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Childhood Obesity

Introduction

Around three out of every ten boys and girls aged 2 to 15 years in England in 2009 were either overweight or obese. The proportion who are overweight has remained largely unchanged since the mid-1990s. However, there has been an increase in childhood obesity – by around one percentage point every 2 years up to 2007. Although this increase now appears to be levelling off, in 2009 around 16% of boys and 15% of girls were classed as obese (see footnote 1).

Evidence shows that at a basic level, obesity is caused by an intake of calories in excess of calories expended. However, obesity is a complex problem with a range of influences and determinants which makes it difficult for people to adapt their behaviour to make changes to their diet and lifestyle (see footnote 2).

Childhood obesity is associated with significant psychological and physiological health problems. As well as increasing mortality, obesity is a risk factor for a range of chronic diseases including Type 2 diabetes, coronary heart disease and some cancers. Most of these are diseases of adult life, but the major risk of obesity and overweight in children is the likelihood that this excess weight will continue through adulthood (overweight adolescents have a 70% chance of becoming overweight or obese adults), but some directly affect children themselves. Of particular concern is the emergence of type 2 diabetes, previously considered to be a disease of adulthood, in obese schoolchildren. Childhood obesity has also been linked to poor self-image, low self-confidence and depression, as well as social and psychological consequences – including stigmatisation, discrimination and prejudice. Postnote 2003 no.205 (PDF, 112KB)

Most of the financial costs of childhood obesity and overweight are likely to be stored up as future costs in treating and managing the arising co-morbidities in adulthood. However, there are examples of more contemporary costs – such as schools needing to purchase specialist classroom and gym equipment to accommodate the needs of obese and overweight children.

In response to growing concerns about rates of obesity, the Department of Health published Healthy lives, healthy people: a call to action on obesity in England (external link) in October 2011 which outlines a national ambition to achieve: “a sustained downward trend in the level of excess weight in children by 2020.”

For further information see Adult obesity and Maternity sections.

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Key Issues and gaps

Key issues

The Foresight Report of 2007 (external link) remains a robust analysis of the causes of excess weight in England and potential solutions. It demonstrated how at the heart of the obesity issue is a fundamental energy imbalance– our calorie intake exceeds our calorie needs. It also showed how a complex interplay of factors drive this imbalance, from economic forces to biological ones. The report stated that no approach to obesity will be effective if it does not combine steps to address underlying environmental factors with individual action. Any approach will therefore need to address a wide range of issues in a coordinated way. The diagram below represents a simplified version of the factors affecting obesity:

Figure 1: Foresight Obesity Systems Atlas.

Figure 1 - Childhood Obesity

‘Healthy lives: a call to action on obesity in England’ states that a range of local interventions are needed to both prevent obesity and treat those who are already obese or overweight. The Healthy Child Programme from 5 to 19 years old (external link) recommends that overweight or obese children should be referred to appropriate weight management services to help them achieve and maintain a healthier weight.

Gaps

Haringey does not currently have a family based weight management programme to offer to families with overweight/obese children.
Reduced funding for Schools Sports Partnerships has had an impact on schools’ ability to provide physical activity interventions.
There is reduced capacity to deliver the Healthy Schools Programme
Reduced funding for Children's Centres means there is a lack of capacity to offer weight management services for families of young children.
The Dietetic Service in Haringey is currently only funded to treat adult patients.

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Who is at risk and why

In adults, obesity is defined by a Body Mass Index (BMI) of 30 or more. NCMP guidance for primary care requires that overweight or obesity be assessed by calculating BMI and plotting it onto a gender-specific BMI chart for children (UK 1990 chart for children aged over 4 years). Children over the 85th centile, and on or under the 95th centile, are categorised as 'overweight'. Children over the 95th centile are classified as 'obese'.
Regular physical activity can reduce the risk of many chronic conditions including coronary heart disease, stroke, type 2 diabetes, cancer, obesity, mental health problems and musculoskeletal conditions. The Department of Health report Start active, stay active: a report on physical activity from the four home countries' Chief Medical Officers (external link) emphasises the benefits of physical activity across the life course and highlights the risks of sedentary behaviour for all age groups. Evidence cited in the report shows an association between sedentary behaviour and overweight and obesity, with some research also suggesting that sedentary behaviour is independently associated with all-cause mortality, type 2 diabetes, some types of cancer and metabolic dysfunction. For children, the report recommends the following:

Early years (under 5s)

Physical activity should be encouraged from birth, particularly through floor based play and water based activities in safe environments.
Children of pre-school age who are capable of walking unaided should be physically active daily for at least 180 minutes (3 hours) spread throughout the day.
All under 5s should minimise the amount of time spent being sedentary for extended periods (except for time spent sleeping).

