The Assessment and Management of Overweight and Obesity in Children and Young People
Scope and Purpose
This guideline was originally intended for Southampton/ Hampshire & Isle of Wight services. Since then the Complications of Excess Weight (CEW) services have been set up as part of the NHSE CYP Transformation Project (2022). This is a network of centres across the South East with a small amount of ringfenced funding to treat a small number of children and young people living with severe and complex obesity which requires management using a biopsychosocial model, i.e. an MDT including medical, nursing, safeguarding, youth work, dietetics, physiotherapy, psychological, and social and community support staff.
We are aware that outside CEW services, the service provision for CYP with severe obesity across the Wessex and South East networks varies considerably. Nonetheless this guideline aims to provide the overall principles of assessment and management of obesity, which can be adapted to individual centres as resources allow. On a case-by-case basis the CEW centres may consider referrals from regional secondary care paediatricians within their ICS (Integrated Care System) if there is a significant co-morbidity proven and where there is no obesity service currently set up in that particular regional centre, although the overall responsibility for the child in these cases should remain with their secondary care provider, albeit with support from the CEW centres. Secondary care is essential for CYP with severe obesity as the families are clear that they need to be seen locally and supported by local services including Children’s Services.
Purpose of guideline:
This guideline was originally intended for Southampton/ Hampshire & Isle of Wight services. Since then the Complications of Excess Weight (CEW) services have been set up as part of the NHSE CYP Transformation Project (2022). This is a network of centres across the South East with a small amount of ringfenced funding to treat a small number of children and young people living with severe and complex obesity which requires management using a biopsychosocial model, i.e. an MDT including medical, nursing, safeguarding, youth work, dietetics, physiotherapy, psychological, and social and community support staff.
We are aware that outside CEW services, the service provision for CYP with severe obesity across the Wessex and South East networks varies considerably. Nonetheless this guideline aims to provide the overall principles of assessment and management of obesity, which can be adapted to individual centres as resources allow. On a case-by-case basis the CEW centres may consider referrals from regional secondary care paediatricians within their ICS (Integrated Care System) if there is a significant co-morbidity proven and where there is no obesity service currently set up in that particular regional centre, although the overall responsibility for the child in these cases should remain with their secondary care provider, albeit with support from the CEW centres. Secondary care is essential for CYP with severe obesity as the families are clear that they need to be seen locally and supported by local services including Children’s Services.
Purpose of guideline:
- To set referral criteria according to NICE guidance and current capacity
- To support assessment of paediatric obesity in secondary care
- To support management in secondary and tertiary care
- To provide guidance and education for all UHS and PIER network staff to be able to manage paediatric obesity
- To ensure management of children and young people is in line with current guidelines and recommendations and is evidence based.
Background
Overweight and obesity in children is becoming more widespread in the UK with reports that 1 in 3 children aged 2-15 are now overweight (1). Children are becoming overweight earlier and staying overweight for longer (2). Children from poorer backgrounds are twice as likely to be overweight or obese at five years old and this is increased to three times as likely by the time, they are eleven years old (3) . The full extent of the long-term effects of this is not known, but the metabolic changes that result are known to lead to type 2 diabetes, metabolic syndrome, cardiovascular disease, cancer and mental illness. These can be linked directly to overweight and obesity, and it is more important than ever that a strategy to prevent obesity is in place in the wider community. For those children who are already overweight and obese, robust support is needed.
The major role of General/Community Paediatrics is to assess and initiate management of those with significant obesity. Assessment should involve an exclusion of an organic cause, assessment of co-morbidity, assessment of diet, exercise and psychosocial factors including motivation, eating behaviour, quality of life and safeguarding issues. Management requires consistency between all health professionals and includes recommendations regarding diet and exercise, SMART goals, self-monitoring and supporting behavioural change.
Overweight and obesity in children is becoming more widespread in the UK with reports that 1 in 3 children aged 2-15 are now overweight (1). Children are becoming overweight earlier and staying overweight for longer (2). Children from poorer backgrounds are twice as likely to be overweight or obese at five years old and this is increased to three times as likely by the time, they are eleven years old (3) . The full extent of the long-term effects of this is not known, but the metabolic changes that result are known to lead to type 2 diabetes, metabolic syndrome, cardiovascular disease, cancer and mental illness. These can be linked directly to overweight and obesity, and it is more important than ever that a strategy to prevent obesity is in place in the wider community. For those children who are already overweight and obese, robust support is needed.
The major role of General/Community Paediatrics is to assess and initiate management of those with significant obesity. Assessment should involve an exclusion of an organic cause, assessment of co-morbidity, assessment of diet, exercise and psychosocial factors including motivation, eating behaviour, quality of life and safeguarding issues. Management requires consistency between all health professionals and includes recommendations regarding diet and exercise, SMART goals, self-monitoring and supporting behavioural change.
Definitions & Diagnosis
According to NICE, the definition of overweight is a BMI percentile >91st percentile and the definition of obesity is a BMI percentile >98th percentile. However, comorbidities are much higher in the group with BMI >99.6th percentile or >3 standard deviation scores (SDS). These cut off points are a useful tool, but do not give the full picture. Other factors such as a family history of type 2 diabetes can indicate a greater risk of developing metabolic complications including diabetes, high blood pressure and raised blood lipids. Ethnicity is also a factor, and patients of Asian origin might require a lower threshold for the definition of overweight and obesity. Conversely patients of black African or Caribbean origin may require a higher threshold. Pubertal patients have a much higher risk of metabolic co-morbidities.
Diagnosis of overweight or obesity would normally occur in primary care. The National Child Measurement Programme (NCMP) letter is a tool used by public health nurses to inform parents of the overweight or obesity status of their child. Initiatives to engage children and families exist, such as ‘change for life’ internet-based resources. Local areas also have access to alternative programmes, such as that run by the Hampshire Fire Service. The public health nurses are best placed to signpost parents to the local diet and lifestyle programmes that exist in a particular area.
For children aged under 2 years, BMI is not a good indicator of body fat, and therefore there are no simple definitions for overweight or obesity in this age group. Therefore, a clinical judgement has to be made, based on the child’s height and weight centiles and the rate of weight gain. This also needs to assess whether the weight is crossing centiles upwards, the family history of obesity and weight related disease, and how the child appears. If a child’s weight is above the 98th centile with a height on or below the 50th percentile, or if the weight is more than 2 centiles above the height, it should always be considered that they might be overweight or obese. It is noted that this is slightly different to the Healthy Weight Pathway for which overweight/obesity is based on arbitrary definition to triage children for referral/intervention based on limited resources.
Upward crossing of 2 weight-for-length percentiles in the first 6 months is associated with the highest prevalence of obesity 5 and 10 years later (4). It is also noted that infants with low birth weight have a predisposition to gain weight rapidly during the first 2 years of postnatal life, particularly for those who had IUGR (5). Rapid weight gain or upward centile crossing in infancy (in first 6 months) and early childhood (3-6 years old), both predict increased adiposity and obesity at 17 years (6). However this has to balanced against assessing infants who may be showing appropriate catch-up growth.
According to NICE, the definition of overweight is a BMI percentile >91st percentile and the definition of obesity is a BMI percentile >98th percentile. However, comorbidities are much higher in the group with BMI >99.6th percentile or >3 standard deviation scores (SDS). These cut off points are a useful tool, but do not give the full picture. Other factors such as a family history of type 2 diabetes can indicate a greater risk of developing metabolic complications including diabetes, high blood pressure and raised blood lipids. Ethnicity is also a factor, and patients of Asian origin might require a lower threshold for the definition of overweight and obesity. Conversely patients of black African or Caribbean origin may require a higher threshold. Pubertal patients have a much higher risk of metabolic co-morbidities.
Diagnosis of overweight or obesity would normally occur in primary care. The National Child Measurement Programme (NCMP) letter is a tool used by public health nurses to inform parents of the overweight or obesity status of their child. Initiatives to engage children and families exist, such as ‘change for life’ internet-based resources. Local areas also have access to alternative programmes, such as that run by the Hampshire Fire Service. The public health nurses are best placed to signpost parents to the local diet and lifestyle programmes that exist in a particular area.
For children aged under 2 years, BMI is not a good indicator of body fat, and therefore there are no simple definitions for overweight or obesity in this age group. Therefore, a clinical judgement has to be made, based on the child’s height and weight centiles and the rate of weight gain. This also needs to assess whether the weight is crossing centiles upwards, the family history of obesity and weight related disease, and how the child appears. If a child’s weight is above the 98th centile with a height on or below the 50th percentile, or if the weight is more than 2 centiles above the height, it should always be considered that they might be overweight or obese. It is noted that this is slightly different to the Healthy Weight Pathway for which overweight/obesity is based on arbitrary definition to triage children for referral/intervention based on limited resources.
Upward crossing of 2 weight-for-length percentiles in the first 6 months is associated with the highest prevalence of obesity 5 and 10 years later (4). It is also noted that infants with low birth weight have a predisposition to gain weight rapidly during the first 2 years of postnatal life, particularly for those who had IUGR (5). Rapid weight gain or upward centile crossing in infancy (in first 6 months) and early childhood (3-6 years old), both predict increased adiposity and obesity at 17 years (6). However this has to balanced against assessing infants who may be showing appropriate catch-up growth.
Flowchart: Southampton Healthy Weight Pathway for Community and Primary Care for 0-5 years old (7)
Flowchart: Southampton Healthy Weight Pathway for Community and Primary Care for 5-16 years old
Recommended Obesity Care Pathway
This pathway defines the recommended referral criteria for General Paediatrics and more specialised services including CEW services.
General Paediatrics Referral Criteria
(It is acknowledged that centres may have their own criteria for referral to General Paediatrics taking into consideration local services and resources. The following is the referral criteria for UHS, and only serves as a guide which centres may choose to adapt accordingly. These are based on NICE criteria.)
