OBESITY
Childhood obesity
Julie Lanigan
Louise Tee
Rachael Brandreth
Abstract
Childhood obesity is a serious global health problem. It begins early in
life during the preschool years, and, for many, the obesity is carried for-
ward into later childhood and adult life. Once established, obesity is
difficult to reverse and is associated with poorer health outcomes in
the short and long term. Tackling obesity in childhood is important to
reduce life-long risk and protect health. However, service provision is
lacking in the UK and other countries. Interventions that are successful
in the prevention and management of childhood obesity are urgently
needed. These should ideally be evidence-based and target the youn-
gest children and their families. Multicomponent lifestyle programmes
and strategies can be effective in reducing childhood obesity. For
greatest success, these should be tailored to individual family needs.
Keywords Childhood; diet; lifestyle interventions; obesity; over-
weight; physical activity; preschool
Introduction
Obesity is a disease of modern life that begins in early childhood.
In the UK, >1 in 5 children are overweight on starting school.1
This is a concern as obese children have a higher risk of devel-
oping diseases including asthma and type 2 diabetes mellitus,
and are reported to have low self-esteem. Once established,
obesity tracks into adulthood and is associated with increased
risk of cardiovascular disease and certain cancers. Reducing
obesity is therefore an important public health goal.
This article considers the possible causes of childhood obesity,
how to identify children at risk, implications for health, prevention
strategies and treatment options. Given that obesity has its ante-
cedence in early childhood, the focus is on this age group.
Causes of obesity
In simple terms, obesity is the result of an energy imbalance. A
strong genetic tendency is indicated by the coexistence of obesity
Julie Lanigan PhD RD is a Registered Dietitian researching childhood
obesity prevention at University College London, Great Ormond
Street Hospital, Institute of Child Health, London, UK. Competing
interests: none declared.
Louise Tee BSc(Hons) RD is a Registered Dietitian working as a
Children’s Dietitian for Weight Management in the Early Years in
Cornwall and the Isles of Scilly, UK. Competing interests: none
declared.
Rachael Brandreth BSc(Hons) PGDip RD is a Registered Dietitian
working as Professional Lead for Dietetics in Cornwall and the Isles of
Scilly, UK. Competing interests: none declared.
MEDICINE xxx:xxx
Please cite this article as: Lanigan J et al., Childhood obesity, Medicine, https://doi.org/10.1016/j.mpmed.2018.12.007
Key points
C Obesity begins in early childhood during the preschool years
C The condition is hard to reverse and tracks into later childhood
and adult life
C Prevention is the best strategy to reduce prevalence of obesity
in children
C Parents or caregivers and children together are the main tar-
gets for interventions that aim to reduce the risk of obesity
in family members. However, external factors are key, and
obesity is widely accepted to result from interactions between
genes and environment.
Diet and physical activity, the risk factors most strongly
related to obesity, have changed markedly since the onset of the
obesity epidemic. This has helped to produce an ‘obesogenic’
environment in which susceptible individuals are more likely to
become overweight. An abundance of energy-dense foods, larger
portion sizes and more frequent episodes eating away from the
home have contributed to excessive energy intake in many in-
dividuals. At the same time, increased use of cars and labour-
saving devices, and online instead of realeworld interaction,
has led to lower physical activity and increased sedentary time.
Collectively, these behaviours favour a positive energy balance
that has contributed to the epidemic.
Once established, obesity is hard to reverse, so prevention is
likely to be the most effective strategy. Interventions targeting
known obesity-related risk factors should begin early with young
children, their parents and other caregivers.
Risk factors for obesity
Whereas lifestyle is the main driver of adult obesity, devel-
opmental factors have recently been identified as important
influencers in early life.2 The factors most strongly associ-
ated with obesity include infant feeding, rapid early
growth (upward centile-crossing) and less healthy dietary
behaviours.2
Infant and young child feeding
Breastfeeding is associated with a lower risk of obesity.3 This
may be partly due to the slower growth pattern of breastfed
compared with formula-fed infants. Faster growth in formula-
fed infants is partly caused by overfeeding: infant formulas
are higher in protein and energy than breast milk, and infants
fed by bottle consume more milk than those who are breast-
fed. Responsive breastfeeding and formula feeding, where a
mother responds appropriately to her infant’s cues of hunger
and satiety, are protective strategies against development of
obesity.
Timely and appropriate introduction of solid foods is impor-
tant in managing obesity risk. Dietary habits established here are
1 Ó 2018 Published by Elsevier Ltd.
 OBESITY

