Beat the Bulge

The treatment of childhood obesity poses a challenge and requires propagation of healthy lifestyle at the individual, community and national level. The goal should to provide children enough calories to maintain linear growth without further increase in weight
BY Amresh Kumar Tiwary

Childhood obesity is an issue of serious medical and social concern. In developing countries including India, it is a phenomenon seen in higher socio-economic strata due to the adoption of western lifestyle. Consumption of high calorie food, lack of physical activity and increased screen time are major risk factors for childhood obesity. But thereare other genetic, prenatal factors and socio-cultural too.
Obese children and adolescents are at increased risk of medical and psychological complications. Insulin resistance is commonly present especially in those with central obesity.It manifests as dyslipidemia, type 2 diabetes mellitus, impaired glucose tolerance, hypertension, polycystic ovarian syndrome and metabolic syndrome.
In India, secular trends clearly demonstrate the steep rise in prevalence of childhood obesity especially in metropolitan cities. A recent multi-centric study reported the prevalence of overweight and obesity in urban children in the age group of 8–18 years to be 18.5 % and 5.3 %, respectively.
Says Arvind Garg, Senior Child Specialist, Apollo Hospital, Noida, “Obese children and adolescents are often assigned to general physicians for management. The latter play a key role in prevention and treatment of obesity as it involves lifestyle modification of the entire family. Obesity and its medical consequences including cardiovascular disease and type 2 diabetes are emerging as a serious public health concern in children worldwide.”
Dr Anup Mohta, Director, Chacha Nehru Bal Chikitsalaya, East Delhi, agrees, “We aim at discussing the diagnostic approach andmanagement of childhood obesity from a general physician’sperspective.The parents of obese children and adolescents often seek advice from general physicians for treatment of this condition. Indeed, the general practitioner plays a key role in management as well as prevention of obesity that involves lifestyle changes for the entire family.”
Know your child’s obesity
Body Mass Index [BMI 0 weight in kg/height in (m) 2] is themost widely used parameter to assess obesity. Adults areconsidered overweight if their BMI is 25 to 29.9 kg/m2 andobese if it is equal to or greater than 30 kg/m2. In view of the increased tendencyfor cardiovascular risk at lower BMIs, it has been proposedto lower these cutoffs to 23 kg/m2 and 25 kg/m2,respectively for Asian Indians. The BMI changes with age in children and therefore absolutecutoffs are not appropriate for them. Instead, childhoodoverweight and obesity are defined as BMI equal to or greater than85th and95th percentile respectively as per age and gender-specificBMI references. Various BMI references are being used to assess obesity in children.
The pattern of distribution of body fat is a better determinant of morbidity than BMI alone. Central (visceral or abdominal) fat deposition is associated with a higher risk of cardiovascular disease and diabetes mellitus, in comparison to gluteal or subcutaneous fat. Waist circumference is generally used as a measurement of central obesity. In Asian Indians, if a waist circumference is equal to or greater than 80 and 88 cm in adult women and men, respectively, it should prompt screening for obesity-related complications. There are no age and gender-specific waist circumference percentiles available for Indian children, apart from a regional study from South India.

