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3.3 Overweight and Obesity
3.3 Overweight and Obesity
3.3 Overweight and Obesity
OVERWEIGHT
AND OBESITY
Learning points
1 The prevalence of obesity in toddlers is increasing. 7 Medical causes of obesity are rare but toddlers in whom
excess energy intake has been ruled out should be
2 The toddler years are an ideal time for families to make referred to a paediatrician. Any toddler with a BMI over
lifestyle choices to prevent obesity in childhood. the 99.6th centile should also be referred.
3 Body Mass Index (BMI) is a calculated relationship 8 Parental obesity is a very strong predictor of childhood
between height and weight and plotting BMI on a centile obesity.
chart is used to assess overweight and obesity. A BMI over
the 91st centile indicates overweight, and above the 98th 9 Often parents do not realise their toddlers or children are
centile is defined as obesity. overweight.
4 Normally the BMI of toddlers decreases from around their 10 Healthy family lifestyles are the key to preventing
first birthday onwards as they become slimmer until about childhood obesity and treating obesity in toddlers.
5-6 years when it begins to increase.
11 Healthcare professionals need an empathetic and non-
5 An early adiposity rebound, the point at which a toddler's judgemental approach to empowering families to make
BMI starts to increase again, is associated with a greater lifestyle changes.
risk of obesity in childhood.
PREVALENCE CAUSES OF
IN THE UK OVERWEIGHT AND
Recent national statistics show that around 12 per OBESITY
cent of English toddlers aged 2-3 years are obese and
a further 15 per cent are overweight1. In Scotland The vast majority of overweight and obesity is caused
almost 11 per cent of 2-6 year olds were found to be by an imbalance between energy intake (amount of
obese with a further 15 per cent overweight2 calories consumed in food and drinks) and energy
(National statistics define overweight as between the expenditure (amount of energy used in activity).
85th and 95th BMI centiles and obesity as at or above In toddlers, as in older children, the excessive weight
the 95th BMI centile). gain is a result of eating food energy in excess of the
energy requirements for their activity level and their
growth and development. The excess weight gain
accumulates as extra adipose tissue (fat) which
contributes to the physical and metabolic changes
seen in obesity.
02
USING BODY MASS INDEX (BMI)
TO DETECT OBESITY
Studies have shown that using clinical judgement to To assess if a toddler is overweight or obese, he or
determine whether a young child is overweight or she should be weighed and measured accurately using
obese is unreliable. Overweight and obesity must be calibrated equipment. See Factsheet 3.1 Calculate
assessed more objectively, using the BMI. the BMI to one decimal place and plot it on a BMI
centile chart for children. There is one for boys and
BMI is defined as weight in kilograms divided by the one for girls (see figures 1 and 2). These charts can be
square of height in metres (BMI=Wt/(Ht)2). Thus a ordered from www.healthforallchildren.co.uk and all
toddler who weighs 13.2 kg and is 91cm tall has a BMI healthcare professionals should have access to them.
of 13.2/0.91x0.91 = 15.9 (a healthy BMI range for
adults of 18.5 - 25 is not applicable to children). Fig. 1 BMI centile chart with 3 plots of two-and-a-half
year old boys showing: (a) - overweight, (b) - obese, (c)
- over the 99.6th centile, requiring referral
Calculating BMI
Weight in kilograms
BMI =
(Height in metres)2
13.2
BMI = = 15.9
0.91 x 0.91
03
Breastfeeding
TODDLERS WHO Whether breastfeeding in early infancy plays a role in
preventing obesity in childhood, remains
RISK DEVELOPING controversial. Formula-fed infants lose less weight in
the first few days after birth and their growth rate and
OBESITY IN pattern is different to that of exclusively breastfed
babies. This is one reason why the World Health
CHILDHOOD Organisation has created growth charts based on the
measurement of healthy breast-fed babies9. However
Adiposity rebound is the term given to the time there are many confounding lifestyle factors
when BMI begins to increase after falling to a low throughout the toddler years and early childhood, in
point at around four to five years. The Avon addition to the mode of milk feeding during infancy,
Longitudinal Study of Parents and Children (ALSPAC), that may contribute to the development of obesity6,10.
also known as Children of the 90s, showed that Exclusive breastfeeding remains the ideal way of
toddlers who have an early adiposity rebound at three feeding an infant until weaning for many other health
to four years of age are at risk of becoming obese in reasons.
childhood7.
