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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Address the growing societal problem of childhood obesity with this practical guide
Childhood obesity and its associated health issues remain major societal concerns across both developed and developing worlds. In the United Kingdom, as many as a quarter of all children starting school are living with obesity, and this prevalence only increases as children and young people age. It has never been more critical for dietitians, nutritionists, and healthcare professionals to understand the mechanisms of childhood obesity and how to tackle this significant public health issue.
Child and Adolescent Obesity offers a comprehensive, practical, evidence-based overview of this subject. Adopting a modern approach, it incorporates global perspectives, including parent interviews, to produce a thorough and rigorous discussion of best practices. Clear and accessible, it is a must-own for all social and healthcare professionals working with children and adolescents.
Readers will also find:
- In-depth discussion of the building blocks of successful programmes
- Detailed discussion of topics including physical activity, family mealtimes, the whole systems approach, and more
- Guidelines for communicating key concepts related to obesity management with policymakers, senior managers, commissioners, and the general public
Child and Adolescent Obesity is ideal for dietitians, nutritionists, health and social care professionals, and students and trainees for these professions.
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Veröffentlichungsjahr: 2024
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Table of Contents
Cover
Table of Contents
Title Page
Copyright Page
Child Obesity – Foreword
Abbreviations
Acknowledgements
Introduction
Introduction
The Voice of Children, Young People Living with Obesity and Their Parents
The Voice of Practitioners Working with Children and Young People Living with Obesity
Conclusions
References
1 What Is Childhood Obesity and Why Does It Matter
Introduction
Defining Obesity in Childhood
Aetiology of Obesity
Why Childhood Obesity Matters
References
2 Socio‐Economic Inequalities and Childhood Obesity
Introduction
Health Inequalities
SES and Obesity
SES and Obesity in Childhood
Influence of Parental Weight on Children
Food Insecurity
The Neighbourhood and Built Environment
References
3 Systems Thinking and Systems Approaches to Address Obesity
Introduction
Systems Definitions and Systems Theory
The Application of Systems Approaches to Obesity
The Evaluation of Systems Approaches to Obesity
Opportunities, Challenges and Future Direction of Systems Approachesto Obesity
Conclusion
Acknowledgements
References
4 Raising the Topic of Child Weight
Introduction
Parental Recognition
Stigma and Weight Bias
Use of Language
Discussing Difficult to Hear Topics
Raising the Topic of a Child’s Weight
Health Literacy
References
5 Changing Behaviours
Introduction
A Person‐Centred Approach
Listening Skills
Behaviour Change Theories
Behaviour Change Tools
References
6 Physical Activity, Screen Time and Sleep
Introduction
Physical Activity
Supporting Increasing Physical Activity Levels in Weight Management Interventions
Sedentary Behaviours
Supporting Reducing Screen Time in Weight Management Interventions
Sleep
Supporting Sleep Quality in Weight Management
References
7 Modifying Energy Intake
Introduction
Balanced Nutritional Intake
Energy Modification Strategies
Portion Sizes
Non‐hunger Eating
References
8 Measuring and Monitoring in Practice
Introduction
Body Mass Index
The Use of BMI in Adults
Visceral Body Adiposity
The Use of BMI in Children and Young People
Waist Measurements
Taking Measurements
Psycho‐socio Measurements
Measuring and Monitoring Lifestyle Behaviour Change
Monitoring Metabolic Complications of Excess Weight in Childhood
Evaluation of Weight Management Programmes
References
9 Understanding Obesity in Early Life
Introduction
Risk Factors for Obesity in Childhood
Genetic Risk Factors for Obesity
Environmental Risk Factors for Obesity
Dietary Risk Factors in Early Life
Physical Activity and Sedentary Behaviours in Preschool Children
Developmental Risk Factors
Nutrition and Growth
Overview
Interventions to Prevent Obesity in Early Life
References
10 Family Meal Times
Introduction
Benefits of Family Mealtimes
Fussy Eating
Behaviour
Parenting Styles
Strategies
Further Considerations
Measuring Progress
Autism Spectrum Disorder and Other Developmental Disorders
Conclusions
References
11 Childhood Weight Management in Practice
Introduction
Service Structure
Programme Structure
Daisy – A Case Study
Continuing the Management Pathway
References
12 Adolescent Weight Management
Introduction
Parental Role
Interpersonal Conflict Leading to Emotional Eating
Neurodevelopment
Neurodiversity
Hormones
Weight Stigma
Sexual and Gender Diversity
Sleep
Physical Activity
Pregnancy
Social Injustice
Adverse Childhood Events
Additional Factors for Clinical Consideration
Making Sense of this Clinically
References
13 Weight Management Considerations in Children Living with Special Educational Needs and Disability
Introduction
Prevalence
Challenges and Risk Factors
Growth Assessment
Components of Management
Behaviour and Environment
Considerations of Management
Summary
References
14 Obesity, Safeguarding and Child Protection
Introduction
Why Do We Need to Know About Safeguarding?
What Do We Mean by Safeguarding?
What Does This Mean When Working with CYP and Families?
Being Able to Recognise Signs of Harm in CYP
Adverse Childhood Experiences and Trauma Informed Practice
Safeguarding Stages
Children in Care
Legislation and Guidance
What Research Tells Us
Serious Case Reviews
References
About the Editor
Notes on Contributors
Index
End User License Agreement
List of Tables
Chapter 0
Table I.1 Emergent key themes for new participants and quotes.
Table I.2 Mapping of relationships with the practitioner.
Chapter 3
Table 3.1 Key concepts in systems thinking.
Chapter 4
Table 4.1 Ask, advise, assist.
Chapter 7
Table 7.1 Example of a traffic light dietary scheme.