Cause of Obesity
Obesity is a result of imbalance between caloric intake and expenditure. The vast majority of children have ‘simple obesity’ as a consequence of caloric excess causing gain in weight as well as height. Occasionally, a child may have a pathological (genetic or endocrine) cause of obesity which inhibits linear growth resulting in short stature.Important endocrine causes of obesity include hypothyroidism, growth hormone (GH) deficiency, Albright’s hereditary osteo-dystrophy (pseudo-hypo parathyroidism) and Cushing syndrome. Hypothalamic obesity is a rare cause of obesity and results from hypothalamic damage from tumors, CNS surgery or irradiation, trauma, anoxic damageor meningitis.
Says Dr Arvind Garg, Senior Child Specialist, “Simple obesity, the commonest form of obesity, is multifactorial in origin. Contributing factors may be genetic,prenatal, socio-cultural and environmental. Indeed, the epidemic of obesity and type 2 DM in the Indian subcontinent is well explained by the changing lifestyles with an underlying genetic predilection for gaining weight.High socio-economic status, lack of physical activity and junk food consumption are strongly associated with obesity.”
Dr S K Mittal, Senior Child Specialist, observes, “The sedentary activities such as television viewing, internet and video games, collectively referred to as screen time, have increased in recent years and consume much of the free time available to children. Academic pressures and paucity of safe open spaces/playgrounds in schools and communities have further contributed to a steep decline in outdoorphysical activities of children.”
The consumption of fast food has risen due to its easy availability, palatability, aggressive advertisement by multinational companies and a lack of awareness of the harmful effects. Of these, television viewing is seen as the most important and modifiable risk factor for obesity. Not only does television displace the time that could be used for physical activity, but it also increases calorie intake. Children tend to passively eat while watching television and consume more junk food and colas by virtue of being exposed to advertisements of these products.
Dr H P Singh, Senior Child Specialist, Mother & Child Clinic, Vaishali, throws a new light, “Offsprings of obese parents tend to be obese and parental obesity is a strong risk factor for adult obesity. Also, intrauterine nutritional deprivation, placental insufficiency and growth retardation cause metabolic alterations in the fetus and predispose to obesity and metabolic syndrome in adulthood.”
Dr Sachin Bhargav, Senior Child Specialist, elaborates, “Over feeding of low-birth weight babies and rapid catch-up growth in infancy are associated with increased risk of obesity. On the other hand, prolonged breast feeding is beneficial and children who are breast-fed for a longer duration have lesser risk of obesity. This is possibly related to the physiologic properties of human milk or feeding patterns associated with breast-feeding. Certain socio-cultural beliefs in India such as viewing a fat child as healthy, force-feeding children and encouraging them to eat large quantities of butter/ghee aggravate the problem of obesity.”
An obese child has an increased risk of being obese as an adult and this risk is nearly 90 % in case of obese adolescents. Apart from immediate medical complications in childhood, obesity also results in long-term health consequences later in life. Obesity, especially central obesity, impairs the metabolic action of insulin on glycemic control, lipids and blood pressure, causing insulin resistance. This is characterized by the ‘metabolic syndrome’ which is a cluster of metabolic derangements including abdominal obesity, dyslipidemia, glucose intolerance and hypertension that predict high risk of cardio vascular disease and diabetes.
According to experts, high socio-economic status, lack of physical activity and junk food consumption are strongly associated with obesity. Sedentary activities such as television viewing, internetand video games, collectively referred to as screen time, have increased in recent years and consume much of the freetime available to children. Academic pressures and paucity of safe open spaces/playgrounds in schools and communities have further contributed to a steep decline in outdoorphysical activities of children.
As Dr Arvind Garg puts it, “The consumption of fast food has risen due to its easy availability, palatability, aggressive advertisement by multinational companies and alack of awareness of the harmful effects. Of these, television viewing is seen as the most important and modifiable risk factor for obesity. Not only does television displace the time that could be used for physical activity,but it also increases calorie intake. Children tend topassively eat while watching television and consume morejunk food and colas by virtue of being exposed to advertisements of these products.”
All children presenting for evaluation of overweight should have their height and weight measured and the BMI plotted on the growth chart. Children with simple obesity tend to be tall for age; the height for age percentile frequently, exceeding mid-parental height percentile. Short stature in an obese child points to a pathological cause of obesity. Patients with morbid obesity (BMI equal or greater than 99th percentile, correspondingto a BMI of 30–32 kg/m2 for 10–12 y age and equal or greater than 34 kg/m2 for 14–16 y), are especially at risk of complications and should receive prompt attention. The American Academy of Pediatrics (AAP) has given cut-offs for the 99th percentile BMI at various ages.
The aim of clinical and laboratory evaluation is to differentiate simple from pathological obesity and assess for complications related to obesity. Previous growth records should be evaluated for determining the age of onset of obesity and linear growth. A review of symptoms will help point to co-morbid conditions. “Assessment of calorie intake and exercise should be undertaken. Questions regarding food seeking behavior, appetite, eating habits, cumulative screen time including that spent on television viewing, computers and other electronic gadgets should be sought in order to identify areas of possible intervention
It is important to identify eating habits and routine of the whole family as interventions aimed at family behavioral patterns are more likely to be successful,” Dr H P Singh, adds.
The birth, family and developmental history should be reviewed. Blood pressure should be measured and a head to toe examination performed for signs of pathological obesity and co-morbid conditions. Acanthosis nigricans, hyperpigmented and hypertrophic skin in the nape of neck and axilla are the hallmark of insulin resistance. The pubertal status is assessed by Tanner’s sexual maturity ratings; commencement of breast enlargement before 8 years in girls and testicular or penile growth before 9 years in males indicates precocious puberty. It may be difficult to distinguish adipose tissue in the breast from true breast development but the presence of pigmented erectile areolaepoints to the latter. In males, stretched penile length is assessed to rule out micropenis in cases of suspected hypogonadisor growth hormone deficiency. Quite often, a supra pubic pad of fat may hide the penis and give a false appearance of micropenis.
The treatment of childhood obesity poses a challenge andrequires long-term and persistent efforts at the individual as wellas family level. Excessive calorie restriction may be detrimentaland weight loss is not recommended unless a serious co-morbidcondition exists. The goal is to provide enough calories tomaintain linear growth without further increase in weight.
The management plan encompasses dietary and physical activity interventions. Simply providing education may not be effective and behavioral therapy techniques including environmental control approaches (parental modeling of healthful eating and activity) as well as monitoring and goal setting, are more effective. In the initial interview, the physician should determine the degree of child’s/parents motivation orreadiness to change. The family is then counseled regarding healthy lifestyle approaches guided by the extent of family motivation. Discussions should be non-judgmental and focuson habits related to eating and physical activity. The approach should promote positive family change without decreasing the self-esteem of the child or family members.

