Downloaded from http://adc.bmj.com/ on June 20, 2015 - Published by group.bmj.com
Editorials
2
3
documents/levels_trends_child_mortality_2013 (accessed 8 Dec 2014). Sidebotham P, Fraser J, Covington T, et al. Understanding why children die in high-income countries. Lancet 2014;384:915–27. Why Children Die. RCPCH and NCB 2014. http:// www.rcpch.ac.uk/index.php?q=child-health/
4
standards-care/health-policy/child-mortality/ child-mortality (accessed 8 Dec 2014). Viner R, Hargreaves D, Coffey C, et al. Deaths in young people aged 0–24 years in the UK compared with the EU15+ countries, 1970–2008: analysis of the WHO Mortality Database. Lancet 2014;384:880–92.
Is the childhood obesity crisis over in England? Julian Hamilton-Shield,1 Debbie Sharp2 Van Jaarsveld and Guilford report the results of their study on childhood obesity trends in England from 1994 to 2013 using primary care electronic healthcare records.1 There is undoubtedly some good news: the year on year rise in obesity levels seen in the first decade of data collection was extremely worrying when the odds of overweight or obesity increased by 8% yearly from 1994 to 2003. In the second decade up to 2013, this astounding increase had slowed to 0.4%. However, in this second decade, it remains extremely concerning that adolescent obesity (ages 11–15 years) appears to still be increasing in both boys and girls. The relative risk of remaining obese as an adult if obese in adolescence is very high,2 and the authors rightly point out that with a third of UK children being overweight or obese, the impact on public health remains a key public health priority. In general, the data from this study broadly agree with the latest Health Survey for England, although the levels of obesity are generally higher. For instance, Hospital Episode Statistics data for 2012 suggest a prevalence of obesity in young people aged 11–15 years of 18.7%3 while both boys and girls in Van Jaarsveld’s paper have prevalence levels between 20% and 25%. One reason the data from the Clinical Practice Research Datalink may give higher levels of obesity could be due to the fact that there is no incentive for general
1
NIHR Bristol Biomedical Research Unit in Nutrition, University of Bristol, Bristol, UK; 2Centre for Academic Primary Care, University of Bristol, Bristol, UK Correspondence to Professor Julian Hamilton-Shield, NIHR Bristol Biomedical Research Unit in Nutrition, University of Bristol, Level 6, Education Centre, Bristol Royal Hospital for Children, Bristol BS2 8AE, UK; [email protected]
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practitioners (GP) to measure height and weight in children routinely. In a study we conducted locally in 27 general practices, only 11.6% of children aged 5–16 years had a body mass index recorded in the practice notes in the two years prior to the study.4 Thus, it is likely the data accrued from the primary care electronic records have an ascertainment bias as children with particular clinical features or problems such as those seeking help for obesity or whose parents are concerned about poor appetite or eating habits are more likely to have measurements recorded. Despite the possibility of a degree of overestimation of the problem in the current study, what is staggering is that both data sets identify that between one in four and one in five adolescents in this country are obese. The implications for such levels of adolescent obesity are profound. Numerous studies in the UK and internationally have demonstrated a litany of complications attendant on significant adolescent obesity, including, but not exclusively, type 2 diabetes, liver disease, sleep apnoea, worsening asthma, gallstones, idiopathic intracranial hypertension and psychological distrurbance.5 In addition, directly through the tracking of obesity into adult life and probably through childhood obesity itself at critical moments of organ development such as in puberty, childhood obesity has implications for adult onset cardiovascular, metabolic and cancer risk. Yet in the face of this scenario, we still have no randomised trial evidence that community-based, lifestyle interventions for childhood obesity are effective. The vast majority of interventions currently being adopted in local authorities in England have little or no robust evidence base nor are outcomes available for external scrutiny. In addition, we know that parents and clinicians struggle to recognise obesity in their
5
6
Fraser J, Sidebotham P, Frederick J, et al. Learning from child death review in the USA, England, Australia, and New Zealand. Lancet 2014;384:894–903. Sidebotham P, Fraser J, Fleming P, et al. Patterns of child death in England and Wales. Lancet 2014;384:904–14.
