obesity in paediatrics

Presenter: Dr Preetham

Moderator: Dr Narayanappa

The Myth

“You are talking of obesity,

while malnutrition is

everywhere”

Reality: The Double Jeopardy

Remarkably Short History for Caloric Beverages:

Might the Absence of Compensation Relate to This Historical Evolution?

100000 BCE

200000 BCE Homo Sapiens

Earliest possible date

Definite date

Water, Breast Milk2000 BCE

Milk (9000 BCE)

Beer (4000 BCE)

Wine (5400 BCE)Wine, Beer, Juice

(8000 BCE)

(206 AD)Tea (500 BCE)

Brandy Distilled (1000-1500)

Coffee (1300-1500)

Lemonade (1500-1600)

Liquor (1700-1800)

Carbonation (1760-70)

Pasteurization (1860-64)

Coca Cola (1886)

US Milk Intake 45 gal/capita(1945)

Juice Concentrates (1945)

US Coffee Intake 46 gal/capita (1946)

US Soda Intake 52/gal/capita (2004)

� Obesity is a major paediatric public health

problem across the world, associated with risk

of complications in childhood and increased

morbidity and mortality throughout adult life.

FatStores

↑ 2% = 2.3 kg ina year

More than 40% of the children eat out once or more in a

70% children eat chips once or more in a week

38% children eat burgers once or more in a week

48% children eat pizzas once or more in a week

40% eat french fries once or more in a week

60% eat noodles and drink colas once or more in a

weekMisra et al., Unpublished data, 2008

� Obesity is a global public health problem,

sparing only dramatically poor regions with

chronic food scarcity.

� As of 2005, more than 1.6 billion persons

≥15 yr old are overweight or obese (WHO).

� In the USA, 30% of adults are obese, and an

additional 35% of adults are overweight. In

children, the prevalence of obesity increased

300% over approximately 40 years.

� Worldwide obesity has more than doubled since 1980.

� In 2008, more than 1.4 billion adults, 20 and older, were overweight. Of these over 200 million men and nearly 300 million women were obese.

� 65% of the world's population live in countries where overweight and obesity kills more people than underweight.

� More than 42 million children under the age of five were overweight in 2010. Close to 35 million of these are living in developing countries.

� Obesity is preventable.

� Childhood obesity, if not addressed, can lead to lifetime health consequences and contribute to adulthood obesity.

� A study found that 80% of obese children aged 10-15 became obese adults (CDC, 2010).

� Untreated childhood obesity can lead to cardiovascular problems, as well as high blood pressure, high cholesterol, and Type 2 diabetes (CDC, 2010).

� At least 2.6 million people each year die as a result of being overweight or obese.(WHO)

Prevalence of overweight/obesity among Adolescents (14-18 yrs), Delhi

AgeGender

Female

Public Schools

Overweight

% (N=2593)

Age wise

prevalence in

Public Schools

GovernmentSchools

Overweight

% (N= 955)

Age wise

prevalence in

GovernmentSchools

12.714 32.6

15 29.9 11.5

16 25.1 8.4

17 25.3

Total%(N = 3548)

OVERALL PREVALENCE = 24.2%

Misra et al. Ann Nutr Metab.2011

Country/City

Global

USA/UK

Australia

India/Chennai

India/Delhi

Prevalence

Misra et al., 2006

What is cut off value for

OBESITY?

95th centile

Author Range Year

Vedavati 22-27 kg/m2 1998

Agarwal 23-27 kg/ m2 1988-1994

Cole 24-29 kg/m2 1963-1993

95th centile

Khadilkar 24-27 kg/m2 2004

Agarwal 22-27 kg/m2 1988-1994

Cole 23-28 kg/m2 1963-1993

� BMI values show wide variations between regions, and the period of the studies.

� Pune study, age 10-13 years, BMI of boys have been even higher than the international values.