carried into later childhood. Less healthy dietary patterns, high in Assessment of obesity in infants and children
refined foods and low in fruit, vegetables and fibre, are linked to
Body mass index (BMI) centiles are not appropriate for clinical
an increased risk of obesity. Earlier introduction of solid foods
assessment of obesity in children <2 years of age. In this age
(before 4 months of age) is associated with a higher risk of
group, weight for height for age and gender at or above the 95th
obesity compared with later introduction (around 6 months of
centile indicates increased risk. Weight and height should be
age).
measured using calibrated equipment and plotted on an appro-
The preschool period is a pivotal time when lifestyle behav-
priate growth reference. Charts include the UKeWorld Health
iours continue to develop and are taken forward into later life.
Organization growth chart 0e4 years and the UK growth chart 2
Studies and dietary surveys report that the diets of preschool
e18 years.4 Based on the UK reference for children >2 years of
children do not meet recommendations. High intakes of protein,
age, overweight is indicated by a BMI at or above the 91st centile,
sugar-sweetened beverages, infant formula and cow’s milk, and
and obesity by a BMI at or above the 98th centile.
unhealthy dietary patterns, have all been linked with increased
risk of later obesity.
Referral and management
Physical activity and sedentary behaviour Parents of infants and children at high risk of becoming overweight
according to the criteria in Table 1 can be managed in primary care.
Low levels of physical activity and increased sedentary behav-
Careful questioning is needed to assess risk factors and guide
iour, including screen-based activities such as television,
management. After assessment, tailored advice to achieve a healthy
computer/tablet/phone-based games and social media, are
lifestyle can be provided. In growing children, the aim is to slow the
strongly associated with increased risk of chronic conditions
weight gain, rather than reduce body weight. Regular monitoring is
including obesity. In the UK and many other countries, it is
essential to support healthy growth and development.
recommended that preschool children should be physically
active for 3 hours daily, and school-aged children should take
Interventions to prevent obesity
part in moderate to vigorous intensity activity for at least 60
minutes every day. However, many children do not reach these The UK National Institute for Health and Care Excellence (NICE)
goals. recommends community-based multicomponent interventions
Establishing a healthy lifestyle during the early years is targeting diet, physical activity and behaviour change as the best
important for obesity prevention. strategy for preventing obesity in children. Interventions are

Risk assessment and management of overweight and obesity in infants and children
Causes for concern
C One or both parents overweight or obese
C Large size at birth (>4 kg) or large for gestational age
C Not breastfed or breastfed for shorter duration (<6 months)
C Rapid growth in infancy (upward crossing of 2 centiles (1 centile space) for weight or length)
C Early (<4 months of age) introduction of solids, diet above requirements for protein and energy
C Toddler/preschool diet: excessive (
500 ml/day) milk intake, high (
1 drink/day) sweetened beverage intake, high in protein and energy, dietary
pattern characterized by high intake of foods high in fat, sugar and salt, and low in fibre
C Toddler/preschool activity level and sedentary behaviour: time spent in moderate activity <3 hours. High time spent sedentary, >30 minutes
screen time daily
Referral criteria Referral options
0 to <2 years of age
One or both parents overweight or obese Monitoring in primary care (e.g. health visitor)
Rapid growth NICE Tier 1 or 2 lifestyle intervention (onward referral to Tier 3)a
Weight >2 centiles above length NICE Tier 1 or 2 lifestyle intervention (onward referral to Tier 3)
Weight for length >95th centile NICE Tier 1 or 2 lifestyle intervention (onward referral to Tier 3)

2 years of age
One or both parents overweight or obese Monitoring in primary care (e.g. health visitor)
Rapid growth NICE Tier 1 or 2 lifestyle intervention
Weight >2 centiles above length NICE Tier 1 or 2 lifestyle intervention
BMI
3.33 standard deviations above mean or as per local protocol NICE Tier 3 lifestyle intervention
BMI
98th centile with co-morbidities NICE Tier 3 lifestyle intervention
a
See Figure 1.