04
LIFESTYLE IDEALS TO PREVENT OBESITY
Because preschool children are dependent on parents Limiting sedentary behaviour
and carers for their food and opportunities for physical Many toddlers spend a lot of time being babysat by a
activity, it is parents and carers who must take TV/DVD/video. There are no evidence based
responsibility for a healthy family lifestyle. guidelines for this in the UK, but in the USA and
elsewhere watching television is not recommended
However providing food is an emotional issue for for the under-two's. For those three and over the
parents and many are more concerned about their American Academy of Pediatrics recommends no
toddlers being underweight than overweight12. more than two hours per day of sedentary behaviours
Initiatives to improve lifestyles in families at risk of such as TV viewing15. The ALSPAC study showed that
obesity need to be undertaken sensitively and should three year olds who watched TV for more than eight
involve support for parents to improve their parenting hours a week (which is over one hour per day) were at
skills. Home visits by healthcare professionals during a higher risk of becoming obese at seven years old
pregnancy and infancy may be a time when parents than those who watched less7. Parents may need help
are receptive to advice on healthy eating for young exploring physical activities that can be substituted
children13. for sedentary behaviour watching TV or DVDs.
05
Healthcare professionals report that running cook- NICE guidance published in 2006 recommends that18:
and-eat sessions for parents improves their cooking
skills and their knowledge of healthy eating, and All nurseries and childcare facilities should:
empowers parents to provide healthier family meals.
minimise sedentary activities during play time, and
provide regular opportunities for enjoyable active
A balanced diet based on a combination of foods
play and structured physical activity sessions
from five groups is outlined in detail in Factsheet 1.2
implement Department for Education and Skills,
By eating the number of servings recommended in
Food Standards Agency and Caroline Walker Trust19
Table 1 toddlers will be assured of getting all the
guidance on food procurement and healthy
nutrients they need to grow and develop. Foods in
catering
the fifth food group are high in fat and sugar. Small
ensure that children eat regular, healthy meals in a
amounts of these foods are acceptable in a toddler
pleasant, sociable environment free from other
diet but many toddlers eat these foods to excess16
distractions (such as television). Children should be
- particularly sweetened drinks and high-fat snack
supervised at mealtimes and, if possible, staff should
foods such as crisps. Restricting these foods in today's
eat with children
environment requires discipline, as preschool children
naturally prefer energy dense foods17. Healthcare
Any programme to prevent obesity in preschool or
professionals could help parents to plan more
childcare settings should incorporate a range of
nutritious meals and snacks that they can then
components (rather than focusing on parental
substitute for the high-fat and high-sugar foods that
education alone).
they may normally offer.
diet: interactive cookery demonstrations, videos
Family meals and group discussions on practical issues such as
Toddlers need encouragement to learn to eat a meal planning and shopping for food and drink
variety of foods and they learn by copying others
See Factsheets 1.1 and 2.2 This is best achieved physical activity: interactive demonstrations, videos
during meals where the family all eat nutritious food and group discussions on practical issues including:
together in a calm, relaxed atmosphere with the TV - ideas for activities
switched off and no other distractions. Toddlers - encouraging more walking instead of always
should be allowed to stop eating when they signal using the car or pushing toddlers around in a
they have had enough - they should not be pressured pushchair
to finish all the food on their plate. Toddlers will also - opportunities for active play
benefit from a routine of meals and planned - concern for safety
nutritious snacks that fit around their sleeping pattern - availability of local facilities
so that the nutritious meals and snacks are given
To comply with this guidance it is good practice for
when they will accept them willingly. Toddlers who
healthcare professionals to have local knowledge of
are over-tired or over-hungry at a meal time may
facilities where toddlers can enjoy opportunities for
refuse to eat.
physical activity. Where facilities and opportunities are
poor practitioners could lobby their local authority to
provide affordable activities for families of young
children through Children's Centres. For example, this
may include a regular weekly subsidised
parent/toddler swim or an organised parent/toddler
health walk or active play group.