� Delhi Agarwal’schart for the 85th and 95th centileshow lower BMI values than the WHO values

�Local BMI values are collected on smaller samples and comparison between them and with international norms are not feasible.

obesity

overweight

Normal BMI

underweight

KHADILKAR, et al.

Conclusions: Contemporary cross-sectional age and sex specific BMI cut-offs for

Indian children linked to Asian cutoffs of 23 and 28 kg/m2 for the assessment of

risk of overweight and obesity, respectively are presented.

� The National Health and Nutrition Examination Survey (NHANES) IV, 1999-2002, found 31% of children older than 2 yr to be overweight or obese, and 16% of children and adolescents 6-19 years were in the obese range.

� Children's risk varies by socioeconomic status, race, maternal education level, and gender

� Across all racial groups, higher maternal education confers protection against childhood obesity.

� A study conducted in mysore in 2009 shows

the prevalence of obesity and overweight

were 3.4%, 8.5% respectively. The prevalence

of obesity was maximum in the age group of

5-7 years and in those from private schools.

� A study conducted in 2011 representing

upper, middle and lower socioeconomic

groups and the children aged 6-15 years of

age were interviewed. The prevalence of

obesity was 3.0% for boys and 5.3% for girls.

The prevalence of obesity (7.5%) and

overweight (21.9%) were highest among high

income group and lowest (1.5% and 2.5%)

among low income group.

� Environmental changes

� Genetic changes

� Endocrine and neurological changes

Environmental changes

• Foods are increasingly prepared by a “food industry,” with high levels of calories, simple carbohydrates, and fat.•The increased consumption of high-carbohydrate beverages, including sodas, sport drinks, fruit punch, and juice•The dramatic increase in the use of high-fructose corn syrup to sweeten beverages

� levels of physical activity in children and adults have declined due to� More reliance on cars and

decreased walking

� For children, pressure for academic performance have led to less time devoted to physical education in schools

� Perception of poor neighbourhood safety

� The advent of television, computers, and video games has resulted in opportunities for sedentary activities that do not burn calories or exercise muscles.

� Increased time at work, increased time

watching television, and a generally faster

pace of life has lead to decreased sleep which

increases risk for weight gain and obesity.

� Rare single-gene disorders resulting in

human obesity are known,

� FTO (fat mass and obesity)

� INSIG2 (insulin-induced gene 2) mutations

� Leptin deficiency and

� Pro-opiomelanocortin deficiency.

� MC4R gene(most commonly known genetic

defect predisposing people to obesity)

� Down syndrome

� Cohen syndrome

� Prader-Willi Syndrome

� Pro-opiomelanocortin deficiency

� Turner syndrome

� Leptin or leptin receptor gene deficiency

� Carpenter syndrome

� Cushings syndrome

� Growth hormone deficiency

� Hyperinsulinism

� Hypothyroidism

� Complications of paediatric obesity occur during childhood and adolescence and persist into adulthood

� More immediate co morbidities include type 2 diabetes, hypertension, hyperlipidemia, and non alcoholic fatty liver disease

� Insulin resistance increases with increasing adiposity and independently affects lipid metabolism and cardiovascular health.

� Non alcoholic fatty liver disease occurs in 10-25% of obese adolescents and can progress to cirrhosis.

� Conditions:

� Metabolic syndrome

� Polycystic ovary syndrome

� Gallbladder disease

� Blount disease (tibia varus)

� Behavioural complications

� Obstructive sleep apnea

� Dyslipidemia

� Type 2 diabetes mellitus

� Overweight and obese children are often

identified as part of routine medical care, and

the child and family may be unaware that the

child has increased adiposity.

� obesity intervention requires a chronic

disease management approach

� Body Mass Index (BMI)

� Waist Circumference

� Waist-to-Hip Ratio

� Skinfold Thickness

� Bioelectric Impedance (BIA)

� Underwater Weighing (Densitometry)

� Air-Displacement Plethysmography

� Dilution Method (Hydrometry)

� Dual Energy X-ray Absorptiometry (DEXA)

� Computerized Tomography (CT) and

Magnetic Resonance Imaging (MRI)

� Consideration of possible medical causes of obesity is essential, as endocrine and genetic causes are rare.

