Are obese children falling through the care net?

Obese children need help on the tricky path to getting back to a healthier lifestyle Keystone

A childhood obesity epidemic is sweeping across Europe. Switzerland has been held up as a good example of how to keep the problem under control. But while progress is being made in prevention, experts warn that treatment is failing to reach families in need.

“To lose weight and to be able to go to the swimming pool again without people laughing at me.” That’s the wish of 13-year-old Volkan.

Like many other boys of his age he likes football. But unlike the majority of his peers, Volkan is obese and needs support to have a chance to live a healthy life.

At a fortnightly group therapy session in St Gallen children’s hospital in eastern Switzerland, Volkan listens to a nutritionist talk about healthy eating. After a brief lesson on the food pyramid,  he is given the task of preparing a carrot salad for the evening meal which the children, their parents and the therapists will eat together.

While the children are in the kitchen, their mothers are taken through their paces by the sports therapist. The format varies every week, with sessions provided by experts in physical activity, nutrition and psychology.

“It is a must for one of the parents to take part because we know a change in behaviour or healthier lifestyle cannot be made by the children alone,” Dunja Wiegand, co-leader of the St Gallen Kidsstep pilot project, tells swissinfo.ch.

“Often it is the case that the whole family or at least one of the parents is also overweight. It is important for the parents to take on some responsibility in this area.”

‘New norm’

A World Health Organization (WHO) report released on February 25 warned of “alarming” rates of overweight children in Europe, and went so far as to call it an “epidemic”. “Being overweight is so common that it risks becoming the new norm,” a statement accompanying the report read.

The report’s country profiles paint a bleak picture of nutrition, obesity and physical inactivity in most of the 53 countries surveyed in the European region based on 2009 figures. In Greece, Portugal, Ireland and Spain at least 30% of 11-year-olds self-reported as overweight, while the rate in Switzerland was 11%.

The most recent Swiss figures are less rosy but they do show that the combined rate of overweight and obese children stabilised between 1999 and 2012 to reach 18.61%, a total of almost 236,000 children.

Some 120,000 of these children would benefit from therapy to reduce the risk of co-morbidity (related illnesses) but unless they visit their doctors with weight-related health problems, the majority of these children are not receiving any kind of intervention or therapy.

The impact of obesity on quality of life cannot be overestimated. Of the 1,251 children who took part in KIDSSTEP, a group therapy programme in place across the country, 45% suffered from mental disorders and 68% had orthopaedic problems at the beginning of the one-year programme. Two years later the children’s scores for mental health, quality of life and eating disorders had considerably improved.

Without intervention, a child who is obese at the age of 10 to 14 has an 80% chance of reaching adulthood obese, with the risk of developing multiple diseases.  So is Switzerland failing its overweight children in not getting them the right help?

Diabetologist Dagmar l’Allemand of the umbrella association for childhood and youth obesity, akj, believes the system is not reaching those in need.

“On the one hand the services are not proactive enough, not seeking out the problem children. And when the problem children come for help, they are meeting obstacles. It remains to be seen whether the extension of insurance coverage will have the desired effect of reaching a wider pool of children.” (see infobox).

Paths to treatment

The recruitment of patients for obesity therapy is known to be difficult. It hasn’t helped that until last year, only two forms of insured therapy were available in Switzerland. The first was the usual medical care provided by physicians for health complications associated with obesity and physical incapacity (high blood pressure, diabetes, orthopaedic illnesses, depression).

The second option open to obese and overweight children, up and running since 2009, has been participation in group programmes run in 19 different centres around the country, within an evaluation project. Just 1,251 children have taken part to date.

This therapy requires a high level of commitment and only four in ten children who were referred by their doctors met the entrance criteria.

The multi-professional group therapy programme, KIDSSTEP, has been covered by mandatory health insurance on a trial basis for the past five years. Since the beginning of this year it will be covered definitively. Health insurers pay a flat rate CHF4,200 for this package of care and families must contribute about 10% themselves and pay transport costs.

A third option for individual therapy, introduced at the beginning of this year, has the potential to reach many more children.

Family doctors now have the right to prescribe six nutrition counselling sessions as well as two physiotherapy sessions in order to establish whether a child is capable of participating in normal sport. If he or she has too many orthopaedic problems, the physiotherapy can continue.

After six months if the child is still gaining weight, they can be referred to a specialised doctor or centre to begin an individual or group programme, involving a psychologist, nutritionist and physiotherapist.

“In Switzerland we now have a network of therapists and a quality control system and evaluation process but nobody is interested in financing it and supporting the network of obesity centres and some have closed down.”

Making lifestyle changes is a very difficult task, as can be seen from smoking and alcohol dependency, L’Allemand, added.

“The problem is you are in an environment where everything acts against overcoming your addiction. You have advertising, you have car use, all the games, television, so the surroundings are toxic for those families.”

“It’s very difficult for one doctor to fight against all this. Therefore it’s very important that intervention take place early so that the children learn how to live in a healthy way,” she added.

Prevention

On the prevention side, Switzerland, along with France, the Netherlands and some Scandinavian countries, has managed to keep the epidemic at a stable level.  Swiss childhood obesity levels have not risen for more than a decade.

The WHO commends these countries for adopting a “whole-of-government” approach.

“The palette of actions includes the promotion of vegetable and fruit consumption in school, along with school lunch initiatives, taxes on [certain] food to reduce intake, tighter controls of advertising … and action to promote physical activity, especially among children.”

Alberto Marcacci of the Swiss Federal Health Office told swissinfo.ch the office worked with partners mainly on changing the context – people’s living environment. “We aim to create the right structure to facilitate healthy choices,” he said.

For example, in 2009 the health office launched an initiative called actionsanté (health action) in partnership with the food industry to promote a range of healthy foods. The initiative included pledges such as improved information for consumers, the reduction of salt, sugar or fat in different food products and restrictions on advertising to children under 12.

Urban planning also plays a role. “In partnership with several offices, efforts have been made to create green spaces and play areas, to create a physical environment which encourages people to do physical activity.”

Healthy weight

Health Promotion Switzerland, a national foundation funded by a health insurance levy, spent CHF5.3 million in 2012, almost a third of its budget, on its awareness-raising ‘Healthy Body Weight’ programme, working with 20 cantons.

“We try to promote projects that have been evaluated and are shown to have an impact. For example a project in Geneva to encourage physical activity among kindergarten age children worked well, so we are replicating that in more cantons,” Michael Kirschner of the foundation told swissinfo.ch.

For children like Volkan, who would like to be a pilot when he grows up, the multi-professional group therapy programme offers a blueprint for a brighter future. Yet with no national system for evaluation or therapy provision, the numbers attending such programmes are likely to stay low.

“The problem is those who are not coming, because they are depressed, they stay at home and don’t have contact with other children or other families. We cannot reach them. We need more programmes in schools or kindergarten. That would be more effective. There’s a need to have a link between the prevention and the therapy,” said l’Allemand.

Health risk

Children who are overweight or obese are at greater risk of poor health in adolescence and also in adulthood.

Among young people, orthopaedic problems and psychosocial problems such as low self-image, depression and impaired quality of life can result from overweight.

Excess weight problems in childhood are associated with an increased risk of being an obese adult, at which point cardiovascular disease, diabetes, certain forms of cancer, osteoarthritis, a reduced quality of life and premature death become health concerns