Children and young people (5-18 years)

All children and young people should engage in moderate to vigorous intensity physical activity for at least 60 minutes and up to several hours a day.
Vigorous intensity activities, including those that strengthen muscle and bone, should be incorporated at least three days a week.
All children and young people should minimise the amount of time spent being sedentary (sitting) for extended periods.
Childhood obesity is closely linked to parental and family influence. If a child has at least one obese parent, they are around three times more likely to be obese than a child with no obese parents (see footnote 3). Parents have a significant influence on the eating habits of their children but for a variety of reasons may not always encourage the healthiest choices for their children. The reasons for this are multifaceted but may include:
- Lack of information
- Conflicting marketing messages about what constitutes healthy food
- “Junk food” may be cheaper and more available locally than fresh healthy food
- The economic situation and increase in food prices may mean people spend less on food or buy foods that are cheaper, energy dense and nutrient poor.

Ethnicity and deprivation

Although children may be inheriting unhealthy lifestyle habits from their parents, some children are genetically more susceptible than others. The London Health Observatory in their review of deprivation and ethnicity (see footnote 4) based on the 2008/09 NCMP data found that:

Children in Black ethnic groups have a significantly higher risk of obesity than those in Mixed, Asian, Other and White ethnic groups.
Children living in deprived areas have a higher risk of obesity than those living in less deprived areas. However, the increased risk associated with deprivation is greatest for White children, whereas it seems to have much less of an effect for Black children. For Asian, Other, and Mixed ethnic children deprivation increases the risk of obesity, but not as much as for White children.

Analysis by the National Obesity Observatory (external link) suggests that ethnicity may not be as strongly linked to obesity as deprivation because weight differences between ethnic groups may be linked to differences in body composition and other physical categories e.g. height (see footnote 5).

The London Health Observatory found that deprivation and ethnicity seem to have a stronger effect on obesity risk in Year 6 than in Reception. Attempts at tackling childhood obesity may therefore be more effective at an earlier rather than later stage, before factors related to deprivation and ethnic group become increasingly pronounced.

A short piece of research was undertaken in Haringey in 2007 which looked at the factors influencing childhood obesity which included access to fast food outlets. Figure 2 describes levels of obesity in relation to the distribution of fast food outlets. Obesity is higher in the east of the borough where there is also a higher concentration of fast food outlets.

Figure 2: Percentage of obese and overweight children in year 6 in 2011 with fast food outlets.

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The level of need in the population

The ‘National Child Measurement Programme’ (NCMP) aims to identify the prevalence of childhood obesity locally to help plan and deliver local support services. Schoolchildren in reception (aged 4–5 years) and in year 6 (aged 10–11 years) have their height and weight measured. In the school year 2010/11, the NCMP showed that around 23% of children in reception and 33% in year 6 were either overweight or obese, and around 9% and 19%, respectively, were obese.(see footnote 6)

The NCMP shows that obesity prevalence rises with increasing socioeconomic deprivation and is more prevalent in urban, compared with rural, areas. Obesity is also more prevalent among children from Black, Asian, ‘Mixed’ and ‘Other’ minority ethnic groups than among their white counterparts.

Nationally, obesity rates amongst year 6 are continuing to increase and rates are considerably higher than they are amongst children in reception classes. It is difficult to see any particular trends in obesity in Haringey as rates have fluctuated year on year. As more data becomes available and the programme continues, data can be aggregated to produce rolling averages that may give us an idea as to the direction of travel.

In Haringey in 2011, 36% of children aged 10-11 are either overweight or obese. Amongst 4-5 year olds 21.5% are obese or overweight.

Figure 3: Trends in obesity in reception.