Public health nurses, health visitors and GPs may consider referring patients to the General Paediatrics if all of the following criteria are met:
CEW Service Referral Criteria
Referrals to more specialised weight management services (Tier 2/ tertiary care/ CEW services) should usually come via secondary care paediatricians (General Paediatrics/ Community Paediatrics) or tertiary care paediatricians due to an obesity-related complication (e.g. OSA diagnosed by Paediatric Respiratory Services). Children with very severe weight related problems are occasionally accepted directly from primary care (after detailed referral and triage or discussion with the CEW team). Unfortunately, very few tertiary weight management services in CYP are commissioned by NHS England/ ICBs currently, and it is estimated that these services across the country can only meet ~1% of the demand according to the criteria below. This is a challenging situation and the future of commissioning for these services is not clear at present. Therefore, despite these criteria, many children will not be accepted into the CEW service due to lack of capacity. This situation is evolving quickly and 2025/2026 is the last year of the NHSE Transformation Pilot Programme for CYP with severe obesity to be commissioned via ring-fenced NHSE commissioning. Further work needs to be done with ICBs to secure and expand commissioning for CEW clinics and other specialised weight management services.
Where there is capacity, patients may be considered for the CEW service if one or more of the following criteria are met:
General Paediatrics Referral Criteria
(It is acknowledged that centres may have their own criteria for referral to General Paediatrics taking into consideration local services and resources. The following is the referral criteria for UHS, and only serves as a guide which centres may choose to adapt accordingly. These are based on NICE criteria.)
Public health nurses, health visitors and GPs may consider referring patients to the General Paediatrics if all of the following criteria are met:
- BMI SDS >2 (approximately equivalent to >98th centile)
- Completed ‘Healthy Weight pathway’ (or equivalent intervention from universal services and/or primary care) but with no successful weight loss
- Bloods have already been performed (or attempted): fasting (ideally) glucose, fasting insulin and C-peptide, FBC, LFTs, TFTs, lipids, ferritin
CEW Service Referral Criteria
Referrals to more specialised weight management services (Tier 2/ tertiary care/ CEW services) should usually come via secondary care paediatricians (General Paediatrics/ Community Paediatrics) or tertiary care paediatricians due to an obesity-related complication (e.g. OSA diagnosed by Paediatric Respiratory Services). Children with very severe weight related problems are occasionally accepted directly from primary care (after detailed referral and triage or discussion with the CEW team). Unfortunately, very few tertiary weight management services in CYP are commissioned by NHS England/ ICBs currently, and it is estimated that these services across the country can only meet ~1% of the demand according to the criteria below. This is a challenging situation and the future of commissioning for these services is not clear at present. Therefore, despite these criteria, many children will not be accepted into the CEW service due to lack of capacity. This situation is evolving quickly and 2025/2026 is the last year of the NHSE Transformation Pilot Programme for CYP with severe obesity to be commissioned via ring-fenced NHSE commissioning. Further work needs to be done with ICBs to secure and expand commissioning for CEW clinics and other specialised weight management services.
Where there is capacity, patients may be considered for the CEW service if one or more of the following criteria are met:
- >100% excess weight (more than double the weight corresponding to the same centile as the height centile)
- BMI SDS >2 with at least one significant weight-related co-morbidity or risk factor including:
- Obstructive sleep apnoea
- Pre-diabetes (HbA1c ≥39 mmol/mol)
- Metabolic dysfunction-associated steatotic liver disease (MASLD) with ALT greater than double upper limit of normal
- Idiopathic intracranial hypertension
- Surgical complications including gallstones, pancreatitis, SUFE
- Concerns regarding PCOS
- Hypertension
- Severe depression/ anxiety related to weight
- Recognised medical cause of obesity (e.g. long-term corticosteroid use)
- Confirmed genetic cause of obesity (e.g. Prader Willi syndrome, Bardet-Biedl syndrome, MC4R mutation)
Calculating percentage excess weight
- Record the centile for height
- Record what the weight would be if on the same centile as the height centile (i.e. if on 75th centile for height, take the weight measurement expected for the 75th centile for weight – this is the ‘ideal weight’)
- Subtract the ideal weight from the actual weight
- Divide the number in step 3 by the ideal weight times by 100 to get the % excess weight
The CEW services across the South East (Portsmouth, Southampton, Oxford, Dartford & Gravesham, Brighton, Frimley and Ashford & St. Peters in Surrey) offer a time-limited intervention (1-2 years of engagement depending on individual needs) to provide a comprehensive assessment with holistic management of excess weight. Obesity is such a major problem in the health service at the moment that there is a need to attempt to concentrate resources on those with the most severe complications in order to support change to their lifestyle and achieve healthier weights in the long term.
Discharge can be before 2 years if there is poor engagement or poor attendance, provided there are no safeguarding or significant harm concerns. However, it is less likely that these patients can be discharged if they are frequent WNB, due to the presence of significant co-morbidity which may require safeguarding or Children’s Services support. Some young people will need long-term support with weight management if they have an organic cause, complex needs and severe co-morbidity.
Discharge can be before 2 years if there is poor engagement or poor attendance, provided there are no safeguarding or significant harm concerns. However, it is less likely that these patients can be discharged if they are frequent WNB, due to the presence of significant co-morbidity which may require safeguarding or Children’s Services support. Some young people will need long-term support with weight management if they have an organic cause, complex needs and severe co-morbidity.
Assessment of Paediatric Obesity
Assessment for organic causes of morbid obesity
The vast majority of children with obesity have ‘simple obesity’ or ‘environmental obesity’, i.e. there is no underlying organic cause for the obesity – obesity is due to a sustained positive energy balance due to taking in more calories than they are using.
There are a number of organic causes of obesity:
This is a short guide to an initial assessment to be done in secondary care Paediatrics to help exclude organic causes of obesity and is based on the following principles:
The vast majority of children with obesity have ‘simple obesity’ or ‘environmental obesity’, i.e. there is no underlying organic cause for the obesity – obesity is due to a sustained positive energy balance due to taking in more calories than they are using.
There are a number of organic causes of obesity:
- Endocrinopathies
- Syndromic conditions
- Non-syndromic conditions with congenital hyperphagia
- Iatrogenic including late effects after childhood cancer
This is a short guide to an initial assessment to be done in secondary care Paediatrics to help exclude organic causes of obesity and is based on the following principles:
- Endocrinopathies are nearly always associated with short stature (patient is short for parental target range or has poor height velocity) as well as obesity. They include growth hormone deficiency, Cushing’s disease, pituitary disease, hypothalamic disease (e.g. late effects after brain tumour, narcolepsy, hypothalamic syndrome), hypothyroidism, and pseudohypoparathyroidism types 1A (Albright’s hereditary osteodystrophy) and 1B.
- Syndromic conditions are nearly always obvious and are associated with developmental delay, dysmorphic features, renal abnormalities, deafness or visual problems.
- Non-syndromic but genetic conditions causing obesity all have a pattern of early onset (during infancy) weight gain and hyperphagia. These are rare but include leptin deficiency, MC4R mutation and a host of other rare conditions currently emerging from genetic studies.
- Iatrogenic causes include chemotherapy, radiotherapy, antipsychotics and steroid use. Hypothalamic and cranial tumours can also cause obesity but again the history here is usually very obvious. Children who have had total body irradiation for bone marrow transplant and those with craniopharyngiomas are particularly severely affected.
.Important points in the medical history
- Birth weight
- Growth
- Age of onset of obesity (early onset is <5 years old )
- History of hyperphagia – examples:
- Waking at night demanding food/ go looking for food
- Demand more food immediately after a meal
- Eat rapidly and is not easily distracted from food
- Never feels full and can eat very large portions
- Development: hearing, vision, behaviour, gross and fine motor, self care
- Pubertal development: Early, Late, Adrenarche
- Family history
- Consanguineous family
- Early-onset obesity
- Type 2 Diabetes, renal or cardiovascular disease
- Hyperphagia
- Ethnicity
- Bariatric surgery, parental GLP1 use
- Co-morbidities of obesity (see Co-morbidities of obesity)
- Diabetes and metabolic syndrome
- Metabolic dysfunction-associated steatotic liver disease (MASLD)
- Polycystic ovarian syndrome
- Developmental and mobility problems
- Obstructive sleep apnoea (also use SDSC questionnaire as screening tool – see Appendix B)
- Psychological problems (also use PedsQL questionnaire which assesses health-related quality of life as screening tool – see Appendix C)
- Orthopaedic problems
- Social and educational exclusion
- Gallstones
- Cancers
- Worsening of other conditions e.g. renal disease
- Incontinence
- Dietary assessment (see separate guideline on ‘Dietary assessment and management of childhood obesity’)
- Physical activity
- Psychosocial risk factors (see Psychological Risk Factors)
- Additional relevant diagnoses
- Neurodevelopmental: Autism/ASD, ADHD/ADD, Sensory processing disorder/difficulties, Social communication difficulties, Learning disability/difficulties, Specific learning need - e.g. dyslexia, EHCP
- Psychological: Low mood/depression, Anxiety, Binge eating disorder, PTSD/ complex trauma, Self-harm, reduced school attendance, home schooling.
