Obesity is a challenge to most health systems across the world, and international and national health strategies address the prevention, treatment and ongoing care needs for those with obesity. Obesity is defined as “abnormal or excessive fat accumulation that presents a risk to health”.1

Written by Dr Grace O’Malley, Clinical Lead, Child and Adolescent Obesity Service, Children’s Health Ireland/Principle Investigator, RCSI Obesity Research and Care Group

Diagnosing obesity in children requires:

1) an assessment of the volume and location of adipose tissue. At a practical level we assess fat tissue using the proxy measurement of body mass index (BMI). We then plot the BMI on age- and sex-adjusted BMI charts. The use of growth charts in childhood is essential.

2) assessment of body systems to determine whether the health of the child is affected by the level of fat tissue or having a body weight above a healthy level. Clinical assessment usually includes assessment of blood pressure and cardiovascular health, overall child development, cardiorespiratory health, musculoskeletal health, gastrointestinal health and mental health.

In Ireland 19% of primary school children and 26% of adolescents have body mass indices in the overweight or obese categories and children who attend schools with lower socioeconomic position have nearly double the likelihood of having obesity.2,3

Figure 1 Health Complications Associated with Obesity

Childhood obesity is concerning during childhood as it is linked to:

• Health difficulties as the child grows and develops (e.g. joint pain, breathing difficulties, skin problems, urinary incontinence)

• A higher risk of developing other chronic diseases in adulthood (e.g. certain cancers, type-2 diabetes, coronary heart disease)

• A higher risk of having obesity as an adult

See Figure 1 from Wyse et al

Due to the higher risk of health complications associated with childhood obesity, early diagnosis and treatment for obesity are important. A major challenge for health professionals is that few are trained in the area of obesity management.

As such it is essential that all health professionals complete basic training in this area. All pharmacists are welcome to complete the Online Childhood Obesity Training Course. The course includes a core module (1 hour) and four advanced modules (1 hour each) and is free of charge through the website www.childhoodobesity.ie.

Up to five FREE CPD points can be earned

Sometimes parents are unsure as to whether their child has obesity or not. It is important therefore, to appreciate the difference between a child whose body weight is above a healthy level for their age but has no health complications (is healthy) versus one who has a body weight above a healthy level PLUS health complications. Parents are often unsure where to go for information and the community pharmacist can play a key role in sharing evidencebased information with families and sign-posting families to suitable resources.

Pharmacist Role 1: using sensitive verbal communication

In 2014, a survey of Irish GPs indicated the majority found it difficult to broach the issue of childhood overweight during consultations. However when GPs started measuring growth in 5-12 year olds attending for unrelated care, parents and children did not find it traumatising, and over 98% of parents indicated this was both useful and acceptable.4 If a family attends the pharmacy and expresses concerns around childhood weight, overweight or obesity the pharmacist can play a key role in addressing the topic appropriately through use of sensitive, respectful and appropriate communication.

Example 1: Addressing parental concern

Parent: “I’m worried about my child’s weight – I think she is too heavy”

Pharmacist: “Children are growing and developing all the time so we would need to check what her growth is like compared to others her age. It’s good that you are thinking about her growth as sometimes children will have difficulties with their health if they gain weight faster than height. If you like we could measure her growth and check it on the growth chart?”

Note: Depending on the situation, it may be more appropriate to avoid speaking about growth in front of the child. In such cases you may decide to advice mum to make an appointment with the child’s GP.

Pharmacist Role 2: providing growth measurement

Depending on the type of pharmacy offering childhood growth measurement might be appropriate. In order to measure growth, pharmacies need to have a weighing scales and an appropriate height measure. In addition they need access to childhood growth charts which are available online (see example below). For a child over 2 years of age, the BMI-for-age centile is a more sensitive indicator of weight issues than the weight centile. A child who is plotted above the 91st centile on the BMI centile falls in the overweight category. A child who is plotted above the 98th centile on the BMI centile is in the very overweight/obesity category. Velocity of physiological weightgain varies between gender, therefore BMI-for-age charts are different for boys and girls.

