Childhood Obesity: A complex picture, AN

EPIDEMIC and Emerging Challenge

Dr. Vikas GuptaPostgraduate Student

• “For the first time in human history, the number of overweight people rivals the number of underweight people.…”

What is overweight and obesity

• In layman’s terms : Overweight and obesity are defined as ''abnormal or excessive fat accumulation that presents a risk to health''.

• As such there is not even single clear definition to define childhood overweight or obesity.

How it is measured

Cut offs on the basis of BMI :• 1. IOTF 90th and 97th percentile • 2. CDC 85th and 95th percentile • 3. WHO 85th and 95th percentile • 4. IAP 85th and 95th percentile

How it is measured

• Bioelectric Impedence Analysis(BIA) cut off: body fat >30% for girls and >25% for boys.

• Triceps skinfold cut off: >85th percentile for age and gender, using Tanner's tables.

• Waist circumference: UK based cut off: >75th and >90th percentile International Diabetic Federation criteria of 90th percentile.

• Waist to height ratio cut off: >0.5 or >95th percentile

Global and Indian Scenario

• Globally, an estimated 170 million children (aged less than 18 years) are now estimated to be overweight .

• The highest prevalence of childhood overweight is in upper-middle-income countries, low-income countries have the lowest prevalence rate.

• However, overweight is rising in almost all countries, with prevalence rates growing fastest in lower-middle-income countries

Global and Indian Scenario

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Prevalence of overweight and obesity

Indian scenario

• Cross-sectional studies performed in various parts of India among school children report that the prevalence of overweight to range between 2.3% and 25.1% and that of obesity to range from 0.3% to 11.3%.

• The prevalence of overweight is 8% in rural Haryana. • The prevalence of overweight and obesity is higher in

upper socioeconomic class (17.2% overweight and 4.8% obese) as compared to lower socioeconomic class (4% and <1%, respectively).

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12.30% OverweightObesity

What are causes and risk factors• 1. Genetics- • Prader-Willi syndrome:

characterized by hyperphagia and food preoccupations.

• The Avon Longitudinal Study demonstrated that the odds of children aged 7yrs becoming obese if the father, mother or both had obesity were 2.93, 4.66 and 11.75.

What are causes and risk factors

• 2. Neuroendocrinology of energy metabolism- leptin(adipose cells) and ghrelin (stomach cells).

• 3. Fundamental phases in evolution of obesity– Birth weight: Increasing birth weight is associated

with increasing prevalence of childhood obesity, low birth weight babies show a dramatic transition to central adiposity and insulin resistance very early in life

What are causes and risk factors

– Breastfeeding: negatively associated with risk of obesity in later childhood.

– Early menarche: is clearly associated with extent of obesity.

– The risk of obesity persisting into adulthood is higher among obese adolescents than among younger children.

What are causes and risk factors

• Societal and Environmental risk factors for obesity:

• Urbanization related intake behaviours like – frequent consumption of meals at fast-food outlets,– consumption of oversized portions at home and at

restaurants, – consumption of high calorie foods, such as high-fat,

low-fiber foods, and intake of sweetened beverages– advertising of fast-food restaurants and candy– access to vending machines and fast-food restaurants

What are causes and risk factors

• Reduced physical activity due to – Automated and automobile-oriented environment– Low prevalence of and access to parks, bike paths,

and sidewalks– Television and video games

• Short sleep duration: in children is also associated with an increase in the odds of becoming obese

Co-morbidities related to obesity

• Metabolic syndrome• Type 2 diabetes mellitus. Also an increased risk of

nephropathy and retinopathy compared to young people with type 1 diabetes, while recent data indicate early signs of cardiovascular disease in youth with type 2 diabetes.

• Cardiovascular abnormalities- Systolic hypertension, Left ventricular hypertrophy, carotid intima media thickness

• Obstructive sleep apnoea

Co-morbidities related to obesity

• Psychosocial abnormalities Depression• Abdominal obesity seems to be strongly associated

with concomitant depression in males. • Though both sexes can be affected by obesity-induced

depression, females demonstrate a more robust association.

• Females obese as adolescents may be at increased risk for development of depression or anxiety disorders.

Obsessive concern about body image

Expectation of rejection

Progressive withdrawal

Low self esteem

Treatment of obesity

Immediate goal 1. decrease the rate

of weight gain, 2. weight

maintenance 3. weight reduction

to improve BMI.

Long-term goal1. to improve quality

of life 2. reduction in

morbidity as well as mortality associated with overweight and obesity.