Examination for obesity
- Height, weight, BMI (and respective SDS/centile), previous height centiles
- Maternal and paternal heights
- Target height centile
- Ideal weight (for height)
- Percentage excess weight (see Section 5 on how to calculate this)
- Waist circumference
- Blood pressure
- Dysmorphic features
- Acanthosis nigricans
- Hair colour
- Pattern of fat distribution: central versus peripheral
- Pubertal Tanner staging (can be reported rather than formally examined)
Investigations and interpretation - First-line Investigations: Paediatric obesity bundle
- Available as UHS eQuest bundle ‘Childhood Obesity metabolic screening bundle’: Fasting sample – HbA1c, insulin, glucose, C-peptide, FBC, U&Es, CRP, LFTs, lipid profile including triglycerides, TFTs, Vitamin B12, bicarbonate
- Consider Vitamin D and iron studies
- Consider genetic testing
Interpretation of test results
Test |
Interpretation/Action |
CRP |
>3 – Independent marker of increased risk of cardiovascular disease >10 – Indicator of chronic inflammation associated with obesity |
Fasting Glucose |
3.9 -5.5 mmol/L – Normal 5.6-6.9 mmol/L – Impaired Fasting Glucose – perform Oral Glucose Tolerance Test (OGTT) ≥7.0 mmol/L – indicates Diabetes – refer to Diabetes team for same day review For further details, see 'High HbA1c pathway for obese/overweight patients'. |
Fasting Insulin and C-Peptide |
Fasted insulin >10 mu/L (if prepubertal) or >20 mu/L (if pubertal), or fasted C-peptide >600 pmol/L suggests insulin resistance – consider starting metformin Also calculate HOMA-IR – see below |
ALT |
See section on ‘MASLD’ for further investigation of raised ALT |
HbA1c |
<39 mmol/mol – normal 39-47 mmol/mol – suggests Pre-diabetes – Perform OGTT ≥48 mmol/mol – indicates Diabetes – refer to Diabetes team for same day review For further details, see 'High HbA1c pathway for obese/overweight patients'. |
Fasting Lipid Profile |
Dyslipidaemia is indicated by fasting levels of one or more of[i]:
|
Vitamin B12 |
Included in test bundle as long-term metformin use may be associated with decreased Vitamin B12 absorption. If low consider dietary advice/ multi-vitamin, or investigation for pernicious anaemia if also anaemic |
Thyroid Function Tests |
May have slightly elevated TSH with normal/slightly elevated free T4 in the context of obesity. If TSH is raised up to twice the upper limit of normal, obtain repeat sample in ~8 weeks and if still raised discuss with Endocrinology. |
Homeostatic model assessment for insulin resistance (HOMA-IR) |
HOMA-IR = fasted insulin (µU/ml) x fasted glucose (mmol/L) / 22.5; or fasted insulin (pmol/L) x fasted glucose (mmol/L) / 135; HOMA-IR ≥4 suggests insulin resistance – perform OGTT For further details, see 'High HbA1c pathway for obese/overweight patients'. |
Investigations and interpretation - Second-line Investigations
Second-line investigations to assess for co-morbidities of obesity should be performed if there are clinical features suggestive of a particular co-morbidity, and also be considered in the presence of risk factors for the development of co-morbidities in obesity – these include non-white ethnicity, being in puberty, a family history of type 2 diabetes, immobility, a known other co-morbidity (e.g. renal impairment, hypertension, SUFE, severe asthma, developmental delay, syndromic condition), long-term use of corticosteroids and profoundly excess weight (e.g. >100% excess weight). As a general rule, the risk of co-morbidities in obesity is proportional to the severity of excess weight.
These investigations include:
Second-line investigations to assess for co-morbidities of obesity should be performed if there are clinical features suggestive of a particular co-morbidity, and also be considered in the presence of risk factors for the development of co-morbidities in obesity – these include non-white ethnicity, being in puberty, a family history of type 2 diabetes, immobility, a known other co-morbidity (e.g. renal impairment, hypertension, SUFE, severe asthma, developmental delay, syndromic condition), long-term use of corticosteroids and profoundly excess weight (e.g. >100% excess weight). As a general rule, the risk of co-morbidities in obesity is proportional to the severity of excess weight.
These investigations include:
- 24-hour ambulatory BP monitoring – if evidence of hypertension (see section on Hypertension)
- Liver ultrasound – if ALT abnormal (See section on ‘MASLD’)
- OGTT – if HbA1c 39-47 mmol/L, HOMA-IR ≥4 or Impaired Fasting Glucose (fasting blood glucose 5.6-6.9 mmol/L) (see see 'High HbA1c pathway for obese/overweight patients'.)
- Sleep study (Cardiorespiratory study assessing Polygraphy, PO and CO2) – if symptoms or questionnaire results suggestive of OSA (see section on Sleep-disordered breathing)
Investigations and interpretation - Genetic testing for obesity
Genes and weight
When families are thinking that their weight is genetic, they are partly correct in that everybody’s weight is modulated by their genetic background to a certain extent. Numerous genes affect our tendency to gain weight via a number of mechanisms including insulin resistance, epigenetic conditioning, cortisol metabolism, adrenaline metabolism, hypothalamic function, activity levels (fidget factor), brown fat, height and growth patterns, ethnicity, body shape and composition, and basal metabolic rate.
Most of these genes individually have a small effect but can be important when put together (polygenic). This is similar to many other biological characteristics like height and IQ. These genes also affect different generations differently because of the interaction with a rapidly changing environment. For instance, in a family with genes for T2DM which is 70% inherited, the grandparents may have developed diabetes at 60 years old as they were lean in childhood in the 50s and 60s as snacks and sugar were scarce and they were very active. Their grandchildren though may be having significant problems with overweight in childhood as the environment is sedentary and processed foods and snacks are freely available, which means they may develop T2DM decades earlier – this is called the accelerator hypothesis.
Monogenic obesity
Rarely though a single gene mutation will have a profound effect on appetite and metabolism. The majority of these monogenic conditions work via altering the hypothalamic sense of feeling full or hungry, and are therefore associated with early-onset obesity and hyperphagia (insatiable appetite from birth).
The commonest monogenic obesity disorder is the MC4R mutation, which accounts for 2-5% of cases of extreme early-onset obesity. Unlike other monogenic conditions which may be also associated with dysmorphic features and developmental problems, patients with MC4R mutations do not usually have extra-obesity features. However this condition has an autosomal dominant inheritance, and therefore often a parent will also have had early-onset obesity with no ‘off switch’ and will be extremely obese, whereas other members of the family may have no difficulties with weight gain.
Examples of monogenic obesity disorders include:
Genes and weight
When families are thinking that their weight is genetic, they are partly correct in that everybody’s weight is modulated by their genetic background to a certain extent. Numerous genes affect our tendency to gain weight via a number of mechanisms including insulin resistance, epigenetic conditioning, cortisol metabolism, adrenaline metabolism, hypothalamic function, activity levels (fidget factor), brown fat, height and growth patterns, ethnicity, body shape and composition, and basal metabolic rate.
Most of these genes individually have a small effect but can be important when put together (polygenic). This is similar to many other biological characteristics like height and IQ. These genes also affect different generations differently because of the interaction with a rapidly changing environment. For instance, in a family with genes for T2DM which is 70% inherited, the grandparents may have developed diabetes at 60 years old as they were lean in childhood in the 50s and 60s as snacks and sugar were scarce and they were very active. Their grandchildren though may be having significant problems with overweight in childhood as the environment is sedentary and processed foods and snacks are freely available, which means they may develop T2DM decades earlier – this is called the accelerator hypothesis.
Monogenic obesity
Rarely though a single gene mutation will have a profound effect on appetite and metabolism. The majority of these monogenic conditions work via altering the hypothalamic sense of feeling full or hungry, and are therefore associated with early-onset obesity and hyperphagia (insatiable appetite from birth).
The commonest monogenic obesity disorder is the MC4R mutation, which accounts for 2-5% of cases of extreme early-onset obesity. Unlike other monogenic conditions which may be also associated with dysmorphic features and developmental problems, patients with MC4R mutations do not usually have extra-obesity features. However this condition has an autosomal dominant inheritance, and therefore often a parent will also have had early-onset obesity with no ‘off switch’ and will be extremely obese, whereas other members of the family may have no difficulties with weight gain.
Examples of monogenic obesity disorders include:
Gene mutation |
Features |
Melanocortin receptor 4 (MC4R) |
Most common form of monogenic obesity. Increased linear growth, hyperphagia with childhood obesity, advanced bone age |
Leptin receptor (LEPR) |
Hyperphagia, early onset obesity during infancy, immune dysfunction, central hypothyroidism, hypogonadotrophic hypogonadism |
Leptin (LEP) |
Leptin deficiency results in similar phenotype to LEPR mutations but with low leptin concentrations amenable to treatment with leptin |
Pre-opiomelanocortin (POMC) |
Present in neonatal life with adrenal crisis, pale skin, red hair, early onset obesity |
Pro-hormone convertase (PCSK1) |
Small bowel enteropathy, diarrhoea, failure to thrive during infancy followed by severe obesity in early childhood, multiple endocrinopathies (central hypothyroidism, growth hormone deficiency, hypogonadotrophic hypogonadism, diabetes insipidus) |
Single minded homolog (SIM1) |
Prader-Willi like syndrome with overlapping features including severe obesity, hypopituitarism, intellectual disability, developmental delay, behavioural problems and facial dysmorphism; however unlike PWS short stature, hypotonia and hypogonadism may be absent |
Brain derived neurotrophic factor (BDNF) |
Hyperphagia, severe obesity, hyperactivity, developmental delay |
Neurotrophic tyrosine kinase receptor type 2 (NTFK2) |
Severe obesity, impaired short-term memory, neurocognitive delay |
Syndromic obesity
A number of syndromes are associated with severe childhood obesity. Learning difficulties, developmental abnormalities and dysmorphic features are usually present along with other manifestations. Neuroendocrine signalling circuits that regulate hunger and satiety may be impaired either by disturbing ciliary function in CNS neurons (e.g. Bardet-Biedl syndrome) or interfering with hypothalamic function (e.g. Prader-Willi syndrome).
Examples of syndromic obesity include:
A number of syndromes are associated with severe childhood obesity. Learning difficulties, developmental abnormalities and dysmorphic features are usually present along with other manifestations. Neuroendocrine signalling circuits that regulate hunger and satiety may be impaired either by disturbing ciliary function in CNS neurons (e.g. Bardet-Biedl syndrome) or interfering with hypothalamic function (e.g. Prader-Willi syndrome).