children or patients and many parents are yet to be convinced that childhood obesity is a serious enough health concern to merit engagement in a structured weight management intervention.6 What is needed to address this rather disturbing impotence to effect real change is research on new avenues of preventative and therapeutic practice addressing not only activity and diet but also eating, sleep and sedentary behaviours. In terms of public health measures that might impact upon obesity prevalence, the government needs to consider how to better inform the general public of the consequences of obesity in order to change attitudes in a subgroup of the population that seem inured to the message that childhood obesity is actually a major health problem for individual families. Revisiting the notion of a ‘fat-tax’ or perhaps more specifically a ‘sugar-tax’ seems prudent as such taxation policies are not necessarily regressive if real improvements in health can be elicited: the paradigm being tobacco taxation. Given the magnitude of the current obesity problem, specialised clinics in secondary care are never going to be able to address this issue. General practice is the medical arena for the identification of obesity and initiation on a treatment pathway. We have long argued that National Child Measurement Programme data should be routinely fed back to GP and there is a cogent argument for either adding a third measure of adiposity in teenagers within schools or in general practice, in the latter case perhaps as a Quality and Outcomes Framework target. In young women in particular, this is an age group that might be starting to visit GP to discuss contraception, which would offer an ideal opportunity for a discussion about lifestyle including weight. Schools offer another possible location for lifestyle advice to obese pupils if the school nursing service felt able to take this on. Once engaged, families need effective weight management interventions that are accessible, family based and culturally relevant. Local authorities commissioning weight management interventions need to do far more to ensure the clinical and cost-effectiveness of Arch Dis Child March 2015 Vol 100 No 3
Downloaded from http://adc.bmj.com/ on June 20, 2015 - Published by group.bmj.com
Editorials the services they finance. But in order to do this, they need robust evidence. Thus far, we simply do not seem to have the tools to manage this problem effectively. The childhood obesity crisis is England is far from over, and our current weapons in the war against fat seem unlikely to provide the answer. The recent call to the chief medical officer to develop a ‘Child Obesity Action Group’ may prove a first step in what is likely to be a very long campaign. Disclaimer This is an independent opinion from a National Institute for Health Research Biomedical Research Unit (NIHR BRU). The views expressed in this publication are those of the authors and not necessarily those of the National Health Service, the NIHR or the Department of Health.
Arch Dis Child March 2015 Vol 100 No 3
Contributors Both authors contributed to the writing of this editorial.
REFERENCES 1
Competing interests None. Provenance and peer review Commissioned; internally peer reviewed.
2
To cite Hamilton-Shield J, Sharp D. Arch Dis Child 2015;100:212–213.
3
Received 2 December 2014 Accepted 12 December 2014 Published Online First 29 January 2015
4
5
▸ http://dx.doi.org/10.1136/archdischild-2014-307151 Arch Dis Child 2015;100:212–213. doi:10.1136/archdischild-2014-307870
6
van Jaarsveld CHM, Gulliford MC. Childhood obesity trends from primary care electronic health records in England between 1994 and 2013: population-based cohort study. Arch Dis Child 2015;100:214–19. Guo SS, Chumlea WC. Tracking of body mass index in children in relation to overweight in adulthood. Am J Clin Nutr 1999;70(1 Part 2):145S–8S. PHE publications gateway number: 2014264 Published: August 2014. http://www.haringey.gov.uk/ phe_2014_-_child_weight_factsheet.pdf Banks J, Shield JP, Sharp D. Barriers engaging families and GPs in childhood weight management strategies. Br J Gen Pract 2011;61:e492–7. Neef M, Weise S, Adler M, et al. Health impact in children and adolescents. Best Pract Res Clin Endocrinol Metab 2013;27:229–38. Hamilton-Shield J, Goodred J, Powell L, et al. Changing eating behaviours to treat childhood obesity in the community using Mandolean: the Community Mandolean randomised controlled trial (ComMando)—a pilot study. Health Technol Assess 2014;18:i–xxiii, 1–75.
