Prevention of overweight and obesity in children

Childhood overweight and obesity can persist into adulthood and increases risk of cardiovascular disease, type 2 diabetes, stroke and poor mental health. Healthy weight checks need to start before the age of five; one in five Australian children are already affected by overweight or obesity at this age. Primary Health Care (PHC) providers can provide anticipatory guidance to prospective parents, families and children to support healthy weight and weight-related behaviours.

During primary school, parents continue to be a key influence in the development of child eating, physical activity and sedentary behaviours with parenting styles playing a role in developing healthy lifestyles.  Role modelling healthy eating, positive body diversity and being active are key to encouraging children to do so also. However, the ability of families to make healthy food choices can be challenging in Australia’s obesogenic environment.

Prevention of overweight and obesity needs to be available across ‘critical time periods’ in the life course: pre-conception and pregnancy; infancy and early childhood; and older childhood and adolescence.

• Opportunistically measure growth and plot annually throughout school years
• Assess and review at least yearly – is the child maintaining consistent growth velocity?

• Discuss child’s growth pattern regularly with the family (using growth charts) and normalise growth monitoring.
• Mention that it is part of standard care.
• Recommend family to also keep child’s growth records until 18 years.

• Ask family for follow-up appointments for growth monitoring (opportunistic at all presentations, minimum yearly).

Measuring growth and monitoring change

Measuring growth is part of standard, routine paediatric clinical practice. Regular growth assessments make it easier to recognise an abnormal growth trajectory and identify children who are at risk of developing overweight and obesity. Serial measurements also normalise growth monitoring and provide an opportunity to discuss growth charts and healthy growth with the family in a standardised, non-stigmatising way.

It is recommended that weight, length/height and BMI are measured, assessed and reviewed at least yearly until age 18 years.

Using percentile charts to measure growth and monitor change

Growth status in children and adolescents (age 0-18 years old) is assessed using age- and sex- specific reference values, as the appropriate ratio of weight to height varies during development. Measuring growth should always be contextualised to a child’s clinical condition.

• For children 2-18 years, use CDC growth charts** (calculate BMI-for-age, weight and height for age).
• Link to Growth Charts

**Queensland Health use WHO chart for children 0-2 years and CDC growth charts for children 2-18 years of age

Early Intervention for children and families

Early intervention is indicated if a child is at-risk of developing overweight or obesity from simple risk factors (see ‘Identifying risk’) identifiable in the first 1,000 days, or later in life if there is a family history of overweight and obesity and the family are demonstrating unhealthy lifestyle behaviours.

• Assess child’s growth (BMI-for-age) and discuss growth pattern with famly (using growth charts)
• Ask about current lifestyle behaviours (fruit and vegetables, sugary drink intake, family meals, take away/eating out, tv and screen time, physical activity/active play, sleep routines).

• Discuss weight in a non-judgmental, sensitive manner.
• Empower and encourage families to make healthy lifestyle changes. Provide healthy eating and physical activity advice and resources (increase fruit and vegetables intake, water as the main drink, avoid sugary drinks and fruit juices, promote family meals, reduce screen time, active play and vigorous physical activity , healthy sleep routines).

• Refer identified/at risk children and their families to allied health/healthy lifestyle programs or 13 HEALTH (note must request to speak with a child health nurse. Available 7d/week).
• Refer to Healthier. Happier. website.

Treatment and management should take place when a child has experienced rapid weight gain or weight is identified as being in the overweight or obese category. Goals of treatment include improvements in sustainable healthy lifestyle behaviours, preventing further weight gain (weight maintenance) and in some cases where appropriate, weight reduction, for example:

• Overweight:weight maintenance rather than weight loss can sometimes be the goal during growth (i.e. to allow gradual decline in BMI as height increases).
• Obesity:goal is often weight loss. Most children and adolescents with obesity will require multicomponent (dietary, physical activity, behavioural), prescriptive advice to promote a decrease in energy intake.