Table 7.2 Energy value of typical drinks.
Chapter 8
Table 8.1 Clinical diagnostic criteria for overweight and obesity in CYP (a...
Table 8.2 Clinical diagnostic criteria for overweight and obesity in CYP (a...
Table 8.3 Case study example of a 10‐year‐old girl and treatment effect....
Table 8.4 Examples of psycho‐socio measurement tools.
Chapter 13
Table 13.1 Aspects of weight management and responsibilities of healthcare ...
List of Illustrations
Chapter 0
Figure I.1 Interplay of themes with stigma.
Chapter 1
Figure 1.1 Simplified foresight mapping.
Chapter 2
Figure 2.1 BMI distribution
a
of children across Scotland school years 2001/2...
Chapter 3
Figure 3.1 ABLe change framework [12].
Figure 3.2 Foresight obesity systems map with thematic clusters.
Figure 3.3 Overview of the different components of the LIKE programme and ho...
Figure 3.4 Public health England’s six‐phase whole systems approach.
Figure 3.5 Overview of the LIKE programme.
Figure 3.6 Overview of the various iterative stages in the ENCOMPASS framewo...
Chapter 5
Figure 5.1 Representation of the model of change.
Figure 5.2 Potential tricky/difficult situations.
Chapter 10
Figure 10.1 Three‐term contingency of behaviour modification.
Chapter 11
Figure 11.1 BDA model and process outline.
Chapter 12
Figure 12.1 Illustrating the continuum at each stage of development.
Guide
Cover Page
Table of Contents
Title Page
Copyright Page
Child Obesity – Foreword
Abbreviations
Acknowledgements
Begin Reading
About the Editor
Notes on Contributors
Index
WILEY END USER LICENSE AGREEMENT
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Child and Adolescent Obesity
A Practical Approach to Clinical Weight Management
Edited by
Dr Laura Stewart
Lead Consultant, Appletree Lifestyle Consultancy, Scotland, UK
This edition first published 2024© 2024 John Wiley & Sons Ltd
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Child Obesity – Foreword
When Dr Stewart (Laura) asked me to write the foreword for her book, it immediately triggered a personal and professional trip down memory lane. I first met Laura at a conference in 2009 having been introduced by Dr JJ Reilly who was already building a team to address the rise in prevalence of child obesity in Scotland and across the globe. With both of us having originally qualified as paediatric dietitians, we exchanged ideas about approaches to clinical care regarding nutrition and weight management for families, research results and collaborated on systematic reviews and educational texts. At that time, obesity among children and adolescents was certainly recognised, but less was known about effectiveness of approaches to treatment, particularly regarding nutrition and less still about the importance of a wholistic approach to management.
Laura has invited guest authors to share their own professional experiences in writing some chapters jointly. Throughout the text she has incorporated comments from her conversations with these other health professionals working in this field, and their extensive experience provides valuables insight and advice for others working with children and families.
This book aims to support practitioners working in fields that intersect with development of healthy weight and growth among children, including dietitians, nutritionists, exercise physiologists, physiotherapists, psychologists, social workers, physicians, teachers and others. It will interest students of these professions as well as practicing clinicians. It reviews the current evidence and best practice while delving into the practical delivery of clinical management and touch on the whole systems agenda.
Dr Laura Stewart is the perfect person to write this book. With 40 years’ experience as a clinical dietitian, she has been a tireless advocate for improving nutrition and weight‐related health for children and families for over two decades. Dr Laura Stewart was awarded her PhD from the Division of Developmental Medicine, Medical Faculty, University of Glasgow, in 2008, for her PhD thesis on dietetic management of childhood obesity. Laura is recognised as a UK expert on the dietetic management of childhood obesity. She has published many peer‐reviewed articles and chapters in medical textbooks on this subject and is an invited member of the Scottish Public Health Network (ScotPHN)’s subgroup the Scottish Public Health Obesity Special Interest Group (SPHOSIG). Dr Stewart was professional adviser to the Scottish Government on the Prevention, Early Detection, Early Intervention Type 2 Diabetes Framework for Scotland, Diet and Healthy Weight Team. She was also an advisor on the Scottish Government on recommendations on child healthy weight programmes in Scotland (2014), the review of the Scottish Obesity Route Map (2015) and until 2018 was an active member of the Scottish Healthy Weight Pathway working group, Diabetes Group’s Diabetes Prevention subgroup and Healthy Weight Leads Network.
She is the right person to bring the authors together in this book to help their experiences with others in this important area.
This book will be an important resource for parents, carers, health professionals, teachers and those who work with children broadly. In writing these chapters, Dr Stewart aims to empower a new generation of professionals in this field.
The book starts with a brief history of methods used to define obesity in young people and summarises what is known about health and psychological impacts of excess adiposity.
Chapter 2 acknowledges the wicked relationship between socio‐economic factors and multigenerational obesity prevalence, an issue which still requires stronger policy action in most countries if the adverse consequences are to be prevented. The discussion of hypotheses and theoretical models that have attempted the global rise in obesity prevalence will be important reading for those new to the field of obesity to gain insight into the factors that have coalesced at this time in history that promote storage of excessive body fat.
Chapter 4 is a must read for all, and especially those working clinically with families. It provides a comprehensive discussion of raising the issue of child weight status with families, an area that health professionals will agree needs to be performed with sensitivity, respect and support in order to create supportive, non‐stigmatising healthcare and where appropriate, treatment plans. The list of strategies parents found helpful when the topic was raised will be very important to guide discussions.
This book confirms this importance of ensuring health professionals and those working with children have access to current, high‐quality continuing professional development in all areas related to child and adolescent obesity and strategies for promotion of healthy lifestyles and healthy growth.
