With record numbers of overweight and obesity in children, Health Europa Quarterly discusses the key risk factors and challenges around policy and care delivery with Professor of Paediatric Nutrition, Dr Mary Fewtrell.
There is a plethora of factors to consider when addressing obesity in children. At its most basic level, eating patterns centred around unhealthy foods and a rise in sedentary behaviour have contributed to a record increase in children becoming overweight or obese. In the UK, one in three children are overweight or obese by the time they leave primary school, leaving them more susceptible to significant health risks later in life. A recent report by the WHO also highlighted that ‘there have been consistent increases in the prevalence of overweight and obesity in the WHO European Region and no Member State is on track to reach the target of halting the rise in obesity by 2025.’
When considering other factors that can impact a child’s access to healthy foods and a healthy lifestyle, tackling overweight and obesity becomes a much more complex issue. For instance, socioeconomic factors, the built environment in which a child lives as well as secondary health issues are all components that need to be addressed when building strategies to mitigate the consumption of unhealthy foods, facilitate healthy lifestyles and ascertain how best to deliver care and support to individuals and families so they can maintain a healthy weight.
As an institution which represents paediatricians in the UK, the Royal College of Paediatrics and Child Health (RCPCH) campaigns for policy changes that support the prevention of overweight and obesity in children. To understand more about the College’s remit in this area, and the challenges in safeguarding child health amid the pandemic and current cost-of-living crisis, Health Europa Quarterly spoke to Dr Mary Fewtrell who is a Professor of Paediatric Nutrition at UCL Great Ormond Street Institute of Child Health and Assistant Officer for Nutrition at the RCPCH.
What are the key risk factors of obesity in children? Are there any specific demographics more at risk?
The risk of overweight and obesity in children essentially relates to the balance of energy in and energy expended, but it is far from that simple in real life. In our current obesogenic environment, the abundance and easy availability of unhealthy foods can result in children not receiving the right foods in the right amounts. This could be due to a lack of knowledge on the part of parents and children, but also the availability and ability of families to provide the right foods, especially in an environment where we are surrounded by high fat and high sugar food options. A family’s ability to prevent their child from becoming overweight and obese is impacted by their sense of agency and having both the knowledge and the means of providing appropriate foods alongside other components of a healthy lifestyle.
We are fortunate in the UK that we have regular metrics on child weight and height, which allow us to monitor rates of overweight and obesity. Children in all four nations are measured when they are in the first year of primary school, and England, we also have exit measurements for children in year six; we have had those figures for many years now and it is a valuable resource. Unfortunately, the figures show that the proportion of children in both reception and in year six in England who are overweight and obese has been increasing. We saw a dramatic increase of 4.5 percentage points between 2019-20 and 2020-21 in England, which is very concerning.
There is a strong link between deprivation and obesity in children, and we hear from RCPCH members all too frequently about the detrimental impact of poverty on children’s health. In 2020/21, obesity prevalence was over twice as high for children living in the most deprived areas (20.3%) than for children living in the least deprived areas (7.8%). Likewise, there are differences across ethnic groups too. Ultimately, healthier choices need to be affordable to tackle obesity and improve health outcomes.
How has the COVID-19 pandemic impacted children’s eating patterns?
There are already some published studies from the UK and other high-income countries, that have found that children’s eating patterns and food intake during the pandemic have deteriorated.
We have known for many years that children from more deprived socioeconomic backgrounds are at greater risk of being overweight or obese. Obesity rates for children from deprived backgrounds are increasing, whilst they are decreasing for those from more affluent backgrounds. As with many other things during the pandemic, and now with the cost-of-living crisis, this inequality gap is getting worse. Struggling families are more likely to rely on cheaper foods which are not necessarily the healthiest. They may also have less access to safe outdoor spaces and facilities for exercise.
It is also important to acknowledge the large increase in children and young people presenting with eating disorders during the pandemic. As a College representing paediatricians, of course, we have a major focus on the prevention and treatment of obesity in children, but we are also very aware that there are a lot of children and young people with eating disorders. Many of these children will be underweight, but there is an overlap between eating disorders, overweight and obesity as well. We know from our colleagues that work with these children and young people that they have concerns about the unintended consequences of some of the strategies that are being promoted, and the messaging around preventing child obesity. For instance, calorie labelling in restaurants can be quite damaging for children and young people who are developing – or have – eating disorders. We supported this move as part of a package of measures to help CYP achieve a healthy weight with the proviso that there needs to be attention paid to its possible effect on people who are restricting their calorie intake in an unhealthy way. It is important to monitor the effects to check that it is having the desired consequence of limiting people’s consumption of high-calorie meals, rather than just making people at the other end of the spectrum very anxious and distressed.
What secondary health issues are commonly associated with childhood obesity?
We know that children living with overweight and obesity are often stigmatised or feel stigmatised and experience bullying and mental health issues. There can also be a vicious cycle where the more overweight or obese a child or person becomes, the less motivated or able they may be to exercise. Obesity increases the risk of developing a range of health conditions. We are seeing children who are developing type two diabetes and high blood pressure and getting metabolic complications which, historically, we would have seen in a middle-aged or older person. In later life, they may have an increased risk of heart disease, stroke and some cancers.
