Ten per cent of the world’s school-aged children are estimated to be carrying excess body fat (Fig. 1), with an increased risk for developing chronic disease. Of these overweight children, a quarter are obese, with a significant likelihood of some having multiple risk factors for type 2 diabetes, heart disease and a variety of other co-morbidities before or during early adulthood. The prevalence of overweight is dramatically higher in economically developed regions, but is rising significantly in most parts of the world. In many countries the problem of childhood obesity is worsening at a dramatic rate. Surveys during the 1990s show that in Brazil and the USA, an additional 0.5% of the entire child population became overweight each year. In Canada, Australia and parts of Europe the rates were higher, with an additional 1% of all children becoming overweight each year. The burden upon the health services cannot yet be estimated. Although childhood obesity brings a number of additional problems in its train – hyperinsulinaemia, poor glucose tolerance and a raised risk of type 2 diabetes, hypertension, sleep apnoea, social exclusion and depression – the greatest health problems will be seen in the next generation of adults as the present childhood obesity epidemic passes through to adulthood. Greatly increased rates of heart disease, diabetes, certain cancers, gall bladder disease, osteoarthritis, endocrine disorders and other obesityrelated conditions will be found in young adult populations, and their need for medical treatment may last for their remaining life-times. The costs to the health services, the losses to society and the burdens carried by the individuals involved will be great. The present report has been written to focus attention on the issue and to urge policy-makers to consider taking action before it is too late. Specifically, the report:

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1467-789X.2004.00133.x

Obesity in children and young people: a crisis in public health.

The PedsQL 4.0 as a pediatric population health measure: feasibility, reliability, and validity.

Scope of the report This report is concerned with the evaluation of measures broadly designed to measure quality of life (QoL) in children and adolescents, either by self-report or proxy raters. Four research questions were identified: (1) To what extent are adult measures used in the evaluation of healthcare interventions in children? (2) How appropriate are adult measures for use with children? (3) To what extent do child self-reports correspond with assessments made by parents and carers? (4) How feasible and reliable are proxy measures of QoL in different disease contexts? Objectives (1) To review the state of the art with regard to measurement of QoL for children. (2) To make recommendations regarding the value of currently available measures for different purposes. (3) To identify further research needs. Method Electronic databases were searched for the period 1980-July 1999 for articles relating to measures of QoL, health status or well-being in children (under 18 years) with chronic disease. Handsearching of relevant journals and cross-referencing with reference lists in identified articles was also carried out. Key workers in the field were contacted for additional information, and the Internet was searched for relevant websites. Results Forty-three measures were identified (19 generic and 24 disease-specific). Sixteen measures allowed for completion by children and parent/caregiver; seven only allowed for completion by a proxy, and the remainder (n = 17) allowed only for child completion. The measures were described as QoL (n = 30), health status, (n = 2), perception of illness (n = 1), life satisfaction (n = 1) and quality of well-being (n = 1). RESULTS - TO WHAT EXTENT ARE ADULT MEASURES USED IN THE EVALUATION OF HEALTHCARE INTERVENTIONS IN CHILDREN?: Three studies were identified where adult measures were used with very few changes made for children. In 11 studies involving nine separate measures of QoL, adult measures were used as a model for work with children. RESULTS - HOW APPROPRIATE ARE ADULT MEASURES FOR USE WITH CHILDREN?: Adult measures may fail to tap the specific aspects of QoL that are important to the child. Measures based on adult work impose considerable response burden for children, in terms of length, reading skills and response scale. Wording and format of adult measures may need to be modified to account for children's cognitive and language skills. More basic research is needed to determine the level of response burden that children of different ages can manage. Assessments of difficulty (e.g. reading age) need to be routinely included with information about new measures. RESULTS - TO WHAT EXTENT DO CHILD SELF-REPORTS CORRESPOND WITH ASSESSMENTS MADE BY PARENTS AND CARERS?: Fourteen studies were identified in which concor-dance between child and parent was investigated, often as part of the development of a new measure. There was some evidence for greater concordance between child and parent for physical functioning compared with social and emotional domains, but greater heterogeneity in the latter measures may contribute to inconsistent results. There was no simple relationship between concordance and moderating variables such as age, gender and illness, but this conclusion was addressed only very rarely. RESULTS - HOW FEASIBLE AND RELIABLE ARE PROXY MEASURES OF QOL IN DIFFERENT DISEASE CONTEXTS?: Only five papers fulfilled the review criteria. Evaluation is difficult because authors fail to justify their choice of measures, and do not report critical information such as completion rates or missing data. Use of existing measures can potentially eliminate the time and expense required to develop a comprehensive measure of QoL, but a full battery of standardised tests may be expensive in terms of time for administration and scoring. In addition, battery measures tend to be lengthy and therefore demanding for sick patients. They are not recommended for work with children. RECOMMENDATIONS FOR RESEARCH - MINIMUM CRITERIA FOR NEW MEASURES: A set of procedures needs to be established for the development of new measures. These need to draw on the experience gained in development of child and adult measures to date. Basic research to enhance understanding of how children interpret questions in QoL measures is recommended. We need to understand the differences in meaning of items between children and adults, and between children of different ages. Some attempt to develop measures for children of 6 years or more have been reported, and these should be further developed. (ABSTRACT TRUNCATED)

