Fighting fat

Childhood obesity is rarely out of the headlines these days, Jennifer Trueland looks at physiotherapists’ role in tackling the growing health problems.

Few would deny that the UK has a major weight problem. And as we pile on the pounds, the knock-on effects are immense. It’s well known that those who are overweight or obese are at higher risk of ill health and early death – which is bad for the economy, pushes up demand on health services and takes an enormous personal toll on the people themselves. It’s also no secret that the seeds of the obesity epidemic are sown in childhood, or perhaps even earlier. That’s presumably why the UK governments are determined to tackle childhood obesity, with a raft of policy documents already in the public domain or about to be published. But what role, if any, are physiotherapists playing in this battle? Indeed, have the policy makers even recognised that they have anything to bring to the table? ‘We think physiotherapists have a unique contribution to make,’ says Bridget Hurley, CSP professional adviser and public health lead. ‘Our focus is on physical activity, we can prescribe exercise and we have knowledge and skills around disease management, all of which would be valuable in fighting obesity. But there are real challenges – we don’t have limitless time, resources or capacity.’ GOVERNMENT TARGETS The Westminster government wants to reduce the proportion of children who are overweight or obese, setting a target of getting the rates down to 2000 levels by 2020. This will be no easy task. Department of Health figures show that between 1995 and 2005, obesity among boys aged two to 10 years rose from 9.6 per cent to 16.6 per cent and in girls, from 10.3 per cent to 16.7 per cent. The government spreads responsibility for achieving this among a number of agencies, including schools, health services and parents. Specific targets include ensuring all five to 16-year-olds participate in two hours of sport in school and that by 2012 all five to 19-year-olds will have the opportunity to participate in an additional three hours of sporting activities a week through a mix of school, community and voluntary providers. Parents are also advised to ensure children are active for an hour a day, and a national measurement plan has been set up in schools. But is increasing exercise the way to reduce childhood obesity levels? According to research from Peninsula Medical School, published this year in the Archives of Diseases in Childhood, it is diet, rather than exercise, which has the greater impact on children’s weight (see panel: The research evidence). MOVE FOR HEALTH The CSP, on the other hand, believes a package of lifestyle measures, including physical activity, is the way forward. That’s why it has set up a five-year project, Move for Health, one strand of which prioritises children (the others are older people and those of working age). Focus groups are to be held across the country to determine how physiotherapists believe the project should be taken forward. According to Peta Smith, chair of the Association of Paediatric Chartered Physiotherapists, physiotherapy has a lot to offer. ‘Children’s physiotherapists have the ability and specialist skills and much to contribute by playing a key role in health promotion to the general public,’ she says. ‘They are able to offer support and guidance to promote health, prevent sickness and identify risks and problems as early as possible. This important universal work needs appropriate investment and development to increase capacity.’ She adds that most children’s physiotherapy services delivered in community settings are targeted to those with complex needs: ‘There’s very little capacity to develop roles in the public health arena.’ As such, many physios would look with envy towards Tower Hamlets, where there is a dedicated childhood obesity team, which is physio and dietician-led. With the third highest childhood obesity level in England, the primary care trust has created permanent posts to tackle the issue. A DEDICATED SERVICE According to Linda Beckett, the physiotherapist in the team, there is a big task to do – so much so, that the PCT has agreed to expand the service. She has no doubt physiotherapists have something special to offer. ‘We can pick up other problems, such as orthopaedic conditions,’ she says. The team’s work includes direct contact with children and their families who have been referred because of specific problems, as well as more general sessions in settings including schools. Ms Beckett also plays an important role in training others and in promoting the importance of physical activity to agencies such as nurseries and in other community settings. In an area with a large Bangladeshi community this has meant making links with Islamic schools and mosques and, indeed, the service is about to take on a Sylheti-speaking male assistant. She believes policy drivers, such as government targets and guidelines, have helped focus the PCT on the issues. But other areas are less fortunate. PHYSIO SETBACK Nicola Shaw knows all about the barriers to setting up a successful service. A senior paediatric physiotherapist in Luton and Dunstable, she and colleagues piloted a weight management