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A discussion of the recent International Consensus Statement
In March 2005 an important document was published in the Journal of Clinical Endocrinology and Metabolism.1 It resulted f rom a meeting held at the Dead Sea in Israel 12 months previously where experts were invited to contribute to the development of a consensus on the widespread crisis in childhood obesity. The group consisted of 65 physicians and other health professionals representing nine countries on four continents. Their aim was to explore the available evidence on childhood obesity and develop a consensus as to the way forward.
The process was rigorous. In the months prior to meeting, participants were assigned to groups addressing prevalence, causes, risks, prevention, diagnosis, treatment, or psychology. Each group communicated electronically, selected key issues for their area, searched the literature, and developed a draft document. So, before they had even met, each group had drawn together their views based on the evidence available. Over the three day meeting every paragraph of these papers were debated, finalised, and signed, initially by each group, and then by the full meeting.
The result is an impressive document where the evidence is summarised, and recommendations developed. Given the importance and prevalence of childhood obesity, there is a remarkable lack of quality evidence,2 so a consensus of experts is a good starting point. The aim of the meeting was to provide a platform directed at future corrective action and to foster ongoing debate in the international community. This was achieved.
The strength of the Statement lies in its clear and succinct review of the evidence. Areas that are covered well include methods for assessing body fat and its distribution, the definition of overweight and obesity, the genetic determinants of obesity, endocrine aspects, psychosocial determinants, metabolic risks, and intervention. The section on treatment is particularly helpful, giving the rationale for intervening early, followed by the research evidence for diet and physical activity, as well as initial evidence for pharmacological and surgical treatments.
The mood of the meeting was positive and assertive. Full debate took place in small groups and in the larger forum, but by the close, there was agreement on a number of recommendations. These are summarised in table 1 and principally relate to:
The definition of obesity and overweight
The need for screening
Assessment of children who are already obese
Treatment and services
HOW SHOULD WE DEFINE OBESITY?
The definition of obesity requires a simple, low cost, accurate, and reproducible measure of fat mass, with relation to the risk of morbidity. Body mass index is far from ideal, but is clearly the only feasible clinical measure, although waist circumference, as a surrogate measure of visceral fat, also received attention because of its association with increased cardiovascular risk in adults.
Recommendations (see table 1) regarding definitions of obesity were based on the epidemiological evidence that impaired glucose intolerance, hypertension, triglycerides, C-reactive protein, and interleukin-6 concentrations all increase significantly when BMI is above the 95th centile.1 Even a BMI between the 85th and 95th centiles places children at increased risk, whereas metabolic disturbances are rare when BMI is below the 85th centile.
The International Obesity Task Force (IOTF) criteria were also discussed. These are based on adult cut-offs, modified for children.3 IOTF centile charts do not exist so they are not suitable for clinically monitoring, but they were supported for epidemiological use and international comparisons.
THE NEED FOR SCREENING AND ASSESSMENT
On the basis of metabolic risk, the meeting recommended that routine identification of obesity should be instituted in order to target lifestyle advice for those who are overweight and treatment for those who are obese. It went on to recommend that children above the high-risk cut-off should be screened for hypertension, sleep apnoea, thyroid and liver function tests, glucose impairment, lipid profile, and orthopaedic problems. Children at higher risk for the metabolic syndrome require full oral glucose tolerance tests, to be repeated periodically from the age of 10.
TREATMENT AND SERVICES
The arguments for intervening early are made forcefully and go beyond the fact that excessive weight gain in childhood increases the risks of adult obesity and its consequences: childhood obesity in and of itself adds to the risks of adult obesity beyond its tracking into adulthood; early vascular lesions are detectable in obese children as young as 3, suggesting that atherogenesis can begin in childhood; severe obesity in very young children already has its complications in terms of sleep apnoea and orthopaedic anomalies; and it is becoming increasingly apparent that glucose intolerance, type 2 diabetes, dyslipidaemia, and hypertension frequently have their onset before puberty. The point is made well therefore that good medical reasons exist for developing paediatric services rather than delaying care until adulthood. There was also some optimism that intervention at a younger age may be more successful and beneficial than treatment of established, severe obesity in adolescence or adulthood.
