A 10 year old girl, Gemma, has been admitted to the general paediatric unit with an acute exacerbation of asthma. She weighs 70kg and is 1.4m tall. Her symptoms have improved and discharge planning has begun. At the end of your round the consultant asks you to go and discuss Gemma’s weight with her family.
What should you do next?
Although your initial reaction may be to send the intern in to have this often awkward and difficult discussion, identifying and managing childhood obesity is becoming an increasingly important skill set for both paediatricians and general practitioners.
Obesity in Australian children is common. At least one in twenty kids are obese (Batch& Baur 2005). When you include data on overweight children the incidence is 25% (NHMRC 2013b).
So firstly it is important to correctly identify overweight and obese children. Spurrier et al (2006) illustrated that GPs who use visual clues to determine normal weight children are often incorrect.
Furthermore even when a practitioner does record height and weight only on half the occasions do they convert these to BMI (Dettori et al 2009).
- BMI is calculated by dividing weight (in kilograms) by the square of the height (in metres)
- BMI then needs to be compared to age and gender appropriate charts
- A child is classified as overweight is a BMI ≥ 85% of the same age and gender
- Obesity is defined as a BMI ≥ 95% of the same age and gender
BMI is a useful tool to determine whether a child is overweight or obese and to monitor their progress over time.
How can you engage the parents?
Not unexpectedly, evidence suggests that practitioners find it difficult to initiate discussions about children’s weight (Dettori et al. 2009, Gerner et al 2006, King et al 2007). Fears regarding offending patients, losing business and alienating clients have all been highlighted as barriers (Dettori et al. 2009, Gerner et al 2006, King et al 2007).
Similar to any difficult discussion it is important to:
- Pick the right location- a busy emergency resuscitation cubicle is not the correct location. Find somewhere private, quiet and comfortable where everyone can take part in the conversation.
- Pick the right time – if their child is acutely unwell, parents will not want to discuss chronic problems no matter how concerned they are about them. If not before, these discussions should be part of discharge planning.
- Ensure you have time – allow time for questions from the parents and the child. Don’t have this discussion five minutes before weekly grand rounds starts.
- Be informed – explain how you will assess their child’s weight status. Explain how classifications of obesity and overweight are made. Be aware of who will follow them up and what extra services are available in the hospital and community.
- Consider involving others – interpreters or indigenous health workers may assist (NHMRC 2013a).
- Be compassionate!
What are the common causes of overweight and obese kids in Australia?
In order to become overweight or obese a disparity occurs between energy input and energy expenditure (AIHW 2011). Being an overweight or obese child is caused by a multitude of factors.
- Sedentary behaviour – overweight and obese children are more sedentary than their peers. (Booth et al 2006).
- Diet – children whom consume large amounts of sugary drinks, snack on highly saturated fats, salt and sugar are more likely to be overweight or obese (AIHW 2011). Additionally, children with higher BMI have been shown in studies to have poorer quality breakfast and are more likely to omit meals in comparison to their normal weight peers (Booth et al 2006).
- Culture – acceptable body sizes, food intake and exercise levels are influenced by culture (Cinelli & O’Dea 2009, Renzaho et al 2008).
- Family – family’s influence children’s eating habits. Children are more likely to be obese if their mothers are obese (O’Dea 2006).
- Socio economic status – children from lower socio economic status are at greater risk of being overweight and obese (O’Dea 2006, Wake et al 2006).
- Built environment – the community in which one lives in and therefore an individual’s access to parks, playgrounds and open public spaces may influence their level of activity (AIHW 2011).
Gemma’s mother states ‘She is only a little bit fat, I don’t understand what all the fuss is about, why is it so bad anyway?’
What are the consequences of being overweight and obese?
Being overweight and obese influences the short and long term health and well being of children. These children are at higher risk of:
- Low self esteem
- Social isolation
- Eating disorders
- Mood disorders
- Early onset puberty
- Sleep apnoea
- Slipped capital femoral epiphysis
- Continuing to be an overweight or obese adult
- Insulin resistance and type 2 diabetes mellitus
- Fatty liver disease
- Cardiovascular disease
(NHMRC 2013a & Williams et al 2005)
What management should be undertaken?
There have been few effective BMI reduction programs illustrated in the Australian literature (Antoine 2012). No trials have proven an effective GP lead management strategy. However the HIKCUPS trial showed that a parent-centred dietary program and child focused exercise approach can be efficacious in BMI reduction (Collins et al 2011, Okely et al 2010).
