Paula Watson manages a project called GOALS, a healthy lifestyle programme for obese children and their families, and appears as an expert in Generation XXL. Find out what she has to say about childhood obesity.
GOALS stands for Getting Our Active Lifestyles Started, and is run by Liverpool John Moores University in partnership with Liverpool PCT, Liverpool City Council, Alder Hey Hospital and the University of Salford.
There are currently a million schoolchildren in the UK who are classified as obese. What are the causes behind this epidemic?
'It's simple on the surface, but it's actually quite complex and very much about lifestyle issues. At the simplest level, the amount of calories children are consuming causes an imbalance with the amount of calories they're burning up through physical activity.
'But that's just on the surface level. The things that are actually contributing to that are much wider. There are environmental factors like the way society has changed in terms of things like automation - we use our cars a lot more, there are all the attractive sedentary pastimes like computer games and televisions.
'On the food side there is all the advertising and the temptation of fast food, high-fat and high-sugar foods wherever we go. The other aspect of the problem is that because we've become bigger as a nation, the awareness of what it actually means to be overweight or obese as a child, and the associated health risks, isn't really there.
'Some of the mums in Generation XXL feel they are depriving their children when they say no to junk food, one mum commenting that she was allowed everything when she was young and it's never done her any harm, and her six-year-old daughter looks cuddly and healthy as she is.
'A child doesn't have to look very big to be classified as obese. It's becoming almost the norm - we're no longer used to how much children are supposed to eat, how active they're supposed to be and what they're supposed to look like.'
Are there socio-economic factors involved? Are children more likely to be overweight if they're from a deprived background?
'There is research to suggest some links between deprivation and obesity but sometimes when you pick it out and look at it in more detail, the link isn't as clear.
'For example, children of working mums are more likely to be overweight or obese, which could be due to a number of factors such as the parent feeling guilty and compensating with treats, having less control over the child's diet or finding it difficult to find the time to incorporate physical activity into their lives.
'Anecdotally, and from our experience, we have people from all walks of life, including very educated families, who come to us for help. There is a lot more to it than just background or education.
'There is also a perception that it's expensive to eat healthily but something the families learn that you can actually end up saving money if you're planning your meals and cooking from fresh.
'There may also be cultural influences on childhood obesity. Asian children are more likely to be obese than children in the general population, which is particularly worrying given the increased risk of cardiovascular disease and diabetes in these groups.
'In Generation XXL we see the ways in which food plays a central role in families from different cultural backgrounds. For example, women from Pakistani, Bangladeshi and Black African communities place an importance on feeding their families 'good food', and on having an open house to share pre-prepared traditional meals with unexpected guests.
'The worrying thing is not only the unhealthy cooking practices through which the food is often prepared (eg deep frying in oil, heavily salted etc) but that children from these communities are also being allowed to consume large quantities of Western convenience foods in addition to their traditional diets.'
Parents are often quick to blame metabolism or genetics for their child's weight problem. Do these factors play a role, or is it more a case of parents looking for a reason that isn't there?
'I'd say the latter more than the former. It does play a part, we are all biologically different and it is easier for some people to maintain their weight than others. But essentially for the vast majority of people it is still about that energy imbalance.
'We used to do medical checks on our children, looking for thyroid complications or any possible underlying causes, and the vast majority would come back normal, totally clear, despite their parents being adamant. Sometimes it is a wake-up call for the parents but it is generally a positive thing because it makes them realise that at least they can control the problem themselves.
'One of the mum's provides an example of this in Generation XXL. Following her trip to Liverpool she begins to realise there may be things in her son's lifestyle that are leading him to be overweight (previously she believed it to be a medical problem) and consequently makes changes to his eating (changing to packed lunches) and activity habits (enrolls him in a rugby club).
'It is true that a child is more likely to be obese if they have obese parents but the link is just as likely to be environmental as biological in those cases.'
What are the health issues connected to obesity?
'Without intervention an obese child is likely to become an obese adult, and obesity in adulthood carries with it a huge range of physical and psychosocial complications, most notably increased risk of heart disease, diabetes and cancer.
'There are very few health complications associated with obesity that are actually 'visible' during childhood but research suggests that, under the surface, these problems might already be building up.
'During recent years there have been cases of type II diabetes developing in obese teenagers - a disease linked to unhealthy lifestyle behaviours and traditionally referred to as 'adult onset diabetes'. There is also a vast array of psychological and social issues faced by obese children and adults.