Targets for obesity treatmentNo targets are defined for treating children < 2 years

2-5 yr • overweight children weight maintenance. • obese children weight maintenance is attempted. A

minimal weight loss of 0.5 kg/month may be permitted if it occurs with a balanced diet supplying adequate calories.

6-11 yrs• Overweight children weight maintenance is

adequate. • Obese children weight maintenance or a minimal

weight loss of 0.5 kg/month may be attempted. • If the child’s BMI is more than 99th percentile, a

moderate weight loss of not more than 1 kg/wk may be attempted.

12-18 yrOverweight adolescents weight maintenance is adequate.Obese adolescents in the same group, a moderate weight loss not more than 1 kg/wk may be attempted

Components and phases of obesity treatment

1. Dietary management 2. Physical activity enhancement 3. Restriction of sedentary behaviour 4. Pharmacotherapy 5. Bariatric surgery

Dietary management1. Fat intake of 30 to 40% kcal in children 1 to 3 yr

old, with a reduction to 25 to 35% in children 4 to 18 yr old;

2. Carbohydrate intake of 45 to 65% kcal in all children and adults;

3. Protein intakes of 5 to 20% kcal in children 1 to 3 yr old with gradual increase to 10 to 30% kcal in children 4 to 18 yr old.

Dietary Intervention Study in Children (DISC)1. In obese children 8 yr or older, the intervention

diet can be introduced without compromising growth, development and pubertal maturity. 58% of total calorie intake to carbohydrates, 28% to fats and 14% to protein.

2. Of the 28% calories from fats, 11 % monounsaturates, 9% polyunsaturates and < 8% saturates.

3. Cholesterol intake < 75 mg/1000 kilocalories, < 150 mg /day.

Age-appropriate serving sizes including 1. >5 servings of fruit and vegetables,2. >3 servings of low fat milk or dairy

products, 3. >6 servings of whole-grain and grain

products per day 4. Adequate amounts of dietary fiber (age in

yr + 5 g/d)

Physical activity enhancement1. Moderate intensity regular physical activity is essential

for the prevention of overweight and obesity as well as for treatment of the same.

2. Children and adolescents should engage >60 min of moderate to vigorous physical activity.

3. Overweight and obese children should target higher levels to achieve similar results.

4. Longer periods of moderate intensity exercises like brisk walking burn more fat as calories and are excellent for reducing body fat.

5. Involving other members of the family in the exercise programme and supervising the activity on a regular basis will improve compliance.

Restriction of sedentary behavior 1. Screen time should be restricted to < 2 hours /day as the

opposite is associated with increased adiposity and higher weight status.

2. In addition, television viewing during early childhood predicts adult body mass index, which reinforces the long-term benefits of reducing screen time in young age.

3. Excessive TV viewing is associated with higher intakes of energy, fat, sweet and salty snacks and carbonated beverages in addition to reducing consumption of fruits and vegetables.

4. This makes TV time restriction an excellent opportunity to complement dietary management.

Pharmacological treatment

1. Sibutramine, a serotonin non adrenaline reuptake inhibitor enhances satiety, the most effective drug in treating adolescent obesity.

2. Orlistat, which is a pancreatic lipase inhibitor, acts by increasing faecal fat loss.

3. Metformin for treatment of obese adolescents with severe insulin resistance, impaired glucose tolerance or polycystic ovarian syndrome

Surgical treatment 1. very severely obese (BMI>40), 2. Skeletal maturity attained(girls>13yr and boys>15

yr) 3. Co-morbidities4. More severe elevation of BMI (>50).

Roux-en-Y gastric bypass and adjustable gastric banding.

Bariatric surgery performed in the adolescent period may be more effective treatment for childhood-onset extreme obesity than delaying surgery till adulthood.

Global Strategy on Diet, Physical Activity and Health(DPAS)

• Endorsed at WHA, May 2004

• In 2009- POPULATION-BASED CHILDHOOD OBESITY PREVENTION STRATEGY(PCOPS)

Guiding principles for PCOPS

• Integrated strategy• Policy support from multiple levels of governance-

national, regional and local• Equity and inclusivity• Environmental support: “upstream,” “midstream,”

or “downstream,”• Monitoring and surveillance

• Engagement with multiple sectors and settings• Transparency• Contextualization• Sustainability • Coordination• Explicit priority setting

Key components of a PCOPS

1. Structures within government to support childhood obesity prevention policies and interventions.

2. Population-wide policies and initiatives

3. Community-based interventions.

Structures to support policies & interventions

1. Leadership2. ‘Health-in-all’ policies3. Dedicated funding for health promotion4. NCD monitoring systems5. Workforce capacity6. Networks and partnerships7. Standards and guidelines

Training teachers in the Caribbean to infuse diet and physical activity recommendations into the

school curriculum

• In 2007, the Caribbean Food and Nutrition Institute launched a school health programme, “Preventing Diabetes and Other Chronic Diseases through a School-based Behavioural Intervention”.

