I recently read an article from the British Medical Association which advised that obesity in children needed to be tackled by all doctors, teachers and social workers, much in the same way as child protection matters; that the crisis in childhood obesity was such that it was beyond something that only health professionals should help manage.

The facts on childhood obesity and its negative impact on health outcomes are overwhelming. In 2012 almost 30% of children aged 2-15 years were estimated to be obese (Solmi 2015); and childhood obesity is associated with adult obesity and negative outcomes including diabetes, heart disease, stroke, asthma, polycystic ovaries, joint problems, poor mental health and cancer (Solmi 2015). Worryingly, with the increase in children’s waistlines, some of these conditions, only associated with adult poor health when I was at medical school (e.g. type 2 diabetes), are now regularly seen in childhood and adolescence (Solmi 2015).

And yet, as a clinician who is aware of all this, I still find it hard to do what the British Medical Association advises me to do. How exactly do I tell a teenage girl presenting with depression and low self-esteem in my clinic “Err, by the way, on top of everything else, you are over-weight.” You can see why that might not go down so well. Of course, if a child brings it up themselves, we jump at the chance to provide help, and in instances where children are clearly obese, I muster the courage to bring it forward as an issue, but where a child is just “overweight” rather an obese; I struggle to bring it up if it is not brought forward as an issue. Who wants angry parents shouting “We came here for your advice on mental health and you tell us our son is fat?” It’s not necessarily how I’d like to spend a morning, and yet, the best prevention for obesity is to curtail problems at this “over-weight” point before “obesity” has set in and psychological and behavioural patterns are entrenched. A quick consult of my medical colleagues and they say the same, unless the condition being consulted on is related to obesity, it is not brought forward routinely. Not many GPs are saying “Here’s the antibiotic for your chest infection, and by the way, I notice you are overweight so would you like a diet plan too?” I wonder if any teachers are actively calling out students and advising them of their weight issues, I would think that that was also pretty hard. Yet, if people in frontline contact with children getting increasingly poorer in health before their eyes do not stop to notify or intervene, what hope is there for prevention? Further as overweight children become the norm, we start to adjust our markers of normality and children who on measurement are overweight go unnoticed.

The issue of weight is a tricky one because of the links between weight, body image and self-esteem. Can you inform someone of their increasingly dangerous weight without affecting their self-esteem? If my own cowardly inaction is representative of most people, it would seem that most people think that you cannot; and there is a strong public perception that preserving self-esteem is more critical than informing someone that their current lifestyle choices may lead them to an early grave. The fear of precipitating low self-esteem and an eating disorder tends to ride high in people’s minds. Yet the prevalence of eating disorders is minute compared to the overwhelming problem of obesity. Reports indicate that even amongst the most at risk groups (females aged 10-19) the highest reported rates of anorexia only reach 34.6 per 100 000 population and bulimia 35.8 per 100 000. Do the maths, and that’s less than 1% of the population compared to 30% suffering from obesity.

The weight issue came up for me a few years back. My frugal upbringing meant that I grew up with the mantra of “Finish everything on your plate” and wasting food was a cardinal sin. I was denied chocolates and cakes, not because of worries about the waistline but purely because my parents couldn’t afford treats. The two unfortunate consequences of this upbringing on my own parenting were a) I continued my parents’ line of a waste not want not attitude to food; but b) I wanted to indulge my children with the cakes I never had.

So it shouldn’t have been such a surprise when Big Sis came home with the school health visitor card showing that she was 50^th percentile for height but 75^th percentile on weight; but it was a big surprise to me (it is optimal health-wise to be on the same percentile for weight as height). In my eyes, she did not look in any way over weight, yet, on paper, her percentiles were heading that way. When I told other mums about it, they all without fail thought denial was an appropriate option. “No, she’s fine, you shouldn’t worry.”; “It’s a mistake” or “You mustn’t let her know.” The thing was, I wasn’t worried, but there was no way that I was going to be in denial about it, and I worry that this type of supportive advice from other parents whilst well-intentioned is counter-productive. It may dissuade parents from taking action and lead to a false sense of security.

That night as Banker piled Big Sis’ plate up high with pasta and insisted she finish it as it was a waste to leave it, I made skewed eyes at him and squeaked side-ways out of my mouth “She doesn’t have to. If she’s full, she doesn’t have to finish it.” From then on, I consciously ensured that there were more healthy snacks around the house and *tried* to curtail the grandparents’ habit of allowing children free reign to chocolate and Oreos. The whole family got involved in more sport at the weekends. It wasn’t a big deal, but it needed to be in my consciousness so I could act. I don’t think that Big Sis’s self-esteem is linked to her weight and I hope to prevent it ever becoming so.

I do wish that we could talk more openly about weight without hurting people’s feelings. I hope that one day society can move towards consciously uncoupling self-esteem from weight; and weight can become a purely physical health concern (like a verruca?), and maybe then doctors, teachers and parents could better prevent this major and deadly health problem.

References:

Currin, Schmidt, Treasure & Jick. Time trends in eating disorder incidence. The British Journal of Psychiatry Jan 2005, 186 (2) 132-135.

Solmi & Morris. Association between childhood obesity and use of regular medications in the UK: longitudinal cohort study of children aged 5–11 years. BMJ Open 2015