A weight management service for children with severe obesity

Introduction

In 2018, there was a serious case review in Manchester of a 13-year-old who died from a heart condition that was exacerbated by their severe obesity (Wiffin and Morgan, 2018). The child had been identified as obese at the age of three years, which raised questions around missed opportunities to address the problem. The case review also found hesitancy among authorities to consider childhood obesity as a safeguarding issue. It was decided there was a need for early intervention in childhood obesity in Manchester, and for safeguarding pathways for clinicians to follow where children’s health risks continued to increase despite intervention.

There was a weight management service in place at the time, delivered by a private provider, mainly in a group format in community venues across Manchester. However, engagement was poor, with only 5% of those referred taking up the offer of support. Weight management services at this time were delivered by lifestyle coaches. Following a series of discussions with the children and their families, several barriers were highlighted about attending group sessions in the community and parents/carers said they would engage more with health professionals.

The case was made that weight management interventions for children might be more successful if individualised and delivered at home or in schools by NHS health professionals, particularly school nurses. The team also wanted to take a more proactive approach to identifying and engaging with families who needed support for severe obesity in children from the National Child Measurement Programme data.

Healthy Weight Project

Established in 2018, the Healthy Weight Project offers a 12-month intervention mainly delivered by nurses, aimed at reducing body mass index (BMI) for children with severe obesity aged four to five years. An obesity steering group had been established by Manchester Children’s Community Health Services and included representatives from children’s social care, early help, endocrinology, school nursing, health visiting, public health commissioning, community safeguarding and general practice. The steering group provided oversight into the development of the multiagency healthy weight pathway, which would initially be piloted through the healthy weight team, comprising a registered dietitian and two school nurses.

Children were identified through the National Child Measurement Programme. The aim was to offer individualised healthy weight support at the earliest possible time in the primary school setting.

Every child who was identified as being on or above the 99.6th centile (severely obese) in reception year of primary school was offered a weight management intervention for 12 months. Parents or carers were contacted by the healthy weight nurses to discuss the National Child Measurement Programme, what the results mean and the health risks for their child. They were then offered a holistic individual assessment with regular ongoing support for a year. For those who failed to engage or did not support their child to maintain or reduce their BMI over 12 months, a referral could be made to children’s social care.

“An impressive nurse-led initiative which has shown that it can deliver statistically significant improvements in a clinical public health issue”
(Judges’ comment)

Results

The project began in September 2018. We identified 216 children in Manchester who were eligible for the intervention. In the first year, 89% of parents and carers were willing to engage with the service, which was a much higher percentage than expected.

The support offered to families was highly individualised and used a holistic approach, for example, referring to supporting agencies if finances were a barrier. We also used interpreters where languages other than English were spoken at home and produced culturally appropriate materials to help families make lifestyle changes. The frequency of visits or amount of support was decided on an individual basis. This could include a family sending the team regular photos of meals or food diaries to receive feedback, regular home visiting and phone calls, and attending multiagency meetings.

An evaluation of the first cohort of children to be offered the intervention was done by the University of Manchester (Goldthorpe and Keyworth, 2021). It showed overall a statistically significant reduction (-0.47) in BMI z-scores (age-standardised) at 12-month follow-up. For those children who were discharged from the healthy weight team without the need for further intervention from social care, there was a statistically significant reduction (-0.54) in the BMI z-scores after 12 months.

Responses from 40 parents or carers indicated that the intervention was acceptable, and they particularly valued the friendly, professional and supportive approach taken by nurses delivering the programme and the way they interacted with the children. Parents and carers also liked that the sessions were delivered in their homes and schools, which made them a good fit with family life. They were conscious of making progress and were well-informed on how this progress would be made.

Barriers and adaptations

While our approach was widely accepted by families, who appreciated it being delivered by NHS nurses, the main challenge was obesity not being recognised as a safeguarding concern by other professionals. To address this, the team delivered training to education, children’s social care, Early Help, school nurses, health visitors and GPs on how obesity can be considered neglect and the multiagency pathway and professional responsibilities around obesity and safeguarding. The team also used these opportunities to highlight how early intervention can make a real difference.

The team have constantly implemented changes to improve the intervention. This includes the way parents are contacted. They now receive a copy of the centile chart and a service leaflet in the post before they are contacted by phone. Changes have also been made to the way information is captured, including developing sections to record the voice of the child and child observations in our electronic patient resources. The team have developed bespoke resources, including seasonal snack swaps, Eatwell be Healthy (a South Asian Eatwell Guide) and a visual guide to size portions.

During the Covid-19 pandemic the team offered postal food diary reviews, home visits in personal protective equipment, and a range of resources to encourage staying active at home. In the first lockdown, between March and June 2020, the team completed home visits for all families who were in most need of support, by identifying the children who were most vulnerable. For the remaining families, the team provided phone support, including help with meal plans and accessing food parcels. Since June 2020, the team has returned to seeing all families face to face.

The future

Childhood obesity is central to the public health agenda, and we believe this is one of the few externally evaluated weight management services delivered by children’s community nurses, which can demonstrate an improvement in children’s health outcomes. It is an evidence-based intervention, which puts the needs of children and families first and is now part of Manchester’s Healthy Weight Strategy 2020-2025.

We have grown from a team of three to a team of 10 and diversified our skill mix. Our team now includes staff from dietetics, health visiting, school nursing, practice nursing, children in care and education. We have expanded the referral criteria to include nursery-age children identified as severely obese by health visitors, so we can support families even earlier to make healthy lifestyle changes. Once our first cohort of children reach Year 6, we plan to evaluate whether the intervention has led to a sustained impact on weight status.

We have plans to develop our intervention to ensure that it meets the needs of children with special educational needs, disabilities and severe obesity in Manchester. We would like to also expand our service to allow us to take referrals immediately after the two-year check by health visitors, so families can receive support as soon as raised BMI is identified as a concern.