Examples of syndromic obesity include:
Syndrome |
Features |
Genetic Investigations to request |
Albright Hereditary Osteodystrophy |
Short metacarpals, rounded facies, +/- hypocalcaemia |
R293 |
Alstrom syndrome |
Retinal one-rod dystrophy, sensorineural hearing loss, dilated cardiomyopathy, hypergonadotrophic hypogonadism |
R106 |
Bardet-Biedl Syndrome |
Retinal cone-rod dystrophy, postaxial polydactyly, intellectual disability, hypogonadotropic hypogonadism, genitourinary malformations, renal malformations |
R107 |
Beckwith-Weidemann syndrome |
Overgrowth, hemihypertrophy, macroglossia, neonatal hypoglycaemia, umbilical hernia/other abdominal wall defect |
R49 |
Börjeson–Forssman–Lehmann syndrome |
Intellectual disability, seizures, hypogonadism, developmental delay, large ears |
R149 |
Carpenter syndrome |
Turricephaly (tower-shaped skull), polydactyly, syndactyly, short stature, undescended testes, intellectual disability |
R27 |
Cohen syndrome |
Failure to thrive in infancy, hypotonia, joint hypermobility, microcephaly, prominent incisors |
R149 |
Grebe syndrome |
Marked distal limb reduction, polydactyly, normal facies |
R104 |
Prader-Willi Syndrome |
Hypotonia, developmental delay, short stature, failure to thrive in infancy followed by hyperphagia and obesity, hypothalamic dysregulation (e.g. hypogonadotropic hypogonadism), sleep disordered breathing |
R48 |
ROHHAD syndrome |
Rapid onset obesity, hypothalamic dysfunction, hypoventilation, autonomic dysfunction |
- |
Temple syndrome |
Growth retardation, hypotonia, joint laxity, motor delay, early onset puberty |
R452 |
Turner syndrome |
Short female, broad chest, wide spacing of nipples, congenital lymphoedema |
Array |
WAGR Syndrome |
Wilms tumour, aniridia, genitourinary anomaly, mental retardation |
Array |
16p11.2 deletion |
Developmental delay, seizures, autism, severe obesity in early childhood, severe insulin resistance |
Array |
Genetic testing pathway
Obtaining a genetic diagnosis can be extremely helpful for a family as it removes stigma and judgement and may open a path for specific approaches to therapy (e.g. early GLP-1 treatment) or other research.
Genetic testing is now available via NHS Genomics England according to the following pathway:
Obtaining a genetic diagnosis can be extremely helpful for a family as it removes stigma and judgement and may open a path for specific approaches to therapy (e.g. early GLP-1 treatment) or other research.
Genetic testing is now available via NHS Genomics England according to the following pathway:
Please see Appendix D for for detailed guidance.
Co-morbidities of Paediatric Obesity
Metabolic dysfunction-associated steatotic liver disease (MASLD)
Metabolic Syndrome (MetS)
Type 2 Diabetes Mellitus
Hypertension
Sleep-disordered breathing
Metabolic Syndrome (MetS)
Type 2 Diabetes Mellitus
Hypertension
Sleep-disordered breathing
Metabolic dysfunction-associated steatotic liver disease (MASLD)
This section includes a summary of recommendations adapted from the British Society of Gastroenterology Hepatology and Nutrition (BSPGHAN) (8).
Metabolic dysfunction-associated steatotic liver disease (MASLD), previously known as Non-Alcoholic Fatty Liver Disease (NAFLD), is defined as the presence of moderate to severe hepatic steatosis, confirmed by imaging or histology, in the absence of alternative aetiologies. Studies have shown that 38-83% of obese children may have a fatty liver (defined as ≥5% of hepatocytes containing macrovesicular fat). However it is important to note that not all children with MASLD are obese. MASLD may progress to steatofibrosis, (metabolic dysfunction-associated steatohepatitis (MASH), cirrhosis, liver failure and hepatocellular carcinoma. It is now amongst the top three indications for liver transplantation in adults.
It is also important to remember that liver blood tests and liver ultrasound appearances may be normal in people with MASLD and do not necessarily reflect the stage of disease (9).
History
Examination – document presence or absence of:
Investigations
The following investigation pathway has been agreed with UHS Paediatric Gastroenterology Dr Nadeem Afzal (UHS Consultant Paediatric Gastroenterologist) and Dr Mark Wright (UHS Consultant Hepatologist), and with contribution from Dr Sophie Robertson and Dr Jennie Pridgeon, Consultant Paediatricians, Queen Alexandra Hospital Portsmouth)
This section includes a summary of recommendations adapted from the British Society of Gastroenterology Hepatology and Nutrition (BSPGHAN) (8).
Metabolic dysfunction-associated steatotic liver disease (MASLD), previously known as Non-Alcoholic Fatty Liver Disease (NAFLD), is defined as the presence of moderate to severe hepatic steatosis, confirmed by imaging or histology, in the absence of alternative aetiologies. Studies have shown that 38-83% of obese children may have a fatty liver (defined as ≥5% of hepatocytes containing macrovesicular fat). However it is important to note that not all children with MASLD are obese. MASLD may progress to steatofibrosis, (metabolic dysfunction-associated steatohepatitis (MASH), cirrhosis, liver failure and hepatocellular carcinoma. It is now amongst the top three indications for liver transplantation in adults.
It is also important to remember that liver blood tests and liver ultrasound appearances may be normal in people with MASLD and do not necessarily reflect the stage of disease (9).
History
- Elucidate symptoms: malaise, fatigue, abdominal pain
- Drug and alcohol history – examples of heptatotoxic drugs that may cause fatty liver include nifedipine, amiodarone, corticosteroids, oestrogens, methotrexate, valproate, L-asparaginase, certain antipsychotics, certain antidepressants, zidovudine and HIV treatments, ethanol, ecstasy, cocaine and solvents
- Nutritional history
- Assess for depression, anxiety and psychological stressors
- Family history of NAFLD/MASLD, type 2 diabetes, cardiovascular disease, dyslipidaemia, metabolic disease and liver disease
Examination – document presence or absence of:
- Organomegaly
- Peripheral stigmata of chronic liver disease
- Evidence of insulin resistance (acanthosis nigricans)
- Measure blood pressure and plot on centile chart
Investigations
The following investigation pathway has been agreed with UHS Paediatric Gastroenterology Dr Nadeem Afzal (UHS Consultant Paediatric Gastroenterologist) and Dr Mark Wright (UHS Consultant Hepatologist), and with contribution from Dr Sophie Robertson and Dr Jennie Pridgeon, Consultant Paediatricians, Queen Alexandra Hospital Portsmouth)
- Baseline liver function test (LFT) – see table below for further investigation if ALT raised
- Assess for additional complications of obesity including physical examination and first-line obesity screening bloods (see Investigations)
ALT Results |
Further Investigation required |
ALT raised up to 2x upper limit of normal (ULN) range |
|
ALT 2-3x ULN |
|
ALT >3x ULN or ALT 2-3x ULN on 2 occasions 3 months apart |
|
Referral criteria
Patients with raised ALT should be discussed with/referred to the tertiary Gastroenterology/Hepatology team if: age <10 years, symptomatic (e.g. excessive tiredness or abdominal pain), jaundice, hepatomegaly, splenomegaly, thrombocytopenia, jaundice, evidence of alternative cause for steatosis detected through screening investigations, AST/ALT ratio >1 (this suggests alternative pathology), raised GGT, panhypopituitarism, raised non-invasive marker of fibrosis measurement (e.g. ELF test), liver synthetic dysfunction (raised PT or low albumin level).
Management
Patients with raised ALT should be discussed with/referred to the tertiary Gastroenterology/Hepatology team if: age <10 years, symptomatic (e.g. excessive tiredness or abdominal pain), jaundice, hepatomegaly, splenomegaly, thrombocytopenia, jaundice, evidence of alternative cause for steatosis detected through screening investigations, AST/ALT ratio >1 (this suggests alternative pathology), raised GGT, panhypopituitarism, raised non-invasive marker of fibrosis measurement (e.g. ELF test), liver synthetic dysfunction (raised PT or low albumin level).
Management
- Weight management is key – lifestyle intervention is the first line of treatment for children with MASLD.
- Weight loss is associated with significant improvement in both laboratory abnormalities and liver histology. The highest rates of steatosis reduction, MASH resolution, and fibrosis regression occur in patients with weight losses ≥10%.
- A low-glycaemic load diet and low-fat diet appear equally effective in decreasing hepatic fat content and transaminases. The limited evidence base inhibits the prescription of a specific dietary strategy.
- Both aerobic and resistance exercise training at vigorous and moderate-to-vigorous intensities may reduce hepatic fat content in children and adolescents.
- There is no currently strong scientific evidence to support the use of any medications to treat paediatric MASLD.
- Offer liver ultrasound to retest children and young people with Type 2 diabetes or metabolic syndrome for MASLD every 3 years.
- Inform families that children with MASLD are at risk of progressive liver disease and liver cancer. Counsel that children with MASLD are also at risk of hypertension, cardiovascular disease, type 2 diabetes and chronic kidney disease.
- Patient information leaflets and guidance for MASLD are available via the Children’s Liver Disease Foundation and the British Liver Trust.
Metabolic Syndrome
Metabolic syndrome (MetS) is a cluster of conditions characterised by a combination of anthropometric, physiological, and biochemical irregularities, increasing the susceptibility of individuals to the onset of Type 2 diabetes (T2DM) and cardiovascular disease.
There is no consistent diagnostic criteria to define MetS in the paediatric population. This is due to the complex physiology of different phases of growth in children and adolescents as puberty where there is an overlap of features of MetS and puberty. In 2004, the International Diabetes Federation (IDF) published a definition of the MetS in adults that included hypertension, dyslipidaemia, glucose intolerance and abdominal obesity as constituents. This cluster of risk factors is related to the development of cardiovascular diseases and type 2 diabetes. The aetiology of MetS is incompletely understood; however, insulin resistance is thought to be central to the development of MetS and play a role in the pathogenesis of its individual metabolic components. In the insulin-resistant state, the suppression of hepatic glucose production is impaired, resulting in abnormal glucose homeostasis. For unknown reasons, insulin action on stimulating hepatic lipogenesis is spared, causing the release of free fatty acids and triglycerides into the circulation resulting in dyslipidaemia and ectopic adipose deposition promoting adipose tissue expansion. This results in the release of adipocytokines, causing a state of low-grade inflammation via inflammatory factors, as plasminogen activator inhibitor-1, tumour necrosis factor α, interleukin 6, and acute phase reactants such as high-sensitivity C-reactive protein and fibrinogen. Insulin resistance, ectopic fat deposition, and inflammation are all key contributors to the components of MetS (10,11,12).
