
==== Front
Glob Pediatr
Glob Pediatr
Global Pediatrics
2667-0097
Elsevier Inc

S2667-0097(24)00054-X
10.1016/j.gpeds.2024.100186
100186
Article
Addressing the growing burden of obesity, diabetes and asthma in children and adolescents: The role of primary health care and the WHO Pocket book in Europe for a healthy future
Jullien Sophie julliens@who.int
⁎
Carai Susanne
Weber Martin W.
World Health Organization, Regional office for Europe, Quality of Care and Patient Safety Office, Ploutarchou 3, Athens, Greece
⁎ Corresponding author. julliens@who.int
1 9 2024
9 2024
9 NoneNone
16 4 2024
15 5 2024
© 2024 Published by Elsevier Inc.
2024

https://creativecommons.org/licenses/by-nc-nd/3.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
The burden of obesity, diabetes mellitus and asthma remains a significant public health issue worldwide. These conditions are associated with premature deaths and a reduced quality of life. Primary health care plays a key role in the prevention, detection, and management of noncommunicable diseases in childhood, including diabetes and asthma. Health promotion is crucial for a healthy life from early childhood, preventing from obesity, a sedentary lifestyle, exposure to tobacco smoke, and other risk factors associated to noncommunicable diseases. Asthma and type 1 diabetes mainly begin in childhood; thus, recognition and early detection at the primary health care level are essential. In the long term, management of children with chronic diseases requires regular follow-up and cooperation with a specialized team. Care coordination by the primary health care provider is key for optimal control of the disease and development of the child or adolescent in the physical, emotional, and social spheres. Over-referral for diagnosis and follow-up is associated with unnecessary specialist overload, patient anxiety, and financial burden for the families and the health system. Clear criteria and referral pathways with efficient communication between the professional team members are essential to empower primary health care providers, avoid unnecessary referrals, and optimize the care and quality of life of children and adolescents with chronic diseases.

The WHO Pocket book of primary health care for children and adolescents was recently developed to address knowledge gaps and improve the diagnosis and management of children and adolescents at the outpatient level. It dedicates an entire chapter to health promotion and disease prevention with counselling messages addressed to children, adolescents and their families; provides guidance for the diagnosis and management of asthma, diabetes and other chronic diseases; and includes additional considerations for adolescents living with chronic conditions.

Keywords

Overweight
Diabetes
Asthma
Child and adolescent health
Primary health care
==== Body
pmcThe burden of obesity, diabetes mellitus and asthma

Noncommunicable diseases have become more prominent among leading causes of death and disability globally.1 Chronic obstructive pulmonary disease and diabetes mellitus constitute a heavy burden; they rank among the top 10 global causes of deaths and the top 10 global causes of disability-adjusted life years (DALYs), causing a significant public health issue worldwide. DALYs from diabetes increased by more than 80 % between 2000 and 2019.1 In 2021, 529 million people were living with diabetes,2 and 262 million people were affected by asthma in 2019.3

Non-communicable diseases are increasingly affecting children and adolescents worldwide and in the Europe Region. Asthma is the most common chronic disease of childhood; its prevalence in children and adolescents was estimated at 4.6–9.1 % in Western Europe and 2.7–5.8 % in Central Europe and Central Asia.4 The Europe Region has the highest number of children and adolescents with type 1 diabetes,5 with an estimated annual incidence increase of 3.4 %.6

Overweight and obesity among children and adolescents constitute one of the major public health challenges in the European Region. The WHO European Childhood Obesity Surveillance Initiative (COSI) was established in 2007 to inform policy development and public health response in combating this challenge in the Region. The last round of data was collected in 2018–2020 from about 411,000 school aged children aged 6 to 9 years across 33 countries. Findings show that 29 % of children are overweight, ranging between 6 % and 43 % between countries, and that 12 % of children live with obesity, ranging between 1 % and 19 % between countries.7

These conditions are associated with premature deaths and reduced quality of life since childhood, in addition to the obvious economic impact. Action is urgently needed to address overweight and obesity and reverse the increasing burden of diabetes, asthma and other chronic diseases since childhood. At the level of health care delivery, this implies health promotion and disease prevention for all children and adolescents, and optimal quality of care in the management and follow-up for those suffering from overweight, obesity, diabetes and asthma.

Health promotion and disease prevention in the fight against diabetes and asthma

Many noncommunicable diseases have their origins in childhood. Unhealthy diets, sedentary lifestyle and exposure to alcohol and tobacco smoke are well-known important risk factors.8 Childhood obesity is associated with greater risk of noncommunicable diseases in adults, such as non-insulin-dependent diabetes (i.e. type 2 diabetes), high blood pressure, asthma, cardiovascular diseases and adverse psychosocial consequences.9

Health promotion is key for a healthy life from early childhood, and therefore essential for preventing from overweight, obesity and the other above-mentioned risk factors associated to noncommunicable diseases. All levels of the health system need to take responsibility for achieving the desired outcomes, including, for example, the governance bodies designing laws to regulate commercial marketing and end harmful advertising. Indeed, the increased exposure to screens of children and adolescents and the aggressive online advertising for sweet beverages, fast food, and addictive substances, contribute to obesity and noncommunicable diseases. At the service delivery level, primary health care is the cornerstone of health promotion for children and adolescents, their families, and the communities.

