Management of infants and children at high risk (excessive adiposity) and children with obesity for improved health, functioning and reduced disability: a primary health care approach

Scope and Purpose

Overweight (pre-obesity) and excess adiposity are a concern in almost all regions of the world.¹ As of 2019 it was estimated that 38.3 million children under 5 years of age had moderate or severe overweight.² There has been no progress to stem the rate of overweight in children under 5 years of age in nearly 20 years. In order to respond to current global epidemiology and to complement existing prevention-focused guidelines, the World Health Organization (WHO) is currently developing a science-informed, people-centred guideline on the integrated management of infants and children at high risk (excessive adiposity) and children with obesity using a primary health care approach.

As part of its commitment to address global and country level needs, this normative work has been prioritized as a global public health good by WHO. The proposed line of work is aligned with the 2030 Agenda for Sustainable Development, target 3.4, to reduce premature mortality from noncommunicable diseases.³ In the context of the Sustainable Development Goals, WHO’s thirteenth general programme of work 2019−2023 highlights the need for achieving universal health coverage for one billion more people.⁴ Universal health coverage entails a people-centred health system with primary care at its foundation. Relatedly, WHO’s thirteenth general programme of work 2019−2023 also aims to achieve one more billion people enjoying better health and well-being, an effort within WHO’s Strategy for Healthier Populations 2020-2030.

The International Classification of Diseases 11 (ICD-11) defines obesity as “a chronic complex disease defined by excessive adiposity that can impair health. It is in most cases a multifactorial disease due to obesogenic environments, psycho-social factors and genetic variants. In a subgroup of patients, single major etiological factors can be identified (medications, diseases, immobilization, iatrogenic procedures, monogenic disease/genetic syndrome). Body mass index (BMI) is a surrogate marker of adiposity calculated as weight (kg)/height² (m²). The BMI categories for defining overweight vary by age and gender in infants, children and adolescents”⁵ WHO's International Classification of Functioning, Disability and Health (ICF) allows for the assessment of individual’s level of functioning as well as for the development of policy and guidelines for needs assessment for the design and evaluation of interventions. The ICF contains considerations for impairment of body functions (e.g., functions of the endocrine system, including weight maintenance), impairments of body structures (e.g., structure related to movement), and activity limitations (e.g., mobility and interpersonal interactions).⁶

The WHO Commission on Ending Childhood Obesity in its 2016 “Report of the commission on ending childhood obesity” issues six recommendations, one of special relevance to this proposal: “Provide family-based, multicomponent lifestyle weight management services for children and young people who are obese”. In detail 6.1. expressed: “Develop and support appropriate weight management services for children and adolescents who are overweight or obese that are family-based, multicomponent (including nutrition, physical activity and psychosocial support) and delivered by multiprofessional teams with appropriate training and resources, as part of Universal Health Coverage”.⁷

A primary health care approach includes three components: 1) meeting people’s health needs throughout their lives; 2) addressing the broader determinants of health through multisectoral policy and action; and 3) empowering individuals, families and communities to take charge of their own health.⁸  The integrated management of childhood illnesses (IMCI) includes three strategies: 1) improving case management skills of health-care staff, 2) improving overall health systems, and 3) improving family and community health practices. In healthcare facilities, the IMCI entails the identification of illness in outpatient settings, adopting a people-centred, integrated care perspective instead of focusing on a specific diagnosis, working with caregivers, and expediting the referral of severely ill children to the appropriate facility or specialist in the health system or network of service providers to address the relevant health needs. People-centred care is an approach to care that consciously adopts the perspectives of individuals, caregivers, families and communities as participants in and beneficiaries of trusted health systems that respond to their needs and preferences inhumane and holistic ways. People-centred care also requires that people have the education and support they need to make decisions and participate in their own care. 

As part of the WHO guideline development process, a Guideline Development Group has been convened. The Guideline Development Group will support WHO 13th General Programme through its normative work by:

• Providing input into the scope of the guideline and assisting the WHO Steering Committee in the development of key questions in PICO (Population, Intervention or Exposure, Comparison, Outcome) format;
• Choosing and ranking priority outcomes that will guide the retrieval, summary and assessment of the evidence to inform the recommendations on interventions;
• Examining and providing technical and programmatic input on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence profiles or other assessments of the certainty of the evidence used to inform the recommendations;
• Interpreting the scientific evidence, with explicit considerations of the overall balance of benefits and harms, following an approach grounded in gender, equity and human rights, and incorporating considerations of people living with disabilities;
• Formulating recommendations and determining their strength taking into account benefits, harms, values and preferences, feasibility, equity, ethics, acceptability, resource requirements and other factors, as appropriate;
• Reviewing the preliminary version of the recommendations in the guideline document before submission for WHO executive clearance process for publication and further dissemination;
• Defining implications for further research and knowledge gaps; and
• Discussing implementation and evaluation considerations of the guideline recommendations impact at country level.

Given the ongoing COVID-19 pandemic, all meetings for this Guideline Development Group will be held virtually during 2021. Each of the scheduled online meetings will be held on two consecutive days for a duration of approximately four hours each day. 

Objectives and expected outcomes of the first Guideline Development Group meeting

The objectives of the first Guideline Development Group meeting are to:

1. Formally launch and present all selected members of the Guideline Development Group and present the WHO Steering Committee;
2. Introduce the WHO guideline development process, including the WHO Handbook for guideline development and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology;
3. Present the primary health care approach and how it relates to this normative work;
4. Discuss the methods proposed in the project to accomplish and end-to-end normative product;
5. Reach consensus on the guideline development decision-making process, decision rules, and other methodological aspects;
6. Present the preliminary findings of commissioned systematic reviews that will inform the guideline development process; and
7. Discuss the context, objectives, strategies and challenges this guideline seeks to address, based among others on the results of an ongoing priority-setting exercise.

The expected outcomes of the first Guideline Development Group meeting are a structured guideline development process with clearly defined roles and expectations for each member as well as an initial assessment of the plans, objectives and steps to follow for the development of this guideline.

¹  NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults. Lancet. 2017; 390: 2627–42.

² United Nations Children’s Fund (UNICEF), World Health Organization, International Bank for Reconstruction and Development/The World Bank. Levels and trends in child malnutrition: Key Findings of the 2020 Edition of the Joint Child Malnutrition Estimates. Geneva: World Health Organization; 2020.

³ Transforming our world: the 2030 Agenda for Sustainable Development. New York: United Nations; 2015.

⁴ Thirteenth General Programme of Work 2019-2023. Geneva: World Health Organization; 2018.

⁵ International classification of diseases for mortality and morbidity statistics (11th Revision). Geneva: World Health Organization; 2020.

⁶ Towards a common language for functioning, disability and health- ICF. Geneva: World Health Organization; 2002.

⁷ Report of the Commission on Ending Childhood Obesity. Geneva: World Health Organization; 2016.

⁸ Technical series on primary health care: Quality in primary health care Geneva: World Health Organization; 2018.