Discussion

As part of this study, we aimed to establish the prevalence of childhood obesity at a single primary care centre. We found that 29.0% of 4- to 11-year-olds had overweight or obesity status, which reflects the national statistic of 28% (Health and Social Care Information Centre, 2019). The prevalence of childhood obesity has increased significantly over the last two decades (Van Jaarsveld and Gulliford, Reference van Jaarsveld and Gulliford2015), irrespective of various government initiatives. The most recent NCMP report shows that the prevalence of childhood obesity is still increasing, and thus a combination of both prevention and surveillance must be adopted to tackle this epidemic.

In the subgroup analysis, we found that the prevalence of obesity in current 10- to 11-year-olds had increased almost threefold from when they were 4–5 years old. This highlights a critical period in child health where increased surveillance for childhood obesity may be necessary. Early intensive interventions have successfully led to a BMI reduction in preschool children (Foster et al., Reference Foster, Farragher, Parker and Sosa2015), and thus, more regular height and weight measurements may be justified. Currently, the UK NSC does not recommend routine weight surveillance in children due to a lack of evidence showing its utility. This has been contested by the RCPCH, who maintain that a lack of evidence does not equate to ‘a lack of effectiveness’ (Royal College of Paediatrics and Child Health, 2018). It is our opinion that whilst there may not be strong evidence for routine weight measurements as part of a screening programme, there is likely a benefit to additional weight surveillance in primary care. Notably, the current 4- to 5-year-olds registered at the practice have an obesity prevalence of 16.4%. If these children follow the same trajectory as their predecessors, then we can predict that up to half of them will develop obesity over the next 6 years.

Most of the current efforts to tackle childhood obesity are in primary prevention. However, we must continue to support children who have become overweight or developed obesity. NICE currently recommends that children with a BMI >91st percentile are to be referred to weight management services (NICE, 2014). However, our study found that only 31.1% of eligible children had documented evidence that a referral had been considered. There is evidence that interventions in this age group can lead to a significant weight reduction (Ho et al., Reference Ho, Garnett, Baur, Burrows, Stewart, Neve and Collins2012); therefore, further investigation is needed to determine why appropriate referrals are not made. We propose that this shortcoming is multifactorial, with both personal and systematic elements. Firstly, healthcare professionals may lack the confidence to initiate conversations about weight management in children, especially as many parents disagree with feedback that their child is overweight or has obesity (Park et al., Reference Park, Falconer, Saxena, Kessel, Croker, Skow, Viner and Kinra2013). In our study, healthcare professionals considered referrals for 23 children; however, only one child was successfully referred to weight management services. From our observations, some parents can represent a significant barrier to service uptake even where referrals are justified. Additionally, there are systematic barriers such as the IT systems used in primary care. These often cannot easily calculate a paediatric BMI, and this prevents GPs from easily tracking changes in a child’s BMI percentile.

Finally, we also looked at the average duration of time since children last had their height and weight measured. We found that the average duration since last measurement was 20.3 months, with the longest duration being 70.4 months (5.9 years). We found significant variation in duration since last measurement between children of different age groups (Figure 1). Only children aged 4, 5 and 11 years had an average duration since last measurement of less than 12 months, which likely reflects involvement in the NCMP. Nine-year-old children had the highest average duration since last measurement at almost 32 months (2.6 years). Currently, the RCPCH proposes extending the NCMP to include children at birth, before school and in adolescence. We support this recommendation but also propose that the NCMP is extended to include children at 7–8 years old, in between the two current measurements. This would provide an invaluable opportunity to identify children who have recently become overweight or developed obesity, so that early interventions can be used to alter their trajectory. Furthermore, we believe that height and weight measurements in children should be financially incentivised via the quality of framework system, as is seen in adults. This may encourage primary care clinicians to include height and weight measurements as part of their paediatric consultations.

We wish to acknowledge that our cohort was taken from a single primary care centre that had a smaller proportion of children than the national average. It would be interesting to complete the same study at a practice with a higher proportion of children to see how the results may differ.