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  2. 2. ETYMOLOGY <ul><li>Obesity is nominal form of “obese” which comes from Latin “obesus” which means “stout,fat or plump”.Esus is the past participle of “edere” which means “to eat”.It’s first attested usage in English was in 1651 ,in Noah Bigg’s Mataeotechnia Medical Praxeos. </li></ul>
  3. 3. Definition of overweight and obesity <ul><li>Body mass index (BMI) is the most appropriate measure of excessive weight in children. BMI is calculated by dividing the weight (kg) by the height squared (m2). </li></ul><ul><li>BMI greater than the 85th percentile suggests overweight, while BMI greater than the 95th percentile suggests obesity </li></ul>BMI greater
  4. 4. PREVELANCE <ul><li>The World Health Organization describes the “escalating global epidemic” of obesity as “one of today’s most blatantly visible yet most neglected — public health problems”. 1 Studies of obesity prevalence over time show an increase of 2.3–3.3-fold over about 25 years in the United States and 2.0–2.8-fold over 10 years in the United Kingdom </li></ul>
  5. 5. MEASUREMENT <ul><li>As per WHO classification, measurement of obesity is the Body Mass Index [BMI=Weight(kg)/Height 2 (m 2 ) </li></ul><ul><li>Other Markers : </li></ul><ul><li>Skin fold thickness (triceps & sub scapular) </li></ul><ul><li>Waist circumference (for central obesity) waist hip ratios. </li></ul><ul><li>Bioelectrical impedance analyses, Dual energy X-ray Absorptionmetry Analysis (DEXA) for actual fat %. </li></ul><ul><li>Of the above none are standardized yet in children for routine clinical practice. </li></ul>
  6. 6. BODY MASS INDEX <ul><li>Rapid changes in BMI occur in normal growth, and BMI varies with age and sex. It rises in the first year of life, then falls during preschool years, before rising again into adolescence. The point at which BMI starts to rise again (usually around 4–6 years of age) is termed “adiposity rebound”. Thus, calculated BMI values need to be compared with age and sex reference standards. For clinical use, the expert working group has recommended the BMI-for-age percentile charts developed in the United States by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Pro motion. </li></ul>
  7. 7. PATHOPHYSIOLOGY <ul><li>A person gains weight when energy input exceeds energy output. Energy input is food. Several studies have shown that, on average, obese children do not consume significantly more calories than their thin peers.11-14 Energy output comprises the basal metabolic rate, the thermal effect of food and activity. The thermal effect of food is the energy required to absorb and digest meals. Of these variables, activity is the one least influenced by genetic inheritance and is therefore the one most susceptible to change.15 By measure, 3,500 calories is equivalent to 1 lb; thus, an excess intake of only 50 to 100 calories per day will lead to a five- to 10-lb weight gain over one year. As a result, a relatively small imbalance between energy input and output can lead to significant weight gain over time. In fact, most obese children demonstrate a slow but consistent weight gain over several years.15 </li></ul>
  8. 8. Aetiology of obesity: heredity v environment <ul><li>Genetic factors </li></ul><ul><li>Several studies have shown that there is a strong genetic basis to the development of obesity. Obesity appears to be a polygenic disorder, with many genes currently linked or associated with a predisposition to excess adiposity. 6 At least five single-gene mutations causing human obesity that present in childhood have been identified. These are rare and all are associated with severe and very early onset obesity, and should prompt referral for further assessment </li></ul>Several studies have shown that a
  9. 9. DIETARY INTAKE <ul><li>The increased prevalence of obesity in recent </li></ul><ul><li>decades may have partly resulted from an increased consumption of high-fat foods or sweetened drinks, although the evidence for a clear effect </li></ul><ul><li>of diet is not strong. In young children, parental influence on food selection is strong. In older </li></ul><ul><li>children and adolescents peer influence is also </li></ul><ul><li>important. Less desirable meal patterns, such </li></ul><ul><li>as frequent snacking, also appear to be </li></ul><ul><li>related to established obesity. </li></ul>
