Childhood obesity

Current statistics suggest that the prevalence of obesity is four times higher today than it was 30 years ago¹. A recent estimate, published by the Parliamentary Office of Science and Technology, suggested that 8.5% of 6 year olds and 15% of 15 year olds are obese. Overweight and obese children have a 70% chance of becoming obese adults and the National Audit Office (NAO)² has projected that by 2010, 1 in 4 of the adult population will be obese. This is a major concern for the long-term health of the nation both physiologically and psychologically. Obesity will also have an impact on NHS and the economy as a whole as direct and indirect costs are set to escalate to £3.6 billion by 2010³. Early intervention with children who are at risk of becoming obese is therefore key, and HCPs can play an important role in raising awareness of what exactly obesity is, what causes it and what parents can do to prevent and manage it.

The causes of obesity
People become obese by taking in more energy than they expend. For almost all children who are obese there is a lifestyle origin to their obesity and genetic causes of obesity are extremely rare³.

The rise in obesity reflects changing eating patterns and levels of physical activity in our society³. For example studies have highlighted children are less likely to participate in sports, and do not walk or cycle to school as much as they did in the past. Research also suggests that a rise in sedentary leisure pursuits such as watching TV, playing computer games or logging on to the internet have, to some extent, taken over from the traditional energy expending pastime of ‘playing outside’³. Changes in dietary composition are also in the frame, with decreasing intakes of fruits and vegetables and increases in the consumption of savoury snacks, confectionery and soft drinks all implicated¹.

A joint WHO/FAO expert group recently considered the strengths of the evidence for various potential factors, the results are summarised in the table below.

Evidence strength	Decreases risk of obesity	Increased risk of obesity
Convincing	Regular physical activity High dietary intake of fibre	Sedentary lifestyle High dietary intake of energy-dense, Micronutrient poor foods
Probable	Home and school Environments that support Healthy food choices for Children Breastfeeding	Heavy marketing of energy dense foods and fast food outlets High intakes of sugar sweetened soft drinks and fruit juices Adverse socio-economic conditions (especially for women in developed countries)
Possible	Low glycaemic index foods*	Large portion sizes High proportion of food prepared outside the home Eating patterns (e.g. strict dieting/binging behaviour)
Insufficient	Increased eating frequency	Alcohol

Source: Diet, nutrition and the prevention of chronic diseases, Joint WHO/FAO expert consultation, WHO, Geneva, 2002.

The overriding factors contributing to the rise in obesity are therefore social and economic and it is therefore unsurprising that socioeconomic profiles are proving to be very good indicators of whether or not a child will be at risk of obesity. In the UK, risk of obesity in children is inextricably linked to social class. The risk approximately doubles from families of the highest social classes to those of the lowest¹. Obviously these are complex issues, but research has identified the following as areas to look out for when assessing risk of obesity:

Risk factors⁴:
Obese or overweight parents: Children whose parents overeat and live a sedentary lifestyle are much more likely to become obese themselves as a consequence of being exposed to unhealthy eating habits and lifestyle choices

Poor housing and living conditions: Children living in dilapidated conditions have been shown to have up a threefold risk of obesity. This can be due to lack of emotional and intellectual stimulation as a consequence of environmental deprivation.

Poor standard of parental education: Studies have shown that children of parents who are poorly educated are more likely to be at risk of obesity. Lack of education can lead to lower levels of cognitive stimulation in the children and a poor understanding of the link between diet and child development.

Family income level and occupational status: Children from low-income families with parents in jobs with low social status have been shown to be at high risk. Such families are more likely to eat processed foods, which are higher in fats and sugar.

A lack of culinary skills often leads to a reliance on takeaways and ready prepared meals. These families also have low rates of physical activity.

How can obesity be prevented?
Individual HCPs obviously cannot take sole responsibility for the wider social causes of obesity, and the government is taking measures of its own to help tackle these underlying issues.

Current government policy states that, ‘Prevention and management of obesity requires a range of coordinated policies to improve diet and physical activity levels in the early years, at schools, and in families and communities’³.

New initiatives to help build public awareness of the problem consist of the following:³.

