Management of Childhood Obesity 1st Edition

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Management of Childhood Obesity

Elizabeth Poskitt has practised and taught paediatrics in the UK and

overseas. Her experience includes over 20 years running clinics for obese
children, first in Birmingham and then Liverpool. She is co-founder of the
European Childhood Obesity Group. She was awarded an OBE in 1998.
Laurel Edmunds has worked with children and their families for over 16 years
and has researched childhood obesity issues for the past 14 years, including
two in practice. She was one of five Specialist Advisors to the House of
Commons Heath Committee’s enquiry into obesity and was a Co-opted Expert
for the NICE Guidelines.
Management of
Childhood Obesity
Elizabeth Poskitt
and

Laurel Edmunds
CAMBRIDGE UNIVERSITY PRESS
Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo

Cambridge University Press

The Edinburgh Building, Cambridge CB2 8RU, UK
Published in the United States of America by Cambridge University Press, New York
www.cambridge.org
Information on this title: www.cambridge.org/9780521609777

© E. Poskitt and L. Edmunds 2008

This publication is in copyright. Subject to statutory exception and to the provision of

relevant collective licensing agreements, no reproduction of any part may take place
without the written permission of Cambridge University Press.
First published in print format 2008

ISBN-13 978-0-511-38853-8 eBook (NetLibrary)

ISBN-13 978-0-521-60977-7 paperback

Cambridge University Press has no responsibility for the persistence or accuracy of urls
for external or third-party internet websites referred to in this publication, and does not
guarantee that any content on such websites is, or will remain, accurate or appropriate.

Every effort has been made in preparing this publication to provide accurate and up-to-
date information which is in accord with accepted standards and practice at the time of
publication. Although case histories are drawn from actual cases, every effort has been
made to disguise the identities of the individuals involved. Nevertheless, the authors,
editors and publishers can make no warranties that the information contained herein is
totally free from error, not least because clinical standards are constantly changing through
research and regulation. The authors, editors and publishers therefore disclaim all liability
for direct or consequential damages resulting from the use of material contained in this
publication. Readers are strongly advised to pay careful attention to information provided
by the manufacturer of any drugs or equipment that they plan to use.
Contents

Foreword by David W. Haslam page vii

Preface ix
Acknowledgements xi
List of abbreviations xii

1 Introduction 1

2 How fat is fat? Measuring and defining overweight

and obesity 15

3 Where should overweight/obese children be managed? 33

4 How do we approach the overweight/obese child and family? 46

5 The clinical assessment: what are the special points? 58

6 What complications should we look for now and later? 72

7 How does psychology influence management? 83

8 Management: what do we mean by lifestyle changes? 96

9 How can we reduce energy intake? 108

10 How can we increase energy expenditure? 132

11 What else can be done? 153

12 How can we sustain healthy weight management? 161

13 What can we do to prevent childhood overweight and obesity? 168

References 188
Index 207

v
Foreword

Childhood obesity is one of the most serious problems facing the developed
world. It is damaging to the medical and psychological well-being of our
children, and casts a shadow on their future health as adults, leading to
serious illness and ultimately premature death.
This book, written by world-renowned leaders in the field, should be
used as a practical tool in the management of the overweight child rather
than left on the shelf to gather dust like some medical books. Its pages should
become well-thumbed by front-line health care professionals, commissioners
and policy-makers alike. It would even be acceptable to turn back the corners
of the pages, and use light pencil markings on the margin to highlight
important passages, because unlike many volumes, this represents first-hand
experiences of practical childhood obesity management, combined with a
profound scientific, clinical and social appreciation of the condition and its
ramifications.
Weight management in children is one of the most difficult challenges
faced by health care professionals who cannot change the environment which
leads to the weight problems in the first place. Only the government, food,
retail, advertising industry, schools, planners and other authorities can do
that. Sweets and chocolates still appear at supermarket check-outs, fast food
outlets still sell vast portions of cheap, unhealthy food at all times of day and
night on every street corner. Many schools still provide inappropriate meals
and too little physical activity for their students; many food and drink
companies still use sports and entertainment idols to flog their wares, thereby
putting enormous pressure on children to obey what is already a powerful
instinct; to eat more and more. Whilst we are waiting for the environment
to change, primary and secondary care workers have the job of managing
the childhood obesity epidemic in our clinics, one person, and one family at
a time.
As a general practitioner, I encounter childhood obesity every day, and it is
one of the most difficult challenges I face. However, a successful result and a
healthy and happy child are the most rewarding and satisfying outcomes for
the primary care team and for the family. As well as providing the scientific
and academic background to childhood weight issues, the authors share their

vii
viii Foreword

immense practical experience of what actually works in the management of

the overweight child in a sympathetic and practical way, and for this reason,
the book should be required reading for everyone involved with childhood
weight problems.
David W. Haslam, MB BS
General Practice Principal Clinical Director,
National Obesity Forum
Preface