Quality-of-life measures in chronic diseases of childhood

Objective Childhood and adolescent overweight and obesity have increased substantially in the past 2 decades, raising concerns about the physical and psychosocial consequences of childhood obesity. We investigated the association between obesity and health-related quality of life in a nationally representative sample of adolescents. Methods A cross-sectional analysis was conducted using the 1996 National Longitudinal Study of Adolescent Health, a nationally representative sample of adolescents in grades 7 to 12 during the 1994-1995 school year, and 4743 adolescents with direct measures of height and weight. Using Centers for Disease Control and Prevention growth charts to determine percentiles, we used 5 body mass categories. Underweight was at or below the 5th percentile, normal BMI was between the 5th and 85th percentiles, at risk for overweight was between the 85th and 95th percentiles, overweight was between the 95th and 97th percentiles + 2 BMI units, and obese was at or above the 97th percentile + 2 BMI units. Four dimensions of health-related quality of life were measured: general health (self-reported general health), physical health (absence or presence of functional limitations and illness symptoms), emotional health (the Center for Epidemiologic Studies Depression Scale and Rosenberg's self-esteem scale), and a school and social functioning scale. Results We found a statistically significant relationship between BMI and general and physical health but not psychosocial outcomes. Adolescents who were overweight had significantly worse self-reported health (odds ratio [OR]: 2.17; 95% confidence interval [CI]: 1.34-3.51), as did obese adolescents (OR: 4.49; 95% CI: 2.87-7.03). Overweight (OR: 1.81; 95% CI: 1.22-2.68) and obese (OR: 1.91; 95% CI: 1.24-1.95) adolescents were also more likely to have a functional limitation. Only among the youngest adolescents (ages 12-14) did we find a significant deleterious impact of overweight and obesity on depression, self-esteem, and school/social functioning. Conclusions Using a nationally representative sample, we found that obesity in adolescence is linked with poor physical quality of life. However, in the general population, adolescents with above normal body mass did not report poorer emotional, school, or social functioning.

Overweight, obesity, and health-related quality of life among adolescents: the National Longitudinal Study of Adolescent Health.

Research on physical activity (PA) has expanded in recent years to examine environmental influences that enhance or limit the opportunities people have to be active. The purpose of this study was to review and critically examine evidence related to parks and recreation as features of the built environment and the relationship of these settings to PA. Fifty studies were retrieved from four major databases that reported an empirical relationship between parks or recreation variables and PA variables. Mixed associations with PA were observed for different types of parks or recreation settings, while proximity to parks or recreation was generally associated with increased PA. Shortcomings exist in this literature and many opportunities for researching parks, recreation, and active living are evident for the future.

Environmental Correlates of Physical Activity: A Review of Evidence about Parks and Recreation

This qualitative study aimed to elicit child and parent views regarding social and environmental barriers to healthy eating, physical activity and child obesity prevention programmes, acceptable foci, and appropriate modes of delivery. To obtain views across a range of social circumstances three demographically diverse primary schools in Victoria, Australia were selected. Children in Grades 2 and 5 participated in focus groups of three to six children.Focus groups with established parent groups were conducted. Comments were recorded, collated, and themes extracted. 119 children and 17 parents participated. Nine themes emerged: information and awareness, contradiction between knowledge and behaviour, lifestyle balance, local environment, barriers to a healthy lifestyle, contradictory messages, myths, roles of the school and family, and timing and content of prevention strategies for childhood obesity.In conclusion, awareness of food ﾑhealthinessﾒ was high however perceptions of the ﾑhealthinessﾒ of some sedentary activities that are otherwise of benefit (e.g. reading) were uncertain. The contradictions in messages children receive were reported to be a barrier to a healthy lifestyle. Parent recommendations regarding the timing and content of childhood obesity prevention strategies were consistent with quantitative research. Contradictions in the explicit and implicit messages children receive around diet and physical activity need to be prevented. Consistent promotion of healthy food and activity choices across settings is core to population prevention programmes for childhood obesity.

Healthy eating, activity and obesity prevention: a qualitative study of parent and child perceptions in Australia.

