Let's Talk About Weight: A Step-by-Step Guide to Conversations about Weight Management with Children and Families for Health and Care Professionals

Overview

This Guidelines summary relates to families of 4–12 year old children and young people. Please refer to the full guideline for the complete set of recommendations.

Why Talk About Weight: the Role of Health and Care Professionals in Child and Family Weight Management

• As a health or care professional, you are in a unique position to talk to families* of children or young people with excess weight (overweight and very overweight), that you come into contact with through your work, about weight management to prevent ill-health. We recognise that some health or care professionals have a high level of contact with children, young people and families and may be confident in discussing weight management and referring families to weight management services
• Children and young people with excess weight (overweight or very overweight) are more likely to be ill, be absent from school due to illness and require additional health care support than children and young people of a healthy weight. Some of these children and young people (very overweight, also referred to as obese) are more likely to become obese adults, and have a higher risk of morbidity, disability and premature mortality in adulthood. Excess weight in childhood can be associated with conditions such as bone and joint problems, pre diabetes, poor psychological and emotional health and many children and young people experience bullying linked to their weight
• Children and young people who live in a family where at least one parent or carer is obese, are more at risk of becoming overweight or very overweight themselves. It is therefore important to consider the whole family’s lifestyle when addressing a child or young person’s weight
• Weight management interventions can support families to make lifestyle changes and achieve and maintain a healthier weight

Tier 2 Weight Management Services

• Tier 2 weight management services are commonly community-based services that take a ‘lifestyle’ approach to helping children and young people with excess weight manage their weight. Tier 2 services are commonly family-based and should support the whole family. These services are commonly multi-component and include diet, physical activity and behaviour change techniques. The focus of tier 2 services for children and young people may be on weight maintenance and growing into a healthier weight, rather than weight loss, depending on the age of the child, stage of growth and degree of excess weight

Tier 3 Specialist Weight Management Services

• Tier 3 specialist weight management services are less common across England. These services usually support children and young people with more complex needs eg higher degrees of excess weight or excess weight with associated comorbidities or psychosocial difficulties, for example. Tier 3 usually refers to clinical treatments provided by specialist services. These services are commonly delivered by specialist multidisciplinary teams composed of dietitians, psychologists, nurses and paediatricians, for example. School Nurses may also provide a source of support in relation to weight management, and may already have an established relationship with the family
• A key first step in supporting families to make lifestyle changes is initiating a conversation. The conversations you have with families should identify those at risk (ASK), explain how best to change behaviour (ADVISE) and refer to obtain help (ASSIST)
• It is important to be familiar with your local obesity care pathway so you are aware of the weight management services available in your area and the referral criteria and process—School Nurses, and the Public Health team at your local authority and clinical commissioning group should be your first point of contact