� Growth hormone deficiency, hypothyroidism, and Cushing syndrome are examples of endocrine disorders that can lead to obesity. In general, these disorders manifest with slow linear growth.

� Polyuria and polydipsia may be noted if the adolescent with obesity develops overt diabetes.

� Children who consume excessive amounts of calories tend to experience accelerated linear growth.

� Genetic disorders associated with obesity can have coexisting dysmorphic features, cognitive impairment, vision and hearing abnormalities, or short stature.

� Children with congenital disorders such as myelodysplasia or muscular dystrophy, lower levels of physical activity can lead to secondary obesity

� A history of damage to the central nervous

system (CNS) (eg, infection, trauma,

hemorrhage, radiation therapy, seizures)

suggests hypothalamic obesity with or without

pituitary growth hormone deficiency or pituitary

hypothyroidism. A history of morning

headaches, vomiting, visual disturbances, and

excessive urination or drinking also suggests that

the obesity may be caused by a tumor or mass in

the hypothalamus.

� The appearance of signs of sexual development at an early age suggests that the weight gain is caused by precocious puberty . However, excessive facial hair, acne, and irregular periods in a teenage girl suggest that the weight gain may be caused by cortisol excess or polycystic ovary syndrome (PCOS).

� Hip or knee pain can be caused by secondary orthopedic problems, including Blount disease and slipped capital femoral epiphysis

� Acanthosis nigricans can suggest insulin resistance and type 2 diabetes

� The objective of interventions in overweight

and obese children and adolescents is the

prevention or amelioration of obesity-related

co-morbidities

� e.g. glucose intolerance and T2DM, metabolic

syndrome, dyslipidemia, and hypertension.

Complications of ObesityPulmonary disease

abnormal function

obstructive sleep apnea

hypoventilation syndrome

Nonalcoholic fatty liver

disease

steatosis

steatohepatitis

cirrhosis

Gall bladder disease

Gynecologic abnormalities

abnormal menses

infertilitypolycystic ovarian syndrome

Osteoarthritis

Idiopathic intracranial

hypertension

Stroke

Cataract

Coronary heart disease

Diabetes

Dyslipidemia

Hypertension

Severe pancreatitis

Cancerbreast, uterus, cervix

colon, esophagus, pancreas

kidney, prostate

Phlebitis

venous stasis

Hypertension

Depression

Heart Diseases

Diabetes RespiratoryProblems

Gall Bladderdisease

Cancer

Obesity

Healthrisks

Osteoarthritis

Opticaldisorders

Infertility

Renal DiseaseStroke

Office visit model

Symptoms

and signsDiagnosis Treatment

Headaches with

nauseaMigraines Medication

Soda, fast food, school

food, video games,

poverty, unsafe

neighbor-hood, single

mother, poor

parenting, depression

ObesityEducation,

motivation,

parenting skills,

social work, screen

and address

comorbidities

1. Lifestyle recommendations:� Dietary,

� Physical activity, and

� Behavioural.

� Avoiding the consumption of calorie-dense, nutrient-poor foods (e.g. sweetened beverages, sports drinks, fruit drinks and juices, most “fast food,” and calorie-dense snacks)

� Increasing the intake of dietary fiber, fruits, and vegetables.

� Eating timely, regular meals, particularly breakfast, and avoiding constant “grazing” during the day.

� Eat a diet with balanced macronutrients (age-appropriate amounts of carbohydrate, protein, & fat)

� Decrease in time spent in sedentary activities,

such as

� watching television(No TV before age 2 years; 2

hours maximum screen time per day after age 2

years),

� playing video games, or

� using computers for recreation.