When one of us first started working with overweight and obese children in
the early 1970s the admission that she ran an obesity clinic for children was
greeted with wry amusement or the comment ‘You don’t achieve anything do
you?’ Today the prevalence of childhood overweight and obesity in not only
the UK but most westernized societies and increasingly in less affluent
countries too has changed this attitude. The comment is now not whether we
achieve anything but an imperative that we must achieve something if we are
to prevent the present generation of young people having lifetimes of high
morbidity and mortality as consequences of their excessive fatness. Yet, for all
the concern about obesity, there is no ‘magic bullet’, ‘wonder diet’ nor
consensus view on how to manage the condition. This book does not pretend
to answer that dilemma but to present guidance which we hope will support
those trying to help these children.
Throughout the book we use both overweight and obesity, often together,
to describe children who are likely to have significant increases in percentage
of body weight as fat. The mixed terminology relates to the fact that most
children are diagnosed as ‘obese’ because they have a high body weight and
thus an abnormal relationship between weight and height for age (whatever
method is used). Technologies that have been developed to be more specific
about body composition in most cases do not directly measure fat in the
body (see Chapter 2). Estimates of body fat are largely confined to research
studies. Thus we prefer to use overweight as a descriptive term for the presumed
overfat children in whom we are concerned. The difference in the definitions
of overweight and obese in practical terms is usually one of degree and has
little significance for pathology except that the more severely affected – the
obese – are generally more prone to the problems associated with being
overfat. However we do recognize that there are problems with the clinical
definition of overweight in that it can include children who have excess lean,
rather than fat, tissue. In our modern, relatively inactive, society such chil-
dren are distinguishable in most cases by their obvious athleticism or their
extreme height for age. A further reason for not confining ourselves to the
term ‘obese’ routinely is that some see this as a derogatory term. We have no
wish to diminish further the self-esteem of a group in the population who

ix
x Preface

may already have a poor image of themselves and feelings of ostracization

and who can justifiably argue that they deserve the respect that should be
given to all.
The overweight/obese children who are the subjects of this book are those
presenting in the community, in primary care or at a general paediatric clinic.
Our advice is therefore aimed at health care practitioners (HCP) in the
community. Perhaps we can also provide some help for those working in
general paediatrics and, at the other end of the scale, for parents making their
own efforts to cope with children whose rapid weight gains and increasing
fatness are concerning. With obesity such a highly prevalent problem, the
majority of those who need to control their weight will probably never get
beyond advice at the primary care level. For this reason we deal no more than
briefly with investigations and therapies likely to apply only to the relatively
few obese children who receive hospital specialist care. However we see it
as important to recognize and distinguish those overweight/obese children
who do need detailed investigation or very specific, possibly invasive,
management.
Modern medical management is perceived as needing an evidence base.
The gold standard for evaluating management is the double-blind rando-
mized controlled trial. The advice for the management of child obesity has a
limited evidence base which has been extensively reviewed in the process of
developing the UK National Institute of Health and Clinical Excellence
(NICE) Guidelines on the management of obesity (NICE 2006). With such a
multifaceted condition as obesity and with the variety of diets, activities,
lifestyles and psychosocial considerations which contribute to the condition
at the individual level, it may be impossible – at least in a free society – to put
some aspects of management to the test. However overweight/obese children
cannot be allowed to get progressively fatter just because there is no abso-
lutely proven method of management. We have tried to follow those NICE
(2006) Guidelines relevant to the children, families and communities we aim
to reach. In addition we incorporate what we believe common sense and our
experience in practice and research indicate as reasonable recommendations
to support that management which already has an evidence base.
The expansion of research into childhood obesity which has taken place in
recent years is a very positive development. A mass of evidence is being
gathered and gradually being published – as the NICE (2006) Guidelines
show. Research programmes developing effective management for childhood
overweight/obesity do not always transfer easily into practices that are
clinically and financially sustainable. There is still a long way to go before the
obesity epidemic in children is under control. It is therefore important that
all involved do all they can to reduce the effects of the epidemic on physical
and psychosocial health. It is time to achieve change: something must be
done. We make suggestions for what this ‘something’ might be.
Acknowledgements

We are obviously indebted to the overweight and other children and their
families who have provided us with clinical experience and opportunities for
research over many years and without whom our comments would have no
rational basis. However, in the immediate circumstances, our particular gra-
titude is to David W. Haslam of the National Obesity Forum who has taken
time to read the book and give us his comments as well as providing a
Foreword and to Louise Diss of TOAST (The Obesity Awareness and Solutions
Trust) for likewise looking through the book and giving us her advice. As sole
authors the responsibility for statements made in the book is ours alone.

xi
 Abbreviations

ALSPAC Avon Longitudinal Study of Parents and Children

AR adiposity rebound
%BF percentage body fat
BI bioelectrical impedance
BMI body mass index
BMR basal metabolic rate
BP blood pressure
CDC Center for Disease Control (USA)
CMO Chief Medical Officer
CT computerized tomography
DEXA dual X-ray absorptiometry
DH Department of Health
FFQ food frequency questionnaire
FSA Food Standards Agency
GDA Guideline Daily Amount
GI glycaemic index
GP general practitioner
HCP health care professional
HDL high density lipoprotein
HFSS high fat, high sugar, high salt
ICP intracranial pressure
IOTF International Obesity Task Force
ISC Indian subcontinent
LBM lean body mass
LDL low density lipoprotein
MEND Mind, Exercise, Nutrition and Do it
MET metabolic equivalent
MRC Medical Research Council
MRI magnetic resonance imaging
NASH non-alcoholic steatohepatitis
NHANES National Health and Nutrition Examination
Survey (USA)

xii
 List of abbreviations xiii

NICE National Institute for Health and Clinical

Excellence
NIDDM non-insulin-dependent diabetes mellitus
NIH National Institutes of Health (USA)
NOF National Obesity Forum
OSAS obstructive sleep apnoea syndrome
PA physical activity
PAL physical activity level
PCOS polycystic ovary syndrome
PCT primary care trust
PE physical education
PWS Prader–Willi syndrome
RCGP Royal College of General Practitioners
RCN Royal College of Nursing
RCPCH Royal College of Paediatrics and Child Health
RMR resting metabolic rate
SES socioeconomic status
SIGN Scottish Intercollegiate Guidelines Network
SUFE slipped upper femoral epiphysis
TLD Traffic Light Diet
WC waist circumference
WHO World Health Organization
WHR waist : hip ratio