Guidance

Childhood obesity: applying All Our Health

Published 1 April 2015

Introduction

Childhood obesity, and excess weight, are significant health issues for individual children, their families and public health. It can have serious implications for the physical and mental health of a child, which can then follow on into adulthood. The numbers of children who continue to have an unhealthy, and potentially dangerous, weight, is a national public health concern.

Why obesity in young children is an issue infographic

Healthcare professionals play an important role that can positively help families take action. Working alongside other professionals and public health teams, they can also influence population level action. Action across the child life course is essential to have an impact on childhood obesity and enable positive behaviour change in relation to eating and activity. The focus should be on:

  • preconception and pregnancy
  • infancy and early childhood
  • older childhood and adolescence
  • transition into independent adulthood

Facts about childhood obesity

Obesity harms young people and children infographic

Obesity and overweight are linked to a wide range of diseases, most notably:

  • diabetes (type 2)
  • asthma
  • hypertension
  • cancer
  • heart disease
  • stroke

Obesity is also associated with poor psychological and emotional health, poor sleep, and many children experience bullying linked to their weight. Obese children are more likely to become obese adults and have a higher risk of morbidity, disability and premature mortality in adulthood.

Using National Child Measurement Programme data of primary school children, the Health and Social Care Information Centre states that:

  • more than 1 in 5 children are overweight or obese when they begin school
  • almost 1 in 3 children are overweight or obese by the time they leave primary school
  • obesity rates are highest in the most deprived 10% of the population - approximately twice that of the least deprived 10%
  • obesity rates are higher in some ethnic minority groups of children (particularly Black African and Bangladeshi ethnicities) and for children with disabilities (particularly those with learning difficulties)
Prevalence of excess weight in children infographic

Risk factors

The main risks factors for children, in terms of the households they are born into and grow up in, include:

  • approximately half of women of childbearing age (16 to 44 years) in England are either overweight or obese, and this rate has increased in the 10 years to 2013
  • there is strong evidence of a significant relationship between maternal obesity and the birth of babies above a normal weight range, and the subsequent development of childhood and adult obesity, independent of genetic and environmental factors
  • children who live in a family where at least one parent or carer is obese, are more at risk of becoming obese themselves
  • children who are obese are more likely to be obese in adulthood and thus increase the risk of obesity for their own children later in life
  • poor diet and a low levels of physical activity are the primary causal factors to excess weight

The amount of sugar that children consume on a daily basis is a major contributing factor to gaining weight. The National Diet and Nutrition Survey found that sugary drinks account for 30% of 4 to 10 year olds’ daily sugar intake. Children’s consumption of added or processed sugars (non-milk extrinsic sugars) significantly exceeds the maximum recommended level. Their consumption of saturated fat, as part of their daily food energy, significantly exceeds the maximum recommended level of 11% of total food energy.

Low levels of physical activity, and increased sedentary behaviours, of children and young people exacerbate the problems of poor diet and nutrition. In England, only 21% of boys and 16% of girls aged 5 to 15 achieve recommended levels of physical activity. As children grow older, the decrease in activity levels is greater for girls than boys: 23% of girls aged 5 to 7 meet the recommended levels of activity, but by ages 13 to 15 only 8% still do.

Core principles for healthcare professionals

Healthcare professionals should:

  • know the needs of individuals, communities and population and the services available
  • think about the resources available in health and wellbeing systems
  • understand specific activities which can prevent, protect, and promote

Use the Making Every Contact Count training website to support all health care professionals to feel confident about raising weight issues, nutrition and physical activity as an issue.

Interventions

Population level

Healthcare professionals should be aware of the interventions at population level and the population context of obesity. These may include:

