Tuesday, 19 January 2016

8 out of 10 mothers - what do front line clinicians need to know about childhood obesity?


Childhood obesity is frequently in the news.  The proportion of children who are overweight or obese in countries such as the UK has risen considerably in the past few decades.  Most overweight children will go onto be overweight adults with all the implied risks.  It is often perceived that health issues in later life are the main reason for concern but many children have significant health problems and psychosocial problems (1) during childhood as a result of their weight.  Tackling the problem is made extremely difficult by a number of factors.  As front line clinicians, what are supposed to be doing about it when we see a child who is overweight?

The first problem is recognition.  How often are children brought to a GP surgery by a parent who is concerned that their child is overweight?  Last month, Archives of Disease in Childhood published a study with an outcome that will surprise few of us. It showed that only 18% of mothers of obese children perceived their child to be moderately overweight. (2) That means that if we take an opportunistic approach, four times out of five we have to break news as well as take the problem forward.  Like I said, not a surprising statistic but a sobering one.

The next problem is the identification of obesity.  Definitions vary and there is disagreement about the best method of determining if a child is obese.  The majority seems to rest with BMI being the least worst measure but then you need a weight, a height, a calculator and a paediatric BMI centile chart.

If you feel defeated already, wait for the punchline: the evidence for the effectiveness of interventions is poor or non-existent.  This is one of the reasons that there are currently no commissioned services specialising in childhood obesity in the UK.  Bariatric surgery aside, there are no interventions that have both a significant impact and a good evidence base, so should we even bother?

I think that the answer is yes, but you can choose your reason.  You may, for example, choose to embrace the idea of making every contact count.  Ideally we all address things like obesity opportunistically.  I can’t pretend to succeed there very often.  One of the problems is the feeling that people don't see it as a problem in the same way that clinicians do.


Alternatively you may wish to know what really needs to be referred to secondary care according to those who specialise in this group of patients.  In 2012, in the absence of guidance from a national body (that would mandate the provision of a clinical service) the Obesity Services for Children and Adolescents (OSCA) group of paediatricians produced a consensus statement (3).  These were the indications for referral according to that statement:

Possible underlying cause to obesity suggested by
  • Short stature
  • Dysmorphism
  • Learning difficulties

Comorbidities suggested by
  • Hypertension
  • Symptoms of sleep apnoea
  • Acanthosis Nigricans
  • Evidence of Polycystic Ovary Syndrome
  • Psychological morbidities
  • Safeguarding concerns
  • Impaired glucose intolerance, dyslipidaemia or liver dysfunction
  • Family history of Type 2 diabetes before the age of 40 or cardiovascular disease before the age of 60 in a close relative

Acanthosis Nigricans (thickened and pigmented patches of skin in the neck and axillae) in children is often associated with insulin insensitivity.  (picture taken from commons.wikimedia)

I can’t argue with any of those as they all seem quite reasonable.  Essentially the experts are saying that children who might have a medical cause or effect of their obesity should be referred. 

The difficulty with this list is that it rather brings me full circle.  In order to know whether a child’s obesity might be secondary to something or might be causing another problem, I need to examine them and ask a few questions.  I can’t really do this without making the diagnosis of obesity.  For this I need to mention that the child might be overweight so I need to do a few measurements.  I should probably explain why I suddenly have an acute interest in the young person's armpits.  Even if I do explain myself, 8 out of 10 mothers will probably be a little surprised.

Edward Snelson
Counting every contact
@sailordoctor



References
  1. Strauss RS, Social marginalization of overweight children, Arch Pediatr Adolesc Med. 2003 Aug;157(8):746-52.
  2. Dowd et al, The association between maternal perceptions of own weight status and weight status of her child: results from a national cohort studyArch Dis Child 2016;101:28-32 doi:10.1136/archdischild-2015-308721
  3. Vine et al, Assessment of childhood obesity in secondary care: OSCA consensus statement: Arch Dis Child Educ Pract Ed 2012;97:98-105 doi:10.1136/edpract-2011-301426

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