The following criteria have been proposed to diagnose Metabolic Syndrome in children.
There is no consistent diagnostic criteria to define MetS in the paediatric population. This is due to the complex physiology of different phases of growth in children and adolescents as puberty where there is an overlap of features of MetS and puberty. In 2004, the International Diabetes Federation (IDF) published a definition of the MetS in adults that included hypertension, dyslipidaemia, glucose intolerance and abdominal obesity as constituents. This cluster of risk factors is related to the development of cardiovascular diseases and type 2 diabetes. The aetiology of MetS is incompletely understood; however, insulin resistance is thought to be central to the development of MetS and play a role in the pathogenesis of its individual metabolic components. In the insulin-resistant state, the suppression of hepatic glucose production is impaired, resulting in abnormal glucose homeostasis. For unknown reasons, insulin action on stimulating hepatic lipogenesis is spared, causing the release of free fatty acids and triglycerides into the circulation resulting in dyslipidaemia and ectopic adipose deposition promoting adipose tissue expansion. This results in the release of adipocytokines, causing a state of low-grade inflammation via inflammatory factors, as plasminogen activator inhibitor-1, tumour necrosis factor α, interleukin 6, and acute phase reactants such as high-sensitivity C-reactive protein and fibrinogen. Insulin resistance, ectopic fat deposition, and inflammation are all key contributors to the components of MetS (10,11,12).
The following criteria have been proposed to diagnose Metabolic Syndrome in children.
.. |
Cook et al (13) |
De Ferranti et al (14) |
International Diabetes Federation (15) – for ages 10-15 years (note: adult criteria if age 16+) |
Defining Criterion |
≥3 criteria |
≥3 criteria |
≥3 criteria (obesity and two risk factors) |
Obesity |
WC ≥90th percentile (age and sex specific) |
WC >75th percentile |
WC ≥90th percentile or adult cut-off if lower |
Glucose Intolerance |
Fasting glucose ≥110 mg/dL (≥6.1 mmol/L) |
Fasting glucose ≥110 mg/dL (≥6.1 mmol/L) |
Fasting glucose ≥100 mg/dL (≥5.6 mmol/L) |
Dyslipidaemia |
Triglycerides ≥110 mg/dL |
Triglycerides ≥100 mg/dL |
Triglycerides ≥150 mg/dL (≥1.7 mmol/L) |
Dyslipidaemia |
HDL-C ≤40 mg/dL (1.03 mmol/L) |
HDL-C ≤50 mg/dL (1.3 mmol/L) |
HDL-C ≤40 mg/dL (1.03 mmol/L) |
High BP |
BP ≥90th percentile (age, sex, and height specific) |
BP >90th percentile |
Systolic BP ≥130 mmHg or diastolic BP ≥85 mmHg |
Management is centred around lifestyle modification and early treatment of obesity in childhood and adolescence to reduce cardiometabolic risk. Furthermore, treatment of obesity and treatment of MetS components share many common elements, and interventions that improve one condition are likely to ameliorate the other. Pharmacotherapeutic options to manage obesity in children is described in detail in here.
Type 2 Diabetes Mellitus
This section contains a summary of recommendations from the NICE guidelines on Diabetes (Type 1 and Type 2) in children and young people [NG18] and ISPAD Clinical Practice Consensus Guidelines on Type 2 diabetes in children and adolescents (16,17). Please refer to these guidelines for detailed guidance.
Obesity is a known risk factor for insulin resistance and Type 2 Diabetes. The SEARCH for Diabetes in Youth study found that among youth with T2DM, the prevalence of obesity was 79.4% and overweight was 10.4% (18). Other risk factors include high risk ethnicity groups as Asian, African, and Afro-Caribbean, family history of type 2 diabetes mellitus, evidence of insulin resistance (acanthosis nigricans), MASLD, PCOS, dyslipidaemia, or hypertension.
Obesity is a known risk factor for insulin resistance and Type 2 Diabetes. The SEARCH for Diabetes in Youth study found that among youth with T2DM, the prevalence of obesity was 79.4% and overweight was 10.4% (18). Other risk factors include high risk ethnicity groups as Asian, African, and Afro-Caribbean, family history of type 2 diabetes mellitus, evidence of insulin resistance (acanthosis nigricans), MASLD, PCOS, dyslipidaemia, or hypertension.
Hypertension
Obesity is a known cause of hypertension in children. The prevalence of hypertension ranges from 3.8% to 24.8% in youth with overweight and obesity, with rates of hypertension increasing in a graded fashion with increasing adiposity (19). It is important that hypertension is appropriately screened for and managed in order to prevent end-organ damage and reduce the risk of long-term cardiovascular disease (20).
Definitions of Hypertension (21)
. |
For children aged 1 to <13 years |
For children aged ≥13 years |
Normal BP |
Systolic and diastolic BP <90th centile for sex, age and height |
<120/<80 mmHg |
Elevated BP |
Systolic and/or diastolic BP ≥90th centile to <95th centile, or 120/80 mmHg to <95th centile (whichever is lower) |
120/<80 to 129/<80 mmHg |
Stage 1 Hypertension |
≥95th centile to <95th centile + 12 mmHg, or 130/80 to 139/89 mmHg (whichever is lower) |
130/80 to 139/89 mmHg |
Stage 2 Hypertension |
≥95th centile + 12 mmHg, or ≥140/90 mmHg (whichever is lower) |
≥140/90 mmHg |
Important: Ensure BP reading is accurate and consistent
- Accurate and repeated measurement of BP is essential for the diagnosis of hypertension. It is easy to get a false measurement.
- The cuff used must encircle the upper arm and its width should cover two-thirds of the distance from the shoulder to the elbow. A sensible rule is to use the largest cuff which fits comfortably.
- If an abnormal BP is detected by automated measurement, this should be confirmed by a manual sphygmomanometer.
- If the first reading is high, retake the blood pressure a total of three times and use the average reading.
Monitoring for hypertension in patients with obesity (22)
- All children being assessed for obesity, including in Tier 3 weight management services, should have BP recorded
- All children under weight management services should have BP checked at each clinic appointment and at a minimum every 6 months
- If systolic BP is elevated (≥95th centile):
- BP should be rechecked that same day and on two further occasions over the following two weeks
- Consider ambulatory BP monitoring – this is helpful in cases of uncertainty, where three BP measurements are borderline, or anxiety cannot be excluded
- Stage 2 hypertension or symptomatic hypertension (e.g. headache, nausea and vomiting, visual disturbance, irritability and tiredness, nose bleeds, cranial nerve palsy, hemiplegia, seizures, reduced consciousness) should be urgently discussed with the on-call Paediatric Nephrology team on the same day
Aetiology of hypertension (23)
. |
Aetiology/ Risk factors |
Situational Hypertension |
Stress, pain, anxiety |
Primary Hypertension |
More likely in children:
|
Secondary Hypertension |
More common than primary hypertension in children <6 years. Possible causes:
|
Assessment
When to refer to Paediatric Nephrology
Management
- History including medications, family history and risk factors
- Examination
- Cardiovascular examination (including palpation of femoral pulses)
- Focal neurology (e.g. facial nerve palsies)
- Fundoscopy (assessing for hypertensive retinopathy)
- Stigmata of underlying cause for hypertension (e.g. multiple striae and round facies in Cushing’s syndrome)
- Initial investigations
- Ambulatory BP monitoring (this is the gold standard investigation, although it is recognised this may not be not available in all centres)
- Urine test: urinalysis, early morning urine for protein:creatinine ratio and albumin:creatinine ratio
- Blood tests: U&Es, bicarbonate, bone profile, magnesium, full blood count, thyroid function tests, random glucose, random lipids (with fasting if results indicate)
- Urine MC&S if symptoms suggestive of urinary tract infection or abnormal urinalysis
- Consider 24-hour urinary free cortisol if features suggestive of Cushing’s syndrome (e.g. rapid onset obesity, stunted growth, central obesity, striae, easy bruising, round facies)
- Echocardiogram if murmur heard or features suggestive of cardiac disease
- Second-line investigations if hypertension confirmed
- Renal ultrasound
- Echocardiogram (if not already done)
- Ophthalmological assessment (assessing for hypertensive retinopathy)
When to refer to Paediatric Nephrology
- If there is documented hypertension (>95th centile) on three occasions -
- Discuss urgently on same day with on-call Paediatric Nephrology team if:
- Stage 2 hypertension
- Symptomatic hypertension
- Hypertensive crisis – defined as a severe acute elevation in BP with evidence of life-threatening symptoms or target organ damage, e.g. hypertensive encepahalopathy (e.g. lethargy, coma, seizures), congestive heart failure, pulmonary oedema
Management
- Non-pharmacological management: lifestyle changes are recommended for children with hypertension and pre-hypertension. These include weight loss, exercise, dietary sodium restriction (no more than 1.5g sodium per day), and manging other cardiovascular risk factors (e.g. blood lipids, glycaemic control)
- Pharmacological management: this should be initiated under the guidance of a Paediatric Nephrologist
Sleep-disordered Breathing
Sleep-disordered breathing (SDB) in children refers to a spectrum of disorders of disturbed respiratory pattern and function which occur during sleep. These include central apnoea, hypoventilation, and obstructive hypoventilation. The most severe manifestation of obstructive hypoventilation is obstructive sleep apnoea (OSA) characterised by prolonged partial and/or intermittent complete upper airway obstruction during sleep which leads to abnormal ventilation and sleep pattern. The prevalence of SDB in children is increasing with the rising trend of childhood obesity. SDB affects 2-11% of children, and causes a range of problems including sleep disruption, educational and cognitive impairment, behavioural problems; and for children with comorbidity, recurrent respiratory illness, hospital admissions and death. (24, 25)
Features associated with OSA (26)
Features associated with OSA (26)
History |
Physical examination |
|
|
Sleep Questionnaire
The Sleep Disturbance Scale for Children (SDSC) is used in CEW services (see Appendix B) to evaluate sleep disorders including difficulties in falling asleep and staying asleep, sleep-disordered breathing, arousal disorders, sleep-wake transition disorders, excessive sleepiness, and excessive sweating during sleep (hyperhidrosis) (27). The tool has demonstrated satisfactory validity and reliability (28).