The worrying thing is that once a child is significantly overweight or obese, the chances of them losing excess weight and being a healthy weight in adulthood become less and less. This then stores up a lot of problems for their future health and has consequences for the health service, which are important reasons for trying to prevent this from happening in the first place.
Are there certain barriers that children and their parents face in accessing support for weight management?
Lack of communication and awareness that a child is becoming overweight or obese means preventative action may come at a much later and more serious stage. We know that many parents do not recognise when their child is overweight or obese, particularly in communities where overweight and obesity have become normalised. At the College, we talk a lot about the importance of ‘making every contact count’ because, regardless of why a child sees a health professional, this is an opportunity to raise the issue of their weight and possible strategies that families could adopt at an early stage to try and prevent them needing more complicated intervention later down the line. How this is communicated is a key concern because it can be a very sensitive topic.
Rising rates of overweight and obesity in children increase the demand for referrals to weight management services to provide tailored support on diet and physical activity. However, when a child is identified as being overweight or obese, it is important to think about the family’s ability to act on the advice provided. For families living in difficult circumstances, with limited income and little or no access to good cooking facilities, eating healthily and preparing meals can be very challenging. These issues need to be addressed at a societal level, for example by government initiatives to reduce child poverty and health inequalities. It is not an individual problem and living a healthy life and being able to maintain a healthy weight must be accessible to everyone.
In severe situations where a child may have medical issues like high blood pressure or type two diabetes, they need to move through the higher-tier weight management services, but these may be limited and vary in terms of what is being offered in different areas of the country.
Commissioning decisions should recognise that these services are delivered not just in health settings but where access is easiest for children and young people and their families, such as within schools and colleges. These programmes should be rigorously evaluated to ensure they continue to confer sustainable improvements in weight for the child, young person, and their family.
Last year, the government put some money aside for research into ways of engaging families and trying to work out the most successful weight management strategies, particularly for the most at-risk groups. A number of local authorities were given money to partake in the pilot project, but this financial support will discontinue next year. It seemed we were moving in the right direction and trying to do something about these complicated issues, but the pandemic and current financial situation have put these initiatives on hold.
Can you highlight any interventions that you feel are (or could be) particularly effective in empowering parents to prevent obesity in children?
Trials that include multicomponent interventions where you are addressing the whole family, and often elements of the environment as well, seem to be the most successful, but they are notoriously difficult to put into practice in real life. While in research, you can show that some of these multicomponent interventions are effective in improving a child’s lifestyle and eating practices, and maybe reducing their BMI in the short term, putting that into practice is difficult, particularly for the most at-risk groups of the population, who are the ones that are most difficult to engage.
The general approach nowadays to preventing obesity is removing the focus from the individual and making it a societal issue, which ultimately it is. There are steps to be taken at government level to tackle the obesogenic environment and reduce health inequalities, such as reformulation of foods to reduce sugar content and restrictions on the marketing of junk food. It may be that other interventions are put forward at a local level if this proves to be more effective, but the initial impetus needs to come from above because having the laws in place and the regulation of food supply is not something that can be done locally. Policy changes would enable people at a local level to use them appropriately to support their local populations.
Unfortunately, in the context of the post-pandemic and current financial situation, it seems difficult to imagine how a whole system change could be enacted. Measures that had seemed quite promising and were moving us in the right direction, albeit slowly, are at risk of being stopped or possibly even reversed.
The UK Government’s obesity strategy seeks to halve childhood obesity by 2030, do you think enough is being done at a policy level to achieve this goal?
In the pre-pandemic world, the UK obesity strategy seemed ambitious but possibly achievable. We do have high overweight and obesity rates in the UK but all high-income countries are having the same issue to one degree or another, and our obesity strategy was more comprehensive than most. It included measures such as the levy on sugar-sweetened beverages which led to the reformulation of many products.
However, the consequences of the pandemic and the current cost-of-living crisis may jeopardise progress towards this goal. On Friday 14 May 2022, the Department for Health and Social Care announced they would delay restrictions on advertising foods high in fat, salt, or sugar for a year and ‘buy one get one free’ offers on these foods. Whilst there is an argument that food offers should not be limited at a time when people are struggling, this is disappointing. Ironically, these offers are for the sorts of foods that are likely to increase overweight and obesity risk and potentially widen existing differences between children from lower and higher-income backgrounds.
The RCPCH responded to this delay by highlighting how disappointing it was to see the government go back on its policies to address junk food marketing and we hope these measures will still be implemented. Given the far-reaching health effects of obesity, we are storing up huge problems for children and young people. The policies now delayed were a crucial step to addressing these issues. We are at a critical moment coming out of the pandemic and in the middle of a cost-of-living crisis. RCPCH has called for the government to support all children and young people by launching a fully funded and cross-departmental child health and wellbeing strategy that considers the full impact of the pandemic as well as inequalities, poverty, geographies, and families. This is the only way to ensure no child is left behind.
Dr Mary Fewtrell
Professor of Paediatric Nutrition
Royal College of Paediatrics and Child Health,
UCL Great Ormond Street Institute of Child Health