TACKLING CHILDHOOD OBESITY
Presentation to the Oireachtas Committee on
Health and Children
Thursday 13th June @ 9.30am
PANEL
From Temple Street Children’s University Hospital
· Dr Sinead Murphy, Consultant Paediatrician and Clinical Lead, W82GO! (Childhood Obesity) Programme
· Dr Aoife Brinkley, Senior Clinical Psychologist
· Grace O’Malley, Senior Physiotherapist, W82GO! (Childhood Obesity) Programme
· Kizzy Moroney, Paediatric Dietitian
From INDI (Irish Nutrition and Dietetic Institute)
· Richelle Flanagan, Dietitian and President, INDI
· Emma Ball, Community Dietitian Manager, HSE North West
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OPENING STATEMENT (V4)
(1) Dr Sinead Murphy, Consultant Paediatrician and Clinical Lead, W82GO! (childhood
obesity) programme, Temple Street
On behalf of the W82GO! programme at the Children’s University Hospital Temple Street and the Irish Nutrition and Dietetic Institute, we would like to thank the Chairman and the Committee for the opportunity to present on the enormous challenge and growing epidemic of childhood obesity.
I would like to begin by contextualising our role in childhood overweight and obesity in Ireland.
I am a Paediatrician and Clinical Lead on the W82GO! Programme which was established eight years ago by a group of committed, enthusiastic health care professionals in Temple Street Children’s University Hospital. I would like at this point to bring your attention to the fact that the W82GO! programme and my position as Clinical Lead on this programme is funded in its entirety by Temple Street’s fundraising arm; Children’s Fund for Health and a research grant which was awarded by the Health Research Board to one of our team members. When this grant expires, the service which is the only one of its kind in Ireland will be forced to cease.
We have joined forces with the INDI in the belief that together and with your support we can address this catastrophe with the urgency that it deserves.
I am joined by representatives from the W82GO! multidisciplinary team, namely Grace O’Malley (physiotherapist, also representing the ASOI - Association for the Study of Obesity in Ireland), Kizzy Moroney (Dietitian with W82GO!) Programme), Dr Aoife Brinkley (Senior Psychologist) and also by Richelle Flanagan (DietiTian and President INDI) and Emma Ball (Community Dietitian Manager).
Childhood Obesity – the Facts
· Recent figures show that 31.8 % of Irish 7 year olds are either overweight or obese, that is more than 1: 4 of our school children. This translates to 100,000 children who are obese and 300,000 children who are overweight in Ireland. The problem begins in childhood and is beginning earlier and earlier – currently 6% of 3 year olds are obese).
· This ranks Ireland in 5th place among 27 EU countries.
· Childhood obesity disproportionately impacts on lower socioeconomic groups. This fact must be considered when addressing potential solutions.
· The situation is steadily getting worse and moreover we know that 70% of these children will become obese adults.
Co-morbidities
· With regard to co-morbidities, the essential and extremely worrying fact is that children are already showing the ill effects of overweight and obesity in childhood.
· Unless these children are provided with the treatment which they need when they need it – which is a matter of extreme urgency, they will have a shorter life expectancy than their parents.
· Over the past 5 years, the W82GO! team has collected data on the co-morbidities in the children who have attended for treatment:
· 70% have musculoskeletal problems
· 40% have high cholesterol levels
· 50% have high blood sugar levels which means that they are well along the pathway to develop early Type 2 Diabetes Mellitus
· 30% have breathing problems
· When it comes to mental health of these children and young people the figures are even more shocking with 60% reporting psychological difficulties such as poor self esteem and depression with 11% reporting severe bullying.
If left untreated, these children will become adults who are obese in whom the complications of obesity such as stroke, heart disease, infertility and increased risk of multiple cancers are well recognised.
The key message is that this can be prevented.
The Cost
Currently the allocation of funding to the pandemic of childhood obesity is patchy and wholly inadequate.
The cost of adult obesity to the state is in excess of 1 billion euro per annum. This will continue to rise exponentially unless childhood obesity is addressed.
The average child who is obese (of whom there are 100,000 in Ireland), if left untreated costs in the region of €5, 000 per year as a direct cost of treating co morbidities in our paediatric centres.