It is important to be aware of resources available locally for families, careers and available for use by to local organisations, as well and regional clinical pathways for treatment.
There are dedicated chapters for specific aspects of lifestyle such as nutrition and physical activity, as well as chapters dedicated to the specific life stages of childhood and adolescence, including those with special needs or disability. While this information is of utmost importance, the chapters on changing behaviour, family meals and measuring and monitoring in practice provide the guidance to implement the learnings from the book.
Importantly the chapters on safeguarding provide an alert to key issues that need to be addressed when supporting development of healthy weight and weight‐related health outcomes for children and adolescents. The chapter on systems thinking provides a sobering reminder that no country has yet managed to reverse the relentless rise in the prevalence of obesity, despite many developing policies, strategic plans and blueprints. There is a clear need for implementation of whole of system approaches. This needs to be accompanied by evaluation of both effectiveness and impact, as well as funding to refine programs based on evaluation results. This will help to conserve healthcare resources and ensure the most successful approaches are adopted at scale, such that every child can access the right care in the right place at the right time. This is needed to allow them and their families and carers to thrive.
Clare Collins
Laureate Professor of Nutrition and Dietetics, The University of Newcastle, NSW, Australia
Abbreviations
Below is a list of abbreviations used throughout this text book. The full terms are written out only once in this book and then the abbreviation is used in subsequent chapters.
AAP
American Academy of Pediatrics
ABLe‐Change
Above and Below Line Change
ACE
Adverse Childhood Experiences
ADHD
Attention‐deficit hyperactivity disorder
AHWP
Amsterdam Healthy Weight Programme
ARFID
Avoidant/restrictive food intake disorder
ASD
Autistic spectrum disorder
AYPH
The Association for Young People’s Health
BED
Binge eating disorder
BMI
Body Mass Index
BOGOF
Buy‐one‐get‐one‐free
BOMSS
British Obesity and Metabolic Surgery Society
CAMH
Children and Adolescent Mental Health
CDP
Chronic Disease Prevention
CMOs
Chief medical officers
COMPACT
Childhood Obesity Modelling for Prevention and Community Transformation
CT
Computer tomography
CV
Cardiovascular
CVD
Cardiovascular disease
CYP
Children and young people/child and young person
DEXA
Dual‐energy X‐ray absorptiometry
EAR
Estimated average requirements
ECPO
European Coalition of People Living with Obesity
EDNP
Energy‐dense nutrient poor
EE
Emotional eating
ENCOMPASS
Evaluation of Programmes in Complex Adaptive Systems
EPODE
Ensemble Prévenons l'Obésité Des Enfants’ (
Together Let's Prevent Childhood Obesity
)
GOOS
Genetics of Obesity Study
GRADE
Grading of Recommendations Assessment, Development and Evaluation
HbA1c
Glycated haemoglobin
HCP
Health Care Professional
HFSS
High in fat, sugar and salt
H&SCP
Health and Social Care Professional
HOMA
Homeostatic Model Assessment
ICAD
International Children Accelerometery Database
IGF‐1
Insulin‐like growth factor‐1
IH
Insurance hypothesis
IMD
Indices of Multiple Deprivation
IOTF
International Obesity Task Force
NAFLD
Non‐alcoholic fatty liver disease
NASH
Non‐alcoholic steatohepatitis
NCD
Non‐communicable diseases
NCD‐RisC
NCD Risk Factor Collaboration
NCMP
National Child Measurement Programme
NDNS
National diet and nutritional survey
NHANES
National Health and Nutrition Examination Survey
NICE
National Institute for Clinical Excellence
NIHR
National Institute for Health and Care Research
NSS
Non‐sugar sweeteners
MASH
Multi agency safeguarding hubs
MC4R
Melanocortin 4 receptor
MDT
Multi‐disciplinary team
MEND
Mind, Exercise, Nutrition, Do It
METs
Metabolic equivalents
MPVA
Moderate to vigorous activity
MRI
Magnetic resonance imaging
OECD
Organisation for Economic Cooperation and Development
OSFED
Other specified feeding or eating disorder
PA
Physical activity
PAQ‐A
Physical Activity Questionnaire for Adolescents
PAQ‐C
Physical Activity Questionnaire for Older Children
PCOS
Polycystic ovarian syndrome
PEC
Picture Exchange Communication
POMC
Propeptide proopiomelanocortin
PHE
Public Health England
PHS
Public Health Scotland
PREM
Patient reported experience measures
PROMS
Patient reported outcome measures
RCPCH
Royal College of Paediatricians and Child Health
RCT
Randomised controlled trials
REM
Ripple Effects Mapping
SAMHSA
Substance Abuse and Mental Health Services Administration
SEIFA
Socio‐Economic Indexes for Areas
SEND
Special educational needs and disabilities
SES
Socio‐economic status
SHANARRI
Safe, Healthy, Achieving, Nurtured, Active, Respected, Responsible, Included
SIGN
Scottish Intercollegiate Guideline Network
SIMD
Scottish Indices of Multiple Deprivation
SLA
Service level agreement
SMART
Specific, Measurable, Achievable, Recorded, Time‐phased
SSB
Sugar sweetened beverages
SUS
Shape Up Somerville
TEI
Total energy intake
TV
Television
UK
United Kingdom
UNICEF
United Nations International Children’s Emergency Fund
US
United States
WHO
World Health Organization
WHOSTOPS
Whole of Systems Trial of Prevention Strategies for Childhood Obesity
WSA
Whole systems approach
Acknowledgements
I would like to give a huge thank you to both Dr Clare Neilson and Dr Thomas Stewart for their exceedingly helpful advice reviewing the content and structure of this book. They helped to give me feedback on each chapter and on the overall book contents. Thank you both for your hard work. Without a doubt, many thanks to the authors of the ‘guest’ chapters and Clare Collins for her gracious foreword.
