Paediatric Guideline

Adolescence 12.4 Obesity

Short Title: / Obesity
Full Title: / Guideline for the Identification and Management of Obesity in Children and Young People
Date of production/Last revision: / June 2008
Explicit definition of patient group to which it applies: / This guideline applies to all children and young people under the age of 19 years.
Name of contact author / Dr Dilip Nathan, Consultant Paediatrician
Dr Damian Wood, Consultant Paediatrician
Ext: 64041
Revision Date / June 2011
This guideline has been registered with the Trust. However, clinical guidelines are 'guidelines' only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

Obesity - Guideline for the Identification and Management in Children and Young People

Introduction

·  Overweight and obesity are an increasing health and social problem in childhood

·  It is likely that obesity in childhood is associated with later cardiovascular risk although the evidence for this is poor quality and contradictory

·  Quality evidence on effective management strategies is scarce

·  Early onset obesity (pre-school) is a concern for a number of reasons

·  The most important management strategy in controlling weight is affecting change of behaviour of both the child and the family

·  Other psychosocial morbidities (eg self harm, low self esteem and substance misuse) are associated with obesity in young people

Purpose of the Guideline

The aim of this guideline is to help clinicians working in secondary and tertiary paediatric care:

·  Identify overweight and obese children

·  Make an assessment of the likelihood of secondary obesity and current cardiovascular risk factors

·  Initiate behaviour change

·  Identify children and young people who require specialist care

This guideline will form part of the overall ‘Integrated care pathway for the prevention, identification and management of overweight and obesity in children’, which will be based on the NICE Obesity guidance (NICE clinical guideline 43, 2006)

Identifying Obese and Overweight Children

Not all children who attend hospital/community clinics (for non-weight reasons) have their BMI calculated.

·  All children with a weight centile which is two or more centile above their height centile should have their BMI calculated and their centile plotted

·  All children with a weight on the 98th centile or above should have their BMI calculated and centile plotted

·  Check that the child looks obese (as opposed to increased lean mass)

·  Pay more attention to children with abdominal adiposity and rapid weight gain in infants and toddlers

Body Mass Index

Body Mass Index (BMI) is currently the most appropriate measure of adiposity in children.

BMI is calculated by dividing the weight (kg) by height squared (m2) [weight (kg)/ height (m2)]. However calculated BMI values need to be compared with age and sex reference standards due to BMI changes that occur in normal growth.

You can use an online BMI Calculator (need URL)

It should then be plotted on an appropriate BMI Centile Chart (Child Growth Foundation, printed & supplied by Harlow Printing Ltd)

Overweight: Overweight is defined as a BMI greater than the ≥91st percentile.

Obesity: Obesity is defined as a BMI greater than the ≥98th percentile.

History

Plot the "obesity trajectory" / Consequences of obesity / Family Risk Profile
Birth weight
Early feeding history
Whether onset of obesity was sudden or gradual and age of onset of obesity
Whether progression of obesity was gradual or rapid
Whether there have been any periods of very rapid weight gain, particularly recently
Whether there have been any periods of weight loss (and why and how)
Who else in the family is obese or has trouble controlling their weight / Medical
Slipped Upper Femoral Epiphysis
Exercise tolerance/asthma
Snoring and symptoms of obstructive sleep apnoea
Skin problems eg genital or axillary candidiasis, acanthosis nigricans
Features of insulin resistance eg acanthosis nigricans; hirsuitism, acne and irregular periods (PCOS) in girls; type 2 diabetes
Psychological
Adolescent HEADSSS assessment
Self esteem/image
Bullying
School problems/refusal / To place the child in the appropriate risk category it is useful to ask about family history (in first and second generations) of components of the insulin resistance syndrome, e.g.:
1. Extreme obesity
2. Type 2 diabetes
3. Hypertension
4. Dyslipidaemia
5. Polycystic ovarian syndrome (PCOS)
6. Early cardiovascular disease (defined as relatives who developed cardiovascular disease in the fifties or earlier)
7. Ethnicity

Examination

Distribution of fat

For example, whether generalised or abdominal or other pattern. The presence or absence of the "buffalo hump" is a poor sign of Cushing’s syndrome, as a prominent nuchal fat pad is common in simple obesity

