Childhood obesity: time for action, not complacency
BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7231.328 (Published 05 February 2000) Cite this as: BMJ 2000;320:328
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Editor - The editorial on childhood obesity by Gema Frubeck 1 wisely
emphasised the important role of the family in treating overweight
children.
However, she did not mention that antenatal advice about good eating
habits can play a major role in the prevention of childhood obesity, as I
found when I was in practice.
Of 167 children, born to mothers who had been under my antenatal
care, and all of whom had been weighed by me, only 3 became obese, whereas
of 165 children born outside the practice and not weighed routinely, no
less than 14 were brought to me because they were obviously overweight.2
Denis Craddock (Retired General Practioner)
Chipstead, Surrey, CR5 3TA
1. Fruhbeck.G. Childhood obesity: time for action, not
complacency. BMJ 2000,320;328-9 (5 Feb)
2. Craddock. D. Obesity and its Management. (3rd Ed.)
Churchill Livingstone. 1978. 178-9.
Competing interests: No competing interests
We were interested to read the editorial on childhood obesity (1)
particulary because, in Liverpool, guidelines for schools on eating
disorders and body image have recently been launched (2).
The guidelines
are part of the
Liverpool Healthy Schools Award Initiative (3). This is supported by the
Health Authority and the City Council, and provides a co-ordinated
approach to promoting health amongst school children. It forges links
between education, health, parents, and the wider community to equip
children and
young people with the personal resources to empower them to pursue healthy
lifestyles.
Fruhbeck refers to the difficulty of maintaining, in the long term,
classroom lessons on nutrition and physical health because of competition
for school time (1). The approach taken in the Healthy Schools Award is
for food and
nutrition (and eight other areas) to be included across the curriculum and
in the general ethos of the school, not as an 'add-on extra'. In relation
to food and nutrition one of the success indicators is 'To develop a cross
-curricular approach to teaching about food and nutrition which enables
pupils and staff to make positive connections between a balanced diet,
safe hygiene practices, and health'.
One hundred and fifty eight Liverpool schools are taking part in the award
and, since 1997, 40 have achieved it. The recent guidelines (2) provide
information about eating disorders, and how schools can establish an
environment which encourages a positive body image to counter some of the
societal pressures which can contribute to eating problems. Schools are
encouraged to promote exercise and eating a healthy balanced diet as the
most effective way to lose weight and maintain weight loss.
The Healthy Schools approach is being promoted nationally by the
government in recognition that the school is a key setting in which to
improve both health and education (4). Liverpool Healthy Schools
programme is currently
undergoing the national accreditation process following the launch, in
November 1999, of the National Healthy School standard. This provides a
national accreditation process for education and health partnerships, the
purpose of which includes ensuring that evidence is gathered to
demonstrate
effectiveness. The standards that local Healthy Schools Programmes must
achieve for accreditation include taking a whole school approach to
healthy eating and physical activity (4).
The Healthy Schools approach is therefore an important means of acting to
prevent and reduce childhood obesity, and in time should provide evidence
about effectiveness interventions.
Dr Joyce Carter
Consultant in Public Health Medicine
Liverpool Health Authority
24 Pall Mall,
Liverpool
L3 6AL
Annette Lyons
Senior Effectiveness Officer, Personal Social and Health Education
City of Liverpool Education and Lifelong Learning Service,
4th Floor, 4 Renshaw Street,
Liverpool
L1 4NX
References
1. Fruhbeck G. Childhood obesity: time for action, not complacency.
British Medical Journal 2000; 320: 328-329 (5 February 2000)
2. City of Liverpool Education and Lifelong Learning Service.
Guidelines for schools on eating disorders and body image. Liverpool
Health Promotion Service 2000
3. City of Liverpool Education and Lifelong Learning Service.
Liverpool Healthy Schools Award Manual. January 2000
4. Healthy Schools. National Healthy School Standard - Guidance.
Department for Education and Employment 1999.
Competing interests: No competing interests
Editor, Fruhbeck does not consider the role of infant feeding in
the aetiology of childhood overweight and obesity.(1)
Dewey et al found that formula fed infants were heavier than those who
received no milk other than breast milk in the first 12 months, though of
similar length and head circumference.(2) They also found that energy
intake of breast fed infants was lower than that of formula fed infants,
even after the introduction of solids, and
suggested that relatively low energy intakes are a function of self-
regulation in the breast fed infant.