• The main outcomes expected were:i) improved diet and physical activity patterns starting at secondary school level, and ii) a sustainable lifestyle intervention programme for secondary schools throughout the countries selected.

• One of the components of the programme focused on the training of teachers to introduce concepts of healthy diet and physical activity, as specified in DPAS, to the school curriculum.

• Training of teachers was conducted over a 3–5-day period during the summer vacation, prior to the start of each new school year.

Population-wide policies and initiatives

1. Policies influencing food environments2. Physical activity policies3. Social marketing campaigns

Policies influencing food environments

1. Marketing of unhealthy foods and beverages to children

2. Nutrition labelling3. Food taxes and subsidies4. Fruit and vegetable initiatives5. Restricting trans-fatty acids initiatives

Nutrition labelling• Levels of energy, protein, total fat, saturated fat,

carbohydrate, sugars and sodium, Front-of-pack nutrition signposting systems include:

• “traffic-light” systems where the nutrient contents such as fat, sugar and salt are colour-coded into high, moderate or low levels.

• Endorsement schemes- Australian Heart Foundation “Pick the Tick” programme (35) and in Sweden the “Green Keyhole” programme.

• The labelling of calories in menus in quick-service restaurants

Restricting trans-fatty acids

• Denmark was the first country to implement stringent laws restricting the trans-fat content of foods.

• In 2003, Legislation was enacted limiting trans-fats to 2% of fats and oils content in foods destined for human consumption

• Other countries: Canada and Switzerland, and in the United States- New York, California and Philadelphia

Healthy food service policies in government institutions, Queensland, Australia

• “A better choice” initiative in September 2008 • The policy aims to increase the healthier

options available in government-run facilities to at least 80% of the total food and non-alcoholic beverages available in these facilities.

• Classified food into “Green” (best choices), “Amber” (choose carefully) and “Red” (limit).

Physical activity policies

• WHO recommends that children and adolescents between 5 and 17 years of age accumulate at least 60 minutes of moderate- to vigorous-intensity physical activity every day.

• Examples: play, games, sports, transportation, recreation, physical education, or planned exercise, in the context of family, school and community activities

Encouraging physical activity in Bogotá, Colombia

• “Cicloviá” initiatives sees certain streets and main avenues closed to cars on Sundays and holidays from 7 am until 2 pm, to promote physical activity including cycling and walking.

• The initiative began in 1974, by 2005 around 10% (approximately 400 000) of the residents of Bogotá were participating in the “Cicloviá” every Sunday.

• Other initiatives include a 300 km bicycle network known as the “Ciclorutas,” the expansion of square meters of green space per inhabitant from 2.5 m2 to 4.5m2, annual car-free days, and the creation of special bus-only lanes to promote use of public transport .

Social marketing campaign promoting physical activity in Brazil

• The Agita São Paulo programme was launched in Brazil in 1996 to promote regular physical activity among the 37 million inhabitants of the State of São Paulo.

• The Agita São Paulo programme targets three main populations: students, workers and the elderly.

• The message is to encourage people to adopt an active lifestyle of at least 30 minutes of moderate to vigorous physical activity most days of the week.

Rahaagiri day initiatives in India

Community-based interventions

1. Multi-component community-based interventions

2. Early childcare settings3. Primary and secondary schools4. Other community settings

Desired behaviours targeted by interventions

1. Increased fruit and vegetable consumption;2. Reduced consumption of beverages high in sugar (e.g.

“Soft” drinks);3. Reduced consumption of foods high in fat, saturated fat,

salt and sugar;4. Decreased television viewing and other screen-based

activities;5. Increased competitive and non-competitive sport

participation;6. Increased active transport to schools.

EPODE (Ensemble Prevenons l’Obesité Des Enfants/Together Let’s Prevent Childhood Obesity)

• Aims to reduce childhood obesity through a societal process in which local environments, childhood settings and family norms become more supportive and facilitate the adoption of healthy lifestyles in children.

The primary EPODE target groups are children aged 0–12 years, and their families, as well as a wide variety of local stakeholders who can initiate micro-changes in children and their families through local initiatives fostering better and balanced eating habits and greater physical activity in everyday life.

