This article was originally published in the July edition of NHD Magazine under the title ‘Childhood Obesity’. This is an important topic to me as childhood obesity is not only a worldwide health and economic issue, but I have seen the individual impact as I cover a childhood weight management clinic as part of my current job.
Childhood obesity is becoming an increasingly worrying issue; in 2014 an estimated 41 million children under 5 worldwide were either overweight or obese1, and figures from the UK from 2015 reveal that almost a third of all children were overweight or obese2. 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 years1. There is also an economic motivation for tackling this issue as it is estimated that the NHS in England spends roughly £5 billion per year on treating conditions related to obesity3.
Causes of Childhood Obesity
The picture is becoming more complex as we learn about the numerous factors which contribute to obesity; 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 obesity1.
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. And conversely, maternal and paternal obesity can also increase the risk of childhood obesity1.
In developed countries, the highest risk of childhood obesity in seen in lower socioeconomic groups and also within minority groups who may be at risk of poor interaction with the health care system1. For example, in the UK children from the lowest income groups have double the risk of becoming obese compared to children from more affluent areas3. 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 diets1.
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 changes1, 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.
Potential Consequences of Childhood Overweight and Obesity
Childhood obesity has been shown to increase the risk of developing diabetes as an adult more than adult-onset obesity does4. Furthermore, children as young as 7 have been diagnosed with type 2 diabetes in the UK5,7. UK data also shows that 95% of children diagnosed with type 2 diabetes were overweight and 83% were obese8, which is supported by similar data from the US9.
Premature puberty is also associated with childhood overweight and obesity, which can impact on growth and behaviour.
A recent systematic review found a 40-50% increased risk of asthma in children who are overweight or obese10. Specifically, a rapid increase in BMI in the first 2 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 asthma12. Research suggests that obstructive sleep apnoea rates may be as high as 60% in obese children and adolescents13. Overweight and obesity can also reduce exercise tolerance and increase fatigue levels.
As well as increasing the risk of developing cardiovascular disease in adulthood, childhood obesity can result in cardiovascular damage in childhood14. Studies have found that 62 – 70% of those with childhood obesity present with cardiovascular risk factors such as hyperlipidemia and hypertension15-16. A study from the US reported that children in the obese category had a fourfold increased risk of developing hypertension as an adult17.
Overweight and obesity can add excess pressure to the musculoskeletal system 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 levels5.
Childhood obesity can increase the risk of developing non-alcoholic steatohepatitis (NASH), where fat can accumulate in the liver causing inflammation and damage6.
Evidence shows an increased risk of: low self-esteem, 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 category518-19. These issues may contribute to the observed association between childhood obesity and reduced educational attainment1.
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 disease1,6,20. Worryingly it has also been reported that obesity can double the risk of premature death3, which could potentially take 3-7 years off an obese adult’s life6.
Reducing Childhood Obesity
It is often discussed that ‘no single intervention will cure childhood obesity’ due to it’s complex background as discussed above. For this reason 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 worldwide1. The main areas WHO have recommended to target are highlighted in the picture below.
The English 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 years3. 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 “Childhood Obesity: A Plan for Action” are summarised in the table below.
|Soft drinks industry levy
||Producers and importers of sugary drinks have 2 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 & 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 which 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”, and 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 sign-posting to reliable websites and resources.|
From my experience 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 performance3.
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.
- 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)
- Health and Social Care Information Centre (2015) Health Survey for England 2014.
- HM government (2016) “Childhood Obesity – A Plan for Action” (available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/546588/Childhood_obesity_2016__2__acc.pdf)
- Haines et al. (2007) “Rising incidence of type 2 diabetes in children in the U.K.”
- Public Health England (2017) “ Health risks of childhood obesity” (available at: https://www.noo.org.uk/NOO_about_obesity/obesity_and_health/health_risk_child)
- Childhood Obesity Foundation “What are the Complications of Childhood Obesity?” (available at: http://childhoodobesityfoundation.ca/what-is-childhood-obesity/complications-childhood-obesity/)
- Diabetes UK (2012) “Key Statistics on Diabetes”
- Richardson et al. (2012) “Timing and duration of obesity in relation to diabetes: findings from an ethnically diverse, nationally representative sample”
- Li et al. (2009) “Prevalence of pre-diabetes and its association with clustering of cardiometabolic risk factors and hyperinsulinemia among U.S. adolescents”
- Egan et al. (2013) “Childhood body mass index and subsequent physician-diagnosed asthma: a systematic review and meta-analysis of prospective cohort studies”
- Rzehak et al. (2013) “Body mass index trajectory classes and incident asthma in childhood: results from 8 European Birth Cohorts”
- Black et al. (2013) “Increased Asthma Risk and Asthma-Related Health Care Complications Associated with Childhood Obesity”
- Kang et al. (2012) “Body weight status and obstructive sleep apnea in children”
- Cote et al. (2013) “Childhood Obesity and Cardiovascular Dysfunction”
- Freedman et al. (2007) “Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the Bogalusa Heart Study”
- Van Emmerik et al. (2012) “High cardiovascular risk in severely obese young children and adolescents”
- Watson et al. (2013) “Adult Hypertension Risk is More than Quadrupled in Obese Children”
- Griffiths et al. (2010) “Self-esteem and quality of life in obese children and adolescents: a systematic review”
- Gatineau et al. (2011) “Is obesity associated with emotional and behavioural problems in children?”
- Pischon et al. (2008) “General and Abdominal Adiposity and Risk of Death in Europe”