Von Kries et al found in children aged 5 and 6 a very substantial, dose
dependent, protective effect of breast feeding on obesity and overweight:
3 to 5 months of exclusive breast feeding was associated with a 35%
reduction in obesity at the age of 5 to 6 years. They discuss the
evidence for a programming effect of breast feeding in
preventing obesity and overweight in later life.(3)
Breast feeding mothers lose weight after pregnancy more effectively than
those who feed artificially, an advantage seen over at least the first 12
months of breast feeding.(4)
It appears that promoting and supporting breast feeding should be part of
the initiative to tackle the "epidemic of obesity".(5)
Carol Campbell MRCGP
Clinical Medical Officer
Community Paediatric Dept,
Foyle H&SS Trust,
Bridgeview House,
Gransha Park,
Londonderry BT47 1TG
References
(1) Fruhbeck G. Childhood obesity: time for action, not
complacency. BMJ 2000;320:328-9.
(2 Dewey KG, Heinig MJ, Nommsen LA, Peerson JM, Lonnerdal B.
Growth of breast-fed and formula-fed infants from 0 to 18 months: the
DARLING Study. Pediatrics 1992;89:1035-41.
(3) Von Kries R, Koletzko B, Sauerveld T, von Mutius E, Barnert D,
Grunert V, von Voss H. Breast feeding and obesity: cross sectional
study. BMJ 1999;319:147-50.
(4) Dewey KG, Heinig MJ, Nommsen LA. Maternal weight loss
patterns during prolonged lactation. Am J Clin Nutr 1993;58:162-166.
(5) Mayor S. European plan to put obesity on governments' health
agenda. (News) BMJ 1999;318:1574.
Competing interests: No competing interests
Editor - the editorial by Gema Frubeck(1) aims to offer evidence
based treatments for the growing problem of childhood obesity. She admits
that a definition of the term remains elusive, yet offers self-monitoring
and goal-setting as examples of evidence based strategies to deal with
obesity.
How can we provide management strategies for a problem when the concept,
is ill-defined and the whole area under researched?
Obesity does not happen suddenly to any child. In the absence of rare
genetic or endocrine conditions, very fat children are either over-fed by
their parents, or have underlying psychological problems which drive their
eating or a mixture of both.
When classifying Eating Disorders in Children, over- eating gets scant
attention from Child and Adolescent Psychiatrists. Obesity is included in
ICD-10(2) as a general medical condition but it does not appear in DSM-
1V(3)
because it has not been established that it is consistently associated
with a psychological or behavioural syndrome.
This is in sharp contrast to the position for anorexia and bulimia
nervosa.
Thirty years ago these topics were hardly mentioned in standard texts.
Over the last 25 years, a massive amount of research into the aetiology,
management and prognosis of these conditions has been generated. One
result of this is that clear evidence based models of best management are
widely available.
I was pleased to see this subject was thought worthy of editorial
notice, but must stress the need for more research into the nature of
obesity.
Prescriptive concepts with at best short-term benefits, may at worst
produce yet another generation of adults who have an uneasy and unhealthy
relationship with food.
1 Frubech Gema, Childhood obesity;time for action not complacency.
BMJ 2000:320;328 (5thFebruary)
2 World Health Organisation (1993) International Classification of
Diseases, 10th revision. Diagnostic Criteria for Research. Geneva: WHO
3 American Psychiatric Association (1994) Diagnostic and Statistical
Manual of Mental Disorders (4th edition)(DSM-1V) Washington DC: American
Psychiatric Association.
Anne West
specialist registrar in child and adolescent psychiatry
Trehafod,
Swansea CAMHS,
Waunarlwydd Road,Cockett,Swansea
SA2 0GB
Competing interests: No competing interests
Obesity is a serious health problem. In half a year all major
journals paid attention to obesity: obesity continues to increase rapidly
in developed countries. Recent editorial say that 'English and Scottish
children showed a roughly twofold increase in weight for height in all age
groups and both sexes'[1]. That is not completely correct: cited study
said that not English, but Scottish children increased their weight, and
obviously their weight is not duplicated for equal height.[2] Right from
similar statement on prevalence of overweight and obesity another
editorial proposed: 'to alter this trend, strategies and programs for
weight maintenance as well as weight reduction must become a higher public
health priority.'[3] Another article use the similar logic: 'The
prevalence of obesityrelated comorbidities emphasizes the need for
concerted efforts to prevent and treat obesity'.[4]
What is disturbing in this logic, that is the action plan
starts not from research, but right from action. 'The time has come to
develop a national comprehensive obesity prevention strategy.'[5] To
develop the armamentarium for this strategy numerous trials of
interventions had place, varying from exercises to drugs[6] and to
interventions in schools to reduce time children spend with TV and
games.[7]
These are type of 'necessity driven' actions, rather then 'evidence
driven'(Dave Sackett). Before children will miss their access to TV, games
and chocolates, lets look at evidence. While some candidate interventions
promise the limited effectiveness in the reduction of weight, no one trial
shows effective prevention of weight gain in population. No one trial
demonstrated the gain in clinically important end points (mortality and
morbidity) after weight reduction or obesity prevention interventions.