Therese Stewart and Thomas Stewart both transcribed the recorded interviews with professional practitioners, undertaken for this book. The introduction chapter could not have been written without this important step, so thank you both. This leads me to thank all the practitioners who agreed to have a recorded conversation with me. Your contribution via these conversations has been of great benefit to the overall sense of this book.
Chin Wai Yip spent a ten‐week internship with me in 2021 as part of her Nutrition course at Abertay University. During this time, she kick started the literature review for this book. I thank her and wish her all the best for her future career in nutrition.
My last thanks are to the team at Wiley for being so supportive, many thanks.
Laura StewartAugust 2024
Introduction: The Voices of Lived Experience
Laura Stewart
Introduction
The aim of this book is to support healthy weight practitioners such as dietitians, nutritionists, psychologists, social workers, physicians, health coaches and other professionals who currently, or indeed wish to, work in the field of childhood obesity and weight management. It will interest students of these professions as well as practicing clinicians. It explores current evidence and best practice while delving into the practical delivery of clinical management and touches on prevention by briefly looking at the whole systems agenda and the early years.
In this introductory chapter, the points of view of children and young people, their parents and carers are given through a synthesis of published qualitative research of interviews with children and young people living with obesity and their parents. It is intended that giving such insight into the lived experience of children and young people and their families, at the beginning of a text book on childhood obesity and weight management, will be thought provoking for the reader. This introductory chapter is intended to aid weight management practitioners in considering their own personal approaches when reading the subsequent chapters, which cover the science, evidence and best practice of this discipline. This has been put into an introductory chapter to emphasise the importance to practitioners of hearing the voice of lived experienced. All direct quotes from children, young people and parents in this section are taken from and referenced to the original published work.
It was an important concept at the outset of writing this book that the voice of the children and young people living with obesity and their parents was heard and was at the forefront of the reader’s mind. Although not the only source, a number of the works quoted below are from published qualitative works by this author and colleagues. Another important resource for this section was the recent work undertaken in 2022 by The Association for Young People’s Health (AYPH) for NHS England [1].
To give another perspective, this book also brings to the fore the views of experienced professionals working in the field of childhood weight management. A number of one‐to‐one semi‐structured conversations were carried out with clinical and research experts in this field by this author between 2021 and 2023. These included experienced dietitians, service managers, public health practitioners, physical activity experts and psychologists. Rich, unique insights with quotes and discussions of important themes that emerged during these conversations are given below in the second section.
The Voice of Children, Young People Living with Obesity and Their Parents
When Do Parents Look for Support?
For many parents, recognising the need to seek help for their child’s weight management is a difficult process. Work by Gillespie et al. found that for some parents even discussing the topic of weight was overwhelming: ‘the problem is too big’, ‘I can’t bear to raise it, and I don’t want to make things worse’[2].
Discussing what their reasons for seeking support for their child’s weight were, this group of parents described possible ‘triggers’ for seeking help including
recognising that their child was being bullied
being aware that their child was wearing outsized clothes for their age
having concerns about their child’s current or future health
[2]
.
Not being able to recognise that their child’s weight was outside the healthy weight zone was something that parents spoke about.
‘I didn’t realise he was so overweight, I didn’t realise he was that, because he doesn’t look it because he’s broad, so he carries it well, but I was quite shocked to find out his actual weight’[3]. This can lead to difficult conversations happening with health professionals who are raising the topic for the first time. While Murtagh et al. reported that young people can be aware of the need for support with their weight and are actually waiting for their parents to take action, ‘I knew about it but my parents didn’t believe me’[4].
Studies reported that consideration of the matter of a child’s weight can be overwhelming for parents, ‘the problem is too big’ and ‘I can’t bear to raise it, and I don’t want to make things worse’[2]. Rigby noted that the young people could also feel overwhelming, ‘time to comprehend so you don’t get overwhelmed’[1].
Attitudes and Qualities of the Health Professional
Families report that the attitudes of health professionals, especially their ability to build and develop rapport, are important to them [5]. Parents in studies have talked about the necessary qualities of the professional as ‘being friendly, supportive, helpful, good listeners, non‐judgemental and non‐patronising’ [1, 2]. As well as how vital it is that they are seen within a non‐stigmatising service [2].
The 2022 work from AYPH discussed the negative feeling that can emerge when professionals do not have the right communication and people skills, ‘One hospital appointment made my child feel set for self‐destruction’[1]. Stewart et al. found that professionals not trained in the use of behavioural change techniques found it harder to form a rapport and make the families feel supported [5].
‘I don’t really think it was a success ‘cause I don’t think we both actually liked the dietitian, em. I think that wasn’t just me, he didn’t like her’ and ‘I expected more than just talk’
[5].
Using Behavioural Change Tools
When it came to aspects of behavioural change tools being used in programmes, it was reported by parents that tools were positive and enabling an improvement in self‐esteem and ownership for the child and young person. ‘None of us like to be told to do things and so it was like forming a partnership and it worked’ and ‘if she wanted a treat of chocolate throughout the day, she had to decide, she has to tell me’[5].
Using the tool of self‐monitoring through keeping a lifestyle diary was seen as helpful in raising awareness of current behaviours, ‘I was happy for C to watch TV but I wasn’t aware of how much time she was actually watching but when we recorded it I was really surprised. I just wasn’t aware of things that is why recording was so good’[5].
Stigma and Self‐esteem
Many studies talked about participants reporting stigmatisation, low self‐esteem and bullying of young people living with obesity [1, 6].
‘he gets bullied, and everything, low self‐esteem, he’s got no friends, he doesn’t go out’[2].
