Management of the Obese Child

Abstract and Introduction

Abstract

The increasing prevalence of overweight and obesity worldwide has prompted interest in the condition. Of particular concern is the increase of excess adiposity, often accompanied by reduced physical activity, in the young. In 2006 the National Institute for health and Clinical Excellence (NICE) published guidance on the identification, assessment and management of overweight and obesity in adults and children. Herein we aim to describe the approach to management of a severely obese child using the NICE guidelines and personal practice from a secondary care weight management clinic.

Introduction

There is increasing recognition both in the UK and worldwide that there is an "obesity epidemic". This is supported by analyses of national surveys going back over twenty years. The issue has received much attention recently from politicians, professionals, the media and the public. Changes in lifestyle, work and leisure probably all contribute to the present situation. Estimates suggest that more than 12 million adults and 1 million children in England will be obese by 2010 if no action is taken. NICE produced guidance on obesity in December 2006. This is the first national guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children in England and Wales. The guidance aims to stem the rising prevalence of obesity and diseases associated with it, increase the effectiveness of interventions to prevent overweight and obesity and to improve the care provided to adults and children with obesity, particularly in primary care.

To illustrate the strengths and limitations of the NICE guidelines let us consider the following letter from a GP to a secondary care clinic:

Dear Doctor,
Please could you see this 14-year-old girl who has been concerned about her excess weight for a number of years? She weighs 170 kg. She has seen the dietitian in the past without benefit. Both her parents are also obese: father has type 2 diabetes and mother has hypertension. Mother has recently undergone bariatric surgery and the family wonders if this is available for young people.

NICE Guideline - Learning Point 1

Referral to specialist care: Consider referral to specialist care if a child has a significant comorbidity or complex needs such as learning or educational difficulties.

This child is very obese but the GP does not appear to have performed any investigations to determine the causes or consequences of obesity. The child would appear to have a significant weight problem, has a family history of obesity, hypertension and type 2 diabetes and the family is also asking about surgery so a referral for evaluation is reasonable.

NICE Guideline - Learning Point 2

Assess lifestyle, comorbidities and willingness to change: This includes presenting symptoms and underlying causes; risk factors and comorbidities; eating behaviours and diet; physical activity; psychosocial factors and willingness to change.

This section will provide an approach to history, examination and management.

History

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  History of presenting symptoms should be sought. Furthermore, questions directed at ruling out underlying causes should be asked. This helps to differentiate simple obesity from pathological causes (Table 1). For example, symptoms of constipation, cold intolerance or lethargy would suggest hypothyroidism. History of headaches, visual symptoms or previous encephalitis would be suggestive of hypothalamo-pituitary pathology. A significant delay in development may suggest a syndromic cause of obesity. Questions regarding symptoms of the potential consequences of obesity should also be pursued (Table 2).
  
  
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  Birth weight and pregnancy history: If very heavy at birth, this suggests an underlying mechanism, such as hyperinsulinism, which may have started in utero. Also maternal diabetes during pregnancy increases risk of diabetes in later life.
  
  
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  Age of onset of weight problems: Early onset obesity before the age of two years, or while exclusively breastfed is more suggestive of a genetic or syndromic cause of obesity.
  
  
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  Appetite: This can be difficult to ascertain as families may feel that value judgements are being made when asking questions about appetite. Families should be informed that intense hyperphagia is seen in genetic causes of obesity. Ask how quickly the child eats, whether the child is distractable whilst eating, how quickly they ask for more i.e., within minutes or hours of finishing a meal and what happens extra food is denied.
  
  
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  Diet: This child needs referral to a dietitian for a formal assessment of dietary patterns not only of the child but also of the whole family.
  
  
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  Physical activity patterns at home and at school. Again quantitative assessment can be difficult. Questions should be aimed at assessing what activities a child may like and what they do not like. Methods of transportation should also be established e.g., whether the child is walking to school. Then patterns of inactivity can also be determined: TV viewing, computer games or time spent on a playstation.
  
  
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  Psychosocial factors: Ask about school performance and, if the child has to face teasing or bullying at school, whether this may be affecting self esteem.
  
  
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  Motivation of child and parents: It is essential to find out how motivated the child and parents are to lose weight and whether either the child or the parents are more motivated, as this can lead to conflict when approaching management. Questions regarding the extent and success of previous interventions to achieve weight control are also useful.
  
  
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  Family history: Ask for family history of obesity, type 2 diabetes, hypertension, premature cardiovascular disease and dyslipidaemia. This child has a strong family history of metabolic disease and it would be important to investigate for early markers of cardiovascular disease risk in this child.