Perhaps, absence of evidence is the main reason why 'less
than half of obese adults report being advised to lose weight by health
care professionals.[8]The rate of physician counseling about exercise is
low nationally.[9] What if physicians are responsible enough and do not
entertain actions without evidence? At last, 'at the individual patient
level, physicians have the critical responsibility.[10] I believe that
physicians must not be pressed to advise patients to buy weight-reducing
devices, but physicians must be armoured with evidence that it is
worthwhile to treat obesity.
We must re-think the history of the obesity research. It is amusing
that after the MLIC study, which had show the reduction of mortality in
obese people who reduces their body mass, and after critique of the
methodological weaknesses of this study, more than 50 years no one study
addressed so important question.
Vasiliy Vlassov
Professor, Saratov Medical University
Saratov, Russia
vvvla@sgu.ru
Reference List
1.Fruhbeck G. Childhood obesity: time for action, not
complacency: Definitions are unclear, but effective interventions exist.
Brit.Med.J. 2000;320:328-9.
2.Chinn S,.Rona RJ. Trends in weight-for-height and
triceps skinfold thickness for English and Scottish children, 1972-1982
and 1982-1990. Paediatr.Perinat.Epidemiol. 1994;8:90-106.
3.Mokdad AH, Serdula MK, Dietz WH, Bowman BA, Marks JS,
Koplan JP. The Spread of the Obesity Epidemic in the United States, 1991-
1998. J.A.M.A. 1999;282:1519-22.
4.Must A, Jacques PF, Dallal GE, Bajema CJ, Dietz WH. Long-
term morbidity and mortality of overweight adolescents. A follow- up of
the Harvard Growth Study of 1922 to 1935. N Engl J Med 1992;327:1350-5.
5.Koplan JP,.Dietz WH. Caloric Imbalance and Public Health
Policy. J.A.M.A. 1999;282.
6.Jakicic JM, Winters C, Lang W, Wing RR. Effects of
Intermittent Exercise and Use of Home Exercise Equipment on Adherence,
Weight Loss, and Fitness in Overweight Women: A Randomized Trial. J.A.M.A.
1999;282:1554-60.
7.Robinson TN. Reducing Children's Television Viewing to
Prevent Obesity: A Randomized Controlled Trial. J.A.M.A.
1999;282:1561-7.
8.Galuska DA, Will JC, Serdula MK. Are Health Care
Professionals Advising Obese Patients to Lose Weight? J.A.M.A.
1999;282:1576-8.
9.Wee CC, McCarthy EP, Davis RB, Phillips RS. Physician
Counseling About Exercise. J.A.M.A. 1999;282:1583-8.
10.Fontanarosa PB. Patients, Physicians, and Weight Control. J.A.M.A.
1999;282.
Competing interests: No competing interests
I am surprised that this editorial makes no mention of the societal /
political factors that have played a pivotal part in the development of
childhood obesity in the last twenty years.
Obesity has been caused by changes in society brought about largely by
short- sighted political decisions that have reduced our population's
ability to make healthy choices.
( Calorie intake has decreased in the last twenty years but physical
activity that has decreased even more.)
Obesity is a political problem that demands population changes and not
some high cost ,low result medical problem. We need to prevent this
problem developing in the first place. Once obesity exists then we all
know...especially those of us who have tried to beat it....that it is an
extremely difficult, if not impossible, condition to reverse.
We surely owe it to our children to provide them with a healthy, less
obesogenic environment. I believe that some of the things we should
urgently be developing are as follows....
1 Childrens Play- outside.
As a child in the fifties
I could play in the street
with hope in my heart
and a ball at my feet
in the streets where once I played
the cars are speeding
in the streets where once I stayed
Childhood now lies bleeding.
I am fed up with people moaning on about children 'playing computer
games and watching so much TV'. The simple fact is that most streets are
now little more than linear car
parks with a race track down the middle. The Children's Play council,
Transport 2000 and other organisations are heavily promoting a Dutch
concept called Home Zones . There are some pilot studies in England at the
moment and a few soon due to start in Scotland...if funding surfaces. It
is a simple and wondrous concept. Home Zones are streets that with the
local community input / agreement and some European /Lottery cash are
tansformed into areas where children can actually play safely outside.