Of note, the BMI cut-offs for children are not the same as adults, and as such, the BMI-for-age centiles should be used (e.g. a 13 year old boy with a BMI of 24.3kg/m2or a 5 year old girl with a BMI of 20kg/ m2 both plot above the 98th centile on respective sex-adjusted BMI-for-age charts). Both of these examples fall in the very overweight/obesity category.

Example 2: Offering/suggesting growth measurement

Parent: “Yes could you check how much she weighs please?”

Pharmacist: “It’s important that we check weight and height so that we can track her growth over time. We need to check how tall she is and how much she weighs. Then we will calculate her body mass index and check it on the growth chart. After that, you may need to visit your GP for more advice”

Note: For growth monitoring training see free courses at www. childhoodobesity.ie and HSELand Do not offer child/adolescent growth measurement if you have not been trained how to do this.

You can use online age- and sexadjusted growth charts to plot weight, height and BMI. You could also signpost the parent to an online growth calculator.

Pharmacist Role 3: explaining treatment options

With increased attention on antiobesity medicines used for adults, some parents may be requesting access to these treatments for their children. It’s crucial that parents are informed about the appropriate treatment options for children and teenagers. The current evidencebase suggests that children and teenagers be offered structured conservative treatment as the first step and all health professionals should be aware of the key targets for such treatment (see Fig 2):

• Getting enough sleep each night for the child’s age

• Drinking enough water and milk, avoiding sugar-sweetened drinks

• Eating child-sized portions of a wide variety of foods at regular times each day (usually 3 meals per day + 2 healthy snacks)

• Playing actively for 60 mins or more each day

• Limiting screen time (especially when eating meals and before/at bed-time)

• Limiting the amount of sitting each day

Example 3: Clarifying appropriate treatment

Parent: “I’d like to get her some anti-obesity drugs. I’ve heard they work really well”

Pharmacist: “The obesity drugs available at the moment are approved for adults. In rare cases if children have signs of type-2 diabetes their hospital doctor may prescribe an anti-obesity medication, so you should chat to your GP about that. For now, treatment should start with making sure she gets the right amount of sleep, play and nutrition for her age. I can show you where to find some helpful tips if you like?”

Note: You could print out the 8-healthy tips infographic or signpost parents to this information available from the childhood obesity training website of to the Safefood Guide for Family Health https:// www.safefood.net/family-health

Pharmacist Role 4: Signposting and onward referral

If parents report that the child has any difficulties with their development (e.g. speech, walking, vision, hearing or learning) the pharmacist should confirm whether the child has a GP. If so, a visit to the GP is recommended. If the child does not have a GP, the pharmacist should recommend that the parent register the child with a local GP and that a visit should be booked in order to check the child. Parents should be made aware that most GP practices offer free services to children under 8-years of age.

Parent: “I know my son is overweight but I don’t know what to do. I’m worried about him”

Pharmacist: “It’s good that you are thinking about your sons health and development. Some children have a body weight above a healthy level for their age and because of this they can have some difficulties with their health. I can suggest some information for you to read and tips to follow but it is really important that you bring him to the GP for a health check. Is he registered with a GP or a public health nurse?”

In summary, pharmacists can play an important role in helping families make decisions about trying to access appropriate health information, clinical assessment and treatment to support healthy child growth and development. In addition, pharmacists are key members of the multi-disciplinary health team and should be supported to access free training in this important area of practice.

Resources

• Up to date advice, tools, online training and research on childhood

obesity prevention and treatment: https://childhoodobesity.ie/ resources/

• Booklet for children and families that provides lifestyle advice needed in a friendly, non-judgemental and engaging way: https://w82go.ie/wpcontent/uploads/2021/01/W82GObooklet-20112020.pdf

• Safefood Ireland website have excellent videos, helpful for parents struggling with literacy, as well as friendly accessible material on good eating habits and food preparation https://www.safefood.net/familyhealth/active-at-home

• HSE Model of Care for Adult and Paediatric Obesity (2021)5 https:// www.hse.ie/eng/about/who/cspd/ ncps/obesity/model-of-care/

References available on request