Childhood Obesity

Laura Stewart, PhD, RD, RNutr

Childhood obesity is widely acknowledged as having become a global epidemic.1,2 The prevalence of childhood
obesity in the UK dramatically increased over a short period of time in the early 1990s. 3,4 The importance of childhood
obesity has gained national significance with the publication of expert reports 5 and evidence-based guidelines.6,7
Doctors in primary, secondary and tertiary care are now more likely to see obese children and adolescents in their
everyday practice.

DEFINITION

As in adult obesity, any definition of childhood overweight and obesity needs to be able to define not only body
fatness but also the clinical relevance of this body fat. Body mass index (BMI) is generally agreed to be the most
appropriate proxy measure for defining and diagnosing childhood obesity and overweight. 68 In childhood, because
body fat and muscle mass alter with age and differ between the sexes, BMI is meaningful only when it is plotted
correctly on age- and sex-specific BMI centile charts (UK 1990). All health professionals should use the UK 1990 BMI
centile charts for diagnosis and monitoring of treatment of childhood obesity.6,7 The UK BMI centile charts are
available from Harlow Printing Ltd, South Shields, England.

Although there remains some disagreement on the precise cut-off points to use for defining overweight and obesity
on BMI charts, both the SIGN 115 (2010) and NICE 43 (2006) guidelines agreed on cut-off points in the UK of 91st
centile as overweight and 98th centile as obese, 6,7 with SIGN 115 defining 99.6th centile as severe obesity. 7 These
cut-off points have been shown to be relevant to excess body fat and associated ill-health consequences.6,7,9
AETIOLOGY

An understanding of the complex aetiology of childhood obesity is helpful to appreciate the changes required to
manage obesity in childhood. The causes of obesity are complex and multifactorial, involving an interaction of our
modern, obesogenic environment and individual lifestyle choices.

Because excess weight gain occurs in a state of positive energy balance, increases in the amount of calorie-dense
foods eaten, and increases in screen time (television, computer and video games) with a simultaneous decrease in
the amount of physical activity undertaken by children have been cited as reasons for the current epidemic.10,11

The understanding of the role of genetics in the predisposition of some individuals to gain excess weight has
improved in recent years.12 However, for the vast majority of obese children, this has not yet impacted on day-to-day
clinical practice.13

CONSEQUENCES

There is good evidence that childhood obesity persists (or tracks) into adulthood. 1417 The likelihood increases
markedly for obese teenagers. A number of consequences of childhood obesity are seen in childhood, adolescence
and later in life. Clustering of cardiovascular risk factors has been reported in children and adolescents: high blood
pressure, dyslipidaemia, abnormalities in left ventricular mass and/or function, abnormalities in endothelial function,
and hyperinsulinaemia and/or insulin resistance.

A body of evidence suggests that these cardiovascular risk factors are seen in adults who were obese children or
adolescents.13,14 There are also instances of insulin resistance, type 2 diabetes and fatty liver disease in obese
adolescents.13,15,16 Psychological problems, particularly in girls, have been reported in relation to low self-esteem and
behavioural problems. There are also long-term consequences of social and economic effects, particularly in women
achieving a lower income.14,17 Table 1 gives a list of consequences of obesity in children and adolescents that
clinicians should consider.

ASSESSMENT

If there are concerns that a child or adolescent may be overweight or obese, baseline measurements of weight and
height should be obtained and plotted on weight- and height-growth centile charts.

For children aged four years and under, the World Health Organization (WHO) growth charts should be used. BMI
should be calculated and plotted at the correct age on the appropriate centile chart for sex (UK 1990). The use of
waist measurements in children has gained support in recent years, and UK waist circumference centile charts 18 can
be found on the flipside of the UK BMI centile charts. However, there is no agreed cut-off point for defining level of fat
and thus those at health risk,9 and although waist measurements are a useful tool in monitoring progress in weight
management, they are not necessary for the current diagnosis of childhood obesity.7,8

Particular consideration should be given to children and adolescents who are obese but also of short stature, as this
may be an indication of a possible underlying endocrine cause of their obesity, such as hypothyroidism, growth
hormone deficiency, Cushings syndrome or pseudohypoparathyroidism. Referral to a paediatric endocrinologist
should always be made for further investigations.7,13 Young children, particularly those under 2 years who have had a
rapid weight gain, are severely obese and appear to be hyperphagic, may have one of the rare single gene defect
cause of their obesity, and further investigations would be advisable. 12 A history of failure to thrive in infancy and
intellectual impairment may alert the diagnosis of PraderWilli syndrome.
DISCUSSING THE SUBJECT OF WEIGHT