• DoH infant feeding initiative – promoting the importance of breastfeeding.
• Healthy Start – support for disadvantaged families providing advice on nutrition, health and early learning.
• The provision of nursery education for all 3 year olds.
• Initiatives aimed at increasing physical activity levels at school.
• Sure Start – providing funding for community based projects such as cooking clubs, food co-ops and cafes.
• While the broader issues and co-ordinated national programmes are being driven by the government, HCPs have a crucial part to play at ground level working with individual families on their caseload⁵.

How you can help tackle obesity
Changing ingrained behaviours is one of the toughest challenges faced by the Healthcare Professional. And because childhood obesity is largely a product of the family environment, it is important to remember that it is the lifestyle of the whole family that will need to adjust if obesity is to be prevented or counteracted.

Once you have identified those children who are at risk, there are a number of things to consider about what motivates people to change. These pointers can help you to ensure that your advice is acted upon.

Behavioural psychologists acknowledge that people will only change their eating habits if two factors are present: they must believe that is important for them make changes and they must have the confidence to believe that they can succeed⁵. The first challenge is to identify whether a family is receptive to change. There is a theoretical behavioral model called the ‘transtheoretical model’ or ‘stages of change’ model that can be helpful in assisting you to recognise where you need to begin your efforts (see table below). This model attempts to define the stages through which one must pass in order to effect and maintain lifestyle change: If the family you are dealing with is in denial about the problem then you will have to focus on the ‘need for change’ and concentrate your efforts here until the next stage of receptiveness is reached. You may find the ‘check list for educators’ in our earlier article, ‘Healthy Nutrition – Getting the Message Across’ in issue 1, 2004 useful. This article discussed ways of developing a realistic understanding of the susceptibility to health conditions as a result of poor eating habits. It also covers the potential severity of these conditions and the benefits of changing behaviour.

Treating childhood obesity¹

• Children rely on their parents to prepare their food and allow them opportunities for physical activity, it is essential to encourage the involvement of parents in any obesity management programme.
• The child’s environment is a critical part of the solution: HCPs need to look at the social and economic circumstances of the family.
• The focus should be on increasing and developing healthy eating and exercise, and reducing energy dense foods and drinks.
• Reductions in sedimentary behaviour are likely to be helpful.
• The emphasis should not be on weight loss, but on weight maintenance, and promoting healthy food and activity choices.

Stage of change	Definition	Practical steps for the educator to take
Pre-Contemplation	Thinking about change, in the near future	Motivate, encourage creation of specific plans. This is a stage of self-reevaluation (with the subject assessing their feelings regarding behaviour). So try to ensure that the outcome is in favour of change by remaining positive and supportive. Encourage movement to the next stage of change.
Decision/Determination	Making a plan to change plans, setting gradual goals	Assist in developing concrete action. For this the individual will need to have belief in their ability to change and have a commitment to do, so assist in formulating simple goals to increase the sense of achievability and create a mental contract. For example, reducing the number of family meals eaten from takeaways, ensuring the 5 pieces of fruit or vegetables are eaten a day, or aiming for 10 minutes walking a day.
Action	Implementation of specific action plans	Assist with feedback, problem solving, social support, and reinforcement. For example you might recommend the following: Reinforcement management (overt and covert rewards). i.e. If a weight target is hit then the family should give themselves a (non food!) treat Ensuring that social support, and self-help groups are available Counterconditioning (alternatives for behavior). i.e. If children demand takeaways, try presenting healthy food in takeaway format so that they have the fun of drinks with straws and eating with their hands without the calories and high salt content Stimulus control (avoid high-risk cues). For example if chocolate is the favourite family binge food don’t stock it in the house.
Maintenance	Continuation of desirable actions, or repeating periodic recommended step(s)	Assist in coping, reminders, finding alternatives, avoiding slips/relapses.

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References

1. Association for the study of obesity. http://www.aso.org.uk
2. National Audit Office (NAO) http://www.nao.gov.uk
3. Childhood Obesity, ‘Postnote’, Parliamentary Office of Science and Technology, September 2003, issue no: 205
4. Strauss, Richard, MD and Knight, Judith, MD, Influence of the Home Environment on the Development of Obesity in Children, In Paediatrics Vol. 103 No. 6, June 1999.
5. All-Party parliamentary Group on Obesity, July 9th 2003