Source: National Obesity Observatory

The obesity rate in Haringey for Reception children is 10.1% (CI = 9.0-11.4) which although higher than the England rate (9.4%) there is no statistical difference. In 08/09 and 09/10 obesity rates in Haringey were significantly higher than rates in England.

In London in 2011 obesity among Reception children is 11.1% (CI=10.9-11.3) There is therefore no statistical difference between Haringey and London.

Figure 4: Trends in obesity in year 6.

Source: National Obesity Observatory

The obesity rate in Haringey in Year 6 in 2011 is 21.1% (CI=19.4-22.9) which is statistically higher then the England rate of 19.0%. This suggests that as Haringey children develop, they are more likely to be obese than their England counterparts by the time they are 10-11 years old. In Year 6 in London in 2011 obesity levels were 21.9% (CI= 21.6-22.2) suggesting there is no statistical difference between Haringey and London.

There are variations within Haringey. Obesity rates are higher in the east of the borough which reflects the demographic profile of Haringey i.e. more deprived in the east and more ethnic diversity.

Figure 5: Percentage of reception age children who are obese - 2011

Figure 6: Percentage of year 6 children who are obese - 2011

(It is worth noting that the participation rate for the NCMP in Haringey in 2011 was lower than in previous years so this may impact on obesity rates in some wards).

Prevalence of Obesity relative to deprivation

Nationally, there is a link between levels of deprivation and obesity. Data from the 2011 NCMP clearly show this link (see chart below where 1 is the most deprived and 10 the most affluent). Each child’s record was assigned a deprivation score based on the child’s address. For both Reception and Year 6 children there is a positive correlation between the two variables.

Figure 7: Prevalence of obesity relative to deprivation.

Source: Department for Communities and Local Government 2010 (there are no postcodes within Haringey that fall within the most affluent deciles).

Ethnicity

The table below (figure 8) shows the local analysis of prevalence of obesity and overweight in children in different ethnic groups. As the numbers in each ethnic group vary considerably and the numbers in some groups are small, it is difficult to make accurate interpretations and comparisons. The largest groups in Haringey, Any Other White, White British and Black African, show differences in rates of obesity in Year 6:

Figure 8: Prevalence of children measured at risk of obesity in Year 6 by ethnic group.

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Current services in relation to need

Prevention:

Haringey is currently working towards Baby Friendly Accreditation to improve the support provided for women to initiate and maintain breastfeeding - see maternity section.
Healthy Start (external link) provides vouchers for fresh fruit and vegetables for eligible families and is promoted in Haringey by midwives, health visitors and Children’s Centres.
Early identification and prevention of obesity is a key priority of the Healthy Child Programme (external link). The Healthy Child programme is currently targeted at vulnerable families in Haringey. Families are given information and advice around breastfeeding, healthy weaning, healthy eating and active play.
Healthy Schools –schools are encouraged to maintain Healthy Schools Status by completing a review detailing how they are promoting Healthy eating and physical activity and to work towards becoming Enhanced Healthy Schools. Schools working towards Enhanced healthy Schools Status can choose from 5 local priorities including childhood obesity and do a targeted piece of work focusing on their most vulnerable pupils.
Despite reduced funding, the Schools Sports Partnership are still working with schools to promote sport and organise competitions between schools.

Treatment:

Families with concerns about their child’s weight can access primary care services via their GP.

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Service users and carers opinion

The Schools Health Education Unit (SHEU) (external link) carried out a survey in 2009/10 in Haringey. A total of over 1800 pupils took part in 17 primary schools and 8 secondary schools in Haringey. The pupils at the Pupil Referral Unit also undertook the exercise. The survey was coordinated by the former Healthy Schools Team in Haringey as a way of collecting robust information about young people’s lifestyles.

Key messages:

Pupils were asked to identify, from a list, the foods which they ate ‘on most days’. 61% of pupils said they have fresh fruit and 43% said vegetables. 19% said crisps and 22% said sweets ‘on most days’.
28% of pupils said that they ‘rarely’ or ‘never’ ate fish or fish fingers. 14% said they ‘rarely’ or ‘never’ had salads.
33% of pupils had eaten 5 or more portions of fruit and vegetables on the day before the survey, 7% had eaten none.

The SHEU survey will be repeated in a sample of Haringey schools in 2012.

