Background! In the past, obesity has been seen as a problem of adults, becoming more prevalent with advancing age.

Fat children have been recognised in literature with Charles Dickens' portrayal of the fat boy in The Pickwick Papers, and Billy Bunter in the 20th century. They were notable because fat children were uncommon.! ! Now obesity is no longer rare in children and the prevalence is increasing at an alarming rate. Pathological processes (see 'Complications' below) start early in life and are accelerated by obesity. See also separate articles Obesity in Adults and Bariatric Surgery.! ! Save time & improve your PDP on Patient.co.uk! Add notes to any clinical page and create a reective diary! Automatically track and log every page you have viewed! Print and export a summary to use in your appraisal! Click to nd out more ! Epidemiology[1]! Globally, the number of overweight children under the age of ve was estimated in 2010 to be more than 42 million.[2]! The greatest annual increases in obesity of school-aged children since 1970 have occurred in North America and Western Europe. However, 75% of overweight and obese children live in low- and middle-income countries.[3]! Obesity gures in England have more than tripled over a period of 25 years. The most recent health survey in England (2010) has shown that 30.3% of children (aged 2-15) were overweight or obese. 16% of all children were obese.[4]! Most recent trends suggest that the rising trend in obesity may be attening out. In 2011, the number of children aged 2-15 increased by only 0.3% and the number who were overweight actually dropped by 1%. [4]! Causes! Obesity is basically caused by an imbalance between energy input and expenditure.[3] There are numerous factors that are thought to contribute to this trend. A few will be considered here. It is worth noting that studies investigating the role of diet or activity are generally small and include diverse methods of risk factor measurement.!

! Dietary habits! There is a growing cohort of children who develop bad eating habits and a taste for junk food that is high in fat and fast carbohydrates. One study found that whilst consumption of fast food was linked to obesity in 13-15 year-olds, public health interventions that placed restrictions on the location of fast food outlets did not uniformly decrease consumption.[5]! ! Exercise! Reduction of physical exercise in the absence of dietary modication contributes to weight gain. Compulsory sport is in decline, although studies suggest that school-based activity programmes aimed to promote physical exercise actually have little impact on children's body mass indices (BMIs).[6] Long periods in front of the television or playing on the games console also contribute to the increasingly sedentary lifestyle.[3]! ! Sleep! Sleep deprivation has been suggested as a contributory factor, although a review of the literature concerning adolescents queried the methodology of many studies.[7] A possible trend of children going to bed later may be, in part, responsible. Lack of physical exercise may also lead to poor sleep.[8] Two hormones, leptin and ghrelin, may be important. Leptin is released by fat cells to tell the brain that fat stores are adequate and ghrelin is released by the stomach, as a signal of hunger. In people with too little sleep, leptin levels are low and ghrelin levels high. Both these would encourage an individual to eat more.[9]! ! Genetic contribution! Studies suggest that obese children are likely to have obese parents. Current thinking is that this is a result of children with a genetic predisposition to obesity living in an obesogenic environment.[10] For a fuller discussion, see separate article Obesity in Adults.! ! Socio-economic situation! A systematic review of countries in the European Union found evidence of a link between obesity and overweight in children and the socioeconomic status of the parents, particularly the mother. Furthermore, the prevalence of childhood overweight is linked to the respective country's

income inequality or relative poverty.[11]! ! New research conducted at Leeds Metropolitan University has, however, raised an interesting slant on the conventional view. The study, which involved a sample of more than 13,000 Leeds schoolchildren, concluded that children living in middle-a"uent areas had the greatest probability of being obese. The study postulated that this group was most likely to indulge in 'snacking' between meals.[12]! ! Other risk factors! High birth weight.[3]! Timing or rate of maturation.! Other behavioural or psychological factors.! Physical conditions such as endocrine causes (rare):[13]! Hypothyroidism - especially Down's syndrome.! Cushing's syndrome - look for truncal obesity, hypertension, hirsutism.! Growth hormone deciency - there may be weight gain with delayed puberty.! Muscular dystrophy and other causes of immobility.! Polycystic ovarian syndrome.! Hypothalamic damage.! Spina bida.! Genetic syndromes associated with hypogonadism.! PatientPlus ! Obesity in Adults! Obesity Hypoventilation Syndrome! Prevention of Type 2 Diabetes! Prader-Willi Syndrome! Raising the issue[1]! It can be a delicate issue to raise with a parent and this may mark the (good or bad) start to a long therapeutic period. The issue may be raised:! ! If the family expresses concern about the child's weight. Try: "We can measure [child's] weight and see if he or she is overweight for his or her age."! If the child has weight-related comorbidities. Try: "[Condition] can sometimes be related to a child's weight. I think we should check [child's] weight."!