The six subscales are rated on a 5-point Likert scale, assessing the occurrences over the past 6 months, with higher numbers reflecting a higher frequency of symptoms. After summing the scores for the different scales, the values are filled in the scoring sheet in order to obtain a sleep profile. The total sleep score is also derived by adding up individual scores, with the potential range being from 26 to 130.
Children identified to score highly on the SDSC should be referred for a sleep study. The sleep profile would also direct the clinician toward specific areas of dysfunction that require further investigation.
The Sleep Disturbance Scale for Children (SDSC) is used in CEW services (see Appendix B) to evaluate sleep disorders including difficulties in falling asleep and staying asleep, sleep-disordered breathing, arousal disorders, sleep-wake transition disorders, excessive sleepiness, and excessive sweating during sleep (hyperhidrosis) (27). The tool has demonstrated satisfactory validity and reliability (28).
The six subscales are rated on a 5-point Likert scale, assessing the occurrences over the past 6 months, with higher numbers reflecting a higher frequency of symptoms. After summing the scores for the different scales, the values are filled in the scoring sheet in order to obtain a sleep profile. The total sleep score is also derived by adding up individual scores, with the potential range being from 26 to 130.
Children identified to score highly on the SDSC should be referred for a sleep study. The sleep profile would also direct the clinician toward specific areas of dysfunction that require further investigation.
Management of Paediatric Obesity
Barriers to Effective Management
The main challenge with managing families with severe obesity is lack of engagement for a range of psychosocial factors. Commonly children in an obese family are not seen as obese by their parents because obesity is normal for them and now normal for the population. Families can feel criticised and judged. Many families are poorly resourced and struggling with economic, health and social challenges and obesity management is therefore not seen as a priority. There is often co-morbid depression, anxiety and low self-esteem.
There is often a level of denial. It is often under-appreciated how toxic obesity is when it starts in childhood. 30% of the current cohort of children who remain slim are expected to live to 100 years old. However the same generation overall has a lower life expectancy than their parents due to obesity related early mortality (29). Obesity has a similar impact on life expectancy to smoking 20 cigarettes per day (30) and this is likely to be accelerated for those who are obese from childhood. Still most people believe it is a cosmetic issue and feel the medical services are overstating the risks (31).
Public Health England report that 600 million pounds was spent in 2016 promoting high sugar foods to children. Unfortunately the food industry has no mandatory responsibility at present to address these problems. Food labelling is very confusing. The average child in this country consumes twice the recommended daily amount of sugar before they leave the breakfast table and three times the recommended level over a whole day (32).
Eating outside of the home is increasing and as more parents work there is increased reliance on processed and fast foods with high levels of sugar, salt and trans-fats. Many people do not cook and falsely believe healthy food to be more expensive. Healthy eating behaviour is also disrupted by working hours.
The main challenge with managing families with severe obesity is lack of engagement for a range of psychosocial factors. Commonly children in an obese family are not seen as obese by their parents because obesity is normal for them and now normal for the population. Families can feel criticised and judged. Many families are poorly resourced and struggling with economic, health and social challenges and obesity management is therefore not seen as a priority. There is often co-morbid depression, anxiety and low self-esteem.
There is often a level of denial. It is often under-appreciated how toxic obesity is when it starts in childhood. 30% of the current cohort of children who remain slim are expected to live to 100 years old. However the same generation overall has a lower life expectancy than their parents due to obesity related early mortality (29). Obesity has a similar impact on life expectancy to smoking 20 cigarettes per day (30) and this is likely to be accelerated for those who are obese from childhood. Still most people believe it is a cosmetic issue and feel the medical services are overstating the risks (31).
Public Health England report that 600 million pounds was spent in 2016 promoting high sugar foods to children. Unfortunately the food industry has no mandatory responsibility at present to address these problems. Food labelling is very confusing. The average child in this country consumes twice the recommended daily amount of sugar before they leave the breakfast table and three times the recommended level over a whole day (32).
Eating outside of the home is increasing and as more parents work there is increased reliance on processed and fast foods with high levels of sugar, salt and trans-fats. Many people do not cook and falsely believe healthy food to be more expensive. Healthy eating behaviour is also disrupted by working hours.
Consultation Style
Most parents engage more effectively with a non-judgemental approach whereby this is discussed as a health problem from the outset rather than a judgement on parenting. We are all living in a highly obesogenic society.
An initial thorough detailed assessment encourages engagement as it personalises the investigations and management plan. Most families require positive support and reinforcement that success is within their grasp. Frequent reviews are required to maintain motivation. Motivational interviewing can be very helpful as it encourages responsibility and self-efficacy. Most information needs to be targeted to the family as a whole unit. For children less than 11 years the parents should be mainly in control of the diet provided to the child, whereas older children need to be supported and educated to make healthy choices independently when outside the home. Advice between different health professionals needs to be as consistent as possible.
Most parents engage more effectively with a non-judgemental approach whereby this is discussed as a health problem from the outset rather than a judgement on parenting. We are all living in a highly obesogenic society.
An initial thorough detailed assessment encourages engagement as it personalises the investigations and management plan. Most families require positive support and reinforcement that success is within their grasp. Frequent reviews are required to maintain motivation. Motivational interviewing can be very helpful as it encourages responsibility and self-efficacy. Most information needs to be targeted to the family as a whole unit. For children less than 11 years the parents should be mainly in control of the diet provided to the child, whereas older children need to be supported and educated to make healthy choices independently when outside the home. Advice between different health professionals needs to be as consistent as possible.
The Universal Basics
These “Universal Basics” are general principles of lifestyle intervention that should underlie the management of childhood obesity.
These “Universal Basics” are general principles of lifestyle intervention that should underlie the management of childhood obesity.
THE UNIVERSAL BASICS
- Regular meals
- Fibre (fruit or vegetables) with every meal - mixed meals
- Portion control
- Avoid processed food
- Drink water
- Eat mindfully in a calm environment
- Eat within 10-12 hour window
- Maximum of 2-3 snacks per day with less than 100 cals each.
- Move move - 10 mins an hour and 1 hour a day
- Do not rely on willpower - change the system and the environment!
- Consider sleep quality and develop good sleep hygiene
Dietary Intervention
(with contribution from Rebecca Weeks and Carrie Miller, Specialist Paediatric Dietitians)
This section offers an overview of dietary management approaches for CYP (children and young people) aged 2-18 years who are overweight or obese.
(with contribution from Rebecca Weeks and Carrie Miller, Specialist Paediatric Dietitians)
This section offers an overview of dietary management approaches for CYP (children and young people) aged 2-18 years who are overweight or obese.
Healthy Eating in Children and Young People
General healthy eating guidance should be provided as a first line approach for all families with overweight and obesity. A detailed 3-day food intake diary can be a starting point to help the family and health care professional compare current food intake with healthy eating recommendations. Adopting a non-judgemental approach and using an open questioning style can help engage families and encourage a more accurate account of food intake. It is essential to not make assumptions about the young person and their families level of knowledge, ideas, understanding and abilities.
The British Dietetic Association recommend a meal pattern of 3 main meals and up to 2 small snacks in between for CYP (33). This should include the right number of age-appropriate food portions from each group across each day as shown in the table below (33,34,35)
General healthy eating guidance should be provided as a first line approach for all families with overweight and obesity. A detailed 3-day food intake diary can be a starting point to help the family and health care professional compare current food intake with healthy eating recommendations. Adopting a non-judgemental approach and using an open questioning style can help engage families and encourage a more accurate account of food intake. It is essential to not make assumptions about the young person and their families level of knowledge, ideas, understanding and abilities.
The British Dietetic Association recommend a meal pattern of 3 main meals and up to 2 small snacks in between for CYP (33). This should include the right number of age-appropriate food portions from each group across each day as shown in the table below (33,34,35)
There are many barriers to healthy eating for families that often result from complex medical and social circumstances. It is often necessary to be explicit about changes and provide clear personalised manageable goals rather than giving broad general guidance on a healthy eating well being plan.
It has been recognised that other aspects of the CYP lifestyle such as mental health, education, sleep routine, home and social environment need to be addressed prior to addressing changes in their dietary habits.
Beyond Healthy Eating Advice
In circumstances where traditional healthy eating advice has been unsuccessful in improving the weight status of the child or young person, it may be appropriate to adopt a more prescriptive approach such as:
Further details outlining how to support a family with the approaches above can be found in the full dietary management guideline.
Management of Food Seeking Behaviour
Children and young people with overweight and obesity may display significant food seeking behaviour which can relate to physiological and psychological reasons. A complex medical and nutritional assessment can help identify the underlying causes to help professionals support families with an individualised management strategy.
Providing a nutritionally balanced diet and a regular daily meal structure can help provide food security (36) and help the CYP feel more physiologically satisfied from the diet. The guidance below can help families with children and young people who display food seeking behaviour.
Estimated Average Energy Requirements
This table shows the Estimated Average Requirement (EAR) for girls and boys aged 1 to 18 years (this is the total energy on average you would expect a healthy active child or adolescent to consume each day). It also shows how much carbohydrate (grams) would need to be eaten to provide the recommended 50% of the daily energy intake. This information can offer some guidance and help establish a healthy eating pattern (39). For young people who are underweight, overweight or particularly active or inactive the recommended daily intake would be different.
