1. Dr Helen Vickerstaff Consultant Community Paediatrician, RCHT Rachael Brandreth RD Children’s Dietitian, Children’s Community Therapy Service, RCHT Julie Benson Nippers Nutrition, Cornwall Council HEALTHY WEIGHT IN THE EARLY YEARS

2. Outline Set the scene – national and local figures Outline the LEAF programme Case studies Prevention – Nippers Nutrition

3. Why should we be worried?

4. Prevalence of obesity among children by school year and sex National Child Measurement Programme 2006/07 – 2010/11 Child obesity: BMI ≥ 95 th centile of the UK90 growth reference © NOO 2012

5. Child prevalence by BMI status National Child Measurement Programme 2010/11 This analysis uses the 2 nd, 85 th and 95 th centiles of the British 1990 growth reference (UK90) for BMI to classify children as underweight, healthy weight, overweight and obese. These thresholds are the most frequently used for population monitoring within England. © NOO 2012

7. NCMP local data Increase in overweight reception 15.1% (SHA 14.3%, ENG 13.2%), 1.1% increase Obesity rate fallen 9% from 10.8%

8. © NOO 2012 Prevalence of obesity by deprivation decile National Child Measurement Programme 2010/11 Child obesity: BMI ≥95 th centile of the UK90 growth reference Deprivation deciles assigned using the Index of Multiple Deprivation 2010

9. Extrapolation from 2 year check data (total for age group 1-6) –26% above 91 st centile –>98 th centile 545 children –>3.5 SD 110 children –Preliminary recent audit outpatients Treliske 34% overweight or obese group Snapshot Data locally

10. Parental obesity Very early (by 43months) adiposity rebound Obese children go on to become obese adults >8 hours screen time/week at 3 years Catch up growth SD score at 8 months and 18 months in top quarter, weight gain in first year Birth weight Short (<10.5 hours) sleep duration at 3 years ALSPAC

12. Foresight report, 2007 Healthy Lives, Healthy People: A call to action on obesity 2011 –A sustained downward trend in the level of excess weight in children by 2020 –Tailored support on weight management –Part of life course approach Government reports

13. Overview Who are we? Who do we see? Format of the LEAF Programme Course outline

14. LEAF (Lifestyles, Eating & Activity for Families) Who are we? Dr Helen Vickerstaff, Community Paediatrician with Specialist Interest in Public Health (Child Health, RCHT) Rachael Brandreth, Children’s Community Dietitian (Children’s Community Therapies, Child Health, RCHT) Kate Laity, Physical Activity Advisor (Healthy Weight Team, Health Promotion, CIOSPCT) Contact the team on LEAF.programme@cornwall.nhs.uk for more info or adviceLEAF.programme@cornwall.nhs.uk

17. LEAF (Lifestyles, Eating & Activity for Families) Tier 3 weight management for overweight children 6yrs & under. Referral criteria: Under 2 years: concerns about rapid weight gain / large size 2 - 6 years: BMI > +3.5sd or BMI >98th centile & co- morbidities or a strong suspicion of an underlying cause. & Ideally worked with key professional e.g. Health Visitor or School Nurse for at least 6 months and obesity progressive (if concerns before / whilst working with the family please contact us for advice).

18. LEAF (Lifestyles, Eating & Activity for Families) Format of the LEAF programme: Initial engagement session MDT clinic (one appointment to see us all) Group sessions (6 x mornings) MDT clinic follow-up Referral back to primary care for longer-term follow-up with support from the MDT team If not able to participate in group follow-up then one-to- one with Dietitian & Health Visitor / team or School Nurse / team & localised follow-up

19. Principles of making changes Getting the balance right – energy balance, nutrient balance Promoting positive behaviour Getting tuned in & me sized meals – portion sizes, hunger & fullness cues & cravings Getting over barriers – problem solving, external triggers How thoughts & feelings affect our intake Hidden fats & sugars Food labelling, shopping, budgeting, snacks & recipe adaption. Getting the kids involved – keeping active & widening food preferences Group sessions: What do we cover?

20. Case Studies

21. Case 1 – ‘Katy’ GP referral to paediatrician and dietitian (Feb ’12) BMI 22.6 at 2 years and 23.2 at 2yr 6mth FH of diabetes and thyroid disease Normal development Worked with health visitor for 6 months www.cornwallhealthyweight.org.uk

22. Case 1 – ‘Katy’ LEAF clinic –Pre clinic visit (RB) 10/10 importance and confidence –Multi-disciplinary clinic +3.5SD –Co-morbidity ?Sleep apnoea –Risk factors – father T2 diabetes, strong FH diabetes and thyroid, paternal g’mother MI age 39

23. Case 1 ‘Katy’ Examination –Height 89cm (9-25 th ) –Weight 18.5kg (99.6 th ) –Normal examination including BP –No clear nutritional contribution at 1 st assessment

25. Case 1 ‘Katy’ TSH Cortisol IGF-1, IGF-BP3 Prolactin Prader-Willi Turner Bone age FBC Ferritin Lipids Glucose LFT’s

26. Case 1 ‘Katy’ Respiratory opinion – apnoea with desats, ENT referral large tonsils Bloods – raised triglycerides, low HDL Clinic follow up – raised parental concern, increase in BMI In depth dietetic – extra snacks family members Previous reluctance to join LEAF programme – increase motivation with raised lipids

28. LEAF Sept Follow up Nov Aim return to primary care follow up Case 1 ‘Katy’

29. Case 2 ‘Ruby’ GP referral April 2012, aged 2 yr 7/12 BMI 22.4 (+ 3.5SD) Ht centile 98 th, Wt 99.6 th Home Visit – Importance 8, Confidence 2 No HV input

30. FH Type 1 diabetes and early cardiac death 43 Drinks diary 1350-1800mls milk Offered LEAF - DNA Discharge to health visitor Case 2 ‘Ruby’

31. Summary Influential time for child and family Good age to modify behaviour Majority can be delivered in primary care www.cornwallhealthyweight.org.uk Contact the team on LEAF.programme@cornwall.nhs.uk for more info or advice LEAF.programme@cornwall.nhs.uk

32. THANKYOU ANY QUESTIONS?