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Reducing childhood obesity

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Childhood obesity remains a major health concern, highlighted by the number of guidelines, reports and recommendations that have been released in the past month.

The Chief Medical Officer, Professor Dame Sally Davies' report, Prevention Pays - Our Children Deserve Better, outlined the importance of educating children about nutrition and engaging them in physical activity. The report also recommended offering every child with vitamin supplements since there has been a widespread resurgence in cases of vitamin D deficiency.1

NICE guidance, Managing Overweight and Obesity among Children and Young People, PH47, has called for commissioners in local authorities and the NHS, and providers of community-based services to take a 'lifestyle' approach to help overweight or obese children and young people manage their weight.2

Recommendations from the Royal College of Paediatrics and Child Health (RCPCH) said that children in Wales should be weighed every time they see a health professional in a submission to the Welsh National Assembly's Children and Young People Committee's inquiry into obesity. In Wales 34 per cent of under 16s are either overweight or obese. The paediatricians said it was important to look for 'holistic' ways to tackle the growing problem of childhood obesity in Wales and for clinical bodies to promote targeted education and training programmes to help practitioners offer these services.

The National Child Measurement Programme, (NCMP), which has been updated for the current school year, developed by PHE, outlines the annual weighing and measuring of all eligible reception year (age four-five) and year six pupils (age 10-11) at state primary and middle schools. The aim of the programme is to provide data on child weight, understand obesity prevalence and trends, and provide parents with feedback on their child's weight and support them if they are overweight. After six years of NCMP measurements, two different trends in obesity prevalence have emerged. In reception year pupils obesity prevalence seems to be decreasing among boys although for girls there is no strong evidence of any change. In year six the data shows a pattern of increasing obesity prevalence for both boys and girls. There also appears to be a strong correlation between obesity and deprivation. Obesity prevalence among children in the most deprived areas in the country are nearly twice that of children living in the least deprived areas.3

Various factors such as lack of vitamins, lack of exercise, poor education about healthy foods and the increased price of fresh produce have all been cited when searching for reasons to explain the rising levels of childhood obesity and poor health.

Healthcare professionals working in primary care such as health visitors, school nurses, practice nurses and midwives are at the forefront of initiatives to stem the tide of childhood obesity.

Early education

Health visitors often use individual and group approaches working with children's centres and families to support breastfeeding and weaning, and to encourage healthy approaches to food and diet in preschool years.

Dave Munday, the professional officer for health visitors at Unite, agrees that supporting breastfeeding and weaning are key to combatting obesity. 'If women breastfeed, children are less likely to be overweight. It is also important to ensure that weaning happens at the right time and there is often conflicting information with regards to weaning guidelines. Major baby food companies suggest weaning can start at four months while the World Health Organisation (WHO) has said that mothers should begin the weaning process at six months. This information needs to become more consistent and health visitors can help in this.

'Health visitors can also teach mothers to prepare weaning foods in order to ensure that children are exposed to various flavours as early on as possible.

'Children will often wake up in the night crying and a mother's natural instinct is to feed them, but hunger might not always be the cause. While it is important to feed children little and often, they shouldn't be fed too much,' says Mr Munday.

Mr Munday also highlights the importance of teaching health visitors how to broach the subject with sensitivity.

Sara Patience, a registered health visitor and nutritionist from Surrey, agrees stressing the importance of the advice. 'Health visitors should also be able to advise families on what constitutes a healthy family diet so ultimately children join in with what the family eats. Health visitors should be aware of when and where to refer the family to, if further help or assessment is required.'

'Trusts may have local training and guidelines. There may be local weight management services, cooking groups, lunch groups and so it is important for healthcare professionals to know what is available,' she added.

In the future, in order to continue the improvement of children's health, Ms Patience believes intervention will be required at a number of levels. 'It is hard for families or health visitors to be successful in certain circumstances if families live in areas where it is more difficult for them to buy fresh foods and there is greater availability of processed foods, which may also be cheaper.

'Some families with housing problems may not have an appropriate kitchen area to cook in and some parents do not have basic cooking skills. Children see many adverts for high fat, salty and sugary foods, and while there are some controls related to TV advertising, this is not controlled on the internet.

'Health visitors could look at running healthy eating groups, or referring to those that may already exist in children centres - it is about educating parents as well as educating children. Good nutrition should be a public health and government priority involving a number of agencies.'

Influencing child health

Practice nurses working in general practice with the local community often have specific expertise in nutrition and weight, related to managing long-term conditions such as diabetes and supporting particular patient groups.

'For nurses it is about developing the skills to have those difficult discussions and on advising children and young people of the small changes they can make to improve their health,' says Fiona Smith, the RCN's advisor in children and young people nursing.

School nurses are the main implementers of the NCMP and Viv Bennett, the director of nursing at PHE, believes they provide support for parents to make changes to a healthier diet and increase physical activity for their children. They also help young people to make healthy choices and decisions. This is often through personalised advice, engagement with local weight management programmes, or support from the Change4life network.