If the child is visibly overweight. Try: "I see more children these days who are a little overweight. Could we check [child's] weight?"! This may be the rst time that weight has been raised with the family. It is a time to be reassuring and supportive. "By taking action now, we have a chance to improve [child's] health in the future."! ! Diagnosis! Any gold standard for diagnosing obesity would be based on body fat content. Adiposity can be directly measured (eg, densitometry, scanning using dual-energy X-ray absorptiometry) and indirectly (anthropomorphic measurements, bio-electrical impedance and air displacement plethysmography).[3] This is not practical in primary care. In adults, BMI is often used. The problem with this approach is that it takes no account of factors which have a marked e#ect on growth in childhood, such as age, gender, puberty and race/ethnicity.[14] As a rule of thumb, in children a BMI of 20 is signicantly overweight and the younger the child, the more this is so.! ! BMI per se is not generally a suitable way to assess obesity in children, although it can be used provided that it is moderated by use of adapted charts. The UK90 charts[15] have been overtaken for use in children aged 2 weeks to 4 years by charts which incorporate data from the World Health Organization (known as the UK-WHO charts)[16] or the like, to be used in children over 2 years old. In this case, a child with a BMI over the 91st BMI percentile is said to be overweight and a child over the 98th BMI percentile is considered to be obese. These precise gures do vary slightly from one publication to the next.! In infants between 2 weeks and 24 months old, the 2006 WHO child growth standards for infants and children are used.[3]! The value of waist circumference in children is unknown and so measuring it is not recommended.! Overweight children tend to be tall but centile charts may show that a child is on the 75th centile for height and the 97th centile for weight. This much higher centile for weight than for height suggests obesity. If an overweight child is not tall, refer to a paediatrician.! In the separate article Centile Charts and Assessing Growth, the problem of diagnosing childhood obesity is discussed more fully.! Parents can be remarkably obtuse in noting that a child is overweight[17]

and charts may be needed to drive the message home. "Puppy fat" is a common excuse or assertions that "his or her glands are the problem." Endocrine causes for childhood obesity are rare. It is worth stressing that obesity is a clinical term with health implications rather than just the way somebody looks.[18]! ! Further evaluation! ! Explore why help is being requested; is it the child or the family or are there comorbid problems? The child may have been agged up during the course of the National Child Measurement Programme.[1][17]! Perform a physical examination, looking for features of physical causes (see 'Other risk factors', above).! If acceptable to the child, evaluate pubertal development.! Height and weight should be in light clothing with no shoes.! Test urine for protein and glucose. Ideally, check blood pressure but the cu# needs to be suitably sized.! The National Institute for Health and Clinical Excellence (NICE) recommends tailored clinical intervention if a child's BMI (adjusted for age and sex) is at the 91st centile or above and that assessment for comorbidities should be considered if their BMI is at the 98th centile or above, using 1990 UK reference charts.[18]! Management! Overweight children and adolescents can be managed in primary care if there is a positive attitude to weight management.! ! General points[1][14][18]! Rapid changes in BMI occur during normal growth; there is a great potential for reducing overweight in children and adolescents.! Unless the child is seriously overweight or has signicant comorbidities, be led by the child's/parent's wishes.! As children are still growing, the aim is often not weight loss but weight maintenance or even a reduction in the rate of gain of weight.! Apart from the basic principle that energy intake should be reduced and energy output in the form of physical activity increased, there is little in the way of evidence to support any particular preventive approach. NICE recommends that school, family and societal interventions should be considered in the management and prevention of obesity in children. This

may include involving parents in weight loss programmes.! The suggestion that inadequate sleep in children may aggravate obesity has been noted above. Ensuring adequate sleep may be important.! Beware of potential underlying psychological factors. There may be 'comfort eating' or even clinical depression that needs treatment.! Overweight adults need caring, compassionate and empathetic attention. This is even more important in children. Praise success at every occasion, however small.! Diet and exercise! The primary aims of management are dietary modication and the initiation of exercise. Losing weight without exercise is very di$cult but the obese child may nd it very tough taking exercise up initially.! ! Diet! ! NICE does not recommend using a dietary approach alone.[18]! It may be helpful to keep a food diary (assists cognitive approach). Do not forget snacks and drinks.! It is very unpleasant being hungry and, rather than just cutting back on all food, it may be easier to move to a diet with less fat and more bre in it.! As with adults, herbal and 'natural' wonders are also to be avoided, as are diets promoted by 'celebrities'.! There is some evidence that dieting is more e#ective when calorie counting is employed. Very low-calorie diets have shown promise but more research is needed.[14]! There may be occasions where there is benet in referral to a dietician, particularly where there is a large amount of weight to be lost and caloric cut has to be balanced by adequate nutrition for ongoing developmental needs.! This is not easy for the patient and it is important to be positive and reinforcing.! Exercise! ! The value of exercise is more than just the calories expended in the session. It tends to increase basal metabolic rate and, after vigorous exercise, metabolism is stimulated for the subsequent 36 hours. It also helps people to feel good about themselves.! Overweight children often shun exercise because of poor mobility, ready

