Child obesity charts open door to treatment

Children and teens who are overweight or obese can be identified by regularly monitoring their growth as a first step to help families, new Canadian guidelines for family doctors recommend.

On Monday, the Canadian Task Force on Preventive Health Care released what it calls the first update on childhood obesity guidelines in more than 20 years. It comes as childhood obesity has more than doubled since the 1970s, with about 20 per cent of children and youth classified as overweight and 12 per cent obese , based on height and weight measurements.

A key recommendation is to measure the height, weight and record the body mass index of those under age 18 at appropriate primary care visits using the WHO Growth Charts for Canada.

"There is no simple one answer," said Dr. Patricia Parkin, chair of the child obesity guideline working group. "There's probably a bit of a perfect storm going on right now in this generation, forces throughout our societies and our communities that is leading to these changes in growth patterns in children."

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Monitoring growth is important because there's good evidence that for some children, weight gain early in life tracks into adulthood, Parkin said.

For children aged 2 to 17 years who are overweight or obese, primary care practitioners should offer or refer to structured behavioural programs with the goal of achieving healthy growth.

"If primary care practitioners are recognizing that the child is developing an unhealthy growth then that is an exceptional opportunity for them to intervene in some way," Parkin said. 

"The sessions, in the various trials are quite different, but they often include dietary recommendations, lifestyle recommendations, physical activity recommendations mental health support and so on. So these are addressing multiple themes that are associated with overweight and obesity in children."

The SickKids Team Obesity Management Program or STOMP is an example. The two-year program is offered to small groups of those aged 12 to 17 with complex obesity who are  followed closely by pediatricians, a nurse practitioner, dietitians, an exercise therapist, a psychologist and a social worker.

Health not weight focus

The goal is to improve health overall, not just focusing on weight but also mental health, healthy nutrition, physical activity, sleep patterns and overall functioning, said pediatrician Dr. Catherine Birken of STOMP.

"It's really difficult work to change your individual behaviours," Birken said. "I believe that the way we've constructed our society is not necessarily supportive of maintaining a healthy weight. So we can't just look at one individual child. We have to look at that child within that family, within that community, within that setting, within their culture and traditions and try to tackle healthy weight from all those angles."

Birken points to promising prevention studies in preschool children. For older children, the evidence for prevention, such as with intensive behavioural management, is harder to interpret. There were small differences in healthy weight outcomes among children who received the preventive programs.

The guidelines recommend family doctors should not routinely offer drug treatments to children or youth who are overweight given the risk of side-effects and incremental benefits, Parkin said.

Similarly, primary care practitioners should not routinely refer children or youth to bariatric surgery because there haven't been trials comparing it to behavioural interventions.

Tackling childhood obesity should not be seen as two halves of prevention and treatment, Dr. Carolyn Summerbell of Durham University in Stockton-on-Tees, U.K., said in commentary published with the guidelines in Monday's Canadian Medical Association Journal.

"It is a continuum, and the grey area in the middle is actually where many children lie for at least some time during their childhood," Summerbell said.

The treatment options are limited to behavioural ones, Summerbell acknowledged.

"It is important to consider the experience of primary care practitioners, seeing distressed children (and their families) who so desperately want to lose weight and "be normal," she concluded.

A journal editorial summarized how schools help children and teenagers develop healthy lifestyles to avoid obesity such as:

• Acquire healthy eating habits.
• Make exercise the norm, including commuting to school.
• Mandate physical education throughout all school years.
• Get students moving during school hours instead of sitting for long periods.
• Sell food and drinks with better nutritional quality.
• Start high school later to reflect how teens' circadian rhythms differ from adults.

The task force is an independent panel of clinicians and experts who review the medical literature and grade its quality before making their recommendations. They also developed tools to help physicians interpret the recommendations.