Need for urgent treatment service provision
Childhood obesity is a highly complex issue which if not addressed as a matter of extreme urgency will have far reaching consequences for the children, their families, future generations and the already massively pressurised health care system.
We must recognise that there are multiple stake holders involved in this epidemic and all of these must share the responsibility when it comes to treatment. Stake holders such as the food industry and advertising agencies need to be encouraged by government to play a role. Additionally, resources such as education which have such wide arching “listenership” and have such great influence on our children need to be facilitated to play their part in addressing this issue
Adult studies and experience show that sustainable weight reduction is extremely difficult in adults who are obese but data so far available indicate that the right programme can in fact achieve sustainable weight reduction and improved cardio metabolic health in children.
A gap analysis conducted by the INDI showed that in spite of almost 1:4 of our children being overweight or obese, 88% of these children and their families do not have access to an overweight or obesity treatment programme. There is one acute hospital based programme which is research grant funded and has a waiting list if 12 months. We know that children on these waiting lists get worse and that co-morbidities increase.
Treatment needs to be available for all children when they need it and where they need it.
Evidence shows that the earlier the treatment, the more likely it is to be successful.
The children of Ireland urgently require treatment programmes at community level to treat overweight and ultimately prevent it and in the hospital setting where specialised multi disciplinary treatment is available to address the current crisis of childhood obesity and its co-morbidities.
We know that a piecemeal approach to a complex problem of this size will not work. An integrated, strategic approach is required so that the same evidence based, cost effective care which has been carefully evaluated is delivered to all children in the community who need it and even more urgently to the 100,000 children with co-morbidities who cannot afford to wait a year for specialised, hospital care.
My colleagues will now present two such programmes.
(2) Emma Ball, Community Dietitian Manager, HSE North West
As Dr Murphy has mentioned already, a gap analysis carried out by the INDI in March this year showed that 88% of the country has no access to a community based obesity treatment programme for children and their families. While children who are obese can be referred for individual dietetic consultation, this service is not available in all parts of the country due to the moratorium.
We do however have programmes developed in the community which reflect evidence and best practice (such as NICE, SIGN, NOO):
Up4it!
o a Cross Border Prevention and Management Childhood Obesity Programmes led out by CAWT (Co-operation and Working together) and funded as part of Interreg IVA funding.
o HSE West – Letterkenny, Youth and Family Services/HSE DNE - Cavan &
Monaghan – Border Counties Childcare Network (BCCN) were 2 pilot sites in ROI with further 2 sites in Northern Ireland.
o Multi-disciplinary programme- nutrition, physical activity, emotional well being and behavioural change
o Healthy Lifestyles for families (prevention programmes) with a child under 5 years (8 week programme with two follow-up sessions at week 16 and week 36)
o Making a Difference (management programme) for families with an overweight/obese child 8 -11years (12 weeks programme AND 4 follow-up sessions up to 48 weeks)
o Both parent and child attends the management programme
o Programmes are designed to suit families needs, are skills based (e.g. cooking) and delivered in local community settings
o Over 585 families participated over 2 years (2011-2013)
o For management programmes 61% of the referrals to the programme were classified as community/ voluntary group referrals. 41% of participants were referred by nursing staff/ primary care teams/ GPs
o Programmes were fully evaluated by CAWT. Data analysis by Northern Ireland Centre for Food and Health( NICHE) at University of Ulster of 146 children enrolled to management programme during Q3 – Q5 of CAWT project showed statistically significant reductions in both BMI z score and waist circumference z score levels over course of programme and follow-up sessions to 48 weeks. There were also statistically significant improvements in their perceptions of their body image over the course of the programme
To see the human benefits of investing now and for the future of our children, we will let the words of our patients speak for themselves:
‘’What I liked was finding out what was wrong with my diet. I was eating too much of everything; not eating enough fruit and vegetables and eating too much junk like all children my age! I liked knowing how to fix my diet and the dietitians helped with that. Since completing the UP4IT! programme, I have joined the athletics club but before the programme I would never have wanted to do anything like this. I am also playing indoor soccer and thinking of joining the local GAA club. My diet and the family’s diet is also healthier. ‘’
(12 year old girl who attended UP4It in Cavan/ Monaghan)
Effective treatment view a community programme costs €600 per family per year based on 15 families per programme. For every family going through the programme there is a multiplier of beneficial effect. The positive effects of the psychology, nutrition and physical activity effects others in the family. So taking the average family of two adults and two children, the actual cost of €600 would reach 60 people (15 families x 4 people) resulting in a cost of only €10 per person. This represents very little investment for a huge potential saving in both human and monetary terms.