These recommendations are dependent on the situation and the child’s individual factors. Clinical judgment is also required when recommending weight maintenance or weight loss.

Childhood overweight and obesity (without co-morbidities) should be managed in primary health care using multi- disciplinary services coordinated by the PHC provider, unless referral to hospital or specialist services is indicated (with co-morbidities).

The components of successful clinical treatment and management include:

• Clinical assessment.
• Behaviour change strategies (e.g. motivational interviewing).
• Active parental involvement – “family-based”.
• Multi-component lifestyle interventions (e.g. diet, physical activity, sleep, screen time).

Clinical Assessment

Relevant history in the context of weight assessment includes developmental history, physical and mental health, and current health behaviours. It is also important to complete a clinical assessment to identify any concerns or potential causes for overweight and obesity and comorbidities.

Additionally, a feeding and sensory assessment should be undertaken and if sensory-motor issues are identified a referral to appropriate services (e.g. speech pathology, occupational therapy or feeding clinic/services) completed.

All of these factors will provide background and information that can be used to form an achievable treatment plan.

• Conduct clinical, developmental, psychosocial and behavioural assessment**
• Regularly monitor growth by measuring height, weight and BMIusing age and sex appropriate percentile charts. (weight-for-age, height/length-for-age, and BMI-for-age).

• Discuss overall assessment and child’s growth pattern with the family (using growth charts) and discuss weight in a non-judgmental, sensitive manner.
• Recommend family to also keep child’s growth record.

• Refer to local allied health/healthy lifestyle programs.
• Refer to hospital and specialist services if indicated: e.g. severe BMI classification; and/or comorbidity; and/or suspicion of genetic or secondary obesity.
• Ask family for frequent follow-up appointments for monitoring and support.

**This may include assessment of the following:

• Developmental History:pregnancy and birth history (including birth weight, maternal GDM); infant growth and development milestones; early feeding practices.
• Physical: growth patterns.
• Family history: g. Type 2 diabetes, hypertension, polycystic ovarian syndrome, dyslipidaemia
• Psychosocial: bullying, school problems; depression and mental health history (e.g. child and parents, including
  parenting stress and mood).
• Health behaviours:diet history; diet behaviours; sleep routine; physical activity; and family ability to implement changes (e.g. parenting style and behaviour), attempted lifestyle changes.
• Medical Assessment:comorbidities (including endocrine disorders, hypertension, musculoskeletal and psychological concerns); underlying causes of overweight or obesity and /or evidence of nutrient deficiency.
• Socioeconomic and environmental history: family and living arrangements, cultural and religious practices, parental occupational status, suburb, exposure to unhealthy behaviours, trauma, and limited health literacy level.

The complexity of the clinical assessment highlights the importance of the team approach to the management of childhood overweight and obesity. If other underlying causes are identified or the child’s health issues are multi-factorial, referral to hospital and specialist services may be indicated.

Intervention for children and families

Encourage a family-centred approach to improving nutrition and physical activity and empower parents to be the agents of change.

Children can remain under the care of the PHC provider if they have a weight classification in the overweight range or obesity weight range with no/or minor co-morbidities.

Referral to hospital and specialist services is indicated for children with:

• Severe BMI classification*; and/or
• Co-morbidities; and/or

Suspected underlying medical or endocrine cause.

• Ask about previous lifestyle interventions.
• Assess the family’s readiness and ability to make and sustain behavioural changes.
• Involve the whole family and emphasise the benefits to the family unit. This is especially important for separated families where a child may live in more than one household.

• Co-design an action plan with the child and family (frame positively, focusing on healthy growth and healthy lifestyle behaviour).
• Develop SMART goals (healthy eating, family meal behaviours, vigorous physical activity/active play, screen time, healthy sleep routine).

• Refer to local allied health/healthy lifestyle programs.
• Refer to Growing Good Habits website.
• Refer to hospital and specialist services if indicated.