The Collaboration of Community-based Obesity Prevention Sites (CO-

OPS Collaboration), AustraliaThe core aims of the CO-OPS Collaboration are to:

1. identify and analyse the lessons learnt from a range of community-based initiatives aimed at tackling obesity, and

2. identify the elements that make community-based obesity prevention initiatives successful and share the knowledge gained with other communities.

Community-based obesity prevention in young children: “Romp & Chomp,”

Australia was a “whole-of-community”

• Obesity prevention demonstration project carried out from 2005 to 2008,

• promoted healthy eating and active play to achieve healthy weight in children less than 5 years of age in Geelong, Victoria, Australia

A school-based, multi-component nutrition and lifestyle intervention in North India

• The study was carried out from May 2008 to January 2009 in eleventh-grade adolescents in a co-educational school.

• The intervention consisted of multiple components, including nutrition education lectures, promotion of physical activity, individual counselling by a trained nutritionist, increased availability of healthier food choices in the school canteen, involvement of teachers and parents and a broad range of other activities to promote a healthy lifestyle.

Diabetes foundation (India)

1. MARG- (Medical education for children/Adolescents for Realistic prevention of obesity and diabetes and for healthy aGeing‘)

2. CHETNA- (“Childrens’ Health Education Through Nutrition and Health Awareness”)

3. TEACHER (Trends in childhood nutrition and lifestyle factors in India)

The school-feeding programme in Jamaica(1926)

• To improve the nutritional quality of children’s diets in Jamaica, a pilot school-feeding programme for basic school children (aged 4–6 years) was conducted in 2005–2006.

• This was structured to ensure that the lunch meal provided 25% of the daily energy needs, with recommended distributions of carbohydrate, protein and fat and 30% of iron and vitamin C requirements.

Facts about MacD and fast foods• The fast food industry is also at fault for the rise in childhood

obesity. This industry spends about $4.2 billion on advertisements aimed at young children.

• McDonald’s alone has thirteen websites that are viewed by 365,000 children and 294,000 teenagers each month. In addition, fast food restaurants give out toys in children’s meals, which helps to entice children to buy the fast food.

• Forty percent of children ask their parents to take them to fast food restaurants on a daily basis.

• To make matters worse, out of 3000 combinations created from popular items on children’s menus at fast food restaurants, only 13 meet the recommended nutritional guidelines for young children.

References 1. Population-based prevention strategies for childhood obesity: report of a WHO forum and technical

meeting, Geneva, 15–17 December 2009. Geneva, World Health Organization, 2012.2. Global obesity federation 2014. 3. Manu Raj & R. Krishna Kumar. Obesity in children & adolescents. Indian J Med Res 132, November

2010, pp 598-607.4. VV KHADILKAR, AV KHADILKAR, AB BORADE AND SA CHIPLONKAR. Body Mass Index

Cut-offs for Screening for Childhood Overweight and Obesity in Indian Children. INDIAN PEDIATRICS,VOLUME 49JANUARY 16, 2012.

5. Community Health Interventions and Education. © 2013 DiabetesFoundationIndia.org.6. Rebecca Kuriyan, Tinku Thomas, S Sumithra, Deepa P Lokesh, Nishita R Sheth, Renju Joy,

Swarnarekha Bhat* and Anura V Kurpad. Potential Factors Related to Waist Circumference in Urban South Indian Children. Indian Pediatr 2012;49: 124-128.

7. Diagnostic accuracy of CDC, IOTF and WHO criteria for obesity classification, in a Portuguese school-aged children population Porto, 15th January 2012.

8. Dr. D Sharad Gedam, MBBS, MD, Editor- in- chief, IJMRR. Childhood Obesity - challenges in the Indian Scenario. Jan-Mar, 2013/ Vol 1/Issue 1

9. Kumaravel V, Shriraam V, Anitharani M, Mahadevan S, Balamurugan AN, Sathiyasekaran B. Are the current Indian growth charts really representative? Analysis of anthropometric assessment of school children in a South Indian district. Indian J Endocr Metab 2014;18:56-62.

10. Misra A , Shah P, Goel K, Hazra DK, Gupta R, Seth P, Tallikoti P, Mohan I, Bhargava R, Bajaj S, Madan J, Gulati S, Bhardwaj S, Sharma R, Gupta N, Pandey RM. The high burden of obesity and abdominal obesity in urban Indian schoolchildren: a multicentric study of 38,296 children. Ann Nutr Metab. 2011;58(3):203-11. doi: 10.1159/000329431. Epub 2011 Jul 14.

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