The year-on-year increase in childhood obesity prevalence may be levelling off,1
but with one in five 11 yearolds currently defined as obese, the country remains faced with a potentially huge burden of increased, obesity-associated, morbidity, and early mortality.2
This has led to wide-ranging searches for effective policies and interventions to identify and treat this condition. Obesity is a clinical condition with no single associated outcome; the clinical problems are the resultant comorbidities, which include a higher risk of diabetes, cancer, and cardiovascular-related morbidity and mortality in adulthood,3,4
and there is evidence that many of the conditions classically considered those of adulthood are manifest in adolescence.5,6
Because obesity is not a distinct clinical problem, there is no single area of clinical practice that ‘owns’ the condition. This is evident in the debate about the management of childhood obesity, much of which revolves around the appropriate setting. There is also a recognised paucity of evidence regarding effective methods of treatment.6,7
The government has made child obesity a health priority, and as part of this strategy they have introduced the National Child Measurement Programme (NCMP),1
which annually records the body mass index (BMI) of all children at reception and year 6. It has also supported MEND,8
a community-based weight-management service, and initiated ‘Change4Life’,9
a range of printed and interactive resources that support healthier lifestyles for children and families.
The National Institute for Health and Clinical Excellence (NICE) recommends primary care as the main focus for the management of childhood obesity,10
and the Department of Health has published a care pathway for children and young people for primary care practitioners.11
However, recent research has cast doubt on the suitability of primary care as a resource for effectively tackling childhood obesity. Qualitative studies have shown that practitioners have expressed doubts about the appropriateness of primary care, arguing that their role should be identifying and alerting patients,12
and that they lack the resources and expertise to deal with a complex phenomenon with a wide range of potential causes.13
This paper examines important issues around identifying obese children and the most appropriate treatment setting. The data derive from the authors' experiences of recruiting patients to the Primary Care-Care Of Childhood Obesity Study (PC-COCO) based in Bristol.14
The study is a pilot randomised controlled trial evaluating the transferability of a successful hospital-based, childhood obesity clinic (the COCO clinic) into primary care. Briefly, the trial design is for obese children referred to the established hospital COCO clinic by their GP, to be recruited and then randomised either to the hospital clinic or to one of two nurse-led primary care clinics.
How this fits in
There is debate about the appropriate setting for the management of child obesity. The National Institute for Health and Clinical Excellence (NICE) has identified primary care as a key site in the identification and treatment of the condition. The data reported here cast doubt as to whether patients and families are willing to engage with primary care on this issue. Furthermore, the data also raise questions about the willingness of primary care practitioners to proactively engage with parents and families on this issue. Without a formal remuneration package and evidence-based care pathways, general practice seems unlikely to be a viable option for universal weight-management interventions. Further work is needed to identify how better to engage parents in discussions and action plans to support weight loss in their obese children, especially now that National Child Measurement Programme data are to be routinely fed back to parents by many primary care trusts.
To augment recruitment, the study team obtained ethical approval to contact local general practices to identify and contact parents of children whose BMI indicated they may be obese. This approach was considered a pragmatic solution to trial recruitment, although the research team had little knowledge of how many children's BMIs were actually recorded on GP databases. It is not routine practice for GPs to record height, weight, and BMI forschool-aged children. This is partly because recording children's BMI is not part of the general practice Quality Outcomes Framework (QOF) contract which determines payment levels to GPs.15
Obesity did feature in the 2006-2007 QOF contract but this was for adults only.15
Furthermore, NCMP data are currently not routinely fed back to the child's primary care practice for those measured in reception and year 6 of primary school.
The team also had to take into consideration the response of parents to an unsolicited invitation indicating their child was obese. Children's weight is a sensitive issue that can invoke shame and guilt in parents.16
Experience from other studies16-18
showed that a sensitively worded invitation letter could be an effective method of contact without causing offence or distress to recipients and their families.