The Statement emphasises the central role of lifestyle change in treatment, and also maps out the pharmacological options and surgery in special cases. It comes down clearly on the need for obese children to receive specialist care, and for those with morbid obesity to be cared for by a multidisciplinary team.
IMPLICATIONS OF THE CONSENSUS FOR THE UK
The UK has among the highest figures for childhood obesity in the Western world with figures currently at 15.5%.5 Encouragingly there is an increasing public awareness of the problem and some political will for action, but no real clarity as to what is required. I (MCJR) therefore feel fortunate that I was invited to take part in the Consensus process. I was left with much food for thought, and also concern that what we have to offer in the UK is far behind those of colleagues elsewhere. I have to admit too that I was troubled that there was a lack of focus on the cost consequences of implementing recommendations at a population level.
The recommendation regarding identification of obese children is very much at variance with the debate taking place in the UK where most paediatricians would argue that screening is inappropriate until we have effective treatment to offer. I suspect that this in part is due to the fact that most participants worked in healthcare systems where regular review of children was possible, and so would not incur substantial costs. We do need to consider in our debate that we have only focused on screening for obesity per se. Once we grasp the enormity of the degree of morbidity already present, we may need to think again, especially as treatment for morbidity may become available before we have found ways to effectively impact on lifestyle.
The recommendation that obese children are fully assessed for comorbidity has further huge implications and costs. Children referred to endocrine services probably have most of the identified tests, but those seen in primary or secondary care probably do not—another example of inequity in paediatric care.
The recommendations regarding treatment largely hinged on an attitude shared by the participants that patients benefited from the care they received, despite the lack of evidence for effective interventions from randomised controlled trials.2 It seemed that the majority saw that the apparent absence of evidence was not evidence of absence. This positive attitude was so distant from attitudes I encounter in the UK, that on my return I surveyed 18 community paediatric colleagues and was not surprised to find that the majority confirmed that they rated their care of obese children as being both ineffective and unrewarding.
Why do we have such a difference in attitude here? It may well relate to the difference in resources and settings in which we work. I polled the Consensus participants to find out the form that their services for obesity take. The majority responded that they worked within settings where dietary and psychological support were readily available, and most worked in the context of good multidisciplinary teams.
My participation in the Consensus meeting left me feeling that it was indeed possible to have an impact on the problem of childhood obesity. It no doubt requires energy and resources, but that with effort much could be achieved. That was a year ago!
Despite the House of Commons Health Select Committee’s call on the NHS to ensure obese children have access to specialist care,4 progress is slow. Colleagues in the British Association of Community Child Health confirm that services are patchy across the country, with access to dietetic and psychological input often very limited with long waiting times, and few areas have specialist multidisciplinary teams. Our experience in Leeds is far from unique. We are struggling to find clinical or research support for a community obesity programme despite some promising results. The paediatric dietetic service accepts no referrals for obesity at all, and our specialist outpatient obesity clinic has no dietetic, psychology, or even nursing support, despite the increasing number of referrals for complex and very young children. Other agencies (Education and Leisure) are better resourced, but are providing initiatives that are not being properly evaluated. Leeds Leisure Services are even measuring BMI on all year 7 pupils in the city to identify obesity, but without reference to growth standards!
It seems that preventive measures are beginning to be put in place, universal monitoring is being discussed, but therapeutic services are lagging behind. If we are to achieve anything within this epidemic we need leadership and resources. This International Consensus Statement has provided a platform for debate and a direction for corrective action. It is worth reading for its review of the evidence and its conclusions. We hope it will stimulate fresh debate as to a way forward and the provision of enough resources that we can begin to provide adequate care for children suffering from obesity and its consequences.
A discussion of the recent International Consensus Statement
Competing interests: none declared
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