Acanthosis nigricans

Acanthosis nigricans, the presence of velvety thickening of the skin around the neck and in skin creases, is suggestive of hyperinsulinism but is neither sensitive or specific

Accurate blood pressure

Using an appropriate size cuff (two readings, lying and sitting) – see hypertension guideline for age appropriate blood pressure values

Pubertal and growth assessment

Those obese before 2 years are tall for age. Many obese girls develop early in puberty. Pubertal and growth assessment is particularly important to assess whether weight maintenance (i.e. growing into their weight) is a viable option for treatment

Signs of hypothyroidism

Short stature, goitre, yellowish skin, dry skin and hair

Signs of Cushing’s syndrome or polycystic ovarian syndrome (PCOS)

Glucocorticoid and androgen excess in Cushing’s syndrome produce striae, acne, telangiectasia, hirsutism, and virilisation. The androgen excess in polycystic ovarian syndrome (PCOS) in girls produces hirsutism and acne. However striae are almost universal in obese children and adolescence and we have not found that the distribution or colour of the striae can help distinguish between the extremely common simple obesity and the extremely rare Cushing’s syndrome. Obesity by itself is practically never the presenting sign of Cushing’s syndrome. Children with Cushing’s will have reduced height velocity.

Signs of genetic obesity syndromes

For example, Prader Willi, Bardet Biedl, leptin deficiency, melanocortin 4 receptor (MC4R) deficiency and other monogenic forms of obesity. Monogenic forms of obesity remain a very rare cause of obesity in the general population, although such syndrome should be considered in those who have very early onset of extreme obesity.

Addressing the Issue

The issue of obesity as an important health concern is often not addressed in the clinical setting. Once you have noted that the child is overweight/obese you may address the issue using the following approach

·  Do no harm! Approach with respect but address the issue!

·  Assess child and parent’s perceptions of the issue - do they even see it as a concern? - do they have differing awareness/concerns?

·  Highlight the issue of weight in the context of health - show the growth chart to the family and explain what the healthiest weight for their child would be; explain they are still growing in height, so probably do not need to actually lose weight they need to grow into their weight

·  Ask what they think they could do and possibly suggest some behaviour change ideas (see below)

Parental Perception

We know that approx 50% of parents of obese children do not perceive that their child is overweight. It is therefore useful to gauge their opinion and experience of this issue as this can shape the ensuing discussion eg ‘What do you think about Sarah’s weight?’

They (and she!) may respond that they are aware and concerned about the issue. This is when you can discuss specific behaviour changes (see below) and arrange referral.

They may instead state that they think her growth is fine. Then your goal is to raise their awareness of the health issues, not necessarily to solve the problem!

Frame discussion of overweight in terms of health -talk about ‘the healthiest weight for Sarah’.

You could respond:

‘Let’s take a look at where Sarah should be on the weight for height chart and I can explain why I am concerned. At 5, Sarah is the weight of an average 8 yr old. This has implications for her future health. We need to slow the rate at which Sarah is putting on weight, and help her grow into her weight’

Behaviour Change

Some behaviour change ideas you can discuss with families

Physical activity

·  Any increase in activity is an improvement but recommendations are at least 60 mins of moderate – vigorous activity/ day. Activity can be in 1 session or several lasting 10 mins. Overweight children may need to do > 60 mins a day

·  Aim for ‘lifestyle’ exercise: using the stairs, walking or cycling to school, walking the dog

·  Involve the whole family (everyone can benefit regardless of weight status) e.g. going to the park, swimming

·  Use after school time to get outdoors and be active

·  Encourage participation in sports & exercise opportunities at school

·  Have bikes, helmets and balls ready to go by the door!

·  Decrease sedentary behaviour e.g. screen based activities (TV, Computer, video games)

It is recommended to reduce to < 2 hrs/d on average or equivalent of 14 hrs/ wk

Nutrition -and don’t forget drinks!

