Clinical Update on
childhood obesity
Dr Helen Vickerstaff
Consultant Community Paediatrician, RCHT
Outline
• Define obesity in children
• Be able to assess for aetiology and
comorbidity
• Understand principles of intervention
• Know local referral routes
• Not dread that consultation!
Definition
Definition/Standards
• Obesity is an abnormal accumulation of
body fat, usually 20% or more over an
individual’s ideal body weight.
• Clinical
• BMI >91st centile overweight
• BMI >98th centile obese
• BMI >3.5 SD extremely obese
Definition/standards
• Differs according to clinical or
population monitoring
• UK90 data BMI centile
– 85th and 95th centile for population
– 91st and 98th clinical assessment
Why should we be worried?
Prevalence
• Great data sources
• National Child Measurement
Programme (NCMP)
• National Obesity Observatory (NOO)
• Chi MAT
Child prevalence by BMI status
National Child Measurement Programme 2010/11
Obese
9.4%
Obese
19.0%
Overweight
13.2%
Underweight
1.0%
Reception
(aged 4-5 years)
Overweight
14.4%
Year 6
(aged 10-11 years)
Healthy Weight
65.3%
Healthy Weight
76.4%
Underweight
1.3%
This analysis uses the 2nd, 85th and 95th centiles of the British 1990 growth reference (UK90) for BMI to classify children as underweight,
healthy weight, overweight and obese. These thresholds are the most frequently used for population monitoring within England.
© NOO 2012
Prevalence of obesity among children by school year
and sex
National
Child Measurement Programme 2006/07 – 2010/11
Year of m easurem ent
2006/07
2007/08
2008/09
2009/10 2010/11
20.0% 20.0%
20.4% 20.6%
19.0%
16.6% 16.5%
17.0%
17.4%
15.8%
10.7% 10.4%
10.3% 10.5% 10.1%
9.1% 8.8% 8.9% 9.2% 8.8%
Reception boys
© NOO 2012
Reception girls
Year 6 boys
Year 6 girls
Child obesity: BMI ≥ 95th centile of the UK90 growth reference
Prevalence
• Reception age 22.6%
– overweight(13.2), obese(9.4)
• Year 6 33.4%
– Overweight (14.4) obese (19.0)
• South West above national average in
reception overweight/obese
• Cornwall figures similar but below SW
average for Year 6
• Relatively poor uptake rate 71% vs national
93%
Risk Factors
ALSPAC
• Parental obesity
• Very early (by 43months) adiposity rebound
• Obese children go on to become obese
adults
• >8 hours screen time/week at 3 years
• Catch up growth
• SD score at 8 months and 18 months in top
quarter, weight gain in first year
• Birth weight
• Short (<10.5 hours) sleep duration at 3
years
When to worry
• Over 2 years
– BMI > 91st centile – overweight (tailored
intervention)
– BMI >98th centile – assess for co-morbidities
• Under 2 years
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Weight >2 centiles above length
Weight >99.6th centile
Weight increases across 2 centiles
Severe progressive obesity
Underlying Causes
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Short for midparental centile
Static growth
Severe progressive obesity
Dysmorphic features
Significant learning difficulties
Endocrinopathy
Cushing’s features
Initial assessment – risk
factors
• Family history (sex
related)
• Physical disability
• Lack of regular
physical activity
and/or sedentary
lifestyle
• Poor dietary habits
• Lower socioeconomic status
• Learning disability
• Syndromes
• Medications
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Corticosteriods
Diabetes mellitus
Psychoactive agents
Antidepressant
ALL treatment
Anti-migraine e.g.
