How should childhood obesity be managed?
 

For further details see An Approach to Weight Management in Children and Adolescents (2-18 years) in Primary Care  Produced for the Royal College of Paediatrics and Child Health and National Obesity Forum  by Penny Gibson, Laurel Edmunds, David W Haslam, Elizabeth Poskitt
www.rcpch.ac.uk  or  Health Education Board For Scotland (HEBS) Learning Centre Childhood Weight Management.
www.hebs.scot.nhs.uk/learningcentre/obesity/childhood/4.0.htm


Not all children and adolescents who are overweight or obese will need the services of a health professional. It is important, therefore, to have a clear idea of when a child requires only advice and monitoring, and when he or she needs more intensive intervention.

When to act?

Although guidelines setting out the levels of BMI which should trigger action are helpful, the child will often be the one to decide when action is taken. The level of commitment to change by the child and their parents is important. If the child and the family are not keen to make changes then it is better to wait until they are ready. And without the child's consent, co-operation and goodwill, the weight management programme is unlikely to get off the ground.
 

Children with related clinical disorders such as sleep apnoea or hyperlipidaemia will need more intervention than those without and should be referred to appropriate services urgently.

Weight management options

In children with no complications, the aim of weight management might not be to reduce weight, but rather to avoid further weight gain while the child increases in height. Weight loss is an unrealistic goal for many obese children, and unrealistic expectations of weight loss can cause disappointment and disillusionment. The goal of reducing, and perhaps even normalising, the BMI might nevertheless be achieved though minimising weight gain while growth occurs. There are two options for these children:
 

NB Rapid weight loss and strict dieting are not appropriate for growing children unless under specialist care. Children over 7 years old with obesity and / or complications may benefit from gradual weight loss e.g. 0.5kg / month. If adolescents have stopped growing, weight loss of around 0.5kg / week may be appropriate.

Increasing activity and decreasing inactivity

The evidence from successful weight management programmes shows that combining activity advice with dietary advice is more effective than concentrating on any single factor in achieving this aim. A review of the effectiveness of weight management programmes in children by the HDA found that involving the whole family is crucial (Mulvihill and Quigley 2003).  Addressing psychosocial and family issues through lifestyle counselling, and training in child management, parenting and communication skills might also be necessary and has been found to be helpful.

Increasing children's activity levels will have a significant effect not only in helping them to avoid gaining weight, but also in improving general health, increasing energy levels, and introducing new opportunities for fun and socialising.

Compile a physical activity diary and include not only “formal” activities like football or swimming but also informal activities like walking, cycling, skateboarding or household chores. Find out which ones the child enjoys and see if there are ways these can be built into his or her life on a more regular basis, for example by walking or cycling to school. Consider how the whole family might develop a more active lifestyle and recognise that this will involve more active participation from everybody than just sitting in front of the television. For example, going on family walks or cycle rides, getting a dog, making the garden a child-friendly place, kicking a football around with them etc.

Reduce inactivity by decreasing TV viewing and other sedentary behaviour such as computer games.


Dietary management

Get a general assessment of the child’s food intake. Not just what food is consumed but at what times and under what circumstances. Many children with obesity may have irregular, inconsistent eating habits, and may grossly under-estimate the amount of food they consume. Drinks should also be included; many might be high in sugar, but the child might omit to mention them unless specifically asked.  Alcoholic drinks should also be considered although this might require sensitive questionning. Food provided by other people, eg school, grandparents, carers, friends’ parents etc or out of pocket money should also be included.

Consider with the child how they can modify their diet in a way which will lead to permanent changes in their eating patterns. Cutting down the number of eating occasions, the amount of food eaten at a time and substituting lower calorie foods for higher calorie ones are all strategies which can be adopted. Having regular meal times will involve the whole family but this will help make the changes permanent.

Replacing energy-dense foods such as fatty or sugary snacks or drinks with less energy dense foods such as fruit, bread, and cereals or water means the child can still eat a lot of satisfying food, but will reduce his or her calorie intake in the process. The Healthy Eating Plate can be used as the basis for planning the proportions of each types of food which are going to work for the young person.

Encourage the child and the family that small, but sustainable changes are going to have more effect than bigger changes which cannot be kept up.


Coping strategies

Depending on the age of the child and their independence, help them to consider coping strategies for difficult situations or for bullying or teasing. How would they deal with not having a chocolate bar after school like everybody else?  How do they deal with the comments about their weight that this might provoke? What steps can be taken to increase their self-confidence and self-esteem. An improvement in confidence in one area, eg learning a new skill can spill over into other areas and  increase their confidence about losing, or not gaining any more, weight. Consider whether counselling would help.

Remember that the child will probably be motivated to keep to their diet for reasons other than health. Help them to consider what losing, or not gaining any more weight would mean for them socially and pyschologically as well as health-wise.


Mulvihill, C. and R. Quigley (2003). The Management of obesity and overweight: An analysis of reviews of diet, physical activity and behavioural approaches - evidence briefing, Health Development Agency.