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Downloaded from http://adc.bmj.com/ on June 20, 2015 - Published by group.bmj.com
Is the childhood obesity crisis over in England? Julian Hamilton-Shield and Debbie Sharp Arch Dis Child 2015 100: 212-213 originally published online January 29, 2015
doi: 10.1136/archdischild-2014-307870 Updated information and services can be found at: http://adc.bmj.com/content/100/3/212
These include:
References Email alerting service
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This article cites 5 articles, 3 of which you can access for free at: http://adc.bmj.com/content/100/3/212#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Press releases (49)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Editorials
2
3
documents/levels_trends_child_mortality_2013 (accessed 8 Dec 2014). Sidebotham P, Fraser J, Covington T, et al. Understanding why children die in high-income countries. Lancet 2014;384:915–27. Why Children Die. RCPCH and NCB 2014. http:// www.rcpch.ac.uk/index.php?q=child-health/
4
standards-care/health-policy/child-mortality/ child-mortality (accessed 8 Dec 2014). Viner R, Hargreaves D, Coffey C, et al. Deaths in young people aged 0–24 years in the UK compared with the EU15+ countries, 1970–2008: analysis of the WHO Mortality Database. Lancet 2014;384:880–92.
Is the childhood obesity crisis over in England? Julian Hamilton-Shield,1 Debbie Sharp2 Van Jaarsveld and Guilford report the results of their study on childhood obesity trends in England from 1994 to 2013 using primary care electronic healthcare records.1 There is undoubtedly some good news: the year on year rise in obesity levels seen in the first decade of data collection was extremely worrying when the odds of overweight or obesity increased by 8% yearly from 1994 to 2003. In the second decade up to 2013, this astounding increase had slowed to 0.4%. However, in this second decade, it remains extremely concerning that adolescent obesity (ages 11–15 years) appears to still be increasing in both boys and girls. The relative risk of remaining obese as an adult if obese in adolescence is very high,2 and the authors rightly point out that with a third of UK children being overweight or obese, the impact on public health remains a key public health priority. In general, the data from this study broadly agree with the latest Health Survey for England, although the levels of obesity are generally higher. For instance, Hospital Episode Statistics data for 2012 suggest a prevalence of obesity in young people aged 11–15 years of 18.7%3 while both boys and girls in Van Jaarsveld’s paper have prevalence levels between 20% and 25%. One reason the data from the Clinical Practice Research Datalink may give higher levels of obesity could be due to the fact that there is no incentive for general
1
NIHR Bristol Biomedical Research Unit in Nutrition, University of Bristol, Bristol, UK; 2Centre for Academic Primary Care, University of Bristol, Bristol, UK Correspondence to Professor Julian Hamilton-Shield, NIHR Bristol Biomedical Research Unit in Nutrition, University of Bristol, Level 6, Education Centre, Bristol Royal Hospital for Children, Bristol BS2 8AE, UK; [email protected]
212
practitioners (GP) to measure height and weight in children routinely. In a study we conducted locally in 27 general practices, only 11.6% of children aged 5–16 years had a body mass index recorded in the practice notes in the two years prior to the study.4 Thus, it is likely the data accrued from the primary care electronic records have an ascertainment bias as children with particular clinical features or problems such as those seeking help for obesity or whose parents are concerned about poor appetite or eating habits are more likely to have measurements recorded. Despite the possibility of a degree of overestimation of the problem in the current study, what is staggering is that both data sets identify that between one in four and one in five adolescents in this country are obese. The implications for such levels of adolescent obesity are profound. Numerous studies in the UK and internationally have demonstrated a litany of complications attendant on significant adolescent obesity, including, but not exclusively, type 2 diabetes, liver disease, sleep apnoea, worsening asthma, gallstones, idiopathic intracranial hypertension and psychological distrurbance.5 In addition, directly through the tracking of obesity into adult life and probably through childhood obesity itself at critical moments of organ development such as in puberty, childhood obesity has implications for adult onset cardiovascular, metabolic and cancer risk. Yet in the face of this scenario, we still have no randomised trial evidence that community-based, lifestyle interventions for childhood obesity are effective. The vast majority of interventions currently being adopted in local authorities in England have little or no robust evidence base nor are outcomes available for external scrutiny. In addition, we know that parents and clinicians struggle to recognise obesity in their
5
6
Fraser J, Sidebotham P, Frederick J, et al. Learning from child death review in the USA, England, Australia, and New Zealand. Lancet 2014;384:894–903. Sidebotham P, Fraser J, Fleming P, et al. Patterns of child death in England and Wales. Lancet 2014;384:904–14.