fatigue and "being no good at games". It is important to discuss the options to nd something appropriate and sustainable. They may be less disadvantaged at swimming, for example, but the attire shows every bulge.! The age and aptitudes of the individual must be taken into account. It must be something that the individual will enjoy or he or she will not persevere. This is very important, as the ethos of exercise is not just for the duration of weight loss but for life.! NICE recommends a total of 60 minutes of at least moderate exercise each day (in one session, or more, shorter sessions lasting a minimum of 10 minutes).! Exercise need not always be 'formal' - walking, using stairs, cycling and active play all count.! It is very helpful to involve all the family in development of an active lifestyle.[19] ! Drugs! The drug management of obesity has been more fully discussed in the separate article Obesity in Adults.! ! Drug treatment is not usually recommended for children. Orlistat does not have market authorisation for use in children. A Cochrane review supports the use of orlistat in adolescents over the age of 12 as an adjunct to lifestyle changes, once the potential for adverse e#ects has been considered.[20] Pharmacists will not issue over-the-counter orlistat to individuals under 18 years of age.[21]! In exceptional cases, where there are physical comorbidities (such as orthopaedic problems or sleep apnoea) or severe psychological comorbidities, there may be a role for drug treatment after dietary, exercise and behavioural programmes have been started and evaluated. [22]! NICE does not recommend the use of these drugs in children aged less than 12.! Treatment should be initiated in a specialist paediatric setting, by multidisciplinary teams with experience of prescribing in this age group. It may be continued in primary care, if local circumstances and/or licensing allow.! Regular monitoring of physical parameters, psychological factors, behaviour, diet and exercise should be part of the treatment package.!

Treatment regimes should not exceed 6-12 months.[22]! It is worth noting that there are a number of drugs prescribed for children and adolescents that aggravate weight gain and the risks and benets should always be considered. They include:[23]! ! Antidepressants including mirtazapine, paroxetine, imipramine.! Anticonvulsants, particularly sodium valproate, gabapentin, vigabatrin.! Antipsychotics, especially the atypical antipsychotics aripiprazole, chlorpromazine, clozapine, olanzapine, pimozide, quetiapine, and risperidone.! Corticosteroids.! Surgery[18]! Bariatric surgery is limited to the severely obese who are refractory to other management. In young people, it is generally not recommended but may be considered in exceptional circumstances if:! ! Physiological maturity has been reached, or almost reached.! The BMI is >40 or if it is between 35 and 40 with signicant comorbidities.! All appropriate non-surgical measures have failed to produce adequate results over six months.! They are receiving intensive specialist assessment.! They are t for anaesthesia and surgery.! Bariatric surgery is associated with larger decreases in BMI and greater improvements of some metabolic markers but it is associated with considerable risks[22] See separate article Bariatric Surgery for more information.! ! Cognitive approach! This is important and should accompany all the other approaches described above. It is as important in helping the individual understand the problem as it is to help them through treatment. Cognitive approaches seem to work best in pre-pubertal children.[24] See separate article Cognitive and Behavioural Therapies which discusses behaviour modication.! ! Follow-up! As with any chronic disease, follow-up must be arranged. This implies interest in the patient's progress. A fortnight to a month would be

appropriate at rst, with intervals getting longer with time; however, treat it as a chronic disease. The practice may have a nurse-run weight control clinic.! ! The achievement of a target weight is not the end of the process. Obesity is a chronic disease and needs to be managed throughout the person's life, as relapse is common. 'Yo-yo dieting' with weight going up and down is undesirable and unhealthy.! ! The management of obesity is a lifelong process. Attitudes towards diet and exercise must change for life.! Related blog posts ! Economic crisis hits youth health - my reaction! The obesity epidemic what do we do about it?! Childhood obesity everybody's problem! Cholesterol - what's the worry?! Should we take slimming pills?! More from the blogs ! ! Referral! Before referral to secondary care, consider referral to community-based treatment programmes such as MEND (mind, exercise, nutrition ... do it!) the only programme provided nationwide in the UK.[25] It runs various age-appropriate courses. Consider referral to a paediatrician if:[26]! ! There is serious morbidity related to the weight.! The height is below the 9th centile, the child is unexpectedly short for the family or if there is a slowed growth velocity.