Trees are planted in the middle of the road and the 'Drivers line of sight
'is removed. Traffic cannot move at more than about 7mph. A child has 'the
right of play' and not at present where our cars paintwork seems to have
priority.
There is also an accelerating loss of greenfield play space in order to
build 'leisue centres ' which primarily exist to service the wrong people
and which invariably allocate 40% of the land to car parking.
2 Childrens play at school.
Once at school there is an assumption that facilities exist to let
them exercise. Unfortunately in many schools physical activity is not
given the importance / time / teaching that it so desperately requires.
Many of these children come from families who have sedentary lifestyles
and they need to have even more input...there is an intergenerational loss
happening here.
We need physical activity teachers to be given much more status and
remuneration.
3 Walking to and from school
80% of children walked to school 20 years ago but now its only about
20% and that's because of all the cars driving children to school. This
unhealthy cycle needs to be broken and that will require a range of
measures.eg... Some enlightened countries have vehicular no-go areas
between certain times near schools.
I could go on and on even more but I'll finish now by saying that if
we want our children healthy then we have to be prepared to make changes
in order to give them back their childhood. A childhood that now lies
bleeding.
Useful addresses-
1 Childrens Play Council 8 Wakeley street London 0171 843 6016 ( Home
Zones)
2 The PEDESTRIANS ASSOCIATION 31-33 Bondway London Sw8ISJ 0171 820
1010
3 Transport 2000 12-18 Hoxton Sreet London 0171 613 0743
(The Booklet 'Living Streets' from Transport 2000 is the best tenner I
have ever spent.)
Competing interests: No competing interests
Childhood obesity: time for action, not complacency
Your recent editorial was heartening in its call for action over
childhood obesity.1 However, we have concerns about the focus of the
editorial.
Firstly, we believe that weight maintenance rather than weight loss should
be the goal of the treatment of obesity in childhood while height growth
continues. Weight loss is difficult to achieve2 and treatment drop-out
rates are up to 90% in large series.2 Additionally, ill-advised intake
restriction may compromise nutrition and growth during vulnerable periods.
Weight maintenance during the growing years is more easily achieved than
weight loss3 and results in a gradual loss of overweight as height growth
occurs. Weight maintenance is achieved by developing a stable calorie
balance, and may therefore more likely to result in long-term maintenance
of a healthy weight.
Secondly, the author failed to recognise the need for quite different
approaches in the treatment of obesity for early childhood, late childhood
and adolescence, particularly in regard to the role of the family. A
family-centred approach is essential in early childhood as parents rather
than children are responsible for the child's intake and energy
expenditure. In later childhood and adolescence, individual work with the
young person must be undertaken but within the context of family
involvement.4; 5
We agree that there is no room for complacency over childhood obesity.
However, the results of existing treatment programs described by the
authors are generally disappointing, given the expense of multi-
disciplinary involvement. Much further work is needed to develop
effective treatment programs that can be undertaken by community health
professionals. Early intervention by programs that emphasise weight
maintenance while height growth continues in childhood and early
adolescence may offer the best and most cost-effective way of preventing
the morbidity associated with adult obesity.
Dr. Russell Viner
Consultant & Honorary Senior Lecturer in Adolescent Medicine
University College London Medical School, Middlesex Hospital, Mortimer
St., London W1N 8AA
Dr. Rachel Bryant-Waugh
Consultant Clinical Psychologist
Great Ormond Street Hospital for
Children, Great Ormond Street, London WC1N 3JH
Dr. Dasha Nicholls
Lecturer in Behavioural Sciences
Institute of Child Health, London Great
Ormond Street Hospital for Children, Great Ormond Street, London WC1N 3JH
Dr. Deborah Christie
Consultant Clinical Psychologist
Middlesex Adolescent Unit, Middlesex
Hospital, Mortimer St., London W1N 8AA
1. Fruhbeck G. Childhood obesity: time for action, not complacency.
BMJ 2000;320:328-29.
2. Pinelli L, Elerdini N, Faith MS, et al. Childhood obesity:
Results of a multicenter study of obesity treatment in Italy. J Ped Endoc
Metab 1999;12:795-99.
3. Braet C, Van Winkel M, Van Leeuwen K. Follow-up results of
different treatment programs for obese children. Acta Paediatr
1997;86:397-402.
4. Epstein LH. Family-based behavioural intervention for obese
children. Int J Obes Relat Metab Disord 1996;20 Suppl 1:S14-21.
5. Epstein LH, Valoski A, Wing RR, McCurley J. Ten-year outcomes of
behavioral family-based treatment for childhood obesity. Health Psychol
1994;13:373-83.
Competing interests: No competing interests