Obesity

Please remember there is a Paediatric Clinical Mailbox that can be used for any non-urgent queries: clinical_paediatrics_crosshousehospital@aapct.scot.nhs.uk

• Obesity in childhood is a risk factor for long term cardiovascular disease, development of type 2
  diabetes, adult obesity and mental health issues.
• The cause of obesity lies in deranged energy balance, but the factors contributing to this in different
  individuals are complex; from personal dietary habits, activity levels and genetics through to societal
  and political factors such as prevalence of fast food, household income and lack of activity spaces.
• Obesity is a public health problem and as such NHSAA have a child healthy weight initiative for families which can be easily accessed – it is known as ‘JumpStart’. Families should be encouraged to self-refer – see Resources below.
• The role of secondary care in childhood obesity is to diagnose pathological causes of obesity (secondary obesity) or to manage morbidity associated with obesity (e.g. type 2 diabetes, fatty liver, sleep apnoea).

Definitions

• Overweight: BMI >91st centile of UK 1990 ref chart.
• Obesity: BMI > 98th centile.
• Severe obesity: BMI > 99.6th centile.
• Extreme obesity: BMI 3.5 Standard Deviations or more above the mean for age (See WHO charts, or
  iGrow if available)

History

• Age of onset of obesity.
• History suggesting obesity-associated morbidities e.g. benign intracranial hypertension, sleep apnoea, obesity hypoventilation syndrome, orthopaedic problems and psychological morbidity.
• Any learning difficulties – may be associated with syndrome e.g. Prader-Willi Syndrome.
• Symptoms of diabetes - polyuria/polydipsia.
• Symptoms of obstructive sleep apnoea- snoring, restless, daytime tiredness.
• In post-pubertal girls – symptoms of PCOS (polycystic ovarian syndrome)
• Lifestyle issues leading to obesity: diet, inactivity.
• Willingness to change lifestyle.

Examination

• Measure child’s height and weight and accurately plot them on growth and BMI cart (child growth foundation, Harlow printing, also in “red book”). Compare these measurements to those done previously in child’s “red book” or medical records.
• If possible measure both parents: Is the child short for their parents? – children with nutritional/simple obesity are usually tall whereas short stature and obesity may indicate an endocrinopathy.
• Measure BP.

Investigations

• A clear history and examination will rule out a pathological cause for obesity in the vast majority of obese children and will rule out the need for any further investigations.
• If the child is asymptomatic, no investigations are necessary.
• Consider investigations depending on symptoms and or signs:
  • Symptoms suggesting hypothyroidism / strong FH of hypothyroidism: TFTs.
  • If there are symptoms of diabetes: random blood glucose, contact paediatric diabetes team, Crosshouse.

Give advice

Encourage family to self-refer and take part in Jumpstart (see Resources below)

Diet

↑↑ increase: consumption of fresh fruit and vegetables, fibre, water.
↓↓reduce: highly processed foods, junk food, sugary snacks, carbonated drinks.

Activity

↑↑Increase: physical activities, time outside – ‘lifestyle activities’ (e.g. walking dog, walking to school, playing on bike) have longer lasting effect than structured activities.
↓↓Reduce: sedentary activities such as screen time, time spent inside.

Treat family as a whole

• Consider voluntary groups such as weight watchers in older children (child and parents attend together)
• Encourage family to eat together, separate eating from other activities such as TV or computer.
• Keep foods that child should be avoiding out of the house.

1. If there are concerns about diabetes, contact Paediatric Assessment Unit on the same day at Crosshouse on 01563 82783.
2. Local Child Health Weight Initiative (JumpStart) – take self-referrals. Inform all children and their families with concerns about healthy weight.
3. Referral to paediatrics secondary care via SCI Gateway if:-
   1. If suspicion of secondary cause of obesity.
      1. Short stature for parental growth potential is an important marker of a potential endocrine or genetic syndrome, as obese children are almost always tall for age. The presence of any significant dysmorphic features or associated learning difficulties should precipitate a referral to secondary care.
   2. Obesity with significant comorbidities or high-risk of comorbidities.
      1. Obstructive sleep apnoea – consider referral to ENT.
      2. Strong FH or increased risk of diabetes of diabetes e.g. child from black or South Asian ethnicities and acanthosis.
   3. If child is <2 years of age and BMI> 99.6th centile (severe obesity)

Please note, these are vetted in a timely manner so the priority status of a referral may change upon review.

The vast majority of overweight and obese children do not have these additional concerns; carers should be encouraged to self-refer to JumpStart.

• Accurate height measurement and recording is essential, not only to calculate BMI, but to detect growth failure e.g. in hypothyroidism or Cushing’s disease.
• A child with simple obesity will either have normal or advanced growth in height – children with endocrine cause of obesity will have growth failure.
• Drugs have virtually no place in the treatment of obesity in childhood.
• Bariatric surgery is not available to children in NHSAA.

• Local Child Health Weight Initiative (NHSAA) JumpStart.
  • Poster 
  • Leaflet