ASK: Weighing, Measuring, and Interpretation of BMI Centile

• Identify those at risk; assess the child or young person’s weight status
• Ask about family lifestyle and behaviours
• It’s not always possible to tell if a child or young persion is a healthy weight for their age, sex and height just by looking. The first step in identifying families at risk is to measure the child or young person’s height and weight. You should use your professional judgement to determine when it is appropriate to initiate a conversation about a child or young person’s weight
• Some families may come to you following receipt of a letter related to the NCMP. If the parent/carer presents you with NCMP feedback information on the child’s height and weight, where possible, suggest that you repeat the measurements so that you can both be confident that you are using current information
• Depending on whether or not the parent or carer has received information about their child’s height and weight measurements already, and how they present to you, choose the most appropriate suggestion for talking about a child or young person’s weight status
• An example of how this conversation could go is:
  • ‘Many parents find it difficult knowing whether their children are growing up healthily, so it can be helpful to measure their height and weight from time to time to monitor their growth. Would it be okay to check [insert name of child]’s height and weight today?’
• Or
  • ‘It’s good that you’ve raised this with me. Many parents find it difficult knowing whether their children are growing up healthily, and some parents find it helpful to receive information about their child’s height and weight measurements. Would you like to talk about the feedback in the letter?’
• Or
  • ‘I understand that receiving the information in this letter can be upsetting, it’s good that you’ve raised this with me. Would you like to talk about the feedback in the letter?’
• A child or young person’s wellbeing and health is influenced by what they eat, if they are physically active, and stay within a certain weight range as they grow. This is called a healthy weight for their age
• The NHS Choices website provides a BMI Healthy Weight calculator tool, which enables you to calculate the child or young person’s BMI centile from their height and weight measurements. This allows a one off measurement to be calculated to determine the child or young person’s weight status at that point in time
• To manually determine the child or young person’s weight status, plot their height and weight on the RCPCH UK Growth Chart 2–18 years, then use the BMI centile look-up tool on the same chart to determine BMI centile. It is important to be aware that in some cases, a child or young person’s weight centile may be within the healthy range for their age and sex, but they may still have excess weight if the height centile is quite different than the weight centile and, as such, determining BMI centile is important. Using a growth chart allows subsequent measurements of the child or young person’s height and weight to be plotted over time so that their growth trajectory can be monitored
• Assessment of BMI centile provides an indication of appropriate weight management options for families

Referral

• It is important to be familiar with your local services, as referral criteria may vary locally
• Understanding the aim of your local services is also important, as this can vary. In general, tier 2 services may focus on maintaining a child or young person’s weight to achieve a gradual decline in BMI as they grow, rather than weight loss. Weight management in children and young people usually focuses on lifestyle changes that influence weight and family involvement plays a very important role

Referral to Tier 2 Services:

• Consider referral to tier 2 lifestyle weight management services for families where the child or young person’s BMI ≥91^st centile

Referral to Tier 3 Services:

• For children or young people with complex or severe excess weight, consider referral to a tier 3 specialist weight management service, where available. Tier 3 services should be considered for families where the child or young person’s BMI ≥99.6^th centile; or ≥91^st centile with significant comorbidities or complex needs (for example, learning disabilities or other additional support needs)
• Referral decisions should be discussed with families and should take into account the health status of the child or young person and the presence of weight related co-morbidities

ADVISE

• Show the parent and child or young person where the child or young person’s growth is plotted on a growth chart
• Discuss the concept of a healthier weight status, and potential impacts of being outside a healthy weight range, using positive, non-judgemental language
• Offer referral to local weight management service where available and appropriate

Providing Feedback

• Discussing the child or young person’s weight status with parents and carers needs to be handled sensitively. Take care with the language you use. Keep it as positive as possible and focus on terms such as ‘healthier weight status’ and ‘healthier lifestyle’, terms such as ‘obese’ are not generally well accepted by parents/carers when talking about their child’s weight
• Think about who should be included in this conversation; you may choose to give feedback to the parent/carer alone or the parent/carer and child or young person together. It may be helpful to use a growth chart in order to visually demonstrate that the child or young person’s weight is outside the healthy weight range. This offers an objective observation
• It may also be useful to explain that there is a wide range for what is considered to be a healthy weight for a child or young person of any given age, height and sex, to avoid giving the impression that there is a particular weight that is correct or a ‘one size fits all’ approach
• An example of how this conversation could go is:
  • ‘I’ve plotted how [insert name of child] is growing on this chart. The chart shows that [insert name of child] is above the healthy weight range for a boy/girl of their height and age.’
• It can be helpful to discuss the importance and concept of the child or young person being a healthier weight as they grow
  • ’Eating a balanced diet, being active and staying within a certain weight range can help children grow up healthily.’