children or patients and many parents are yet to be convinced that childhood obesity is a serious enough health concern to merit engagement in a structured weight management intervention.6 What is needed to address this rather disturbing impotence to effect real change is research on new avenues of preventative and therapeutic practice addressing not only activity and diet but also eating, sleep and sedentary behaviours. In terms of public health measures that might impact upon obesity prevalence, the government needs to consider how to better inform the general public of the consequences of obesity in order to change attitudes in a subgroup of the population that seem inured to the message that childhood obesity is actually a major health problem for individual families. Revisiting the notion of a ‘fat-tax’ or perhaps more specifically a ‘sugar-tax’ seems prudent as such taxation policies are not necessarily regressive if real improvements in health can be elicited: the paradigm being tobacco taxation. Given the magnitude of the current obesity problem, specialised clinics in secondary care are never going to be able to address this issue. General practice is the medical arena for the identification of obesity and initiation on a treatment pathway. We have long argued that National Child Measurement Programme data should be routinely fed back to GP and there is a cogent argument for either adding a third measure of adiposity in teenagers within schools or in general practice, in the latter case perhaps as a Quality and Outcomes Framework target. In young women in particular, this is an age group that might be starting to visit GP to discuss contraception, which would offer an ideal opportunity for a discussion about lifestyle including weight. Schools offer another possible location for lifestyle advice to obese pupils if the school nursing service felt able to take this on. Once engaged, families need effective weight management interventions that are accessible, family based and culturally relevant. Local authorities commissioning weight management interventions need to do far more to ensure the clinical and cost-effectiveness of Arch Dis Child March 2015 Vol 100 No 3
Downloaded from http://adc.bmj.com/ on June 20, 2015 - Published by group.bmj.com
Editorials the services they finance. But in order to do this, they need robust evidence. Thus far, we simply do not seem to have the tools to manage this problem effectively. The childhood obesity crisis is England is far from over, and our current weapons in the war against fat seem unlikely to provide the answer. The recent call to the chief medical officer to develop a ‘Child Obesity Action Group’ may prove a first step in what is likely to be a very long campaign. Disclaimer This is an independent opinion from a National Institute for Health Research Biomedical Research Unit (NIHR BRU). The views expressed in this publication are those of the authors and not necessarily those of the National Health Service, the NIHR or the Department of Health.
Arch Dis Child March 2015 Vol 100 No 3
Contributors Both authors contributed to the writing of this editorial.
REFERENCES 1
Competing interests None. Provenance and peer review Commissioned; internally peer reviewed.
2
To cite Hamilton-Shield J, Sharp D. Arch Dis Child 2015;100:212–213.
3
Received 2 December 2014 Accepted 12 December 2014 Published Online First 29 January 2015
4
5
▸ http://dx.doi.org/10.1136/archdischild-2014-307151 Arch Dis Child 2015;100:212–213. doi:10.1136/archdischild-2014-307870
6
van Jaarsveld CHM, Gulliford MC. Childhood obesity trends from primary care electronic health records in England between 1994 and 2013: population-based cohort study. Arch Dis Child 2015;100:214–19. Guo SS, Chumlea WC. Tracking of body mass index in children in relation to overweight in adulthood. Am J Clin Nutr 1999;70(1 Part 2):145S–8S. PHE publications gateway number: 2014264 Published: August 2014. http://www.haringey.gov.uk/ phe_2014_-_child_weight_factsheet.pdf Banks J, Shield JP, Sharp D. Barriers engaging families and GPs in childhood weight management strategies. Br J Gen Pract 2011;61:e492–7. Neef M, Weise S, Adler M, et al. Health impact in children and adolescents. Best Pract Res Clin Endocrinol Metab 2013;27:229–38. Hamilton-Shield J, Goodred J, Powell L, et al. Changing eating behaviours to treat childhood obesity in the community using Mandolean: the Community Mandolean randomised controlled trial (ComMando)—a pilot study. Health Technol Assess 2014;18:i–xxiii, 1–75.
213
Downloaded from http://adc.bmj.com/ on June 20, 2015 - Published by group.bmj.com
Is the childhood obesity crisis over in England? Julian Hamilton-Shield and Debbie Sharp Arch Dis Child 2015 100: 212-213 originally published online January 29, 2015
doi: 10.1136/archdischild-2014-307870 Updated information and services can be found at: http://adc.bmj.com/content/100/3/212
These include:
References Email alerting service
Topic Collections
This article cites 5 articles, 3 of which you can access for free at: http://adc.bmj.com/content/100/3/212#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Press releases (49)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