There is a large body of evidence that shows that many parents do not recognize overweight and even severe
obesity in their own children.1921 This can make the discussion of weight with families daunting for clinicians and
health professionals. Recent work tells us that this should be approached directly, first with the parents in an
empathetic and nonjudgemental manner.20,22,23 Parents should be asked in a stepwise manner if they consider their
childs weight a problem? Do they wish to do anything about their childs weight? And what changes they feel ready to
make?22 Parents perceive a dialogue around their childs physical activity levels as less threatening and less
judgemental of their parenting than questioning about their eating habits.23

MANAGEMENT

Management of childhood obesity is multifaceted, with interventions made complex by the interaction of the child or
adolescent with their parents and families. Parental weight is known to influence the weight and lifestyle of the
children in a family, so the involvement of parents is fundamental to any childhood weight-management
programme.7,24 Recent guidelines and the Cochrane review25 on childhood obesity showed a consensus on the
following points:

treatment should be commenced only when the parents are ready and willing to make lifestyle changes
treatment should be family-based, with at least one of the parents/carers involved.6,7,25

Table 2 summarizes the advice that should be given to children, their parents and families. It is important to
emphasize that changes in total energy intake, screen time and physical activity are all of equal importance in
childhood weight management.7 Some families are able to make positive changes when given simple advice, but the
majority of children and parents will require to attend an ongoing group or individual programme over a number of
months. From current evidence, the optimal length of a weight management programme is unclear, 7 but programmes
that include the use of behavioural change tools would appear to be beneficial.25 Clinicians should be aware of their
local childhood weight management programmes and referral pathways.6,7
Outcomes

Weight maintenance in combination with increasing height growth is an acceptable goal of treatment, as this will lead
to BMI decreasing over time. For older adolescents, particularly those in the very severe BMI range, weight loss may
be required; if so, a weight loss of 12 lbs per month would be advised. 7 Most research projects report outcomes as
change in BMI standard deviation scores (SDS). There is emerging evidence and debate over the clinical significance
of change in BMI SDS in children and adolescents, particularly in relation to improvement in insulin resistance,
dyslipidaemia, and cardiovascular and metabolic risk factors. At present, studies suggest a decrease in BMI SDS
ranging from -0.5 to -0.25 may lead to an improvement of risk factors in obese children.26, 27

Radical Therapies

Both the NICE 2006 and SIGN 2010 guidelines recommended that, in certain circumstances and under close
supervision, anti-obesity drugs and bariatric surgery could be considered in adolescents. Anti-obesity drug therapy
could be considered for prescription to obese adolescents who are attending a specialist weightmanagement clinic. 6,7
SIGN 115 further recommended that anti-obesity drugs should be prescribed only for adolescents with severe obesity
(BMI > 99.6th percentile) and with co-morbidities.7 Presently, orlistat is the only anti-obesity drug available for use in
the UK, and is not licensed for use in children. It functions primarily by preventing the absorption of fats, thereby
decreasing the available energy from the diet. It is recommended that patients are regularly reviewed throughout the
period of use, with careful monitoring for side effects.7 Although in adults orlistat does not cause hypovitaminosis, it
does reduce circulating levels, so early vitamin supplementation may be indicated for children.

Although bariatric surgery in children and adolescents is uncommon in the UK, both guidelines suggest that bariatric
surgery for weight loss could be considered for post-pubertal adolescents with very severe obesity and co-
morbidities, and stress that surgery should be undertaken only in a centre of excellence in adult bariatric surgery. 6,7
Since the long-term side effects of bariatric surgery in adolescents are unknown, it is highly desirable that follow-up
should be for life.

2010 Elsevier Ltd. Initially published in Medicine 2010;39(1):4244.

About the Author

Dr Stewart is Team Lead at the Paediatric Overweight Service Tayside, NHS Tayside, and Consultant Trainer and
Director at the Childrens Weight Clinic, Edinburgh, UK. Competing interests: none declared.
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