Dr Francesca Neale (Foundation Year 1) and Dr Behrouz Nezafat-Maldonado (Paediatrics ST1)

Aiden is a 7-year-old boy brought by ambulance due to difficulty in breathing. He has a history of poorly controlled asthma and an expiratory wheeze on examination. You start treatment with burst therapy as per your local protocol and take a history. On further examination, you notice that he is in the 98% percentile for weight and has several tooth fillings and cavities. After building rapport with his mum she reveals that she is a single parent and struggles to afford food and find time to cook for her children. She tells you that Aiden’s diet mainly consists of junk food and sugary drinks.

Child Health and Nutrition

Nutrition is fundamental for good health and development, especially during the early years of life. If children don’t eat a balanced diet with the right amount of macro and micronutrients, they may become ill, have delayed development and suffer other adverse effects

Children’s early years provide an important foundation for their future health and influence many aspects of overall well-being. Food preferences and eating habits are formed in early life, determined by the environment they live in. It’s important to recognise the double burden of malnutrition in clinical practice – the coexistence of undernutrition along with being overweight and obese, or having diet-related non-communicable diseases. 

Identifying child malnutrition

  1. During your assessment take a dietary history. Focus on two main things: Energy/nutritional values of the diet and eating behaviours.
    Ask about number of fresh fruit and vegetables per day, sugary drinks and confectionery as well as use of fast-food outlets. 
  2. Take measures including weight for age (WFA), height for age (HFA), weight for height (WFH) and body mass index (BMI) for age. Plot these measurements a in a growth chart. This will help to identify potential stunting and wasting. Remember some children can suffer from both. 
  3. Look for complications of malnutrition: tooth decay, delayed sexual development, impaired cognitive and physical development, signs of rickets and anaemia. 

What are children’s diets like in the UK?

The National Diet and Nutrition Survey (2008-2017) found that across all age groups, the mean fruit and vegetable intake falls below the 5-a-day recommendation. It’s estimated that only 7% of girls and 10% of boys in the UK eat the recommended five or more fruit and vegetables a day. Recent research has shown that the global height ranking of 19-year-old British teenagers has fallen over the past 35 years. Around 16% of children in the UK are deficient in Vitamin D and The Department of Health recommends that all children aged 6 months to 5 years get vitamin supplements containing Vitamins A, C and D.

The most common cause of tooth decay in children is consumption of sugar in foods and drinks. Just under a quarter of children five years old have tooth decay; tooth extraction is the most common reason for a child to have an anaesthetic in hospital.

1 in 3 children are overweight or obese when they leave primary school. Obesity currently costs the NHS £5-6 billion a year and, as you would expect, unhealthy diets are linked to significant morbidity and mortality. 

How is diet linked to social deprivation?

In the UK, 4.2 million children live in poverty, making up 30% of all children in the UK and a recent YouGov poll suggested that 2.4 million (17%) children are living in food-insecure households.

In London, almost 1 in 10 children report going to bed hungry. Deprived inner London boroughs continue to have the highest rates of child poverty but recently Middlesbrough, Newcastle and Birmingham have also seen large rises in child poverty. The State of Food Security and Nutrition 2020 reports that 14% of parents/guarding experienced food insecurity between March and August 2020. Currently 1.4 million children in the UK are eligible for free school meals though this number is likely to increase due to the effects of the COVID-19 pandemic.

In all age groups, lower levels of income and education are associated with less healthy diets. Numerous studies have shown that social deprivation is linked to poorer diet quality and that there are many barriers that play a role in this including food prices and food ‘deserts’ or ‘swamps’. UNICEF describe these as places where “an abundance of high-calorie, low- nutrient junk food outlets line the streets”.  England’s poorest areas are fast-food hotspots, with five times more outlets than in the most affluent areas. Children from poorer areas are disproportionately exposed to takeaways, and poorer areas also have more visible advertising for unhealthy foods than wealthier areas. 

Children from families with higher incomes tend to eat more fruit and vegetables – unhealthy foods can be three times cheaper than healthy foods. A study by the Food Foundation thinktank found that “the poorest fifth of families would have to set aside more that 40% of their total weekly income after housing costs to satisfy the requirements of the Government’s Eatwell guide”. Children living in the most deprived communities are twice as likely to be obese as those in the least deprived. 