‘if my daughter felt better about herself, she wouldn’t be so angry all the time, she’s got quite a lot of emotional issues due to being a bit heavy’[2].
‘People call me names because they think it’s funny but it’s not’[4].
For young people, they felt that health services should give equal consideration to their mental health and well‐being as to their physical health [1, 7]. Indeed, an important theme emerging from Yerges et al. was titled ‘health is like a physical, mental and social balance’. Their work suggested that weight management programmes need to have a holistic‐person‐centred approach, taking equally into account these three interlinked aspects of a young person and their family’s live [7].
‘Because I mean like anything that affects a person’s like day‐to‐day life I think could fall under health care, whether it is physical or mentally’[7].
A number of studies reported that parents were aware, and anxious, about the emotional effect of their child’s weight. They talked about wishing for their child to be happy and how important it is to them, as parents, for their child’s self‐esteem to be positively impacted by the programme [1, 2].
‘she used to be embarrassed at school cause there were things she couldn’t do in PE that she can do now’[5].
‘He used to wear jogging bottoms for comfort, but we managed to get him dress (in) trousers for school. He was saying it’s really good isn’t it, it has been really good for him’[3].
Programme Outcomes
This leads to consider what it is that children, young people and their parents regard as a desired outcome of treatment. For those children, young people and the parents interviewed, they reported that concentrating on a weight outcome of treatment was not always a positive concept. There was a reported ambivalence from young people towards being weighed and comments that interactions should be more than just about the number on the scales [7].
‘Some days, weight is just a number, and then some day’s weight is something that is weighing me down’[7].
Informal Support
Yerges et al. noted that although the young people felt able to discuss their knowledge of a ‘healthy lifestyle’: they knew that they should ‘eat healthier’ and ‘take more’ physical exercise, and they struggled to ‘actualise these health ideals’[7]. This is an interesting point which suggests that there is a need for support for problem‐solving and developing realistic goals for making day‐to‐day lifestyle behaviour changes.
The benefit of informal support from others in the kinship circle was reported and from their peers in the weight management peer group [1].
‘To do it alone and without support can mean we go back into our old ways’[1], while ‘Being able to see what others can do and that I can do it too if I try hard enough’[1], and ‘I don’t think I would have carried on if … my friend … wasn’t there’[1].
What was seen as supportive and important was a person‐centred approach that was tailored to the child and young person’s needs, ‘need to encourage them to take on at their own pace, more likely to achieve’[1].
The importance of family‐based programmes which encourage parental and kinship support is underlined by quotes from young people not feeling supported by the families.
‘since I do not buy the groceries I have no control over what we have in the house’[8].
‘some people in my family, they motivate me to eat well. Then, a couple of days later, they’ll start eating the wrong things and they’ll try to feed me it and try to make me eat it, and I’m trying to stay healthy in all things. They just keep switching back and forth’[8].
Potential Barriers
A major barrier cited to achieving lifestyle change goals was eating behaviours, especially around non‐hunger eating and having access to easily available high‐energy foods [8]. This could be worsened when trying to fit in with peer groups [7, 8].
‘You’re not gonna be like, oh, let me eat a salad while all my friends are eating pizza or whatever, you know?’[8].
The other potential barriers to change cited by the young people and their parents was bullying and the fear of bullying [1]. In addition to the pressures of life such as school work, exams, keeping up with their peers and social pressure, ‘[I feel] different and terrible, like I’m not like everyone else’ [1, 4].
In a study where only females were interviewed, they talked of embarrassment around physical activities and not knowing what or how to do activities [8]. Other studies mention that young people spoke of wanting a ‘safe environment’ to undertake physical activity [1, 9].
‘Doing sports around people who are physically healthier than you can cause a lot of anxiety and it takes a lot of help to get rid of that anxiety’[1].
The Voice of Practitioners Working with Children and Young People Living with Obesity
Most of the conversations with practitioners took place virtually, with a few conducted in person. They all took around one‐and‐a‐half hours. The conversations were recorded and then transcribed in full. A framework analysis approach was used to allow themes and concepts to emerge from the transcribed conversations [10]. The outputs from these conversations are unique to this book and have not been published elsewhere.
A qualitative‐type semi‐structured script was used as the starting point of the conversations. Some questions were asked as standard for all the participants, while some were pertinent to their particular field and/or profession. While the script was a starting point for discussion, the conversations developed organically following the responses and thoughts of each practitioner. These took place with an understanding of the participants remaining anonymous and none of the quotes in this section are referenced.
Key Advice for New Practitioners
All participants were asked ‘what would be the key piece of advice you would wish to give to a new practitioner in the field of childhood weight management’. From this question, three significant themes stood out; these are outlined in Table I.1. Participants acknowledged that while this was a challenging area to work in, it was also rewarding.
Analysis of all the conversations added a further six themes. These nine themes are now briefly summarised and illustrated with quotes.
Person Centred
The importance of taking a person‐centred, holistic approach and not a ‘the professional knows best’ approach was emphasised by the participants.
Table I.1 Emergent key themes for new participants and quotes.
Themes
Participant quotes
Complexity
‘It is so so complex. And they need to have an understanding of the challenges that are for all families, but particularly for those that are maybe in more deprived areas, who are more vulnerable to the obesogenic environment’
.
Relationships
‘The importance of developing good relationships with the people you are working with and also with your team members, and having that mutual respect and understanding for each other, Being able to learn from each other and deliver messages by learning from each other is really key’
.
Person centred
‘You need to look at the whole perceptive in order to effectively fully understand what is right for that child’
.
‘You need to spend the time fully understanding the child and the circumstances of the family. And when I say fully understanding, it is not just diet, it is not just activity. It is understanding the social context, the psycho‐social context, the mental health’.