•  Importance of breakfast, regular meals and healthy snacks, in a sociable environment with no distractions

•  Parents should eat with children & all members eat the same foods

•  Separate eating from other activities such as watching TV or doing schoolwork

•  Offer healthy options but agree 1-2 treats per week

•  Encourage the child to listen to internal hunger cues and to eat to appetite. Eat slowly so you can register fullness in time

•  Serving sizes (does the 5 yr old get served as much as Mum or Dad?)

•  Instead of offering food as a reward, try alternatives e.g. stickers, going to the cinema, new book or toy, or having a friend to stay overnight

•  Comfort with attention, listening and hugs instead of food

•  Keep foods that the child should be avoiding out of the house e.g. crisps, sweets

•  Avoid classifying foods as good or bad

•  The approach a parent takes to a child’s behaviour should always be consistent

·  Water is the best drink: cut out squash, fizzy drinks, fruit juice. Diluted fruit juice (at least 50:50) is acceptable occasionally during the day if water is not drunk.

·  Better to eat the fruit rather than drink fruit juice.

·  Semi skimmed milk (<500mls/day) is preferred for children over 2 years of age

·  Basic food label reading and awareness of the ‘traps’ ie ‘no fat’ might mean large amounts of sugar and therefore the same number of calories

·  Planning ahead, avoiding regular take-away

·  The whole family need to be involved within nutrition change

·  Ask for help from friends and family in supporting behaviour change

Behavioural interventions for children should include, as appropriate:

•  Stimulus control

•  Self monitoring

•  Goal setting

•  Rewards for reaching goals

•  Problem solving

Setting Change of Activity and Nutrition goals

·  Set some simple and achievable lifestyle goals for the next visit.

·  Ask the young person/family to keep a 5 day food and activity diary (preferably including a weekend). You can use this as a focus for discussion at the next visit

·  Cheer on successes – no matter how small!

·  Identify areas of change and suggest alternatives

·  Emphasise weight maintenance in growing children

·  Early follow up (weeks) is required if you are to help maintain motivation

Providing information

Provide the young person/family with some written information to support your advice. We recommend the leaflet ‘Why your child’s weight matters’ plus details on specific individual goals, which should be SMART (specific, measurable, achievable, relevant, time specific).

Local Activity and Lifestyle Schemes

Young people aged between 5 and 13 years can be referred to the Go4 It programme, a school nurse led programme run collaboratively with leisure services in 3 leisure centres across Nottingham. Priority is offered to children living in City of Nottingham but is currently open to children from all areas.

Investigation

If the child has simple obesity with no family or personal risk factors for the insulin resistance syndrome no investigations are required.

Simple obesity with

·  family history of IRS (see table in history section)

·  signs of IRS - acanthosis nigricans, PCOS

·  marked abdominal obesity

·  extreme obesity BMI >98th Centile

Remember

·  recurrent genital candidiasis in an obese teenager can be an early sign of diabetes

·  delayed periods in an obese teenager may be early manifestation of PCOS

Consider:

1.  oral glucose tolerance test

2.  fasting lipids (total and HDL cholesterol, triglycerides)

3.  LFT

4.  TFT

If there are significant symptoms to suggest obstructive sleep apnoea (snoring, difficult to wake, nightmares, and daytime somnolence) consider referral for a sleep study to exclude other causes of obstructive sleep apnoea.

Suspected secondary obesity

If there are signs or symptoms suggestive of secondary obesity then do the blood tests described above plus: Karyotype

Midnight and 8 am cortisol

In children with early onset (pre-school) of extreme obesity consider DNA screening for monogenic forms of obesity**

**DNA samples are part of the GOOS Study- a Cambridge University initiative (contact Sadaf Farooqi - tel 01223 762634)

Referrals

Only a small minority of overweight/obese children and young people will require onward referral. The success of weight management is usually dependent on the motivation of the child/family and not on the number of referrals made.

Paediatric Endocrinologist – children or young people with insulin resistance syndrome or evidence of a secondary cause for their obesity (see flow chart)

Dietician – children or young people who would benefit from education about their diet

Community paediatrician/adolescent health – motivated children and young people with significant psychosocial or psychological co-morbidities.

Flow Chart

References

NICE, 2006. Obesity –guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. NICE clinical guideline 43. www.nice.org.uk