Food poverty

Food poverty is the inability to afford or have access to food to make up a healthy diet. The Trussell Trust, UK’s largest network of food banks, has predicted a 61% increase in the number of food parcels needed in the coming months. Its latest report also confirms that facilities with children have been among those hit hardest by the pandemic. 

Identifying risk of food poverty:

  1. Family and social history: large families, single parents, unemployment, parents with chronic physical or mental health

2. Adapted ‘HEADSS’ tool for poverty

HomeOvercrowding? Heating? Damp? 
Employment/EducationParent’s employment details – stable income? Dependent on universal credit? School attendance?
ActivitiesHobbies? After-school activities? Holidays? 
DietHistory of skipping meals? Fresh food? Cooking facilities?
Safeguarding/SupportSocial or family worker? Safeguarding concerns?

The policy framework

Addressing the double burden of malnutrition is an important part of working towards the Sustainable Development Goals (Goal 2, Target 3.5) and the Commitment of the Rome Declaration on Nutrition.  

The UK Government has pledged to halve childhood obesity and reduce the obesity gap between children from the richest and poorest areas by 2030. Other public health initiatives have included: 

  • Healthy Start Scheme introduced in 2006 to provide food and vegetable vouchers to low-income families
  • Local authorities to limit the opening of additional fast-food outlets close to schools.
  • Reducing sugar in commercial baby foods and end misleading labelling practices.
  • Sugary drinks industry levy – introduced in 2018 
  • Sugar reduction programme aimed at 20% reduction in most popular products consumed by children by 2020
  • New legislation to ban unhealthy foods at checkout area, store entrances and end of aisle as well as promotions that encourage over consumption – expected to be introduced in 2022

What can Paediatricians do to help?

In October 2020, in reaction to the government’s decision not to fund free school meals during school holidays, Russel Viner, president of the Royal College of Paediatrics and Child Health said;

“We care for children who don’t have enough to eat. We see far too many of them. It is heart-breaking that it has become a normal part of our jobs and hunger is all too common for millions of families in the UK”.

A survey of Paediatricians in 2016 found that more than 60% said that food insecurity contributed to the ill health amongst the children that they treat.  

Though real systemic change is needed at a national level, medical professionals can play a role in educating and informing our patients when we have the opportunity. 

The key step is to identify child poverty and malnutrition. It’s important to be understanding of the family’s social and financial situation, always keeping this context in mind. This sensitive topic must be discussed in a non-judgemental and understanding manner, recognising your own implicit bias to ensure that families do not feel stigmatised. An intersectional approach is key when addressing child poverty, considering all factors that may contribute towards the patient’s vulnerability.

Ensure all interaction with patients and families promote healthy eating and regular exercise, and signpost to local community fridge initiatives and Healthy Start. The Citizen’s Advice Bureaus and Money Advice Services can provide further advice on income and entitlements. Referring to social services early can also be very helpful. Highlighting these actions in the discharge letter to the GP is also a helpful thing to do. 

Primary care based social prescribing signposts to services that focus on the social determinants of health.  Social prescribing link workers will be able to refer on to sources of financial support; local food banks; childcare support and other practical services.

Broader actions that aim to evaluate and improve health services in a local and regional level are also necessary. In addition, paediatricians should be involved in advocacy efforts to influence local and national policy, campaigning for wider government level changes. 

Before discharging Aiden, you give his mum the details of The Trussell Trust so that she can access a local food bank. You also advise her to contact her local Citizen’s Advice Bureau for ensure that the family is receiving all the benefits that they’re entitled to. You include your findings in the discharge summary to make sure Aiden’s GP is aware of the family’s situation and complete a referral to social services to provide support to the family. 

Key Learning Points

  • Children’s diets in the UK are amongst the worst in Europe and have shown little improvement over the past two decades. 
  • Social deprivation is strongly linked to poorer diets and higher rates of malnutrition and obesity. 
  • Though change is needed at a national level, paediatricians can play a role in education and informing their patients and patients’ families. 

Resources for patients and families

Trussell Trust website – find a foodbank

British Dietetics Association. Healthy Eating Fact Sheet

NHS advice for the parents of healthy weight children

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