‘To take that person centred approach, to not be judgemental, not be didactic, but to explore first. To get permission, understand the family environment and that wider setting. It is not just about education; it is about that wider psychological change. It is not just about what we do or what we eat. But how we do these things and how it fits together’.
‘Getting to know the child. Exploring the child’s world. The social dynamics, their routine, food choices. Don’t just jump into advice, get to know them. Work out what you can tailor to that individual. It’s not simple and you might get your information over multiple appointments’.
Challenges and Complexity
The complexities of childhood obesity and its management was returned to time and again as a major challenge for any practitioner. The complexities discussed varied from family dynamics and circumstances, the obesogenic environment, the underlying psycho‐social components and societal attitudes to children and young people living with obesity.
‘By complexity, I mean the family dynamic, the social circumstances and sometimes underlying disabilities or additional needs that child might have’.
‘It’s so multi‐factorial, it’s so not down to individual choice, it’s so wrapped up into politics and social norms and beliefs and values’.
‘In reality it is such a complex, multi‐component condition. And it is a condition that people are living with, experiencing with not just physical but psychological and social, daily impacts. So, we really need a bio‐social model to be able to deliver the care people need’.
Relationships
Relationships came up in every conversation. From the point of view of the practitioner, these relationships were between themselves and the child and young person and their parents, the team and possible gatekeepers (a term for those who refer into the service). This concept of relationships is mapped out in Table I.2.
Rapport
The need for the practitioner to be approachable and have the ability to establish and develop rapport was a strong sub‐theme of relationships.
‘It’s about the importance of establishing rapport, the importance of having a relationship with the family whereby you can start. Having empathy with them and showing that you can understand the position, or circumstance they are in, to enable you to work with them and for them to have the trust in you is quite important as well. And that can sometimes take a lot of time’.
‘But I genuinely think that being open and honest with the families is important to building that rapport’.
Parenting
A further sub‐theme of relationships was characterised in the thematic analysis as ‘parenting’. This included both the role of parents in supporting their child and also the act of parenting.
‘I think with that, with food as well, it is all about role modelling. It’s so important. If you have got a parent that goes out on that Sunday run, they do it without fail. That is important role modelling for a child’.
‘For those patterns to change or to be challenged can be very difficult. I think it is important we don’t place sole responsibility on the young person. It is expected their parents will be part of that process’.
Table I.2 Mapping of relationships with the practitioner.
Child/young person (CYP)
‘It can take them a while to open up to a healthcare professional, having the consistency and seeing the same person, being able to build on that relationship, helps them open up and it’s a bit more of two‐way street when you are negotiating things
’.
Parents
‘Helping to manage the parents’ frustrations, which, you know, are concerns. And not look, and that’s where it comes back, I suppose to the behavioural to the parenting side of it, and not looking reinforce these behaviours but helping the family, the parents to manage them and have boundaries’
.
Practitioner’s relationships to
CYP and parents
‘For those patterns to change or to be challenged can be very difficult. I think it is important we don’t place sole responsibility on the young person. It is expected their family will be part of that process’
.
The team
‘I say inter‐professional rather than multi‐disciplinary deliberately. Because sometimes I feel you can have a multi‐disciplinary team that functions separately to one another. When you are dealing with obesity you really want to be dealing with all of those different aspects together’
.
Gatekeepers
‘Likewise for the school nurses, likewise for the health visitors. Because I think sometimes that training either exists as a one off at the start and then never gets refreshed and clued up. And I think these people need to be on regular refresher training on growth, nutrition, feeding advice, as a general thing’
.
The Team
The participants included those who had worked within a formal multidisciplinary team (MDT) and a uni profession (usually) dietetic‐led weight management service. This led to rich and varied points of view on the role teams play in supporting both individual practitioners and the children and young people they work with.
‘The person who that family have really clicked with. You decide in those first assessments, who is the priority area for that family. Is it that you really need to be focussing on the social side of things? So, the social worker is the person who you really need to be moving through the stages of change? Then bringing in some expert advice from the rest of the team’.
‘It is important the team can understand that, that we are all working towards the same goal. That being informed by the family, but also supporting the team with aspects of training. We support each other’.
Psychologist
The role of a psychologist was understood by participants to be fundamental in supporting weight management, behaviour change and mental well‐being for children and young people. Best practice was considered to be a psychologist embedded within a team, with at the very least a good working relationship with the local psychology service. Access to informal discussions with psychologist was considered to be valuable in supporting up skilling practitioners and with reflective practice.
‘I think it is crucial for the psychologist to be embedded within the team so they can learn from everybody else in the team and everybody else can learn from them’.
‘Psychology is key. That might be our tier three families who are that bit more complex and have more additional needs. They might need that psychology. If not a specific child healthy weight psychology, then at least links and pathways into CAMHS (child and adolescent mental health service) to be able to provide that’.
Stigma
Stigma interfaced and overlapped with a number of other themes, as illustrated in Figure I.1. Stigma here encompasses weight stigma and bias.
‘If we haven’t had the forethought to plan ahead for example, or services haven’t got the right equipment that contributes to a young person feeling different and embarrassed. Which is going to affect how they feel about coming back and the conversations that they have’.
Figure I.1 Interplay of themes with stigma.
‘So that then leads me to think about, in terms of society’s view, that that is actually one of the most fundamental challenges as well. Because of the stigma that overweight and people living with obesity have. And I think that needs to be addressed as well, and I think it is being addressed’.
‘Because a lot of their parents would have had similar experiences. They would have been overweight and obese themselves, and therefore probably have experienced stigma and negative associations with that. And that stays with them, and therefore that makes it difficult for them to seek out support. If they’ve had a difficult experience, or a negative experience, themselves in addressing their own weight, or perhaps not addressing it and just internalising it, then that then impacts on their child as well. So, I think it is through all layers’.