Table 1

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Please cite this article as: Lanigan J et al., Childhood obesity, Medicine, https://doi.org/10.1016/j.mpmed.2018.12.007
 OBESITY

Assessment framework if cause for concern identified

Cause for concern identified

Primary care assessment

• Measure and plot weight, length/height Consider
and BMI safe-guarding
• Consider lifestyle, co-morbidities and
readiness to change

If not ready to change, reinforce

Referral to appropriate family-focused
healthy lifestyle messages and
lifestyle interventions
allow to come back in future

Tier 3 – specialist assessment following

*Tier 1 – brief intervention
delivered by health visitor,
school nurse or family
support worker
Tier 2 – Lifestyle weight
Obesity Services for Children and
management programmes
Adolescents (OSCA) guidelines
Planet Munch
LEAF and Planet Munch

Follow-up and support to

enable maintenance

*NICE tiers indicate referral levels in the UK. These will differ internationally.
Source: Obesity Services for Children and Adolescents Network Group. OSCA Obesity Assessment Protocol: OSCA consensus
statement on the assessment of obese children & adolescents for paediatricians.
https://www.cornwallhealthyweight.org.uk/OSCA_Guidelines.pdf (accessed 3 Aug 2018).

Figure 1

most effective in younger children (age 6 years).5 Programmes
should include at least one other family member and can be
accessed by self-referral or via primary care practitioners. How-
ever, very few evidence-based programmes are available, and
only a small number target preschool children. Planet Munch is
one healthy lifestyle programme with evidence showing effec-
tiveness in reducing obesity risk in preschool children.
Planet Munch (Figure 1), also known as Trim Tots, was
developed to meet UK NICE guideline CG189. It is a 24-week
multicomponent programme with an emphasis on family
participation and learning through art and play. The intervention
has been evaluated in two small-scale randomized controlled
trials. The first trial tested the intervention in a high-risk popu-
lation who were already overweight or at increased risk; the
second was carried out in the general preschool population. In
trial 1, BMI was lower in the intervention group after participa-
tion compared with waiting list controls (mean difference in BMI
z-score 0.9, 95% confidence interval (CI) 1.4 to 0.4, p ¼
0.001). This was sustained in 39 children followed up 2 years
later, when BMI was lower than baseline (mean difference in
BMI z-score 0.3, 95% CI 0.6 to 0.1, p ¼ 0.007). In trial 2,
BMI was lower in the intervention group compared with controls
immediately after participation (mean difference in BMI z-score
0.3, 95% CI 0.8 to 0.3, p ¼ 0.3).
In England, almost a quarter of under-5s are already over-
weight, and severe obesity in children in year 6 (age 10e11
years) has reached the highest point since the National Child
Measurement Programme started in 2006. Thus, there is an ur-
gent need for obesity management services for families and
children. The Lifestyles, Eating and Activity for Families (LEAF)
programme has been successful in managing obesity in the early
years.
Lifestyles, Eating and Activity for Families programme
LEAF was developed to treat childhood obesity in line with NICE
guideline CG189 (Figure 1). The programme is available to
families of young severely obese children (6 years) living in
Cornwall and the neighbouring Isles of Scilly, supporting and
empowering families to lead healthier lifestyles. Families in areas
of high deprivation are prioritized because of a strong association
between socioeconomic status and obesity.
An initial home visit is made by the team’s paediatric dietitian
and physical activity advisor. This allows assessment of lifestyle
behaviours and the family’s motivation to change. After this, a full
assessment including anthropometry, beverage consumption,
physical activity level, sedentary time and sleep patterns is carried
out by the multidisciplinary team (including a paediatrician) in a
clinic setting.

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Please cite this article as: Lanigan J et al., Childhood obesity, Medicine, https://doi.org/10.1016/j.mpmed.2018.12.007
 OBESITY

made, are referred back to the primary care team. BMI data are
Examples of topics covered in community group reported to the multidisciplinary team for monitoring and further
workshops intervention if necessary. Families are offered further support if
Workshop title Topics covered there is no clinically significant reduction in BMI.