06
Table 1 Healthy eating recommendations for toddlers
Food Group Foods included Main nutrients supplied Recommendations for toddlers
1. Bread, cereals and Bread, chapatti, Carbohydrate Serve at each meal and some snacks
potatoes breakfast cereals, B vitamins
rice, couscous, Fibre
pasta, millet, Some iron, zinc and
potatoes, yam, and calcium
foods made with
flour such as pizza
bases, buns,
pancakes
2. Fruit and vegetables Fresh, frozen, Vitamin C Serve at each meal and some snacks.
tinned and dried Phytochemicals The more variety the better, although
fruits and Fibre this may be difficult to achieve with
vegetables Also Carotenes fussy eaters
pure fruit juices
3. Milk, cheese and Breast milk, infant Calcium Three servings a day
yogurt formula milks, Protein One serving is
follow-on and Iodine about 100-120ml/3-4oz milk in a
growing up milks, Riboflavin beaker or cup
cows' milk, yogurts, one pot yogurt or fromage frais
cheese, calcium a serving of cheese in a sandwich
enriched soya or on a pizza
milks, tofu a milk based pudding
a serving of tofu
4. Meat, fish and Meat, fish eggs, Iron Two servings a day
vegetarian pulses, dahl, nuts Protein Three for vegetarians
alternatives Zinc
Magnesium Fish should be offered twice per
B vitamins week and oily fish at least once per
Vitamin A week but no more than four servings
Omega 3 long chain per week for boys and two servings
fatty acids: EPA and per week for girls
DHA from oily fish
5. Foods high in fat Cream, butter, Oils such as olive, soya, Small amounts in addition to but not
and / or sugar margarines, walnut and rapeseed instead of the other food groups.
cooking and salad give a good balance of Too much of them increases the risk
oils, mayonnaise, omega 3 & 6 fatty acids of obesity
chocolate,
confectionery,
sweetened drinks,
jam, syrup, crisps
and other high fat
savoury snacks
See Factsheets 1.1 and 1.2 for further information about healthy eating.
07
Treating OVERWEIGHT AND obesity
NICE guidelines recommend that18:
a supportive environment should be created that helps overweight or obese children and their families to make
lifestyle changes
decisions on the approach to management of a child's overweight or obesity should be made in partnership
with the child and family and be tailored to the needs and preferences of both
weight management interventions should include behaviour change strategies to increase physical activity
levels or decrease inactivity, improve eating behaviour and the quality of the diet and reduce energy intake
dietary changes should be individualised, tailored to food preference and allow for flexible approaches to
reducing calorie intake
Most parents do not recognise that their toddlers The aim of treatment is to improve the energy
are overweight or obese, so healthcare professionals imbalance and this will be achieved by a combination
need to be sensitive when discussing the issue. of any of the following:
Parents could be asked how they feel about their
child's weight as a way of beginning a discussion. decreasing the energy content of food and drinks
Measurement of the toddler's weight and eaten by limiting high calorie foods and drinks
height/length could then be offered. Showing increasing physical activity
parents how the BMI of their overweight/obese decreasing sedentary behaviour
toddler relates to the normal range, by using the BMI ensuring adequate sleep for growth
centile chart, is a good way to continue the discussion.
The barriers to making these changes may be
Unless parents acknowledge that there is a problem considerable for some families because of:
and are ready to change their lifestyle there is little
that can be achieved for an overweight or obese the family lifestyle
toddler. lack of knowledge of what a healthy balanced diet is
lack of cooking skills to prepare lower energy foods
There is usually no need for overweight toddlers and housing and immediate local environment
young children to actively lose weight, but weight limited finances
gain should be slowed or stopped temporarily
through healthy eating and physical activity so that
BMI declines as the child grows taller.
08
SUPPORTING PARENTS TO MAKE
LIFESTYLE CHANGES
The whole family will need to make lifestyle changes
that become a normal part of their family life so that
they are maintained long-term.