Offering Referral

• Once you have determined the child or young person’s weight status, and the suitability of referral to a weight management service for the family, you should ADVISE the family that making lifestyle changes to achieve a healthier weight as the child or young person grows can be easier with support. Discuss with the family what services are available to them and offer referral
• An example of how this conversation could go is:
  • ‘We know from working with other families, one thing they have found useful to help them to make lifestyle changes is support from others, and there are fun, free/low-cost, healthy lifestyle programmes available. I can refer you now if you are willing to give it a go?’
• In your offer you should:
  • inform the family about what the service offers i.e. support to make lifestyle changes
  • who the service is for i.e. the family, not just the child or young person
  • advise of the practicalities including duration of the programme, location, time and any cost associated, if you are aware of this information

ASSIST

• Explore and discuss with the family what they can do to maintain a healthier lifestyle
• Assist the family to consider their options and set achievable goals
• Offer ongoing assistance and support
• Refer to local weight management services
• Once you have discussed the options with the family, you should then ASSIST them by, making a referral to the service you have agreed on, or offering your continued support
• The following scenarios give examples of how these conversations might go, and what key points you should consider including in your conversations to maximise engagement

Parent or Carer Is Concerned About Their Child’s Weight and Receives Advice and Offer of Referral Positively

• For those parents/carers already concerned about their child’s weight, they may to be glad of the opportunity to discuss it

• Let the family know what the next steps are

‘I’ll refer you to the service now. You’ll get an appointment through the post.’

• Reassure the family that you are there to help them. Suggest a follow up appointment to monitor the family and provide help and encouragement

Parent or Carer Does Not Perceive That Their Child Has Excess Weight

• Acknowledge the difficulties in recognising and understanding overweight

‘It can be difficult to tell whether a child or young person is a healthy weight just by looking at them, especially when their friends and peers may be a similar size.’

• Reassure the family that support is available; acknowledge that this is a difficult decision. Explain what the family could expect from the service and re-offer referral

Parent or Carer is Visibly Upset or Angry and Does Not Want to Engage in Conversation About Their Child’s Weight

• Show acceptance of the parent/carer’s wishes, reassure them that you are there to help and re-offer your support should they change their mind. Don’t force the issue but leave the door open

‘Okay, that’s fine. I understand that now might not be a good time to discuss this. If this is something you want to talk about in the future, I’m here to help and I am keen to support your family.’

Follow up

• Follow up appointments provide an opportunity to review a family’s situation. Continued engagement is recommended as this may encourage families to respond positively
• You may find it helpful to follow the sequence below in these situations, and where referral to a weight management service was initially turned down, to re-offer referral
  • ask how the attempt to make lifestyle changes is going or where the family were initially uninterested, ask if this is something they might be interested in now
  • offer to weigh and measure the child or young person
  • plot the child or young person’s height and weight on the RCPCH UK Growth Chart 2–18 years, then use the BMI centile look-up tool on the same chart to determine BMI centile and consider any change
  • give feedback, sensitively but clearly
  • review the proposed action for lifestyle change, and build on this if possible
  • re-offer referral to the appropriate service, considering any changes in BMI centile.

Resources for Further Learning and Information

• Change Talk: Childhood Obesity app
  • Google Play
  • App Store
• Chief Medical Officers’ physical activity for children and young people (5–18 years old): infographic
• Childhood obesity: applying All Our Health
• Health Education England e-learning modules for healthcare professionals working with children aged 5–12 years
  • Growth and Nutrition: (assessing normal and abnormal growth, puberty and essential nutrition)
  • Understanding and tackling obesity: (childhood obesity and childhood eating behaviours)
• Health Education England obesity e-learning modules for practitioners in the NHS and local authorities working in weight management (managing obesity: supporting behaviour change, guiding and enabling behaviour change)
• Making Every Contact Count resources (tools to aid implementation and support individuals when considering MECC activity)
  • gov.uk/government/publications/making-every-contact-count-mecc-practical-resources
  • learning.wm.hee.nhs.uk/mecc
  • makingeverycontactcount.org.uk/
• Public Health Childhood Obesity Impact Pathway
• The Royal College of Paediatrics and Child Health Growth Charts.

Support for Parents

• Change4life: Your child’s weight
• NHS Choices: What can I do if my child is overweight
• Weight Concern: Talking to my child about weight.