'So for parents, it is about learning to balance the child's immediate wants with their long-term health. These children may be healthy now but unless something changes they risk serious health problems when they are older.'
Some of the kids featured in Generation XXL are picked on because they're overweight. Are the kids you see often bullied?
'Most of the children we see have had some experience of 'fat-teasing' or bullying. It is linked to self-esteem and we can help children deal with these situations by raising their self-confidence and helping them develop a positive image of themselves that goes beyond their weight.
'It can be very difficult for children who feel they look 'different', and some of the older children in Generation XXL are beginning to be aware how others see them. For example, one boy is 10 years old and at almost six foot is already conscious he and his mate are seen as 'little and large'.
'Psychosocial issues such as bullying are the urgent motivation for a lot of children to lose weight. Sometimes it can be difficult for children or their parents to worry about an abstract health problem that may be decades down the line, but the immediate issue can be the psychological side of it. They talk a lot about not being able to fit into clothes of their own age, as we see with one of the seven-year-olds in Generation XXL who has to buy clothes for 11 to 12-year-olds, and the 10-year-old boy who has to buy adult XXL sportswear because they don't do school uniform in his size. It is not surprising that shopping can be an emotional experience.
'Some of the things we hear children say are sad. They often remark they like coming here because they're treated normally, nobody picks on them, and people say hello to them. The thought that it is exceptional for these kids rather than the norm just shows what the rest of their life must be like.'
In the series, when you're giving the parents the results of their children's tests showing their BMI or their percentage of body fat, you don't pull any punches. Is it part of your job to slightly scare them when you're giving them those results?
'This is a difficult thing to do because the parents were clearly surprised by the results and by the extent to which their children were overweight. But yes, it is a case of being cruel to be kind, which is exactly what we're asking them to do with their kids.
'It can be hard to do at the time, but sometimes to have that emotional realisation could be a life-turning point. I think we have a responsibility, as professionals, to tell them how it is - openly but most important sensitively and with empathy. I think sometimes people can be too worried about dealing with weight, because it's a sensitive issue, and so in the end nothing gets done.'
What are the ways of treating childhood obesity? Is it about adjusting diet, getting them to do more exercise, or tackling the psychological aspects?
'What we're ultimately working towards, when we work with families, is getting them to eat a healthy, balanced diet, and do a sufficient amount of physical activity (it is recommended that children engage in moderate to vigorous physical activity for at least an hour every day, and this requirement may be more for children who are obese).
'Sometimes people will come who already eat a healthy diet but don't do enough exercise, or vice versa, so it's about tailoring it to the individual needs in each case.
'The psychological side of it cannot be ignored. The parents of these children will have habits they've developed over 30 or 40 years and we need to work with them to change those habits. That's obviously going to take time. And the whole approach has to involve the parents, and the wider family as well.'
What you hear time and again is parents who complain that their children won't eat anything healthy, even when it's cooked for them. How do you deal with a kid who only wants to eat junk food?
'This is easier said than done, and takes perseverance. It's about resetting the rules and the boundaries, because the reason children will keep pestering for those things is because they know their parents are going to give in, through experience. But gradually, if they realise that their parents aren't going to give in, the children will gradually begin to accept it.
'It's about being strong enough that if the child really is refusing what's on the table, they don't get anything to eat. You could see this with one of the children in Generation XXL who happily eats the food given to her by her childminder (who simply puts the food in front of the children) but refuses to eat the same food when prepared at home by her mum (which involves a long negotiation process each mealtime).
'Also, by being strong enough to keep the high fat, high sugary foods out of the house so temptation isn't there. There are examples in Generation XXL where the children are sneaking food from cupboards, food that if it wasn't there, they couldn't sneak.
'We also try and find fun ways of introducing them to new types of food. They're more likely to try things with us, in an environment with other people, than they are at home. When they're all learning in a room together, with us, it gives the parents a bit of back up.
'And it's about explaining to them the reasons behind it and the importance of being healthy, rather than just saying 'no' to them. If they have it explained, children will often be a lot more accepting of it.'
How serious a problem is our society building up for the future, if this epidemic goes unchecked?
'Very, very serious. If you look at the figures over the past three decades or so, the prevalence of childhood obesity has increased threefold in that time. The Foresight Report in 2007 predicted that by 2050 over 70% of girls under 20 would be overweight or obese.
'We've never yet had a generation grow up with such high obesity rates, so it is difficult to know exactly how serious a burden this will place on public health. But we do know that the estimated cost to lives, society and to the NHS is expected to be enormous.'