'School nurses work closely with school staff to provide input at assemblies, parents evenings and drop-in sessions regarding healthy eating and promoting physical activities. Many school nurses have developed information, advice and guidance sections on school websites, which parents can access,' she says.

Ms Smith agrees that school nurses have a varied role in improving the health of children. 'They can work with teachers and head teachers to put dietary focused measures in place like ensuring healthier snacks and foods are available in the canteen and ensuring children have access to drinking water through the day.'

School nurses can also assist children directly as they grow older and start to become more responsible for their own health and wellbeing and wish to lead healthier lifestyles. Many nurses organise cooking workshops and during Personal, Social, Health and Economic (PSHE) programmes can educate children and young people about ingredients in foods.

'There are various guidelines and programmes around now to target child obesity. CCGs are looking at how they can provide services locally as well as how they can encourage school nurses and practice nurses to provide support locally,' Ms Smith added.

Local initiatives

One example of prevention on a local level is the Lambeth Child Obesity Programme. Lambeth CCG and the council is implementing a five-year child obesity programme aimed at health professionals to help tackle the rising levels of childhood obesity in the borough. The five year programme includes a range of preventive and treatment services and programmes to support healthy weight and address childhood obesity. It includes capacity building, support and training provision for all professionals working with families and children aged up to 11 years old. The aim is to enable all those working with children and families to understand childhood obesity and to be able to provide consistent and evidence-based brief interventions as well as to sign post and refer to appropriate local services.

The Lambeth programme also includes a school 'healthy weight promotion' programme. Schools and school staff have been encouraged and supported to promote healthy weight by providing an environment that enables and supports children and staff to make healthier choices. Free training and resources are offered to school staff to help them promote healthy weight, provide interventions where required and refer children to other services.

The specialist obesity school nurse is a new post that has been created within the Lambeth school nursing team to support the implementation of the child obesity programme. The specialist nurse has a key role in the assessment and referral of children and families to appropriate services to address healthy weight issues, as well as establishing key links with staff and practitioners. An example of the work carried out by the specialist role includes working across the primary schools in the borough to coordinate services, assess children using the NCMP, and establish links with key staff so that children are referred to the appropriate preventive or weight management services.

Bimpe Oki, a consultant in public health and programme lead, says that the programme has been highlighted as an example of good practice and appears to be meeting local needs. 'We are monitoring and reviewing the effectiveness of the programme including the role of the specialist obesity school nurse at every step of the way and there is a possibility that we may increase these services if the demand is there.'

Warwickshire has also developed a useful approach to using Change4Life advisers linked to school nursing teams to provide tailored and intensive support. Their aim is to reduce obesity in children before they reach year six.

Community based nurses, local areas and projects, and commissioning groups, are key to implementing programmes and guidelines that support and educate families and children about nutrition and good health.

Future projects to help tackle obesity on a national level include a piece of work by the Department of Health with PHE and key stakeholders, including school nurses and teachers, to develop a pathway to support local service delivery based on good practice and evidence. This will be available from next spring, says Ms Bennett.

Intervention is required in the future to continue to target the rising levels of childhood obesity. Continuing to engage healthcare professionals about the importance of teaching families and children about the importance of healthy eating and nutrition is vital to improving their future health.

References

1. Department of Health. CMO's annual report. 2013. London. http://bit.ly/187xTUJ. Accessed October 2013.

2. NICE. Managing overweight and obesity among children and young people, PH47.2013. http://bit.ly/17w4nd9. Accessed October 2013.

3. Public Health England. NCMP for 2013/14 school year. 2013. http://bit.ly/1crTFBJ. Accessed October 2013.

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National Child Measurement Programme 2011/12: key findings
  • 93 per cent of eligible children measured during the 2011/12 school year.
  • Obesity prevalence roughly doubled from 9.5 per cent of children at the start of primary school to 19.2 per cent at the end of primary school (that is between reception year and year six).
  • In reception year, over a fifth of the children measured were of excess weight (either overweight or obese). In year six, this proportion was one in three.
  • For year six children, the data shows a trend of increasing obesity prevalence for both boys and girls between 2007/08 and 2011/12.
  • For reception year boys, there was a significant decrease in obesity prevalence since 2010/11 and evidence of a downward trend over the period covered by the NCMP.
  • For reception year girls, there is a significant increase in obesity prevalence since 2010/11, but over the whole period covered by the NCMP there is no statistically significant trend.
  • Correlation between obesity prevalence and deprivation is very strong, with prevalence roughly double that in the most deprived areas compared with that in the least deprived (12.3 per cent versus 6.8 per cent in reception year and 24.3 per cent vs 13.7 per cent in year six).
  • Socioeconomic inequalities in obesity prevalence have widened over the period covered by the NCMP.

Source: National Child Measurement Programme, Department of Health