� Promote moderate to vigorous physical

activity for at least 60 minutes per day.

� Educate parents about the need for healthy rearing patterns related to diet and activity.� parental modeling of

healthy habits,

� avoidance of overly strict dieting,

� setting limits of acceptable behaviours, and

� avoidance of using food as a reward or punishment.

� Pharmacotherapy (in combination with lifestyle modification) be considered if a formal program of intensive lifestyle modification has failed to limit weight gain or to mollify comorbidities in obese children.

� Overweight children should not be treated with pharmacotherapeutic agents unless significant, severe co-morbidities persist despite intensive lifestyle modification.

� Bariatric surgery be considered only under the

following conditions:

� The child has attained Tanner 4 or 5 pubertal

development and final or near-final adult height.

� The child has a BMI greater than 40 kg/m2 or has BMI

above 35 kg/m2 and significant, severe co morbidities.

� Severe obesity and co-morbidities persist despite a

formal program of lifestyle modification, with or

without a trial of pharmacotherapy

� There is access to an experienced surgeon in a

medical center employing a team capable of long

term follow-up of the metabolic and psychosocial

needs of the patient and family

� The patient demonstrates the ability to adhere to

the principles of healthy dietary and activity habits.

• Bariatric surgery is not recommended for

preadolescent children, for pregnant or

breastfeeding adolescents, and for those planning to

become pregnant within 2 yr of surgery; for any

patient who has not mastered the principles of

healthy dietary and activity habits; for any patient

with an unresolved eating disorder, untreated

psychiatric disorder, or Prader-Willi syndrome

1. Predominantly malabsorptive procedures:

� Biliopancreatic diversion

� Jejunoileal bypass

▪ Not performed anymore

2. Predominantly restrictive procedures

� Vertical banded gastroplasty

� Adjustable gastric band:▪ It is considered one of the

safest procedures performed today with a mortality rate of 0.05%.

� Sleeve gastrectomy▪ procedure in which the stomach is reduced to

about 15% of its original size.

▪ The procedure permanently reduces the size of

the stomach. The procedure is performed

laparoscopically and is not reversible.

Mixed procedures

� Gastric bypass surgery:

▪ MC- Roux-en-Y gastric bypass

� PREGNANCY� Normalize body mass index before pregnancy.

� Do not smoke.

� Maintain moderate exercise as tolerated.

� In gestational diabetics, provide meticulous glucose control.

� POSTPARTUM AND INFANCY� Breast-feeding is preferred for a minimum of 3 mo.

� Postpone the introduction of solid foods and sweet liquids.

� FAMILIES

� Eat meals as a family in a fixed place and time.

� Do not skip meals, especially breakfast.

� No television during meals.

� Use small plates, and keep serving dishes away from the

table.

� Avoid unnecessary sweet or fatty foods and soft drinks.

� Remove televisions from children's bedrooms.

� restrict times for television viewing and video games.

� SCHOOLS� Eliminate fundraisers with candy and cookie sales.

� Review the contents of vending machines and replace with healthier choices.

� Educate teachers, especially physical education and science faculty, about basic nutrition and the benefits of physical activity.

� Educate children from preschool through high school on appropriate diet and lifestyle.

� Mandate minimum standards for physical education, including 30-45 min of strenuous exercise 2-3 times weekly.

� Encourage “the walking schoolbus”: Groups of children walking to school with an adult.

� COMMUNITIES:

� Increase family-friendly exercise and play facilities

for children of all ages.

� Discourage the use of elevators and moving

walkways.

� Provide information on how to shop and prepare

healthier versions of culture-specific foods.

� INDUSTRY:

� Mandate age-appropriate nutrition labeling for

products aimed at children (e.g., red light/green

light foods, with portion sizes).

� Encourage marketing of interactive video games

in which children must exercise in order to play.

� Use celebrity advertising directed at children for

healthful foods to promote breakfast and regular

meals.