It has been recognised that other aspects of the CYP lifestyle such as mental health, education, sleep routine, home and social environment need to be addressed prior to addressing changes in their dietary habits.
Beyond Healthy Eating Advice
In circumstances where traditional healthy eating advice has been unsuccessful in improving the weight status of the child or young person, it may be appropriate to adopt a more prescriptive approach such as:
- Calorie and carbohydrate tracking
- Time-restricted eating
- Semi-structured meal plans
- Partial meal replacement therapy
Further details outlining how to support a family with the approaches above can be found in the full dietary management guideline.
Management of Food Seeking Behaviour
Children and young people with overweight and obesity may display significant food seeking behaviour which can relate to physiological and psychological reasons. A complex medical and nutritional assessment can help identify the underlying causes to help professionals support families with an individualised management strategy.
Providing a nutritionally balanced diet and a regular daily meal structure can help provide food security (36) and help the CYP feel more physiologically satisfied from the diet. The guidance below can help families with children and young people who display food seeking behaviour.
- Create a meal timetable that includes meal and snacks that will be offered, as well as the approximate times these will be provided. This will ensure the CYP has no doubt about daily food provision.
- Not offering unplanned extras (this can worsen preoccupation with seeking food if the CYP learns that occasionally extra food is given).
- Manage hunger driven by insulin resistance (37) or nutritional imbalance by providing age-appropriate carbohydrate portions at mealtimes (alongside a cupped handful of vegetables and a portion of a protein rich food) and opting for lower sugar products in the diet (signposting to the NHS food scanner can help families understand food labels and suggest helpful swaps).
- Encouraging mindful eating and family mealtimes where possible (38)
- Allowing planned fun foods in the context of a healthy diet to encourage a healthy relationship with food
Estimated Average Energy Requirements
This table shows the Estimated Average Requirement (EAR) for girls and boys aged 1 to 18 years (this is the total energy on average you would expect a healthy active child or adolescent to consume each day). It also shows how much carbohydrate (grams) would need to be eaten to provide the recommended 50% of the daily energy intake. This information can offer some guidance and help establish a healthy eating pattern (39). For young people who are underweight, overweight or particularly active or inactive the recommended daily intake would be different.
These energy requirements are based on the assumption that the child has normal body composition and takes the recommended amount of exercise. In practice >75% of obese young people are not taking appropriate levels of exercise and so these energy recommendations often need to be reduced by 25%. If healthy eating and portion control have failed then some obese children need to be recommended a much more prescriptive diet i.e. calorie controlled, carbohydrate controlled, increased protein and high fibre according to their individual energy expenditure.
Exercise
For children and young people between 5 and 18 years old, current recommendations are that they should engage in moderate-to-vigorous intensity physical activity for an average of at least 60 minutes per day (3 metabolic equivalents) across the week (40). 10,000 steps per day is the recommended minimum and equate to around 80 minutes of walking. Moderate to vigorous intensity physical activities are activities that cause the child to get warm, go red and start to sweat, and include high impact activities to promote bone health (e.g. skipping, jumping, running & dancing). On at least three times a week, children should engage in high impact activities.
60 minutes of moderate to vigorous physical activity in childhood is associated with improvements in adiposity, cardiovascular risk factors, metabolic syndrome, aerobic fitness, asthma, blood pressure, mental health and academic performance.
Resistance/weights based activities are also recommended now for children >10 years and are also very effective in improving metabolic health. Going to the gym 3 times weekly has the same effect as 1g twice daily of metformin in the insulin resistant adolescent, and both together are synergistic. Weights used should be light enough to be able to do 12 or more repetitions so as not to damage growth plates.
In addition to encouraging activity, screen time should also be reduced to 2 hours per day. This does not include school work but includes computer based recreational screen time, TV, iPhones etc. It is also helpful to limit long journeys and other long periods of inactivity where possible.
60 minutes of moderate to vigorous physical activity in childhood is associated with improvements in adiposity, cardiovascular risk factors, metabolic syndrome, aerobic fitness, asthma, blood pressure, mental health and academic performance.
Resistance/weights based activities are also recommended now for children >10 years and are also very effective in improving metabolic health. Going to the gym 3 times weekly has the same effect as 1g twice daily of metformin in the insulin resistant adolescent, and both together are synergistic. Weights used should be light enough to be able to do 12 or more repetitions so as not to damage growth plates.
In addition to encouraging activity, screen time should also be reduced to 2 hours per day. This does not include school work but includes computer based recreational screen time, TV, iPhones etc. It is also helpful to limit long journeys and other long periods of inactivity where possible.
Psychological Barriers
Significant psychosocial barriers to success should be addressed in a supportive way whenever possible e.g. helping a parent with behavioural support and obtaining psychological or CAMHS management for anxiety and depression.
However persistent denial, lack of engagement and WNBs can require escalation to MASH or children’s services depending on the age of the child and the level of harm being suffered in terms of the child’s co-morbidities and overall functioning.
Summary of psychosocial risk factors associated with severe obesity in CEW clinics (with contribution from Portsmouth CEW service evaluation data 2022-2024
However persistent denial, lack of engagement and WNBs can require escalation to MASH or children’s services depending on the age of the child and the level of harm being suffered in terms of the child’s co-morbidities and overall functioning.
Summary of psychosocial risk factors associated with severe obesity in CEW clinics (with contribution from Portsmouth CEW service evaluation data 2022-2024
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Southampton and Portsmouth Childhood Obesity Safeguarding Strategy
Note: Whilst the principles of safeguarding are universal, the safeguarding framework for individual trusts may vary – please also consider local policies.
Introduction
Childhood obesity is a growing public health concern nationally and in Southampton. The Government has committed to tackling childhood obesity through publication of the childhood obesity plan for action (1,41), Southampton City Council created an Inquiry Panel to address tackling childhood obesity (42).
Southampton Children and Learning Services are part of Southampton City’s Council’s whole system approach to tackling child obesity and promoting the health and wellbeing of families across the city. A key element of this approach is developing a closer partnership between health and children’s social care to ensure that families receive the right support at the right time.
This strategy has been produced in response to, several children becoming known to Children Services with severe physical health, mental health and educational complications related to their obesity, and where safeguarding opportunities were not always considered, escalated, or effective, at enabling children to become healthier.
The aim of the strategy is to:
This strategy does not include methods for reducing the obesogenic environment at the population level, nor provisions at community level, although these are likely to have the highest impact in the prevention of child obesity. Information and services about promoting healthy lifestyles at home and in school, are available elsewhere.
In the Paediatric Obesity medical service in Southampton it has been found that 50% excess weight in children is associated with an 85% chance of weight-related complications. 100% excess weight (i.e. if a CYP is double their ideal weight) is always associated with weight-related complications and usually with more than one complication.
Southampton Children and Learning Services are part of Southampton City’s Council’s whole system approach to tackling child obesity and promoting the health and wellbeing of families across the city. A key element of this approach is developing a closer partnership between health and children’s social care to ensure that families receive the right support at the right time.
This strategy has been produced in response to, several children becoming known to Children Services with severe physical health, mental health and educational complications related to their obesity, and where safeguarding opportunities were not always considered, escalated, or effective, at enabling children to become healthier.
The aim of the strategy is to:
- Raise awareness that a child’s health is everyone’s responsibility, and to clarify expectations on professionals to prevent and manage obesity in children.
- Outline the health and child services pathways and threshold for intervention with child obesity from universal to targeted services, enabling escalation and de-escalation between tiers.
- Enable closer partnership working between agencies and services caring for the child
- To indicate when child obesity might become a safeguarding issue
This strategy does not include methods for reducing the obesogenic environment at the population level, nor provisions at community level, although these are likely to have the highest impact in the prevention of child obesity. Information and services about promoting healthy lifestyles at home and in school, are available elsewhere.
In the Paediatric Obesity medical service in Southampton it has been found that 50% excess weight in children is associated with an 85% chance of weight-related complications. 100% excess weight (i.e. if a CYP is double their ideal weight) is always associated with weight-related complications and usually with more than one complication.
Prevalence of childhood obesity in Southampton
The prevalence of overweight and obesity in children in Southampton has increased beyond the national levels. In Southampton (2022/23), 22.5% of children in Reception year (aged 4-5 years) and 40.5% of children in Year 6 (aged 10-11 years) are overweight or obese (versus England: 21.3% and 36.6% respectively) (43).
In England, the obesity prevalence in boys is higher than girls for both age group. For children living in the most deprived areas in England, the prevalence of obesity was twice as high compared with those living in the least deprived areas (44).
In England, the obesity prevalence in boys is higher than girls for both age group. For children living in the most deprived areas in England, the prevalence of obesity was twice as high compared with those living in the least deprived areas (44).
When does childhood obesity become a safeguarding concern?
Only a small number of obese children will reach the threshold for safeguarding referral. The causes of obesity are multifactorial and results from the interplay between genetic, environmental and personal vulnerability factors. Interventions can produce small changes that are often hard to maintain. There are no interventions that have been evidenced to work consistently. Therefore, if caregivers are engaging sufficiently with treatment, it can be difficult to criticise them, even if their child’s BMI is not falling.
However, there are two situations that are important when considering whether obesity should be escalated as a safeguarding concern:
There are also two key issues that always need to be considered:
However, there are two situations that are important when considering whether obesity should be escalated as a safeguarding concern:
- When caregivers are not able to engage with support and apply lifestyle changes, especially in young children who are dependent solely on their caregiver. It is the caregivers that decide how often and what food a young child is given to eat, and they are also largely in control of how much opportunity young children have to be active and to take exercise. If caregivers have been given adequate information to help them understand what is required to prevent serious risks from obesity, and if they have been offered appropriate support to help with this, but are unable/unwilling to consistently engage or to make the necessary changes, this may constitute neglect. Particular concerns arise if parents are actively subverting weight management advice, or if the child is at imminent risk of complications of obesity, such as sleep apnoea, diabetes or orthopaedic problems.