Getting started C What is a healthy person? Evaluation of LEAF programme: the programme was evaluated
C Principles of making changes in 76 children and found to be effective in reducing BMI (mean
C SMARTa goal and reward setting difference in BMI z-score 0.4, 95% CI 0.3 to 0.6; p < 0.001).
Getting the balance C Energy balance (energy in versus energy Forty-six children completed 2-day beverage diaries. Energy from
right out) beverages was lower after participation (median pre-intervention
C Nutrient balance 326 kcal/day, standard error  334 kcal/day; post-
C Promoting positive behaviour intervention  134 kcal/day, standard error 104 kcal/day; z-
Getting tuned in C Portion sizes score 4.77, p < 001). A
and ‘me-sized’ C Cravings
meals C Hunger and fullness cues
KEY REFERENCES
Getting over C Problem-solving
1 NHS Digitial. National Child Measurement Programme e England,
barriers C External triggers
2016e17. https://digital.nhs.uk/catalogue/PUB30113 (accessed 16
C Fats and sugars
Jan 2019).
C How thoughts and feelings affect our
2 Woo Baidal JA, Locks LM, Cheng ER, et al. Risk factors for
behaviour
childhood obesity in the first 1,000 days: a systematic review. Am J
Getting ready for C Food labelling
Prev Med 2016; 50: 761e79.
the future C Shopping
3 Victora CG, Bahl R, Barros AJ, et al. Breastfeeding in the 21st
C Budgeting
century: epidemiology, mechanisms, and lifelong effect. Lancet
C Recipe adaptation
2016; 387: 475e90.
Getting the kids C Keeping active/reducing sedentary
4 Royal College of Paediatrics and Child Health. UK-World Health
involved behaviour
Organization growth charts e 2e18 years. https://www.rcpch.ac.
C Widening food preferences
uk/resources/uk-world-health-organisation-growth-charts-2-18
C Where now?
years (accessed 16 Jan 2019).
a
A SMART goal is one that is defined as Specific, Measurable, Achievable, 5 Waters E, de Silva-Sanigorski A, Hall BJ, et al. Interventions for
Realistic and Time Limited. preventing obesity in children. Cochrane Database Syst Rev 2011;
12: CD001871.
Table 2

Community group workshops (Table 2) are held at local

centres. All family members can attend, and a creche is provided
to encourage engagement. Workshops of 3 hours’ duration are
Acknowledgements
delivered by the dietitian and physical activity advisor. Families
unable to attend are offered support at home.
The authors thank Lia Clarke, Cornwall Children’s Research Service/
A review takes place 3 months after completing the workshops.
University of Exeter for data analysis on the LEAF evaluation.
Families who have achieved a healthier lifestyle, evidenced by a
reduction in BMI and beverage consumption and increased phys-
ical activity, and who are confident to continue with the changes

TEST YOURSELF
To test your knowledge based on the article you have just read, please complete the questions below. The answers can be found at the
end of the issue or online here.

Question 1 What is the most appropriate measure of excess weight in

A 3-year-old child presented with her mother because the mother children of this age?
thought she was ‘getting too fat’. A Percentile growth charts plotting weight against age and
gender
B Body mass index (BMI) with figures denoting ‘overweight’
and ‘obesity’
C Gender-specific percentile charts plotting BMI against age
D Skin-fold thickness over the triceps muscle
E Bioelectrical impedance analysis

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Please cite this article as: Lanigan J et al., Childhood obesity, Medicine, https://doi.org/10.1016/j.mpmed.2018.12.007
 OBESITY
Question 2
A public health initiative is to reduce overweight and obesity
levels in children by targeting at risk populations.
Which of these combinations is most likely to be protective in
the early years?
A Prolongation of breastfeeding, avoiding rapid weight gain,
delaying introduction of solids to beyond 4 months,
establishing healthy dietary patterns, and encouraging >3
hours a day of moderate activity
B Early introduction of solids, 1 hour of activity per day, and
limited sugar and fat intake
C Cow’s milk intake of >500 ml/day, reduced sedentary
time, and a higher fibre diet
D Rapid growth in infancy, <30 minutes’ screen time per day,
and breastfeeding for >6 months
E Large size at birth, overweight parents, and no
breastfeeding
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Question 3
A 4-year-old child was reviewed. He had been seen 3 months
previously and had started on a programme designed to reduce
his weight.
Which of the following would be the strongest indicator that
obesity had decreased?
A. Weight gain was now less rapid
B. The child was now able to wear more age-appropriate/
appropriately sized clothes
C. When plotted, the body mass index (BMI) percentile had
decreased
D. Weight and height had increased, but the BMI centile
remained the same
E. The child was now able to run and play with friends
without getting out of breath as quickly
5 Ó 2018 Published by Elsevier Ltd.