� GOVERNMENT AND REGULATORY AGENCIES:� Classify obesity as a legitimate disease.

� Provide financial incentives to industry to develop more healthful products and to educate the consumer on product content.

� Provide financial incentives to schools that initiate innovative physical activity and nutrition programs.

� Allow tax deductions for the cost of weight loss and exercise programs.

� Provide urban planners with funding to establish bicycle, jogging, and walking paths.

� Ban advertising of fast foods directed at preschool children, and restrict advertising to school-aged children.

Health and Nutrition Education Initiatives

by Diabetes Foundation (India)

Diabetes Foundation (India) has pioneered in

launching Health and Nutrition Education

initiatives, the first of their kinds in the whole of

South Asia to spread the awareness of Obesity and

Diabetes prevention amongst the youth

Diabetes and Obesity Awareness for Children/Adolescents &Adults

A 50 city country wide awareness and education program

Initiative of National Diabetes, Obesity, and Cholesterol Diseases Foundation

March 5, 2011

Objectives

Overall Aim:

To create mass awareness about diabetes

and obesity among children and adultsand to thus act as change agents for better

lifestyles and prevention of diabetes

& Emcure Pharmaceutical (India) Pvt. LtdMarch 5, 2011

Objectives

Specific Objectives

• To enhance awareness among school children, andadults about diabetes and obesity through– Lectures on “Diabetes: Causes, Consequences, Prevention

& Care”

– School Health Camps

– Public Awareness Campaign:• Public Health Lectures on “Diabetes: Causes, Consequences,

Prevention and Care”

• Diabetes Health Camps

• Walk for Awareness about Diabetes Prevention on November14, 2011 – World Diabetes Day

• Distribution of printed education material to children andadults

• Message dissemination through media

Participating Teams

Across

50 citiesin India

Initiatives being implemented in

various cities of India

New DelhiMumbai

JaipurAgra

Chandigarh

VadodaraNoida

DehradunAllahabad

BangalorePantnagar

LucknowBhubaneshwar

“MARG” (The Path)

Medical education for children/

Adolescents for Realistic prevention of

obesity and diabetes and for healthy aGing

A Project of

Diabetes Foundation (India)

Funded by: World Diabetes Foundation

(Denmark)

The initiatives are organizing activities to focus on:

changing the individual

(children, family, teachers)

changing the environment

(school, home)

Information and Educational Material for

Children, Parents and Teachers

“TEACHER””Trends in Childhood Nutrition and

Lifestyle Factors in India

A 6 City Countrywide Project of

“CHETNA”Children’s Health Education Through

Nutrition and Health Awareness Program

A Project of

Funded by: Rotary Club South East (Delhi)

Children attending the lectures on

Healthy Living

Teachers participating in a lecture

on Healthy Living

Mothers participating in a Focused Group Discussion

Poster Making Competition

Cooking Competition

Skit Competition

Extempore Competition

Quiz Competition

StudySchool-based Intervention Trial for Prevention of

Childhood Obesity: The MARG Study

Objective:

To study the effect of an educative and participatory

intervention trial for a period of 6 months on the

improvement of knowledge levels, anthropometric

measurements, body composition and blood profile of

urban adolescents aged 15-17 years.

A Case-Control Community Intervention Trial

101 cases and 108 controls

6 months: July, 2008-January, 2009

Misra et al., Eur J Clin Nutr 2010

Intervention Trial (6 months):

Case Control Design

1. Intensive intervention vs. usual intervention

2. Improvements in the following aspects:a.

Knowledge levels

Dietary habits

Anthropometric measurements

Body fat composition

Glycemic indicators

Insulin levels, CRP levels

Lipid profile

Key Activities:

Phase 2:Interventions

Weekly individual counseling of children

LecturesActivities: Skits, quiz competition, extempore, focused groupdiscussions

Replacing unhealthy food in canteen with healthy alternatives

Health camp for parents and teachers

Recipe demonstration for healthy Tiffin

Skit demonstration by the intervention group in morningassembly on important days like the World Food Day