What to take
Healthy practices for meal preparation such as boiling, roasting and steaming should be encouraged instead of deepfrying. Meals including dairy products, vegetables and fruits should be planned according to sufficient calorie intake, balanced food, seeking behavior of proper appetite and eating interest.

Advice
Caloric excess with lack of physical activity is the major cause of childhood obesity. A pathological cause should be suspected in those children who have concomitant short stature, dysmorphism, developmental delay, hypogonadismor early-onset severe obesity. Obese children and adolescentsneed to be appropriately worked up for associated comorbidities.Treatment encompasses a holistic approach to
diet and physical activity. The use of drugs and bariatric surgery is limited to adolescents with severe obesity and co morbidities who have failed behavioral management. Medical practitioners are best placed for diagnosing, counselingand initiating management of obese children. They can playa vital role in curbing the obesity epidemic and need to be
active advocates of healthy lifestyle at the individual, community and national level.

Kids at Risk

Overweight in children is a serious public health problem that continues into adulthood with a higher risk of morbidity and mortality
By Abhigyan

While underweight in childhood is still a major public health problem in the Indian subcontinent, the increasing prevalence of overweight poses an additional threat to public health.
Obesity can be seen as the first wave of a defined cluster of non-communicable diseases called “New World Syndrome”, creating an enormous socio-economic and public health burden in poorer countries. The World Health Organization (WHO) has described obesity as one of today’s most neglected public health problems, affecting every region of the globe.
The problem of overweight and obesity in childhood and adolescence is a global phenomenon and has been increasing in the developing world. In childhood, the condition of overweight is a serious public health problem that tracks into adulthood with a higher risk of morbidity and mortality. The morbidities associated with overweight include an increased risk of heart disease as well as other chronic diseases in adult life, such as type 2 diabetes mellitus, atherosclerosis, hypertension, dyslipidemia, and metabolic syndrome, which are all becoming common among children and adolescents.
Childhood obesity in developed countries has reached alarming proportions and developing countries are not far behind. It has been estimated that worldwide over 22 million children under the age of 5 are obese, and one in 10 children is overweight. Studies reports the prevalence of childhood obesity to fluctuate in different countries, with the prevalence of overweight in Africa and Asia averaging well below 10 per cent and in the Americas and Europe above 20 per cent. The proportion of school-going children affected almost doubled by 2010 compared with the surveys from the late 1990s up to 2003.
In the Indian subcontinent, especially India, Bangladesh, and Pakistan, malnutrition leading to underweight has been the major public health concern for decades, with little or no attention being paid to overweight until recently. The recent studies report the prevalence of overweight to be as high as 35−40 per cent, which is close to the national estimates of overweight in many industrialised countries, including the United States and Australia. While underweight in childhood is still a major public health problem in the Indian subcontinent, the increasing prevalence of overweight poses an additional threat to public health.
There is significant heterogeneity in this time trend of obesity in India. Socio-economic trends in childhood obesity in India are also emerging. Studies from north, south, east, west, and central parts of India have reported varying prevalence rates of overweight and obesity in children and adolescents, suggesting strong geographical, economic, and societal influences on the progression of this massive epidemic.
Socio-economic trends in childhood obesity in India are emerging. A study from northern India reported a childhood obesity prevalence of 5.59 per cent in the higher socio-economic strata when compared to 0.42 per cent in the lower socio-economic strata.

