A combination of larger portion sizes, sedentary lifestyles, not enough sleep, and easy access to energy-dense, low-nutrient foods are some of the primary factors driving childhood obesity. But the complications of children being above a healthy weight range can result in a "very premature demise", John Hunter Children's Hospital paediatrician, Dr Elizabeth Percival, warns.

"We have seen children in our region who have died because of complications related to being above a healthy weight, and that is heartbreaking for a parent to hear that that has happened," Dr Percival said.

A population health survey estimates that between 2015 and 2018, 21.5 per cent of children living within Hunter New England were considered overweight or obese.

Dr Percival typically sees children on the "extreme" end of the scale.

She works within the hospital's Weight Management Service - which holds outpatient clinics for children and young people with a body mass index (BMI) above the 95^th percentile.

The service sees children presenting with high blood pressure, psychosocial issues including depression and eating disorders, kidney scarring, hypertension and heart problems, as well as gallstones and fatty liver disease.

Some young patients are pre-diabetic, or - in some cases - have already developed Type 2 diabetes, and some suffer from respiratory and musculoskeletal issues.

But sleep apnea, in particular, was a "significant" and often immediate threat to their lives, Dr Percival said.

"That can be a combination of when the airways become obstructed while they sleep, or when their respiratory centre in their brain has not communicated with their lungs to breathe," she said. "That can lead to pauses in their breathing, and when that is not treated, it can result in both respiratory failure initially, and heart failure, and in some extreme cases, death - which is extremely concerning and sad."

Dr Percival said the multi-disciplinary weight management services team - which also includes a trainee paediatrician, psychologist, dietitian, physiotherapist, social worker and nurse - works within the John Hunter Children's Hospital one day a week to provide a short-term education and assessment program.

It is focused on helping children aged two-to-12, and adolescents aged 13-to-17.

Children can be referred by a GP if their BMI is above the 95th percentile, they have complications related to their weight, and they have had no improvement despite lifestyle changes.

"We have had referrals for children who are 15 months," Dr Percival said.

"We don't see as many referrals for under fives. There are a few that come through, but we see more in that five-to-12 age group, and the adolescent age group.

"The younger you are, the less likely you are to have the really severe complications. But there has been a few very young children, those four or five years of age, who have had severe problems.

"But certainly, once they are school-aged, we are seeing more complications, which is primarily sleep apnea, high blood pressure, evidence of pre-diabetes, or in some extreme cases, Type 2 diabetes."

Typically, the service aimed to help children and families who had already tried other measures - such as NSW Health's Go4Fun program - but had been unsuccessful at improving their weight status.

"This is a really tricky issue, and it is so multi-factorial," she said. "There is rarely ever one thing that has contributed to a child's health problems.

"There are some things we can't change. We can't change your genetics. We can't change what has happened to you in the past that may have contributed. So we focus on the modifiable risk factors, which are predominantly lifestyle and environment, and what we can do differently. We focus on promoting good health not just for the child, but for the whole family.

"And as best we can, we try to engage with, support and motivate families without judging them harshly.

"Lifestyle habits can be really hard to change."

Dr Percival said every two-to-four months, they invited between 30 and 40 referred families to an "orientation" to explain how the program worked and the level of commitment required.

"Of those invitations, we'd see maybe a dozen families, and from that - about two-thirds might participate," she said. "We get a lot of referrals, and families can't always participate in our program. Being on a Thursday afternoon, and with it being still in school hours for primary school kids, and just after for the adolescent children, running fortnightly over four months - we are not able to engage with all families that have been referred to us."

Dr Percival recommended families follow the "8 Healthy Habits", which included getting enough sleep, drinking water instead of soft drinks, juice or cordial, limiting screen time to no more than an hour a day for children aged two-to-five, and up to two hours a day for children aged six and above.

"Aim to eat at least five serves of vegetables, and no more than two serves of fruit a day," she said. "Start each day with a healthy breakfast, know your portion and serve sizes, and choose healthier snacks and fewer treat foods."

University of Newcastle Associate Professor Tracy Burrows said the gaps in public weight management services - and the often lengthy wait times to access them - had inspired her team of nutrition and dietetics researchers to look into using a "telehealth" intervention to support more families.

"There are only a few tertiary weight management services available in Australia. John Hunter Children's Hospital is one of them. But there can be really long waiting times for those kinds of services," she said.

"Because of that, there is a lot of failure to attend, and often the opportunity to engage in behaviour-change is lost. Go4Fun is NSW Health's program, but it is limited in the fact that it is only for children aged seven-to-13 years, and it runs for 10 weeks but only during school term.

"Even with Go4Fun online, and Go4Fun Indigenous, there are still gaps."

Their recently published telehealth study offered online consultations with a dietitian - outside of standard working hours if required. It also gave families living in more remote locations access to support. In some cases, text messages were also sent to motivate and remind participants of their goals.

"Our latest study showed that an online telehealth intervention was feasible and acceptable to families, and that it significantly improved dietary intakes of primary school-aged children," she said. "We found we could improve dietary outcomes by increasing the access and reach of the message that is delivered."

Professor Burrows said behaviours developed in childhood tracked through to adulthood, which was why establishing good dietary intakes and behaviours early was important.

Times had changed, she said.

Now, families were busy with more parents in the workforce. Children and families had increased access to an "abundance" of inexpensive, easy and convenient energy-dense and nutrient-poor foods, and the prevalence of overweight and obesity in children - one-in-four in Australia - had also made it more difficult for parents to recognise when there was a problem.

"In our current environment, it's very easy to over-consume foods," she said. "One of the initial issues we find is the acknowledgement of parents to recognise the need for help. With the prevalence of overweight and obesity, it's very normal to see overweight children, so our social perceptions have actually changed."

Professor Burrows said cases of children as young as 15 months being considered above, or well above, a healthy weight range was becoming more common.

"Technology used for the right reasons, and delivered in the right way, can be really useful in improving dietary intakes and behaviours."

But a weight loss app targeted at children and teenagers could be a "risky" way to address obesity. WW - formerly Weight Watchers - recently launched a weight loss app for children aged eight and above in the US.

Professor Burrows said unsupervised use of an app that encourages children to count calories and track their weight carried the danger of perpetuating body image issues and leading to disordered eating.

"When you have programs where it may not be the parent who is the agent of change, which can be downloaded by children themselves, there is whole extra level of detail that needs to be considered," she said.

"All of the evidence suggests a whole of family approach, with close monitoring and guidance from health professionals, which can't be achieved when you have a stand alone app."

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