a ‘flavour bridge’ to infants, which can influence acceptance of certain foods later in life.7 Focusing on the psychological aspects of obesity, influencing and promoting children to have a healthy relationship with food early on increases the likelihood that children will develop good eating habits throughout childhood and later in life.8 Four common feeding styles have been observed by Wardle et al9 that contribute to the development of childhood obesity: • instrumental feeding • emotional feeding • control over eating • prompting/encouragement to eat The former two types of feeding are associated with eating in the absence of hunger.9 Children generally eat what their parents eat: if an adult eats five portions of fruit and veg a day, it is likely that their children will do the same.

Similarly, if an adult eats a burger and chips for dinner every night, then in most instances (and there are, of course, practical reasons for this), the children will have the same meal. Several studies have reflected that parental food behaviour does reflect on children,9 such as intake of high energy fluids, snacks and take-outs, as well as finding a correlation between parental internal motivation and body dissatisfaction and that of their children.10 In regards to controlling over eating, restrictive diets early in life may result in disordered eating habits when food autonomy starts to develop, not only in the teen years, but throughout primary education. Furthermore, exposure to adults who have disordered relationships with food may intensify poor relationships with food in children, which can follow into adulthood.9 Hence, it can be argued that a parent’s role is to provide a non-restrictive and healthy varied food environment for young children during weaning and beyond, to the best of their ability, which can influence eating and dieting behaviours in early childhood, as well as later in life.9 In a similar vein, encouraging body confidence and positivity amongst children early on is instrumental for children to feel empowered to make the choices that are right for them throughout their lifetime. Shaming children for their weight often leads to a cascade of issues, including continuing poor relationships with food,

NHD CPD eArticle often a contributing factor for rapid weight gain or weight loss. On the other hand, as aforementioned, parents of overweight or obese children often perceive their children to be at a healthy weight. This is not an isolated observation – this warped perception has been observed in several studies.11 Moreover, there is a strong association between childhood trauma and disordered or over-eating. Generally, happier children with protection from adversity and trauma in early years are less likely to develop eating disorders or behaviours that may lead to obesity, ie, overeating/emotional eating, as well as eating disorders such as bulimia and anorexia nervosa. Obese early years’ children are more likely to have behavioural issues and obese children are more likely to be burdened by mental and psychological issues into adulthood.12 Despite the generally clear and widely perceived view that parents are responsible for weight management of their children, there are inconsistencies in this body of research, where some associations are much stronger than others. More long-term clinical studies may need to be conducted in order to be able to confidently declare a relationship between parental influence on food consumption and childhood obesity. THE HEREDITARY ROLE OF THE PARENT

Some individuals are genetically predisposed to retaining excess adipose tissue. Parents who have this predisposition play an inevitable role in obesity in their biological children, although the likelihood of becoming obese in childhood could be mitigated in various ways, for example, being birthed naturally (ie, not via caesarean section), being breastfed, or having a healthy varied diet during early childhood.13 However, it is an inescapable reality that some individuals are simply more likely to gain weight (and keep it) than others, regardless of lifestyle and dietary choices. Furthermore, individuals belonging to certain ethnic groups are more susceptible to overweight and obesity than others. However, this can be due to a combination of factors, including social deprivation and biological factors. In girls, obesity prevalence is highest among those in black African, black Caribbean and other black ethnic groups. In boys, obesity prevalence is highest in black African and black other and Pakistani ethic groups. The lowest obesity prevalence is found in

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Chinese and white/Asian mixed backgrounds.5 Linked in part to ethnic groups, socioeconomic factors are strongly linked to obesity prevalence.5,14,15 Deprivation indices against obesity prevalence consistently show that affluent areas have less individuals with overweight and obesity than less affluent areas. In Year 6 children, 26.3% of those in the most deprived areas were found to be obese, compared to only 11.4% of children in the least deprived areas.5 PHYSICAL ACTIVITY

We know all too well that we live in a technological age, where both occupational and leisure activities are increasingly technology-based, resulting in physical activity falling for all age groups and average Physical Activity Levels (PAL) being lower than is recommended. Children are able to access a myriad of educational and entertainment resources from smartphones and tablets, which sometimes comes with its benefits, but also means that outdoor play is scarcer and thus physical activity is reduced. Arguably, it is the parents’ role to encourage active play and enrol children into sports classes and the like, whether via after-school clubs or activity sessions outside of the educational sphere. Early exposure to active play and team sports are linked to various physical and mental benefits later in life, as well as for maintaining a healthy weight. Undoubtedly, social deprivation acts as a barrier to parents who often have less time and/ or money to spend on taking children to sports classes. Structural and institutional social change might allow for increased provision for free afterschool sports clubs and free access to active leisure facilities, or concessionary and reduced prices. Since 2009, the PHE campaign Change4Life18 has offered free, fun and informal guides to being active for children and families. It is the first public health campaign in the country designed to specifically tackle the rising obesity epidemic. Over the summer holiday period, it is possible to sign up to a fun scheme to ensure physical activity takes place in and around the home. Change4Life has proven to be a huge success, exceeding all of its first year targets, including the reach of 99% of targeted families, and receiving 1.9 million responses.16 In Change4Life’s 10th year of championing physical activity in children and families, has the campaign done enough to tackle childhood obesity?