  • informing local commissioners about local issues that either help or hinder work to reduce child obesity
  • supporting local commissioners and providers to involve children, young people and families in commissioning and designing services so they meet the needs of local people
  • feeding back on where there are problems accessing support for families
  • identifying where services are working well
  • local Health and Wellbeing Boards tackling childhood obesity in the Joint Strategic Needs Assessment (JSNA) and Health and Wellbeing Strategy, action plan and local commissioning plans to address the needs of the population
  • local authorities setting out approaches in sports and physical activity plans and food strategies that improve the diet and levels of activity in local communities (which might include things like using supplementary planning guidance to limit the number of new hot food takeaways being opened near schools and leisure centres, or developing active travel plans for local schools, health services and leisure facilities
  • local authorities adapting the built environment to make healthier choices around physical activity and food choices (promoting opportunities for active play is a really important aspect of this to support both physical activity and social and emotional development of children in their early years)
  • being aware of the local physical activity offer to signpost children, young people and families into more active lifestyles (local authorities will often have a section of their website which provides information on what’s available locally and the County Sports Partnerships are local networks of physical activity providers who are often really keen to engage with local healthcare professionals to get the word out about what’s available)

Community level

Community level interventions may be based around a specific area or community of identity or interest, such as an ethnic minority community group.

Healthcare professionals can support these interventions by:

  • building community capacity to enable local families to promote healthy eating and physical activity through children centre group work or peer to peer programmes
  • promoting healthy food with community-led initiatives, for example improving cooking methods and use of healthier ingredients for particular ethnic groups and how to use healthy ingredients in low-income settings
  • working with the community to facilitate active lifestyles; examples include youth clubs, safe neighbourhoods, StreetPlay and outdoor play
  • considering how the working environment is promoting healthy food and physical activity for both staff and patients through things like active travel plans and using government food buying standards in all on-site catering and food and drink vending
Asset based community development approaches

Baby Friendly Standard is a UNICEF initiative which aims to create breast feeding friendly spaces to encourage and support breastfeeding, often supported by peer education and peer support networks. Healthcare professionals can support this work by:

  • ensuring your clinical space is breastfeeding friendly and all staff are trained to support and enable breastfeeding on-site for staff and clients
  • promoting breastfeeding as a positive choice for both mother and child and be aware of the local support offer
  • using evidence-based commissioning support tools to influence commissioning and ensure that breastfeeding support services are matched to local need

Children’s Centres provide a wide range of parenting support and advice and can be real hubs for intervention and signposting for families. Healthcare professionals can support their work by:

  • promoting awareness of the Healthy Start scheme which provides free vouchers to families on low-incomes that can be exchanged for fresh or frozen fruit or vegetables, milk and infant formula and vitamins for mother and baby
  • ensuring access to free vitamins for Healthy Start beneficiaries through children’s centres, clinics and other community settings by providing products directly to clients and through working with local commissioners to increase the number and type of access points such as community pharmacies

Whole school approaches to tackling dietary and physical activity issues amongst school aged children can be really effective. Healthcare professionals can support this work by:

  • offering evidence-based advice and ideas for using the Primary School Premium
  • encouraging schools to work proactively with the National Child Measurement Programme so that it is an integral element of the whole school approach to healthy weight and thinking about what role you can play in supporting children and young people who are identified as overweight or obese
  • utilising Our Healthy Year resources (helping school nursing teams explain NCMP and engage parents using classroom activities, information for head teachers and governors, practical tips to parents and educational tools)
  • supporting schools to adopt healthy eating policies, including hydration, which cover what food and drink is brought into the school as well as what the school provides
  • supporting the development of school bullying policies so that they include obesity and overweight as a possible cause and thinking about the role of school nurses and other professionals can play in supporting young people affected by bullying

Family and individual level

Healthcare professionals can have an impact at an individual level by:

  • acknowledging children, young people and parents’ concerns about weight issues and commending them for raising the issue and wanting to take action
  • recognising that individuals and families may take time to find the right solution for them; much like quitting smoking, achieving and maintaining a healthy weight sometimes takes multiple attempts to find the way that works best for the individual and there isn’t a single solution that works for everyone
  • using motivational interviewing techniques can help understand when a person wants to start improving their health
  • understanding that a healthy weight is primarily achieved through improving dietary intake and portion control and physical activity
  • understanding the specific activities and interventions which can support individuals and families to achieve and maintain a healthy weight
  • being aware of the services and support available locally, from the NHS, local authorities and voluntary and community sectors
  • engaging with children and their families to make links to local services, encourage their take up and reinforce the support that they offer
  • promoting breastfeeding and help mothers sustain breastfeeding (it is a protective factor against childhood obesity and provides a good start for a child’s nutritional grounding as they grow but, although just over 74% of women are starting to breastfeed their children, by 6 to 8 weeks this has fallen to less than 44%)
  • including information, advice and support around healthy lifestyle and where appropriate weight management as part of routine daily contact with children, young people and families; making every contact count as an opportunity to educate and empower children, young people and families to make positive choices about their own health
  • raising the conversation about weight issues with a young person or a family, often this might be as a result of the National Child Measurement Programme feedback letter
  • communicating the risks of being overweight and obese to a young person, parent or child
  • giving permission for a young person, parent or child to talk about weight issues by opening the conversation and raising the issue of weight
  • explaining the principles of the Eatwell Guide, 5-a-day and signpost families to further information on NHS choices and Change4Life
  • explaining the Chief Medical Officer’s physical activity guidelines for children and adults and advise about local opportunities for physical activity including active travel and active play
  • utilising the Start active, stay active: infographics explaining the Chief Medical Officer’s physical activity guidelines to achieve general health benefits for different age ranges
  • recommending families join Change4Life for tips, vouchers and recipes and to download the Food Smart app
  • standardising the approach across the service, for example, ensuring the 5 mandated health visitor reviews are offered for every family, or by ensuring all clinics have the Eat Well Guide and physical activity infographics displayed on the wall in the waiting room
  • being aware of the local Healthy Child programme and what is available through the universal and targeted support for families for children from birth to 19 years
  • thinking about how the service can support sharing appropriate data between health, education, social care and community organisations to target prevention activity and coordinate intervention
  • thinking about how the service can help smooth transitions between support services to wrap around the family and child and really provide holistic support to address weight issues using the NICE guidelines to really embed evidence-based practice
  • thinking about how you as a healthcare professional are role modelling healthy behaviours and how you can support your peers and colleagues with their own weight issues
  • signposting local weight management services that can help individuals and families eat healthier and balanced diets (think about what advice you can give to help them set realistic goals and start using the Eatwell guide to get a head-start and not lose the momentum to change)
Eatwell Guide

If you work with expectant or new parents think specifically about how you can:

  • talk about breastfeeding, introducing healthy solid foods and if appropriate Healthy Start vouchers for women who are receiving benefits or are less than 18 years old
  • encourage parents to sign up for the Start4Life information service for parents from 0 to 5 years; the service provides evidence based information for parents on pregnancy and child health development from 0 to 5 years, including important messages on breastfeeding initiation and continuation and improved nutrition

Healthcare professionals who work with young people can also think about:

  • using the strength of the advisory relationship that school nurses can build with older children and young people to address issues with low self-esteem associated with their body weight
  • having a conversation with a young person and about the support available locally for young people to support both their mental health and weight issues
  • how to discuss with young people their views on weight issues, achieving and maintaining a healthy weight and the dangers of ‘fad diets’

Measuring outcomes

At an individual and family level, weight outcomes should be measured through body mass index and waist circumference. Weight loss should be gradual to help individuals adjust to new healthy habits and maintain a healthy weight.

At a population level, the following outcome measures can help build a picture of the obesity related risk factors in the population:

  • Department of Health and Local Government Association’s guide for school readiness
  • the Early Years High Impact Area 4 which sets out the key components on health weight and nutrition for professionals and commissioners

Breastfeeding outcome measures

Breastfeeding rates are reported at a population level through the Public Health Outcomes Framework indicators. The data collected by NHS England includes:

National Childhood Measurement Programme data

Child obesity data from the National Child Measurement Programme (NCMP) 2006 and 2007 to 2015 and 2016 is now available in the online tool NCMP Local Authority Child Data Profile.

The tool:

  • provides local authority level child data (underweight, healthy weight, obese, excess weight, overweight including obese) for reception (aged 4 to 5 years) and Year 6 (aged 10 to 11 years)
  • presents trend data and enables easy comparison of local authority data, allowing users to compare regional neighbours and local authorities with similar characteristics
  • includes data quality indicators, for example, rate of participation in the NCMP
  • includes inequalities data (sex, deprivation and ethnic group) by local authority

Child health profiles provides a snapshot of child health and wellbeing for each local authority in England using key health indicators, which enables comparison locally, regionally and nationally.

