Clinical Update on childhood obesity

Dr Helen VickerstaffConsultant Community Paediatrician, RCHT

Outline

• Define obesity in children

• Be able to assess for aetiology and comorbidity

• Understand principles of intervention

• Know local referral routes

• Not dread that consultation!

Definition

Definition/Standards

• Obesity is an abnormal accumulation of body fat, usually 20% or more over an individual’s ideal body weight.

• Clinical

• BMI >91st centile overweight

• BMI >98th centile obese

• BMI >3.5 SD extremely obese

Definition/standards

• Differs according to clinical or population monitoring

• UK90 data BMI centile– 85th and 95th centile for population– 91st and 98th clinical assessment

Why should we be worried?

Prevalence

• Great data sources

• National Child Measurement Programme (NCMP)

• National Obesity Observatory (NOO)

• Chi MAT

Child prevalence by BMI statusNational Child Measurement Programme 2010/11

This analysis uses the 2nd, 85th and 95th centiles of the British 1990 growth reference (UK90) for BMI to classify children as underweight, healthy weight, overweight and obese. These thresholds are the most frequently used for population monitoring within England.

Healthy Weight65.3%

Underweight1.3%

Overweight14.4%

Obese19.0%

Year 6(aged 10-11 years)

Healthy Weight76.4%

Underweight1.0%

Overweight13.2%

Obese9.4%

Reception(aged 4-5 years)

© NOO 2012

10.7%

9.1%

19.0%

15.8%

10.4%

8.8%

20.0%

16.6%

10.3%

8.9%

20.0%

16.5%

10.5%

9.2%

20.4%

17.0%

10.1%

8.8%

20.6%

17.4%

Reception boys Reception girls Year 6 boys Year 6 girls

Year of measurement

2006/07 2007/08 2008/09 2009/10 2010/11

Prevalence of obesity among children by school year and sexNational Child Measurement Programme 2006/07 – 2010/11

Child obesity: BMI ≥ 95th centile of the UK90 growth reference © NOO 2012

Prevalence

• Reception age 22.6% – overweight(13.2), obese(9.4)

• Year 6 33.4% – Overweight (14.4) obese (19.0)

• South West above national average in reception overweight/obese

• Cornwall figures similar but below SW average for Year 6

• Relatively poor uptake rate 71% vs national 93%

Risk Factors

• Parental obesity• Very early (by 43months) adiposity rebound• Obese children go on to become obese

adults• >8 hours screen time/week at 3 years• Catch up growth• SD score at 8 months and 18 months in top

quarter, weight gain in first year• Birth weight• Short (<10.5 hours) sleep duration at 3

years

ALSPAC

When to worry

• Over 2 years– BMI > 91st centile – overweight (tailored

intervention)– BMI >98th centile – assess for co-morbidities

• Under 2 years– Weight >2 centiles above length– Weight >99.6th centile– Weight increases across 2 centiles– Severe progressive obesity

Underlying Causes

• Short for midparental centile

• Static growth

• Severe progressive obesity

• Dysmorphic features

• Significant learning difficulties

• Endocrinopathy

• Cushing’s features

Initial assessment – risk factors

• Family history (sex related)

• Physical disability• Lack of regular

physical activity and/or sedentary lifestyle

• Poor dietary habits• Lower socio-

economic status• Learning disability

• Syndromes• Medications

– Corticosteriods– Diabetes mellitus– Psychoactive agents– Antidepressant– ALL treatment– Anti-migraine e.g.

pizotifen– Anti-epileptics

Syndromes associated

• Prader Willi sydrome• Down’s syndrome• Biemond syndrome• Alstrom sydrome• Bardet-Biedl syndrome• Carpenter syndrome• Cohen syndrome• Borjeson-Forssman-Lehman syndrome

Clinical features of concern

• Severe unremitting obesity

• Abnormal facies• Disorders of eyes• Retinal problems• Narrow palpebral

fissures• Abnormal position

palpebral fissures• Severe squint• Skeletal abnormalities• polydactyly

• Syndactyly• Kyphoscoliosis• Sensorineural deafness• Microcephaly and/or

abnormal skull shape• Learning difficulties• Hypotonia• Hypogonadism• Cryptorchidism• Micropenis• Delayed puberty

Single Gene Abnormalities

• Congenital leptin deficiency

• Leptin receptor mutation

• Pro-hormone convertase 1 mutation

• Melanocortin 4 receptor mutation

Examination

Examination

• Calculate and plot BMI centile or z-score

• (Waist circumference)• Pattern of adiposity• BP• Pubertal assessment• Acanthosis nigricans