09
Lifestyle changes may benefit from:
Goal setting. Begin by agreeing simple goals for Removing inconsistencies in the family
behaviour change and what benefits they will environment. Parents should limit the availability
achieve. Make sure the goals will not lead to conflict of foods and triggers that lead to overeating. Ideally
between family members and limit the number of they should, for example:
goals to three or less. Make the goals SMART (Table 2).
Keep records of the goals and the achievements not bring high calorie, low nutrient foods into the
so that they can be reviewed when necessary. When house at all
goals are not achieved, make it an opportunity to buy an individual packet rather than multi packs
re-evaluate motivation and the complexity or effort of snack foods or biscuits that must be stored
required to achieve that goal. somewhere in the house
not go to 'all you can eat for x' style restaurants
Reward systems. Toddlers are more willing to have set mealtimes, preferably with all the
repeat behaviours which are rewarded with parental family eating together
attention and praise. Parents should be encouraged to have readily available healthy snacks to use in
praise their toddlers for good behaviour and never to between meals
use food or drinks as rewards. More suitable rewards resist spontaneous snack rewards or incentives in
are, for example, playing indoor games with them, and outside the home
reading books to them, taking them on a swimming
trip or playing with them in the park.
Specific Have water or diluted fruit juice in place Choose healthy drinks
of sweetened squashes and fizzy drinks.
Dilute fruit juice using one part juice to
6-10 parts water
Measurable Limit crisps for everyone to 4-6 crisps Eat fewer crisps
at one meal each week
Achievable 1. Toddlers can walk the last 200 metres 1. Walk all the way to nursery
to nursery rather than being pushed in (which might be over a mile and
the buggy or driven in the car too far for a toddler to walk)
2. Use the stairs rather than escalators 2. Only use stairs, never escalators
or lifts in the shopping centre - (the family may live at the top of a tall
particularly when not encumbered with tower block)
heavy shopping or pushchairs
10
Page suitable for photocopying for healthcare professionals to give to parents
Obesity in children is becoming more eating a healthy diet and limiting foods
common and obese children tend to high in fat or sugar such as crisps,
remain obese as they grow up and sweets, and fizzy drinks to once a week
become adults. or less
Obese children have a weight that is too It is best to make small gradual changes to
great for their height. The excess weight is family behaviour. Make a list of changes
stored as fat which affects their health. you think will be possible for your family
Medical causes of obesity are very rare and to make. Choose up to three of them.
most children become obese because of Discuss them in your family and decide
their lifestyle. when you will start each change.
Children who are obese are more likely to Talk to your extended family, such as
get health problems such as asthma, high grandparents, aunts and uncles, about the
blood pressure, heart disease and changes you are making so that they will
diabetes. They are also more likely to be not undermine them when they see your
bullied. toddler. Also tell any other people who
come to your home, such as baby sitters
There are no medicines to treat young and friends.
children who are obese. The only way to
help toddlers and children overcome When the changes are successful choose
obesity is to increase activity and change up to three more to change.
the type of foods that the whole family eats. Praise your children when they make these
Toddlers learn by copying you and others changes. They are more likely to follow them
around them. The whole family making again as they like praise from parents.
changes towards a healthy family lifestyle Praise your children when they are active.
while your child is a toddler will help to For example: 'You are good at running and
prevent them becoming overweight or you run so fast now.'
obese as they get older. In this way When choosing rewards for your children,
toddlers learn and develop healthy habits. choose things other than food. Do not give
You may need to make lifestyle changes sweets or high-fat foods such as crisps as
such as: rewards.
increasing the time when you are all If toddlers are overweight or obese they
physically active - walking, playing do not have to lose weight. By staying the
together e.g. ball games, dancing, same weight they will get slimmer as they
swimming grow taller.
decreasing the time you spend in
sedentary pursuits - such as sitting
watching TV or playing computer
games
11
References
1. Health Survey for England 2010. Chapter 11 Children's BMI overweight and obesity.
2. The Scottish Health Survey. Vol 1: Main Report. Table 7.4 Proportion of children with BMI outwith the healthy range, and
prevalence of overweight and obesity in children, 1998, 2003, 2008, 2009, 2010, by age and sex.