- Obesity may be one aspect of wider safeguarding concerns, e.g. about neglect, or emotional, physical or sexual abuse. If obesity is associated with other indicators of neglect, emotional or behavioural difficulties, poor school attendance, exposure to or involvement in violence, or with family factors such as drug or alcohol misuse or parental mental health problems, a multidisciplinary or multiagency assessment may be indicated.
There are also two key issues that always need to be considered:
- The voice of the child being heard and understood – professionals involved with children should gather information about what life is like for the child, their views and what they say.
- Agencies working in silos – information should be shared and concerns escalated between agencies working with families.
Taking a social history
When assessing a child who is obese it is important to take a full social history including:
When assessing a child who is obese it is important to take a full social history including:
- Who lives at home, ages, occupations
- Parental and sibling weight, medical, including dental, and mental health
- Family use of alcohol and drugs
- Current or previous social care assessment or support
- School attendance, experience of bullying, isolation, or locked in
- Use of food banks, free school meals, access to supermarkets
- History of developmental delay, learning difficulties, ADHD, ASD
- Siblings with additional needs
- History of domestic violence or other Adverse Childhood Experiences (ACEs), such as family bereavement, parental separation, parental incarceration, homelessness
- Parent or care giver educational level, understanding of English, health understanding and learning difficulties
- Previous non-attendance at health appointments
- Agencies and professionals involved including previous or current Early Help or Children’s Services input, Adult Services, CAMHS, Learning Disability team, Youth Offending Team
Indicators of Neglect
In a child with obesity, and especially if the child is young or there are significant co-morbidities, the following have been identified as indicators when considering whether childhood obesity should be considered as neglect:
Agencies need to be aware of how caregivers can distract professionals both within one agency and across agencies from focusing on the child by favouring one agency/professional over another. Behaviours can include:
Professionals need to understand the child’s needs and be prepared to challenge both parents and other practitioners working with the child/family. The Neglect Toolkit can be useful at identifying whether there are concerns for a child’s health needs not being met, although it does not specifically reference obesity.
It is important to use the right terminology when liaising with Children’s Services who may not necessarily understand the impact of health complications from childhood obesity. Therefore, it is essential to not only list the health complication but to describe how it directly affects the child’s daily living together with any long-term impact.
- Caregivers unable to effectively provide for the child’s health needs due to family factors, such as learning difficulties, socio-economic issues, unmet parental needs, bereavement, parental ill-health, domestic abuse, social isolation
- Caregivers unwilling or unable to bring their child to appointments
- Weight/BMI continues, or appears to continue, to increase/or not to decrease despite appropriate support and intervention by agencies
- Caregivers unwilling to make any changes to child’s lifestyle even with appropriate support and intervention by agencies
- Caregivers unwilling or unable to engage with professional advice regarding ongoing significant health risks to their child if the weight continues to increase
- Caregivers are not able to understand the impact of obesity on their child’s health
- Transient or intermittent engagement by the caregivers
- Caregivers actively frustrating efforts of professionals or child to reduce weight gain, including disrupting treatments
- Oppositional behaviour: caregivers unwilling or unable to set and maintain boundaries with child to manage lifestyle changes
- Caregivers refusing height or weight measurement of their child without reason
- Disguised compliance where caregivers appear to be, or report to be, following advice but are not making any changes to lifestyle which would make a significant difference to the child’s well-being.
- Parent/carer unwilling/unable to model appropriate behaviour to facilitate lifestyle changes
- Discrepancy between what the parent/carer reports they give their child to eat, and what is observed
Agencies need to be aware of how caregivers can distract professionals both within one agency and across agencies from focusing on the child by favouring one agency/professional over another. Behaviours can include:
- Appearing helpless and/or overwhelmed
- Being aggressive and/or confrontational
- Using complaints processes, media and/or politicians and/or legal advisers to challenge the professionals
- Over sensationalising particular comments/issues to detract from the significant harm being experienced by the child/young person.
- Using medical diagnoses to justify their inability to adhere to recommended advice.
Professionals need to understand the child’s needs and be prepared to challenge both parents and other practitioners working with the child/family. The Neglect Toolkit can be useful at identifying whether there are concerns for a child’s health needs not being met, although it does not specifically reference obesity.
It is important to use the right terminology when liaising with Children’s Services who may not necessarily understand the impact of health complications from childhood obesity. Therefore, it is essential to not only list the health complication but to describe how it directly affects the child’s daily living together with any long-term impact.
Thresholds
- At all points – All professionals and agencies have a role in promoting healthy lifestyles, where possible using a family-based approach. If any professional (e.g. from health, social care, education) is concerned that a child may be overweight or obese they should give advice as appropriate, and they should liaise with the child’s health visitor, school nurse or GP so that appropriate checks can be made.
- If it has not been possible to address a child’s obesity within the Healthy Weight Pathway or universal or enhanced services, and there is evidence that the family require additional support to, a referral to the Children’s Resource Service should be made with a clear outline of the harm the child is or will experience, what services have been offered and provided, and request support.
- Early Help – Where a family is receiving support from universal or enhanced health services for their weight, and there is evidence that the family require some additional support to make and sustain the necessary changes, Early Help support can be requested. Support can be provided to parents to help them to put in place the changes requested
- Child In Need – Where a family has not been able to make the necessary changes to increase the health and wellbeing of the child as set out as achievable by health colleagues, or there are underlying complicating factors that suggest a co-ordinated multi-agency approach would be beneficial, a referral should be made to request support through Child in Need planning. This would target children that are around 50-80% excess weight, or those with symptoms or early indications of co-morbidities.
- Child Protection Plan – Where a child is experiencing significant harm as a result of the impact of health complications associated with their weight, and health services have been unable to help the family make or sustain the necessary change to reduce these harms, a Child Protection Plan may be required. Significant harm occurs when there are (or are likely to be) co-morbidities within the health needs of the child, such as outlined above, or a child has 100% excess weight.
- Public Law Outline – When a child remains at significant risk of harm, and a child protection plan has not been successful at increasing the health and wellbeing of a child relating to their health, legal advice will be sought to inform whether a child can safely remain at home with his or her parents.
The Southampton Pathways Document provides guidance on accessing safeguarding support services (including threshold guidance), and further information on Indicators of Neglect.
Escalation and de-escalation
Section 47 boundaries and child protection plans are usually highly successful at instigating positive change for families which results in successful weight management and younger children are often particularly amenable to positive lifestyle change. Maintenance of these changes over a prolonged period of time can be more challenging as families often need ongoing support to maintain success and build resilience against new challenges. Severe obesity is considered a chronic disease in its own right and remission followed by relapse is common if support is withdrawn too soon. Weight related medical complications are usually resolved after 10-20% weight loss which can be achieved in 6-12 months. Families often need ongoing support from the medical teams and children’s services for 2 years in order to consolidate learning and resilience in the long term.
Pharmacological management of Paediatric Obesity
The use of metformin and semaglutide (Wegovy) is established for selected children and young people with obesity in our cohort.
Please see Pharmacological Management of Obesity in Children and Young People for detailed guidelines
The use of metformin and semaglutide (Wegovy) is established for selected children and young people with obesity in our cohort.
Please see Pharmacological Management of Obesity in Children and Young People for detailed guidelines
Useful Signposting Resources
Link |
Description |
Portion Sizes for toddlers |
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Food portioning - 1-4 years |
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Food portioning - adults (may be applicable to teenagers) |
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The Eatwell Guide shows how much of what we eat overall should come from each food group to achieve a healthy, balanced diet |
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NHS advice about healthy living, including eating a balanced diet, healthy weight, exercise, quitting smoking and drinking less alcohol. |
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Food facts for adolescent with information on diet in certain medical conditions as PCOS. |
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Provides resources and facts about different components in diet and their impact on health. |
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Sugar: the Facts |
Effect of sugar on health with guidance on how to cut sugar in diet |
Recipe Finder - Enjoy Food |
Recipes with low glycaemic index |
Practical guidelines to eating well among specific vulnerable population groups. Useful resources including Eating well recipes with photocards for different age groups |
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Information on healthy balanced diet, portion size and healthy snacks |
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Healthy recipes for cooking |
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Healthy eating on a budget |
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Introducing a new food in 32 steps for children with food refusal |
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Fussy Eating Videos (available in Polish, Bengali, Punjabi, Urdu, Pashto, Arabic, Kurdish, Tigrinya) |
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Advice of physical activity guidelines for children under 5 years |
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Self-help guide for people with Binge Eating Disorder |
Appendix A - Referral To Paediatric Weight Management Service At Southampton Children’s Hospital
Appendix B - Sleep Disturbance Scale for Children (SDSC)
Appendix C - PedsQL Questionnaires
- PedsQL Questionnaire - Toddlers - 2-4
- PedsQL Questionnaire - Young Child - 5-7
- PedsQL Questionnaire - Young Child - 5-7 - Parent
- PedsQL Questionnaire - Child - 8-12
- PedsQL Questionnaire - Child - 8-12 - Parent
- PedsQL Questionnaire - Teens - 12-18
- PedsQL Questionnaire - Teens - 12-18 - Parent
- PedsQL Questionnaire - Young Adult- 18-25
- PedsQL Questionnaire -Young Adult - 18-25 - Parent
Appendix D: Guidance on Genetic Testing for Obesity
(To download, hover over document and click printer icon)
(To download, hover over document and click printer icon)
References
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- Healthy eating. British Dietetic Association. 2024. Available here.
- Food portions. British Heart Foundation. Available here.
- The Eatwell Guide. NHS England. 2022. Available here.
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Document Version:
1.0 Lead Author: Dr David Lim Dr Rooha Ghauri Dr Nikki Davis, Paediatric Consultant Endocrinology & Diabetes Additional Author: James Barrett, Paediatric Dietitian Carrie Miller, Paediatric Dietitian Rebecca Weeks, Paediatric Dietitian |
Approving Network:
Paediatric Nutrition and Hydration Group Date of Approval: 12/2024 Review Date: 12/2027 |
PIER Contact |
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