Child Obesity and excess weight prevalence by clinical commissioning group (CCG) is prevalence data for reception (aged 4 to 5 years) and year 6 (aged 10 to 11 years) children by 2015 CCG of child’s residence. Prevalence data by CCG is supplied for each NCMP collection year from 2007 to 2013.

Guidance

NICE guidelines on obesity

Weight management before during and after pregnancy (PH27) includes 6 recommendations based on approaches that have been proven to be effective for the whole population.

Maternal and child nutrition (PH11) relates to pregnant women (and those who are planning to become pregnant), mothers and other carers of children aged under 5 and their children. It is particularly aimed at those on a low income or from a disadvantaged group.

Weight management: lifestyle services for overweight or obese children and young people (PH47) makes recommendations on lifestyle weight management (sometimes called tier 2) services for overweight and obese children and young people aged under 18.

Preventing excess weight gain (NG7) makes recommendations on behaviours that may help people maintain a healthy weight or prevent excess weight gain.

Obesity: working with local communities (PH42) aims to support effective, sustainable and community-wide action to prevent obesity.

Obesity Prevention (CG43) is the first national guidance on the prevention of overweight and obesity in adults and children in England and Wales.

NICE guidelines on physical activity

Physical activity for children and young people (PH17) is guidance for all those who are involved in promoting physical activity among children and young people, including parents and carers.

Physical activity and the environment (PH8) offers evidence-based recommendations on how to improve the physical environment to encourage physical activity.

Physical activity: brief advice for adults in primary care (PH44 aims to support routine provision of brief advice on physical activity in primary care practice.

NICE Quality Standards

Obesity in children and young people: prevention and lifestyle weight management programmes (QS94) covers a range of approaches at a population level to prevent children and young people aged under 18 years from becoming overweight or obese.

NICE advice

Preventing obesity and helping people manage their weight (LGB9) summarises NICE’s recommendations for local authorities and partner organisations on preventing people becoming overweight and obese and helping them to manage their weight.

Physical activity (LGB3) summarises NICE’s recommendations for local authorities and partner organisations on how to encourage people to be physically active.

Walking and cycling (LGB8) summarises NICE’s recommendations for local authorities and partner organisations on walking and cycling.

PHE, NHS and other government supporting materials

NOO PowerPoint slide sets present important data and information on child obesity in clear, easy to understand charts and graphics. The charts in the slide set can be used freely in publications and presentations with acknowledgement to Public Health England, Risk Factors Intelligence.

NOO data factsheets provide up-to-date important information and data about obesity and its determinants in an easily readable format.

Making the case for tackling obesity - why invest? PowerPoint slides illustrate the facts and figures about obesity, the costs, the benefits of investing and the potential routes to action.

Healthy weight calculator.

Healthy start offers free vouchers every week to spend on milk, plain fresh and frozen fruit and vegetables, and infant formula milk. You can also get free vitamins.

Start4Life offers help and advice during pregnancy, birth and parenthood.

NHS Choices tips for healthy eating provides 8 practical tips covering the basics of healthy eating.

The Eatwell Guide shows the proportions in which different types of foods are needed to have a well-balanced and healthy diet.

5-a-day gives advice and recommendations about the benefits of eating 5 portions of fruits and vegetables a day.

Guidance on healthier and more sustainable catering (PDF, 381KB, 17 pages).

Change4Life is an England and Wales campaign offering advice on making healthy choices and reducing sugar.

UK physical activity guidelines is advice from the Chief Medical Officer on how much physical activity people should be doing.

Start active, stay active: report on physical activity in the UK is UK-wide report with guidelines on the volume, duration, frequency and type of physical activity required to achieve general health benefits.

Everybody active, every day is an evidence-based framework to embed physical activity into everyday life.

National child measurement programme (NCMP) operational guidance advises local commissioners and providers on running the NCMP.

Other useful resources

Children’s Food Trust offers advice and guidance in cooking healthy meals from scratch.

The Caroline Walker Trust produces nutritional and practical guidelines to encourage eating well among vulnerable population groups.

First Steps Nutrition Trust is an independent public health nutrition charity that provides information and resources to support eating well from preconception to 5 years.