(insulin resistance)• Obstructive sleep

apnoea• Drug use –

glucocorticoids, atypical antipsychotics

• Genetic obesity syndromes– Early onset– LD– Dysmorphism– Epilepsy– Retinitis– Genitalia– Skeletal– Red hair

• Endocrinopathy– Hypothyroidism– Cushings – striae, central,

rapid progressive

Other concerns

• Family History– Early onset type 2 diabetes < 40 years– CV disease < 60 years

Investigation – co-morbidity

• Routine– Fasting glucose

and insulin– Fasting lipid

profile (full)– ALT– Urinanalysis– TFT’s

• Additional– Oral glucose

tolerance test– PCOS investigation– Sleep investigation

Investigation - aetiology

• Genetic studies– Syndromes– Genetics referral is

significant concern– Offer inclusion in

GOOS (genetics of obesity study)

– Thyroid antibodies– Ca/PO4

(pseudohypoparathyroidism

• Suspicion of secondary obesity– Height deceleration– Short duration

obesity or rapid weight gain

– Severe hypertension,acne or hirsuitism

GOOS Study

•Research study

•Look at monogenic causes and also measure leptin levels

•May provide future treatments

•Parents like to have a cause

•Management is the same

•10ml clotted blood or buccal swabs for young children

Management

• If no suspected underlying cause established then frequent follow up usually in primary care

• Multi-strategy approach to healthy weight– Diet, lifestyle and behavioural change– Long term risks– SMART goals– Weight maintenance

Management

• Primary Care – GP, school nurses and health visitors regular training to support via Rachael Brandreth (specialist dietitian)

• 3 monthly follow up• Reduction in BMI SDS or z score by 0.5

reduces atherogenic profile and insulin resistance, inflammatory markers

• Consider re-referral if develop or worsening co-morbidities or progressive obesity despite intervention

Secondary Care

• Investigation of aetiology and co-morbidity• Multi-component weight management

programme• Consideration of Orlistat

– lipase inhibitor– >12 years with extreme obesity or significant co-

morbidities–

Surgical Intervention

• Last possible option in obese adolescents with co-morbidity

• Not recommended in children

• Exceptional circumstances close to physiological maturity

• MDT with full assessment

Local Pathways

• Obesity pathway• Assessment in primary care and recognition

of co-morbidites/possible underlying aetiology• Centralised referral number for weight

management strategies (healthy weight team)• Tier 1/2 programmes

– health visitor HENRY- under 5’s– Keep It in the Family (MEND) – 7-13 years (>91st

centile)

LEAF Programme

•Fits into NICE and SIGN guidance of behaviour change components, family based, aim to change whole family behaviour.

•Target decreasing overall dietary intake, increase levels of activity and decrease time spent on sedentary behaviour

•Evaluation

•Solution focused

Weight Management Programmes in Cornwall

• Tier 1 and 2 – refer to health visitor or school nurse

• Tier 2-3• Age 0-6 LEAF programme • 7-13 MEND programme (call healthy

weight team 01209 310062)• 14+ current training SHINE

programme (as above)

GAPS

• Special schools – looking at work of programme with school nurses and possibly behavioural team

• Psychology support

• Concerns – identify co-morbidities but no guidance on management

Child Protection Issue?

• Childhood obesity alone is not a child protection issue

• Failure to reduce overweight alone is not a child protection concern (very difficult to treat)

• Consistent failure to change lifestyle and engage with outside support indicates neglect, particularly in younger children

• Obesity may be part of wider concerns about neglect or emotional abuse (1/3 adult bariatric report SA)

• Assessment should include systemic (family and environmental) factors

Sources of information

• National Obesity Observatory (NOO) Website

• NICE guideline (2006)• SIGN guideline• Map of Medicine• OSCA statement (RCPCH) Obesity

Services for Children and Adolescent Network Group

Any questions?

• www.cornwallhealthyweight.org.uk

• Contact the team on LEAF.programme@cornwall.nhs.uk

‘Katie’ – age 6

• BMI 31.9• Mild sleep apnoea• Fatty liver• Behavioural problems, including stealing• Social services involved• Joint custody – spends half the week with Mum, other half with

Dad• Both parents have struggled with their weight• Dad has type II diabetes (since 15 yrs)• Mum has admitted to having an unhealthy relationship with food• Mum has also acknowledged that her relationship with Susie is

“too adult”