Outcomes
There was much discourse during the conversations on the need of outcomes (as collected from a service point of view) to be person centred and include a mixture of quantifiable and qualitative type data, such as patient stories and patient outcome measures, for example being able to fit into smaller clothes sizes or being able to run for longer or faster.
‘The focus from their point of view is the focus on weight can be counter‐intuitive and can create stress and pressure. We want to be in a place we can quickly identify those patterns of behaviour and seek additional specialist help’.
‘Often the parents will say they want the child to be healthier. In terms of physical health and to lose weight. I will always ask the young person what they want. They would often say words to that affect. When I ask what that means for them, it might be about be about keeping up with their peers, running as fast as them, not getting out of breath, choosing different clothes, feeling more confident in social situations. Everyone is different’.
The use of Body Mass Index (BMI) was categorised as a sub‐theme of outcomes. While participants consider collection of weight, height and thus BMI necessary, they clearly expressed a point of view that it should not be the only measurement of success for the children and young people, the parents or the service.
‘For example, I think in younger children when you are working with them it is things like families eating meals together. It’s these sort of things where sometimes that sort of thing becomes lost. So, it can be families eating meals together. I think reducing screen time. If there’s more stories going on in the house. Things like that can be a stepping stone towards making changes. I actually think I’m, yeah, I’m becoming less interested in the BMI in outcomes for families’.
‘If we think about all the different dimensions there, there is something there about health and well‐being part of that and weight and BMI being one part of that as well. So, I do think there needs to be more than that. I don’t think it can just be down to BMI’.
Systems
Systems brought together wider aspects of the world we live in, such as discussions around the obesogenic environment, interplay of environment and genetics, targeting early years interventions.
‘So, there’s something there about the connection between working with individual families, but understanding the context that these families are living in, and getting that balance right between addressing all of those things that are needing to be’.
‘And that, to my mind, means starting earlier. If we are going to have a hope of more effective treatments, or more successful prevention of adulthood obesity, we need to start our treatments earlier. I think that’s the other thing that has come out from the evidence, children are coming into treatment when it is probably already getting a bit late. Children are coming into treatment when they are already on a particular trajectory of lifestyle behaviours, a particular trajectory of weight and treatment has to start earlier in my view. I think the evidence is pretty clear on that’.
‘But I think we are at the point now where we do need to acknowledge that there is something there about genetics as well’.
Programmes
There was strong feeling that childhood weight management programmes should be underpinned by the best available evidence and be structured while at the same time supporting an individualised approach.
‘I do think it is helpful to have structured programmes, that you can use. That’s consistency from the practitioner’s point of view, but also for families who may drop out or re‐engage with your service over time, because that happens quite a lot. That they’re hearing the same thing’.
‘We have to do multiple things at multiple different stages and we will have an impact, accumulatively with all those things’.
‘But it's multicomponent. It's more than just educating. You have to be able to achieve the behaviour change or the appropriate behaviour in families. You have to have the psychological component. You have to have interactive teaching, where everything is co‐creating what their lifestyle is going to be. It has got to be meaningful for them, something they want to do’.
Eating Behaviours
While all aspects of lifestyle advice/energy balance were discussed eating behaviours stood out as challenging for both the practitioner and the families.
‘I suppose around fussy eating and, fussy eating which can then on a continuum become restrictive eating and looking to help to challenge in that area’.
‘I think a lot of people assume because they are coming to a weight management clinic, we are going to turn their diet upside down. They are going to have to change everything they eat, but for a lot of young people it might be about portions, or might be about making slight different snack choices. It’s actually quantity rather than variety’.
‘I find a diet history isn’t my preferred method, but I try and do it so its not an interrogation but a chat through the day’.
Conclusions
It can be seen from both of these sections that there are many similarities between what the young people, their parents and the practitioners consider to be important. All of the points raised in this chapter are explored and expanded on in the chapters of this book.
This book has been written from the point of view of delivering a person‐centred, compassionate approach to childhood weight management. It is hoped that this introductory chapter has helped to set the scene from the perspective of those with lived experience. To keep this voice in the readers mind, each chapter commences with a suitable quote.
References
1 Rigby, E., McKoewn, R., and Wortley, L. (2022). The experiences of young people and their families living with excess weight: themes from engagement work.
https://ayph.org.uk/wp‐content/uploads/2022/04/CEW‐Themes‐from‐engagement‐work.pdf
(accessed 29 March 2024).
2 Gillespie, J., Midmore, C., Hoeflich, J. et al. (2015). Parents as the start of the solution: a social marketing approach to understanding triggers and barriers to entering a childhood weight management service.
J. Hum. Nutr. Diet.
28: 83–92.
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3 Stewart, L., Chapple, J., Hughes, A.R. et al. (2008). Parents’ journey through treatment for their child’s obesity: a qualitative study.
Arch. Dis. Child.
93: 35–39.
https://doi.org/10.1136/adc.2007.125146
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4 Murtagh, J., Dixey, R., and Rudolf, M. (2006). A qualitative investigation into the levers and barriers to weight loss in children: opinions of obese children.
Arch. Dis. Child.
91: 920–923.
https://doi.org/10.1136/adc.2005.085712
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5 Stewart, L., Chapple, J., Hughes, A.R. et al. (2008). The use of behavioural change techniques in the treatment of paediatric obesity: qualitative evaluation of parental perspectives on treatment.
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https://doi.org/10.1111/j.1365‐277X.2008.00888.x
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6 Hagell, A. and Wortley, L. (2022) The experiences of young people and their families affected by excess weight: evidence from existing research. AYPH
7 Yerges, A.L., Snethen, J.A., and Carrel, A.L. (2021). Adolescent girls with overweight and obesity feel physically healthy and highlight the importance of mental health.