pizotifen
– Anti-epileptics
Syndromes associated
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Prader Willi sydrome
Down’s syndrome
Biemond syndrome
Alstrom sydrome
Bardet-Biedl syndrome
Carpenter syndrome
Cohen syndrome
Borjeson-Forssman-Lehman syndrome
Clinical features of concern
• Severe unremitting
obesity
• Abnormal facies
• Disorders of eyes
• Retinal problems
• Narrow palpebral
fissures
• Abnormal position
palpebral fissures
• Severe squint
• Skeletal abnormalities
• polydactyly
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Syndactyly
Kyphoscoliosis
Sensorineural deafness
Microcephaly and/or
abnormal skull shape
Learning difficulties
Hypotonia
Hypogonadism
Cryptorchidism
Micropenis
Delayed puberty
Single Gene Abnormalities
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Congenital leptin deficiency
Leptin receptor mutation
Pro-hormone convertase 1 mutation
Melanocortin 4 receptor mutation
Examination
Examination
• Calculate and plot BMI
centile or z-score
• (Waist circumference)
• Pattern of adiposity
• BP
• Pubertal assessment
• Acanthosis nigricans
(insulin resistance)
• Obstructive sleep
apnoea
• Drug use –
glucocorticoids, atypical
antipsychotics
• Genetic obesity syndromes
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Early onset
LD
Dysmorphism
Epilepsy
Retinitis
Genitalia
Skeletal
Red hair
• Endocrinopathy
– Hypothyroidism
– Cushings – striae, central,
rapid progressive
Other concerns
• Family History
– Early onset type 2 diabetes < 40 years
– CV disease < 60 years
Investigation – co-morbidity
• Routine
– Fasting glucose
and insulin
– Fasting lipid
profile (full)
– ALT
– Urinanalysis
– TFT’s
• Additional
– Oral glucose
tolerance test
– PCOS investigation
– Sleep investigation
Investigation - aetiology
• Genetic studies
– Syndromes
– Genetics referral is
significant concern
– Offer inclusion in
GOOS (genetics of
obesity study)
– Thyroid antibodies
– Ca/PO4
(pseudohypoparathyr
oidism
• Suspicion of
secondary obesity
– Height deceleration
– Short duration
obesity or rapid
weight gain
– Severe
hypertension,acne or
hirsuitism
GOOS Study
•Research study
•Look at monogenic causes and also
measure leptin levels
•May provide future treatments
•Parents like to have a cause
•Management is the same
•10ml clotted blood or buccal swabs for
young children
Management
• If no suspected underlying cause established
then frequent follow up usually in primary
care
• Multi-strategy approach to healthy weight
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Diet, lifestyle and behavioural change
Long term risks
SMART goals
Weight maintenance
Management
• Primary Care – GP, school nurses and health
visitors regular training to support via Rachael
Brandreth (specialist dietitian)
• 3 monthly follow up
• Reduction in BMI SDS or z score by 0.5
reduces atherogenic profile and insulin
resistance, inflammatory markers
• Consider re-referral if develop or worsening
co-morbidities or progressive obesity despite
intervention
Secondary Care
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Investigation of aetiology and co-morbidity
Multi-component weight management
programme
Consideration of Orlistat
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lipase inhibitor
>12 years with extreme obesity or significant comorbidities
Surgical Intervention
• Last possible option in obese
adolescents with co-morbidity
• Not recommended in children
• Exceptional circumstances close to
physiological maturity
• MDT with full assessment
Local Pathways
• Obesity pathway
• Assessment in primary care and recognition
of co-morbidites/possible underlying aetiology
• Centralised referral number for weight
management strategies (healthy weight team)
• Tier 1/2 programmes
– health visitor HENRY- under 5’s
– Keep It in the Family (MEND) – 7-13 years (>91st
centile)
LEAF Programme
•Fits into NICE and SIGN guidance of
behaviour change components, family
based, aim to change whole family
behaviour.
•Target decreasing overall dietary intake,
increase levels of activity and decrease time
spent on sedentary behaviour
•Evaluation
•Solution focused
Weight Management
Programmes in Cornwall
• Tier 1 and 2 – refer to health visitor or
school nurse
• Tier 2-3
• Age 0-6 LEAF programme
• 7-13 MEND programme (call healthy
weight team 01209 310062)
• 14+ current training SHINE programme
(as above)
GAPS
• Special schools – looking at work of
programme with school nurses and
possibly behavioural team
• Psychology support
• Concerns – identify co-morbidities but
no guidance on management
Child Protection Issue?
• Childhood obesity alone is not a child protection
issue
• Failure to reduce overweight alone is not a child
protection concern (very difficult to treat)
• Consistent failure to change lifestyle and engage
with outside support indicates neglect,
particularly in younger children
• Obesity may be part of wider concerns about
neglect or emotional abuse (1/3 adult bariatric
report SA)
• Assessment should include systemic (family and
environmental) factors
Sources of information
• National Obesity Observatory
(NOO) Website
• NICE guideline (2006)
• SIGN guideline
• Map of Medicine
• OSCA statement (RCPCH) Obesity
Services for Children and
Adolescent Network Group
Any questions?
• www.cornwallhealthyweight.org.uk
• Contact the team on
LEAF.programme@cornwall.nhs.uk
‘Katie’ – age 6
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BMI 31.9
Mild sleep apnoea
Fatty liver
Behavioural problems, including stealing
Social services involved
Joint custody – spends half the week with Mum, other half with
Dad
Both parents have struggled with their weight
Dad has type II diabetes (since 15 yrs)
Mum has admitted to having an unhealthy relationship with food
Mum has also acknowledged that her relationship with Susie is
“too adult”