Introduction: Childhood overweight/obesity is associated with poor physical and psychosocial health in clinical samples. However, there is little information on the health status of overweight and obese children in the community, who now represent a large proportion of the child population. We examined parent-reported child health and well-being and parent concern about child weight by body mass index (BMI) category in a population sample of primary school children. Design: A stratified two-stage random cluster sample of 24 primary schools representative of the state of Victoria, Australia. Measures: BMI (weight/height2) transformed to normalised Z-scores using the 1990 UK Growth Reference; the Child Health Questionnaire (CHQ), a 13-scale 50-item parent-completed measure of health and well-being; parent self-reported height and weight; parent concern about child's weight. Results: Data were available for 2863 children aged 5–13 y (50.5% male), of whom 17% were overweight and 5.7% obese. Using logistic regression analyses with ‘normal weight’ as the referent category, obese boys were at greater risk of poor health (ie <15th centile) on seven of the 12 CHQ scales: Physical Functioning (odds ratio (OR) 2.8), Bodily Pain (OR 1.8), General Health (OR 3.5), Mental Health (OR 2.8), Self Esteem (OR 1.8), Parent Impact—Emotional (OR 1.7) and Parent Impact—Time (OR 1.9). Obese girls were at greater risk of poor health on only two scales: General Health (OR 2.1) and Self Esteem (OR 1.8). Forty-two percent of parents with obese children and 81% with overweight children did not report concern about their child's weight. Parents were more likely to report concern if the child was obese (OR 21.3), overweight (OR 3.5) or underweight (OR 5.4) than normal weight (P<0.05). Concern was not related to child gender, parental BMI or parental education after controlling for child BMI. Perceived health and well-being of overweight/obese children varied little by weight category of the reporting parent (overweight vs non-overweight). Conclusions: Parents were more likely to report poorer health and well-being for overweight and obese children (particularly obese boys). Parental concern about their child's weight was strongly associated with their child's actual BMI. Despite this, most parents of overweight and obese children did not report poor health or well-being, and a high proportion did not report concern. This has implications for the early identification of such children and the success of prevention and intervention efforts.

Parent-reported health status of overweight and obese Australian primary school children: a cross-sectional population survey

Background. Although there is clear evidence of the influence of parental factors on child health outcomes, the influence of parental perceptions of their health and illness on the reporting of child health remains primarily unknown. Objectives. To examine relationships between parents9 reporting of their own health and illness with the reporting of their children9s health and illness. Method. We surveyed parents of a representative population-based sample of children aged 5 to 18 years. One parent of each child completed a written questionnaire including the Child Health Questionnaire, a subjective measure of functional health and well-being, and an assessment of self-reported parental health and illness. Logistic regression models were used to examine relationships between parent and child health and illness. Main Results. 5340 parents responded (86% mothers, 14% fathers). After adjusting for confounding effects, parents self-reporting poor health had increased odds of reporting their children with poor health (odds ratio: 7.5), although the effect was modified by parent gender. There were increased odds of mothers with self-reporting poor global health reporting their children with poor global health and illness (odds ratio: 9.0 and 2.5, respectively) that were not observed for fathers. Conclusions. A mother9s self-reported health is strongly associated with her reporting of her child9s health; this was not observed for fathers. These results suggest that parental gender should be considered as a mediating factor in the reporting of child health.

Influence of parental gender and self-reported health and illness on parent-reported child health.

Objective: To improve the ability to describe and compare child health within and between countries, using standardized multidimensional child health measures. Methods: Data on population-specific psychometrics, the measurement structure, and norms are a vital prerequisite. These properties for the Child Health Questionnaire (CHQ) were examined for an Australian population and compared with the originating U.S. data. The CHQ50-item parent-report was completed by 5,414 parents of children aged 5–18 years. Multi-item/multi-trait analysis tested convergent and discriminatory validity. Construct validity, test-retest reliability, comparative population mean scale scores, and the summary score factor structure were examined. Results: Item and scale internal consistency and item discriminant validity results were good to excellent, and construct (concurrent) validity was supported. Australian children had higher scores than U.S. children except for Family Activities and Physical Functioning. The factor structure of the two summary scores for American children was not replicated in the normative sample but held for a subsample of children with one or more health conditions. Conclusions: The CHQPF50 performed well in Australia at item and scale level. However, the physical and psychosocial summary scores are not supported for population-level analyses but may be of value for subgroups of children with health problems.

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The Parent-Form Child Health Questionnaire in Australia: Comparison of Reliability, Validity, Structure, and Norms

The aim of this study was to describe child health and well-being across the spectrum of cerebral palsy (CP) and to report on psychometric properties of the Child Health Questionnaire (CHQ) in this population. Parents of 80 individuals (45 males, 35 females; mean age 11 years 4 months, SD 3 years 6 months; range 5 to 18 years) attending a CP clinic in Victoria, Australia were surveyed. Measures included the CHQ PF-50, a 50-item parent-reported heath status measure; severity of CP, based on the Gross Motor Function Classification System; and cognitive status and presence of epilepsy. CHQ data were compared with normative data collected in Victoria two years earlier. The CHQ demonstrated good psychometric properties for children with CP. Children with CP had markedly poorer health on every CHQ scale than those in the normative sample. Health status did not vary by cognitive status or epilepsy. Children with severe CP had the poorest physical health, but psychosocial health and emotional impact on parents were similar for mild and severe CP showing that these should not be assumed to be less prevalent when CP is mild.

Louisa Salmon

Papers

Healthy eating, activity and obesity prevention: a qualitative study of parent and child perceptions in Australia.

Parent-reported health status of overweight and obese Australian primary school children: a cross-sectional population survey

Influence of parental gender and self-reported health and illness on parent-reported child health.

The Parent-Form Child Health Questionnaire in Australia: Comparison of Reliability, Validity, Structure, and Norms

Health status of Australian children with mild to severe cerebral palsy: cross-sectional survey using the Child Health Questionnaire