The reality is that even though we have evidence based, best practice programmes on our doorstep, they are not being sustained.
The Up4it! funding ended in March 2013. There are small pockets of local funding being provided in number of locations throughout the country to promote obesity programmes but there is no dedicated, sustained funding to tackle this issue. In our local area Up4it! is exploring ways to sustain the project using a community development approach partnered with primary care teams but we urgently need for the Department of Health/ HSE to commit to resourcing the roll-out of successful model of best practice in the community.
In Northern Ireland the Project’s programmes have been extended for a further one year delivery by the Public Health Agency (PHA) while they put in place their longer term plans. The Project’s programme approach and outcomes will however shape the PHA’s future specification for children’s programmes.
(3) Grace O’Malley, Senior Physiotherapist, W82GO! (Childhood Obesity) Programme
Thank you. As previously highlighted by Dr Murphy, our team in Temple Street is seeing children who are clinically obese. To explain this further, the average 9 year old child in Ireland weighs 34 kg (5 stone 5 pounds). The average 9 year old attending our clinic is 55 kg (8 stone 9).
In keeping with the ICGP/HSE algorithm for childhood obesity management, all the children referred to our centre are clinically obese. We have seen over 400 children to date and there are a further 150 children on the waiting list today.
These children have the greatest need for urgent holistic care- 70% already have health problems). 40% already have risk factors for heart disease; and worryingly 17% meet the criteria for having the Metabolic Syndrome. 40% of our patients have significant and severe mental health problems, 75% have experienced bullying, with 11% experiencing severe bullying. Unfortunately a number of the children seen have a history of self harm or suicidal intent.
These children have complex needs and as we know from other EU experiences they are most effectively managed as outpatients of a paediatric hospital where they have access to the specialties required by them. Over 40% are from deprived to severely deprived areas so we are seeing first hand the effects of inequality on health outcomes.
Our patients range from 18 months to 16 years old and we receive referrals for specialist management from all over Ireland. From a study of 196 children who attended our treatment programme we have seen a reduction in obesity in line with best practice internationally. The obesity levels of children on our waiting list however continue to rise.
The W82GO! programme is delivered in the evening as a family-based group programme and uses facilities in Temple Street and in a nearby school. Families attend for 6 weeks during the intensive Phase 1 of treatment and then return for booster group sessions at 3-, 6, 9 and 12 months in phase 2 of treatment. The Group programme is delivered to children aged 6-12 years and aged 12-16 years. For children who are not appropriate for group treatment, we provide an outpatient 3-monthly review. This part of the service however has been reduced significantly due to the HSE staff embargo.
The treatment aims to improve nutrition; improve fitness, increase physical activity levels; reduce sedentary/sitting time and improve emotional well-being and family functioning. We deliver educational and practical session to improve health literacy and empower families to make healthy lifestyle choices. Families learn how to shop and to read food labels. They learn how change thir attitudes and working together as a unit committed to getting healthier.
I will take a moment to focus your attention on one girl who presented to us at 13 years of age, with high cholesterol, evidence of fatty liver disease and who was pre-diabetc. During treatment she lost 15 KG and thankfully reversed her pre-diabetes. We received a recent letter from one of our patients and in order to let you hear the voice of the child I shall read an excerpt: “My love for food had brought my weight to an all time high when I became a teenager and as a result, my self- esteem had gone down the drain. Growing up as an obese teenager had affected me in so many ways both physically and mentally. I was barely able to walk to school comfortably and I often lacked concentration at school. Now I feel completely transformed in ways that are indescribable – I’m now able to run and walk up and down the stairs and I now wear clothes that I could only dream of wearing before and this has made me a more confident person than I was prior to starting the program.”