3. Lagou V, Manios Y, Moran CN, Bailey ME, Grammatikaki E, Oikonomou E et al. Developmental changes in adiposity in toddlers
and preschoolers in the GENESIS study and associations with the ACE I/D polymorphism, 2007.
4. Oswal A, Yeo GS. The leptin melanocortin pathway and the control of body weight: lessons from human and murine
genetics. Obes Rev 2007 Jul; 8(4): 293-306.
5. Dorosty AR, Emmett PM, Cowin IS, Reilly JJ. ALSPAC Study Team. Factors associated with early adiposity rebound. Pediatrics
2000;105:1115-1118.
6. Hediger ML, Overpeck MD, Kuczmarski RJ, Ruan WJ. Association between infant breastfeeding and overweight in young
children. JAMA 2001;285:2453-2460.
7. Reilly JJ, Armstrong J, Dorosty AR, Emmett PM, Ness A, Rogers I et al. Early life risk factors for obesity in childhood: cohort
study. BMJ 2005;330:1357-1359.
8. Scottish Intercollegiate Guidelines Network (SIGN). Obesity in children and young people: a national clinical guideline SIGN
69 (www.sign.ac.uk).
9. www.who.int/childgrowth/standards
10. Clifford TJ. Breastfeeding and Obesity. BMJ 2003;327:879-880.
11. National Audit Office (NAO). Tackling Child Obesity - First Steps. London: The Stationery Office, 2006.
12. Pagnini DL, Wilkenfeld RL, King LA, Booth ML, Booth SL. Mothers of pre-school children talk about overweight and obesity:
The Weight of Opinion study,Journal of Paediatrics and Child Health 2007 (in press).
13. Bull J, McCormick G, Swann C, Mulvihill C. Ante-and post-natal home-visitng programmes: a review of reviews: Evidence
Briefing Health Development Agency 2004.
14. Department of Health 2011 Start active, stay active: a report on physical activity from the four home countries Chief Medical
Officers. DH, London.
15. Gidding SS, Dennison BA, Birch LL, Daniels SR, Gillman MW, Lichtenstein AH et al. American Heart Association Dietary
recommendations for children and adolescents: a guide for practitioners. Pediatrics 2006 117(2):544-59.
16. Gregory JR, Collins DL, Davies PSW, Hughes JM, Clarke PC. National Diet and Nutrition Survey: children aged 11/2 to 41/2 years.
Volume 1: Report of the diet and nutrition survey. Ministry of Agriculture, Fisheries and Food and Department of Health.
1995. London: HMSO.
17. Cooke L. The development and modification of children's eating habits. Nutrition Bulletin 2004;29:31-35.
18. NICE. Clincial Guideline 43. Obesity. 2006.
19. The Caroline Walker Trust (2005) http://www.cwt.org.uk
Further Reading
1. Matyka K. Managing obesity in children. Obesity In Practice 2002: 4 (2) 2-8.
2. Taheri S. The link between short sleep duration and obesity: we should recommend more sleep to prevent obesity. Arch Dis
Child 2006: 91: 881-884.
3. Zaninotto P, Wardle H, Stamatakis E, Mindell J and Head J. Forecasting Obesity to 2010. Prepared by the Joint Health Surveys
Unit for the Department of Health. 2006.
4. The Information Centre. Statistics on Obesity, Physical Activity and Diet: England, January 2008. Government Statistical
Centre. 2008. www.ic.nhs.uk/pubs/opadjan08
Glossary
Cushing's syndrome: caused by excessive levels of the hormone cortisol which causes rapid weight gain, particularly of the trunk and face
endocrine disorders: abnormalities of hormone secretion or action
growth hormone: a hormone secreted by the pituitary gland which stimulates growth and cell reproduction. It controls the growth in
toddlers and young children
hypothyroidism: insufficient production of thyroid hormone by the thyroid gland
leptin: a hormone secreted by adipose tissue, that plays a key role in regulating energy intake and energy expenditure, including the
regulation of appetite and metabolism
Prader-Willi syndrome: a condition due to a chromosomal abnormality. Babies are floppy at birth and go on to develop obesity due
to an excessive appetite and overeating. Other characteristics are small hands and feet, mental retardation, poor emotional and social
development and immature development of sexual organs and other sexual characteristics