NHD CPD eArticle SUMMARY

It is clear that we live in an obesogenic environment that affects children’s ability to maintain healthy lifestyles through little fault of their own. Although existing research has established a causal relationship between parents’ control and influence of children’s diets and childhood obesity, more specific research needs to be conducted in this area over a longer timeframe.

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Despite this, there are clear links between parental BMI, parental food intake and dietary preferences and their effect on childhood overweight factors. It is encouraging that the worryingly rapid rise of obesity has, to an extent, halted in the UK. Nevertheless, more intervention is required if we are to make a significant dent in the obese young person population.

References 1 World Health Organisation (2018). Obesity and Overweight. Available via: www.who.int/news-room/fact-sheets/detail/obesity-and-overweight [Accessed 7th June 2019] 2 National Children’s Bureau (2017). Working together to reduce childhood obesity: Ideas and approaches involving the VCSE sector, education and local government 3 Dyer O (2002). First cases of Type 2 diabetes found in white UK teenagers. BMJ (Clinical research ed), 324 (7336), 506 4 National Paediatric Diabetes Audit and Royal College of Paediatrics and Child Health (2018) National Paediatric Diabetes Audit 2016-17. Care Processes and Outcomes. Available: www.rcpch.ac.uk/sites/default/files/2018-07/npda_annual_report_2016_-_2017_april_2018_final_updated_3.pdf] [Accessed 7th June 2019] 5 Public Health England (2018). Patterns and trends in child obesity. Updated Jan 2019. Available via www.gov.uk/guidance/phe-data-and-analysistools#obesity-diet-and-physical-activity [Accessed: 7th June 2019] 6 Health Survey for England 2017 (2018). Summary of key findings. Available via https://files.digital.nhs.uk/5B/B1297D/HSE%20report%20summary.pdf 7 Savage JS, Fisher JO and Birch LL (2007). Parental influence on eating behaviour: conception to adolescence. The Journal of law, medicine & ethics: a journal of the American Society of Law, Medicine & Ethics, 35(1), 22-34 8 IL Tzou, NF Chu (2012). Parental influence on childhood obesity: A review. Health 4: 1464-1470 9 Wardle J, Sanderson S, Guthrie CA, Rapoport L and Plomin R (2002). Parental feeding style and the intergenerational transmission of obesity risk. Obesity, 10, 453-462 10 Campbell KJ, Crawford DA, Salmon J, Carver A, Garnett SP and Baur LA (2007). Associations between the home food environment and obesitypromoting eating behaviours in adolescence. Obesity, 15, 719-730 11 McKee C, Long L, Southward LH, Walker B, McCown J (2016). The Role of Parental Misperception of Child’s Body Weight in Childhood Obesity, Journal of Pediatric Nursing 31(2): 196-203 12 Rankin J et al (2016). Psychological consequences of childhood obesity: psychiatric comorbidity and prevention. Adolescent Health, Medicine and Therapeutics, 7: 125-146 13 Lindsay A, Sussner KM, Kim J and Gortmaker SL (2006). The Role of Parents in Preventing Childhood Obesity. The Future of children/Centre for the Future of Children, the David and Lucile Packard Foundation. 16: 169-86 14 Loring B and Robertson A (2014). Obesity and inequities. Guidance for addressing inequities in overweight and obesity. Copenhagen: World Health Organisation. 15 Goisis A, Sacker A and Kelly Y (2016). Why are poorer children at higher risk of obesity and overweight? A UK cohort study. Eur J Public Health. 26(1): 7-13 16 The National Social Marketing Centre (2012). Change4Life case study. Available via www.thensmc.com/resources/showcase/change4life 17 National Child Measurement Programme 2016/17, Public Health England. https://digital.nhs.uk/data-and-information/publications/statistical/ national-child-measurement-programme/2016-17-school-year 18 www.nhs.uk/change4life/

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NHD CPD eArticle Volume 9.12 - 10th October 2019

Questions relating to: Preteen obesity: the parent’s role Type your answers below, download and save or print for your records, or print and complete by hand. Q.1

What are the main causes of obesity and overweight?

Q.2

Summarise the findings of Public Health England’s report on childhood obesity.

Q.3

What is the ‘flavour bridge’?

Q.4

Give two examples of how parental food behaviour impacts on children’s eating habits.

Q.5

What impact can restrictive eating have early in life?

Q.6

How can body confidence affect a child’s weight?

Q.7

Explain the association between childhood trauma and over-eating.

Q.8

Summarise the hereditary role of the parent.

Q.9

How does active play and PE impact on childhood obesity?

Please type additional notes here . . .