Detection and management of chronic conditions

Asthma and insulin-dependent (type 1) diabetes mainly commence in childhood; therefore, recognition and early detection are crucial mainly by health care providers caring for children at the primary health care level. Referral is then usually required for confirmatory diagnosis and specialist assessment.

In the long term, management of children with chronic diseases require lifelong treatment, regular follow-up, and cooperation with a specialized team. Care coordination by the primary health care providers is key for disease control and optimal development of the child or adolescent in the physical, emotional, and social spheres.

Over-referral for diagnosis and follow-up is associated with unnecessary specialist overload, patient anxiety, and financial burden for the families and the health system. Clear criteria and referral pathways with efficient communications between the professional team members are therefore essential to empower primary health care providers, avoid unnecessary referrals, and optimize the care and quality of life of children and adolescents with chronic diseases.

Chronic conditions in adolescence

Adolescence is an important time for laying the foundations of good health. Adolescents experience rapid physical, cognitive and psychosocial growth, affecting how they feel, think, and make decisions. On the one hand, chronic conditions may affect several aspects of the adolescent life, such as growth and puberty, social life, and capacity to attend school. On the other hand, the changes experienced in the adolescent phase influencing their mood, behaviour, and interaction with the world around them constitute a major challenge to develop and maintain healthy habits, which is especially important for adolescents living with a chronic disease. This in turn poses a challenge to the individual, their family, and the healthcare team to ensure optimal management and control of the disease.

The role of primary health care in combating obesity, diabetes and asthma for healthy futures

Primary health care plays a vital role in health promotion as well as in the prevention, detection, and management of obesity, diabetes and asthma, as well as other chronic diseases in childhood. The primary health care providers often know the children since their early childhood, accompany them in the diagnosis and management of their chronic disease, and play a key role to ensure continuity during the adolescence until the transition to adult services.

Children and adolescents with chronic conditions need multiple contacts with the health system. Primary health care providers often act as the first point of contact in the health system for these children and their families and are in a privileged position for the coordination of the multidisciplinary care they require, ensuring timely referral to other health professionals such as medical specialists, nutritionists, mental health professionals and social services.

However, primary health care for children in Europe is often not optimal. While the cause is multifactorial from the different levels of the overall functioning health system, a series of applied health system assessments identified major knowledge gaps among health providers and non-evidence-based practices as major contributors.

The who pocket book of primary health care for children and adolescents

To address these knowledge gaps in the care delivery for children and adolescents, the WHO regional office for Europe developed the pocket book of primary health care for children and adolescents10 (Fig. 1). It compiles evidence-based guidelines on how to manage and when to refer children and adolescents presenting with common and severe complaints and conditions. Its main characteristics are described elsewhere.11 The pocket book is available in the public domain, it is for use by doctors, nurses and other health workers responsible for the care of children and adolescents at the primary health care level.10 A mobile application for iOS and Android devices comprising the content of the pocket book and additional features such as drug dosage calculators and others described below can be download for free (Fig. 1).Fig. 1 The hard copy of the pocket book of primary health care for children and adolescents (left) and its mobile app icon (middle) and landing page and content (right).

Fig 1

How does the pocket book contribute to reducing the burden of overweight, obesity, asthma, diabetes, and other chronic conditions, and improving the care for children and adolescents suffering from these conditions?

The pocket book dedicates an entire chapter to health promotion and disease prevention to support primary health care providers with counselling on nutrition and sedentary behaviour among others as well as with early identification of congenital diseases for example through screening tests. Important counselling messages using simple and clear language are presented in counselling boxes addressed directly to the children, adolescents and their families that can be downloaded and shared through the mobile app.

The core chapter of the pocket book employs a symptom-based approach to support the health care provider to care for a child or adolescent presenting with a specific symptom or complaint. This symptom-based approach leads the health care provider through a systematic process of history taking, examination, and possible investigations, to contemplate differential diagnosis until a diagnosis can be made. Asthma, for example, is taken into account in the differential diagnosis of a child presenting with cough or wheeze.