A recent publication from the National Health and Medical Research Council (NHMRC 2013a) recommends the following management strategies:
- Ask and assess: current dietary intake, level of exercise and medical history. Perform a full examination including – height and weight, looking for signs of complications of being overweight or obese.
- Advise: promote the benefits of a healthy lifestyle and diet. Current guidelines recommend at least 60 minutes of moderate exercise per day (AIHW 2011). Children should have no more than two hours of non educational screen time per day (AIHW 2011). Advise families to make healthy eating choices – have regular meals together in a social atmosphere (NHMRC 2013a).
- Assist: provide education on the causes and consequences of obesity.
- Arrange: follow up and referral as required to allied health members – dietitian, exercise physiologist and psychologist as well as general paediatricians, endocrinologist etc.
- Weight loss is not recommended for most children. Maintaining weight during growth will permit a gradual decrease in BMI (NHMRC 2013a).
- Some tertiary hospitals will have weight reduction services or physicians with special interest in this field.
- Involve the General Practitioner – they will likely see the child more frequently that you will. Let them know the management strategies provided to the family and what services you have linked them with.
Antoine 2012, ‘Where to from here for Australian childhood obesity’, Australian Medical Student Journal, vol 3, Issue 2, pp 20-23.
Australian Institute of Health and Welfare (AIHW) 2011, Young Australians: their health and wellbeing, AIHW, viewed 28th September 2013, <www.aihw.gov.au/publications-detail/?id=10737419261>.
Batch JA, Baur LA. Management and prevention of obesity and its complications in children and adolescents. Med J Aust. 2005;182:130-5.
Booth ML, Okely AD, Denney-Wilson E, Hardy L, Yang B, Dobbins T. NSW Schools Physical Activity and Nutrition Survey (SPANS) 2004 Summary Report. Sydney: NSW Department of Health 2006.
Cinelli RL, O’Dea JA. Body image and obesity among Australian adolescents from indigenous and Anglo-European backgrounds: implications for health promotion and obesity prevention among Aboriginal youth. Health Educ Res. 2009 Dec;24(6):1059-68.
Collins CE, Okely AD, Morgan PJ, Jones RA, Burrows TL, Cliff DP et al. Parent diet modification, child activity, or both in obese children: an RCT. Pediatr. 2011;127(4):619-27.
Dettori H, Elliott H, Horn J, Leong G. Barriers to the management of obesity in children: A cross sectional survey of GPs. Aust Fam Physician. 2009;38(6):460-4.
Gerner B, McCallum Z, Sheehan J, Harris C, Wake M. Are general practitioners equipped to detect child overweight/obesity? Survey and audit. J Paediatr Child Health. 2006;42(4):206-11.
National Health and Medical Research Council (NHMRC) 2013a, Clinical Guidelines for the Management of Overweight and Obesity in Adults, Adolescents and Children in Australia, NHMRC 2013, Canberra, AUS, viewed 28th September 2013, Children in Australia 2013, <www.nhmrc.gov.au/guidelines/publications/N57>.
National Health and Medical Research Council (NHMRC) 2013b, Obesity and overweight, 31 May, NHMRC, viewed 28th September 2013, <http://www.nhmrc.gov.au/your-health/obesity-and-overweight>.
O’Dea JA, Wilson R. Socio-cognitive and nutritional factors associated with body mass index in children and adolescents: possibilities for childhood obesity prevention. Health Educ Res. 2006 December 1, 2006;21(6):796-805.
Okely AD, Collins CE, Morgan PJ, Jones RA, Warren JM, Cliff DP et al. Multi-site randomized controlled trial of a child-centered physical activity program, a parent-centered dietary-modification program, or both in overweight children: the HIKCUPS study. J Pediatr. 2010;157(3):388-94.
Renzaho AMN, Swinburn B, Burns C. Maintenance of traditional cultural orientation is associated with lower rates of obesity and sedentary behaviours among African migrant children to Australia. Int J Obes. 2008;32(4):594-600.
Spurrier NJ, Magarey A, Wong C. Recognition and management of childhood overweight and obesity by clinicians. J Paediatr Child Health. 2006;42:7-8.
Wake M, Hardy P, Canterford L, Sawyer M, Carlin JB. Overweight, obesity and girth of Australian preschoolers: prevalence and socio-economic correlates. Int J Obes. 2006;31(7):1044-51.
Williams J, Wake M, Hesketh K, Maher E, Waters E. Health-Related Quality of Life of Overweight and Obese Children. JAMA. 2005 January 5, 2005;293(1):70-6.