Determinants of Adolescent Obesity
A variety of mechanisms participate in weight regulation and the development of obesity in children, including genetics, developmental influences (“metabolic programming”, or epigenetics), and environmental factors. The relative importance of each of these mechanisms is the subject of ongoing research and probably varies considerably between individuals and populations. The rapidly changing dietary habits along with the adoption of sedentary lifestyle increases enormously the obesity-related non-communicable diseases such as insulin resistance, type 2 diabetes mellitus, and metabolic syndrome. In developed countries, it is seen that greater social inequality is associated with increase chance of obesity contrary to developing countries. And once obesity is established, the role of primary prevention is of paramount importance with strategies of behavioural changes, diet control, and physical activity being the core interventions.
Key determinants of childhood obesity include lack of physical activity, excess caloric intake, lifestyle related factors like daily allowance (pocket money) to purchase lunch, easy availability of domestic help to take care of household chores, commuting to school by bus or car instead of walking or bicycling, aggressive advertising by transnational fast-food and cola companies. Socio-cultural factors and urbanisation like overprotection and forced feeding by parents, false traditional beliefs about health and nutrition, low knowledge about nutrition in parents and caregivers also contribute to obesity. Again limited availability of open spaces and parks due to population expansion and illegal settlements with abundance of fast-food outlets and eating points increase the chance of the child becoming obese.

What India can learn from developed nations?
In India, we are still struggling with the burden of malnutrition but the issue of over-nutrition cannot be ignored. Effectively addressing this complex problem calls for a sustained, multi-sectoral response involving the public, private, and health professional and non-governmental sectors. Timely action must be initiated to combat the rising epidemic of childhood obesity. There is considerable knowledge, research and scientific information about the risk factors on the causes and consequences of childhood obesity. India should also formulate a national policy and partner with the private sector to end the childhood obesity problem. Effective policies and tools to guide healthy eating and active living are within our grasp. Some of the specific recommendations are as follows:
Surveillance such as periodic monitoring of nutritional and obesity status of children including adults. Health education for all children and their families, routine health care should include obesity-focused education, Community mobilisation like organisation and participation in health walks and healthy food festivals.
In early infancy and prenatal period like balanced nutrition to pregnant mothers, encourage exclusive breastfeeding, avoidance of catch-up obesity in children.
School- based interventions like high importance on physical activity, making healthier choice available and banning un-healthy food in cafeteria, (sweetened beverages and energy-dense junk food). Teachers can play a vital role in this initiative, training of teachers regarding nutrition education.
Home- based interventions like key goals to address the common diet-related problems encountered in children, set firm limits on television and other media early in the child’s life. Also, kids should establish habits of frequent physical activity, TV/computer time to be restricted to maximum 2 h/day, restriction on eating out at weekends and restricting availability of junk foods at home.
Policy formulation like creation of national task force for obesity, decrease in taxes and prices of fruits and vegetables, proper food labelling practices and quality monitoring, more playgrounds, parks and walking and bicycle tracks.
To conclude, childhood obesity is a growing menace in India and the world over. We need to bring in lifestyle modifications early in this life phase so as to prevent serious implications later in life.