The pocket book also has a chapter providing guidance for the management of children and adolescents who have or might have asthma, diabetes or other chronic diseases such as cystic fibrosis, sickle cell disease or chronic kidney diseases. For asthma, a tool is available in the mobile app to facilitate the correct classification of the severity of an asthma exacerbation based on the age and presenting symptoms of the patient. Guidance for the medical management and referral is then provided according to the severity as per the classification (Fig. 2). Another tool supports the assessment of asthma symptom control, useful in the long-term management and follow-up visits of children and adolescents with asthma. Evidence suggests that written information reduces medication errors and improves treatment adherence.12 Therefore, an asthma action plan was developed that can be populated with the patient´s name and dosages of the controller and reliever medications so that the child or adolescent and their family know what to do when the asthma is well controlled, when it is getting worse, and when there are severe symptoms. The personalised action plan can be sent directly to the patient through the mobile app. For diabetes, the pocket book includes counselling boxes with information on what the child or adolescent needs to do when they have low blood glucose, and how to inject insulin correctly (Fig. 3).Fig. 2 Mobile app tool for the classification of severity of asthma exacerbation (left) with management according to severity (middle and right).

Fig 2

Fig. 3 Counselling boxes for children and adolescents with diabetes and their caregivers.

Fig 3

Another chapter is dedicated to conditions specific to adolescence and provides additional considerations for adolescents living with chronic conditions. The pocket book also provides information on conditions which are usually managed by specialists, to enable primary health care providers to fulfil their coordination role. Overall, the pocket book defines standards for optimal quality of care for children and adolescents at the primary health care level, including detection, management and long-term follow-up of children with noncommunicable diseases, as well as how to prevent them.

Conclusion

The high burden of overweight, obesity, diabetes mellitus and asthma in children and adolescents is a major challenge in the European Region. Preventable deaths still occur due to the inappropriate management of these conditions. The role of primary health care in combatting overweight, obesity, diabetes and asthma is key for a healthy future, from health prevention to diagnosis and management of children and adolescents suffering from these conditions. The WHO pocket book of primary health care for children and adolescents and its mobile application is a useful resource to support primary health care providers: it brings evidence-based guidance and tools on how to manage and when to refer children and adolescents with overweight, obesity, diabetes and asthma; it enables them to coordinate the continued care of children and adolescents with chronic conditions between the members of the multidisciplinary team of professionals; and it provides counselling boxes messages for children, adolescents and caregivers.

Disclaimer

The opinions expressed are those of the authors and do not necessarily reflect the positions and policies of the World Health Organization.

CRediT authorship contribution statement

Sophie Jullien: Conceptualization, Writing – original draft. Susanne Carai: Writing – review & editing. Martin W. Weber: Conceptualization, Writing – review & editing.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
==== Refs
References

1 Leading Causes of Death and disability. A visual Summary of Global and Regional Rends 2000-2019 2024 World Health Organization https://www.who.int/data/stories/leading-causes-of-death-and-disability-2000-2019-a-visual-summary
2 GBD 2021 Diabetes Collaborators Global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the global burden of disease study 2021 The Lancet 402 10397 2023 203 234 10.1016/S0140-6736(23)01301-6
3 Wang Z. Li Y. Gao Y. Fu Y. Lin J. Lei X. Global, regional, and national burden of asthma and its attributable risk factors from 1990 to 2019: a systematic analysis for the global burden of disease study 2019 Respir. Res. 24 1 2023 10.1186/s12931-023-02475-6
4 Global burden of disease study 2019 Data Resources 2019 IHME https://ghdx.healthdata.org/gbd-2019
5 Diabetes in Europe. International diabetes federation; 2021 (www.diabetesatlas.org).
6 Díez-Fernández A. Ruiz-Grao M.C. Mesas A.E. Martinez-Vizcaino V. Garrido-Miguel M. Type 1 diabetes incidence trends in children and adolescents aged 0-14 years in Europe: a systematic review and meta-analysis protocol BMJ Open 11 10 2021 10.1136/bmjopen-2021-054962
7 Report on the fifth round of data collection, 2018–2020 WHO European Childhood Obesity Surveillance Initiative (COSI) 2022 WHO Regional Office for Europe Copenhagen Licence: CC BY-NC-SA 3.0 IGO https://www.who.int/europe/publications/i/item/WHO-EURO-2022-6594-46360-67071
8 Prevention of Noncommunicable Diseases 2024 World Health Organization https://www.who.int/teams/maternal-newborn-child-adolescent-health-and-ageing/child-health/prevention-of-noncommunicable-diseases
9 Fact sheet: Obesity and Overweight 2024 World Health Organization https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight
10 Pocket Book of Primary Health Care For Children and adolescents: Guidelines For Health promotion, Disease Prevention and Management from the Newborn Period to Adolescence 2022 WHO Regional Office for Europe Copenhagen Licence: CC BY- NC-SA 3.0 IGO https://iris.who.int/handle/10665/352485
11 Weber M. Black M. Carai S. Jullien S. WHO Strategies to Improve Child Health in Europe 2024 In press
12 Rameshkumar T. Haputhanthrige I.U. Misbahunnisa M.Y. Galappatthy P. Patients' knowledge about medicines improves when provided with written compared to verbal information in their native language PLoS ONE 17 10 2022 e0274901 10.1371/journal.pone.0274901