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1What Is Childhood Obesity and Why Does It Matter
Laura Stewart
‘The problem is too big’. [1]
Introduction
Managing and securing a sustained decrease in the prevalence of childhood obesity is one of the major public health challenges of the 21st century. In 2021, the World Health Organization (WHO) reported that there were 39 million children under the age of 5 living with overweight or obesity in the year 2020, while there were over 340 million children and young people (CYP)1 aged 5–19 living with overweight or obesity in the year 2016 [2]. The WHO demonstrated the importance they placed on tackling childhood obesity to worldwide health by setting a target in 2011 for worldwide childhood obesity prevalence to be no more than 2010 levels by the year 2025 [3].
In 2017 the NCD Risk Factor Collaboration (NCD‐RisC) looked at the worldwide trends of body mass index (BMI) in CYP from 1975 to 2016. They found an increase in the prevalence of obesity for girls in that time from 0.7% (0.4–1.2) to 5.6% (4.8–6.5). For boys the prevalence increased from 0.9% (0.5–1.3) in 1975 to 7.8% (6.7–9.1) in 2016. The trend in rising CYP’s BMI now appears to have levelled out. These raised levels remain in high‐income countries, while the prevalence is continuing to increase in certain parts of Asia [4]. There is also evidence to suggest that the COVID‐19 lockdowns were associated with a higher rate of increase in BMI compared to the pre‐pandemic period [5].
The writing of this book started during the COVID‐19 pandemic of 2020–2021, during which there emerged an association between obesity and type 2 diabetes and a higher likelihood of acquiring COVID‐19 as well as worse outcomes from the illness including death. While the death risk from COVID‐19 was greatest in the older population, it was also seen in younger adults who had higher BMI [6]. This experience further emphasised the need to consider excess weight and high BMIs as health risks. This matters for our consideration of childhood obesity, as will be discussed in this chapter there is a higher likelihood of a young person with obesity becoming an adult living with obesity.
This first chapter seeks to ‘set the scene’ around how we define obesity in childhood and why this is an important topic in terms of health and socio‐psycho consequences. Viewing obesity as a chronic disease, requiring long‐term support and management [5] throughout the life course, is the starting position of writing this text book.
Defining Obesity in Childhood
It is important to understand when considering a definition of clinical obesity that it is an excess accumulation of body fat (adipose) that has led to, or has increased the risk of, chronic disease and co‐morbidities [7]. There is strong evidence that central visceral fat distribution in children and adolescents is associated with increased health risks [8, 9]. Meaning that the health risk is due to where the excess body fat actually sits within the body and not just the actual amount.
Co‐morbidities associated with excess body fat will include:
Cardiovascular disease
Insulin resistance
Pre‐diabetes
Type 2 diabetes
Dyslipidaemia
Hypertension
Psychological and social morbidity
Asthma
Impaired fertility
Orthopaedic problems, e.g. in the hips and ankles
Breathing problems and sleep apnoea
Fatty liver disease
Some cancers, e.g. breast, bowel, pancreatic, oesophageal and gallbladder
Acceleration of puberty in both girls and boys
Persistence of obesity into adulthood [
10
,
11
]
Regardless of age, we cannot tell if someone has overweight or obesity simply by looking at them. Being able to accurately measure total body fat and its distribution is not practical from a routine perspective. Total body fat can be measured using dual‐energy X‐ray absorptiometry (DEXA) scan [5]; however, the DEXA scan cannot measure visceral fat accurately. While, accurate measurements of visceral fat can be made using computer tomography (CT) and magnetic resonance imaging (MRI) [12].
Therefore, the ‘easy to use’ proxy measurement of BMI is widely used for day‐to‐day clinical practice in childhood weight management. While the calculation of BMI in childhood is the same as for adults, the dynamic growth and changes in body fat seen during growth require it to be plotted on an age‐ and sex‐related BMI centile chart [5, 13].
Body Mass Index
The use of BMI to categorise childhood overweight and obesity requires clinical relevance of this proxy measurement of body fat. That is at what level of BMI is there a significant increase in the adverse health consequences of childhood overweight and obesity [14–16]. A cut off with a high specificity has generally been regarded as more important for clinical applications than a high sensitivity to avoid unnecessarily classifying some children as having obesity [5, 17, 18].
BMI in children rises steadily in the period following birth and then drops during the pre‐school years. It then subsequently slowly increases during childhood until adulthood. Adiposity rebound is the term used to describe the point when the BMI starts to rise again after the lowest point. Evidence suggests that the earlier the age of adiposity rebound is associated with an increased risk of later obesity in childhood [20, 21]. Due to this changing curve of BMI during childhood and in differences between male and female, BMI needs to be plotted on a national specific, sex appropriate BMI centile chart and from this a weight category can be made.
BMI Centile Charts
For some years the diagnosis of obesity has been based on the cut‐off point of the 95th centile, with the 85th centile taken as the cut off for overweight, first on the United States’ (US) National Health and Nutrition Examination Surveys (NHANES) charts and then on other national BMI centile charts. It was considered that children with a BMI over the 95th centile had a higher risk of persistence of obesity in adulthood and of obesity‐related diseases [16, 22]. This cut‐off point had been noted by Himes and Dietz as having a high specificity and a moderate to high sensitivity [16].
Discussion of BMI and BMI charts is returned to in depth in Chapter 8. At this point it is worth noting that in the United Kingdom (UK), the WHO/UK 1990 BMI centile charts should be used. Unlike other countries in the UK, there are essentially two definitions with different BMI centile cut‐off points used:
For clinical work, the ≥98th BMI centile for defining obesity is used, with the ≥91st