scheme in 2006. Although two pilots – one that lasted six weeks and the other 12 – were successful, the PCT decided not to fund it as a mainstream service. ‘Our results were fantastic and we wrote a full business plan which the PCT liked. The problem was, they took our business plan and said they could do it more cheaply without physios, but using sports therapists instead,’ Ms Shaw says. She is particularly disappointed that the added value from physio input wasn’t appreciated sufficiently. ‘Many of these children have other medical problems and a sports therapist won’t have the clinical knowledge to deal with that. It’s not just about exercise prescriptions,’ she says. The pilot projects were both hospital based, making use of the physiotherapy gym. The physiotherapist carried out initial assessments, including quality-of-life questionnaires, waist measurements, body mass index and six-minute walk tests. Then the children were invited to take part in an hour-long exercise session after school. LACK OF RESEARCH The assessment was repeated at the end of the pilots and showed particularly good results in quality of life, waist measurement and the walk test. As well as a lack of funding and a failure to recognise the worth of physio involvement, Ms Shaw says the research deficit was a barrier. ‘The big problem is that there is so little evidence out there – that’s why we did the pilot projects, so we had our own results. But it’s difficult when you’re trying to persuade people to put money into something, when you can’t back it up.’ According to Ms Smith, physiotherapists have been and continue to be involved in both informing and delivering national policy. ‘We’d like to encourage commissioners of children’s health services to recognise that physiotherapists have this expertise, knowledge and skill to offer in promoting the health and well-being of children,’ she says. ‘This would enable the achievement of the [government] Every Child Matters – Change for Children outcomes: “be healthy” and “enjoy and achieve”.’ FL Exercise does not benefit BMI Increasing the amount of exercise taken by children is unlikely in itself to beat the obesity time bomb, one study found. Experts from the Peninsula Medical School in Plymouth found that improving children’s diets would be more likely to have a greater impact on their overall health and weight. The research team worked with 212 children from 54 schools in Plymouth as part of the Early Bird study, which has followed the development of this group of children, born in 1995 and 1996. The results were published this year in the Archives of Diseases in Childhood. The researchers found 42 per cent of boys and 11 per cent of girls aged five to eight met government recommended daily exercise levels of one hour a day. But they also found exercise alone had no positive benefit on weight control and did not have an effect on body mass index. Brad Metcalf, researcher in the department of endocrinology and metabolism at Peninsula Medical School, says the results do not mean children should not exercise. Children who met the activity levels had healthier blood pressure, cholesterol levels and insulin resistance – a precursor to type 2 diabetes. ‘We are keen to stress children should be encouraged to be active because our study showed that regular exercise improved metabolic health, even without improving BMI,’ Dr Metcalf says. Reference Metcalf et al. ‘Physical activity at the government-recommended level and obesity-related health outcomes: a longitudinal study (Early Bird 37)’, Archives of Diseases in Childhood (2008), 93: 772 ABC of back care Back problems not only afflict the workforce – children suffer too. Indeed, by the time they are 14, more than half of children will have experienced back pain according to research by the charity BackCare. Almost 10 years ago, three physiotherapists decided to tackle this by forming Airedale Backcare for Children. The ABC programme uses interactive methods to promote the lifestyle and environment that reduce the risks of back problems. In its first year, physios delivered the programme to more than 5,000 children, with positive results. Jayne Duffy, one of the ABC founders, says the project has gone from strength to strength, and may be rolled out across England. This would be achieved by helping schools to deliver the programme inhouse – particularly useful where primary care trusts decide not to fund physios to do it. ‘The ABC team is currently working with the National healthy schools initiative to see if we can make the programme a web-based tool, accessible free to all schools, with a supporting web-based manual for teachers and Healthy Schools coordinators,’ she says. ‘This overcomes the potential barrier of local PCT priorities while ensuring the message is given robustly and still enables physios to deliver where their PCT chooses to adopt this delivery method.’ Ms Duffy says the programme – which includes exercise, information and workshops – succeeds partly because children find it fun. ‘This has been a fantastic opportunity for physios to try and influence practice nationally – a back care equivalent to five-a-day,’ she adds.
Jennifer Trueland

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