Quiz competition in class

Paragraph writing on topics like: Ways in which you canprevent yourself from diabetes and heart disease in the next 5-8years, healthy alternatives to junk food, planning a day’s diet forthemselves, planning their own tiffins for a week

Checking tiffins of younger classes in their school by theintervention group

% Decrease in Consumption Patterns of ‘Energy-Dense Foods”

Consumption of Food Articles

Sweetened carbonated drinks > 3 times/w

Western ‘energy-dense’ foods (Burgers,

pizzas, french fries, noodles) > 3 times/w

Chips/ Namkeen/Maggi > 3 times/w

Indian ‘energy-dense’ food > 3 times/w

All differences are statistically significant

Case School

Control School

No change

Singhal N, Misra A, Shah P, Gulati S. Eur J Clin Nutr, in press

Consumption of Fruits (brought in Tiffin)

Case School

Baseline

Follow-up

*Statistically significant

Control School

40.4%*

% Change in Time Spent in TV Viewing

and Physical Activity

Variables

TV Viewing > 2 h/d

Physical Activity

30-60 min/d

All differences are statistically significant

School

Control

School

Pre- and Post Surveys Show significant Increase in Knowledge

Healthy

living

Obesity Diet and

Knowledge, Attitude and Practice about

Nutrition, Obesity and Diabetes:

Shah P, Misra A et al., Br J Nutr 2010

% Change in Anthropometric Parameters

WC Mid -thigh SAD Triceps Biceps

P< 0.05 in Control SAD

P< 0.001 in Case biceps

Case Control

% Change in Metabolic Parameters

Variable

Fasting Glucose

*p < 0.001

Case School

-4.9%*

Control School

% Change in Fasting Serum Insulin and CRP

CONT.INT. CONT.

Insulin

Misra et al., Unpublished data

Hs-CRP

Summary

• Rising childhood obesity in urban India and inother Developing Countries is of great concern,and would fuel the diabetes and the metabolicsyndrome epidemics further.

• Overall, it is more in urban areas (vs. rural), andpublic schools.

• Its consequences, insulin resistance, PCOS,hirsutism, type 2 diabetes, subclinicalinflammation and hepatic steatosis are nowfrequently seen in children .

• Countrywide programs, akin to our program“MARG” in schoolchildren are urgently needed.

The Myths

“What will happen if a child isfat. He/she will not have any

diseases”

Reality:

• Diabetes may strike early

• Polycystic ovaries, excess facial hair andinfertility may occur in girls

The Myths

“Heart Disease startsat old age”

Reality:

Hardening and blockage of the arteriesstarts at 11 years in boys and 15 years

in girls

The Myths

“A fat child isotherwise healthy”

Reality:

28% of urban children have syndrome X, onestep away from diabetes and 2 steps away

from heart disease

The Myths

“A child does notdevelop high bloodpressure or high

cholesterol”

Reality:

Many children will have high blood pressure andlow good cholesterol

The Myths

“A child should enjoy,and eat and relax. Suchtime will not come again

later”

Reality:

Parents do not realize, but children are eatingjunk food all the time.

The Myths

“All children are doingrequired physical

activity”

Reality:

Time on TV, internet and studies leaves littletime for play. Even in pd assigned for physical

activity, many do not participate

The Myths

“All of us (parents,teachers) teach them

correct diet and lifestyle”

Reality:

Most do not have correct knowledge or time toeducate children. Healthy snacks are notprepared at home. Many parents and teachersare obese themselves! No cohesive interventionprogram in India

The Myths

“So what if there aremetabolic abnormalitiesor diseases, these can

be easily treated”

Reality:

Most of these diseases are catastrophicand have complications that cannot bereversed. Most will shorten lifespan

THANK YOU FOR PATIENT HEARING ☺

obesity in paediatrics

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