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Expert opinion and evidence base

There is a vast amount of evidence relating to obesity. The key documents are listed below.

Department of Health: Healthy lives, healthy people: a call to action on obesity in England (external link)
The Foresight Report of 2007 (external link)
Greater London Authority: Childhood Obesity in London. April 2011 (PDF, 2.36MB - external link)
Parliamentary Office of Science and Technology: Postnote 2003 no.205 (PDF, 112KB)
Weight management before, during and after pregnancy. NICE public health guidance 27 (2010).
Prevention of cardiovascular disease. NICE public health guidance 25 (2010).
Promoting physical activity for children and young people. NICE public health guidance 17 (2009).
Maternal and child nutrition. NICE public health guidance 11 (2008).
Physical activity and the environment. NICE public health guidance 8 (2008).
Behaviour change. NICE public health guidance 6 (2007).
Obesity. NICE clinical guideline 43 (2006).
National Institute for Health and Clinical Excellence: Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children 2006 (external link)
The Marmot Review 2010 Fair society, healthy lives: strategic review of health inequalities in England post 2010 (external link)
Healthy child programme: Pregnancy and the first 5 years of life (external link)
Healthy child programme: The two year review (external link)
Healthy child programme: From 5–19 years old (external link)
Healthy lives, healthy people: a call to action on obesity in England (external link)

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Projected service use in 3-5 years and 5-10 years

Healthy Weight Healthy Lives A toolkit for developing local strategies (external link) stated that the proportion of children who are obese in the under 20 age group will rise to approximately 15% in 2025 (with slightly lower prevalence in boys than in girls).

By 2050, it is estimated that 25% of under 20 year olds will be obese.
By 2050, it is predicted that 70% of girls could be overweight or obese, with only 30% in the healthy BMI range. For boys, it is estimated that 55% could be overweight or obese and around 45% could be in the healthy range.

Age

Among children aged 6-10 years, boys will be more obese than girls, with an estimate of 35% of boys being obese by 2050, compared with 20% of girls.
Among children aged 11-15 years, more girls than boys will be obese by 2050 – 23% of boys and 35% of girls

These figures were extrapolated by Foresight in 2007 (see footnote 7) using Health Survey for England unweighted data for 1995-2004 (see footnote 8)

Predicted figures should be viewed with caution as confidence intervals associated with these figures grow larger as one projects into the future.

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Unmet needs and service gaps

There are no specific family based weight management services for obese children and their families in Haringey.
Reduced funding and capacity has implications for commissioning weight management services.

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Recommendations for Commissioning

Utilise the broad range of partners at the Health and Wellbeing Board to oversee the strategic high impact changes that commissioners and leaders can embed into service specifications, tenders and service level agreements to tackle the broad range of factors affecting childhood obesity.
Explore the possibility of commissioning an evidence based weight management provider to offer intensive family based interventions for obese children in Haringey.
Work with the Clinical Commissioning Groups to ensure that both primary care and secondary care have a role in identification, brief advice, onward referral and commissioning clinical action.
Continue to undertake the NCMP to build local intelligence in order to inform service planning through robust analysis of childhood obesity “hotspots”.
Share the evidence base with schools, Children’s Centres and other providers of services to children to enable them to make the best decisions to improve the health of the children in their care.
Ensure early identification and prevention of obesity through the commissioning of the Healthy Child Programme to encourage health professionals to provide nutrition and physical activity information/advice to pregnant women and parents of young children.
Continue to work with schools, supporting them to maintain their Healthy Schools Status and work to achieve an Enhanced Healthy Schools Status, which has reducing childhood obesity as a key priority.
Utilise the evidence base to implement school based interventions using local capacity e.g. the Tottenham Hotspur Foundation, Schools Sports Partnership and Healthy Schools team within Public Health.
Commission training from Department of Health approved weight management providers to train the early years, schools and community workforce in how to recognise childhood obesity, raise the issue with families in a sensitive way and offer brief interventions to families as appropriate.
Use opportunities in the local media to raise awareness of childhood obesity and healthy lifestyle information with the general population.
Work with partners in the Council to restrict the number of new fast food outlets, particularly near schools.
Work with fast food outlets to support them in reducing the salt, fat and sugar content in their menus.