  10. 10. OTHER RISK FACTORS FOR OBESITY IN CHILDHOOD AND ADOLESCENCE : <ul><li>Early infant feeding : Breastfeeding is possibly protective for the development of obesity. 8 </li></ul><ul><li>Parental obesity, eating patterns, and attitudes : Parental obesity more than doubles the risk of adult obesity among both obese and non-obese children. 9 Dietary disinhibition in the mothers of preschoolers is associated with subsequent excess weight gain in their daughters, 10 and a 6-year outcome study of children showed that parental dietary disinhibition is associated with greater increases in body fatness. 11 </li></ul>
  11. 11. Contd. <ul><li>Early adiposity rebound : Earlier adiposity rebound is associated with increased body fatness in adolescence.ir children to eat have heavier children. 12 </li></ul><ul><li>Socioeconomic status : In some developed countries, poorer children or those who live in rural settings are more at risk of obesity, whereas in countries undergoing economic transition childhood obesity is associated with a more affluent lifestyle and with living in urban regions. </li></ul><ul><li>Ethnicity : Data from the United States show that there is an increased risk of obesity in Native Americans and Hispanic Americans compared with white Americans, although these differences may be largely related to differences in socioeconomic status </li></ul>
  12. 12. cont. <ul><li>Underlying medical disorders : Secondary obesity may occur with medical conditions, including hypothyroidism, hypercortisolism, growth hormone deficiency and hypothalamic damage. </li></ul><ul><li>Prescription drugs : Some drugs may contribute to obesity. These include glucocorticoids, antipsychotic drugs (eg, risperidone) and some antiepileptic medications. </li></ul>
  13. 13. EVALUATION OF OBESE CHILDREN <ul><li>Only a small percentage of childhood obesity is associated with a hormonal or genetic defect, with the remainder being idiopathic in nature. An endogenous cause for obesity can be either suspected or eliminated from the differential diagnosis in virtually all children based on a careful history and physical examination. In most cases, this should negate the need for expensive and unnecessary laboratory evaluations. </li></ul><ul><li>Growth failure characterizes endogenous obesity </li></ul>
  14. 14. ENDOGENOUS CAUSES OF CHILDHOOD OBESITY <ul><li>Hypothyroidism </li></ul><ul><li>Hypercortisolism </li></ul><ul><li>Primary hyperinsulinism </li></ul><ul><li>Pseudohypoparathyroidism </li></ul><ul><li>Acquired hypothalamic </li></ul><ul><li>Increased TSH, decreased thyroxine (T4) levels </li></ul><ul><li>Abnormal dexamethasone suppression test; increased 24-hour free urinary cortisol level </li></ul><ul><li>Increased plasma insulin, increased C-peptide levels </li></ul><ul><li>Hypocalcemia, hyperphosphatemia, increased PTH level </li></ul><ul><li>Presence of hypothalamic tumor, infection, syndrome trauma, vascular lesion </li></ul>
  15. 15. Characteristics of idiopathic & endogenous obesity <ul><li>Idiopathic obesity </li></ul><ul><li>Tall stature (usually>50 percentile) </li></ul><ul><li>Family history of obesity common </li></ul><ul><li>Mental function normal </li></ul><ul><li>Normal >90% of cases </li></ul><ul><li>or advanced bone age </li></ul><ul><li>Physical examination otherwise normal </li></ul><ul><li>Endogenous obesity </li></ul><ul><ul><li><10% of cases </li></ul></ul><ul><ul><li>Short stature </li></ul></ul><ul><ul><li>Family history </li></ul></ul><ul><ul><li>Often mentally impaired </li></ul></ul><ul><ul><li>Delayed bone age </li></ul></ul><ul><ul><li>Associated stigmata on physical examination </li></ul></ul>
  16. 16. GENETIC SYNDROMES <ul><li>Prader-Willi </li></ul><ul><li>Laurence-Moon/ Bardet-Biedl </li></ul><ul><li>Alström </li></ul><ul><li>Börjeson-Forssman-Lehmann </li></ul><ul><li>Cohen </li></ul><ul><li>Turner's </li></ul><ul><li>Familial lipodystrophy </li></ul>
  17. 17. GENE ASSOCIATIONS <ul><li>Leptin </li></ul><ul><li>Beta3-adrenergic receptor </li></ul>
  19. 19. COMPLICATIONS: <ul><li>Childhood obesity is a chronic paediatric disease with possible immediate and long-term complications involving many body systems . </li></ul><ul><li>Insulin resistance </li></ul><ul><li>Obesity in childhood and adolescence may be associated with insulin resistance. Without appropriate medical intervention, severe obesity and insulin resistance may progress to type 2 diabetes, which now accounts for up to 50% of newly diagnosed diabetes in some paediatric populations. </li></ul>
  20. 20. Contd. <ul><li>Acanthosis nigricans is considered to be a marker of insulin resistance in children and adolescents . </li></ul><ul><li>Steatohepatitis Non-alcoholic steatohepatitis (NASH) was first described in 1979 in adults. NASH also occurs in childhood, but is less well characterised. Liver biopsies from obese prepubertal children with NASH may show fatty change, inflammation and fibrosis, with progression to necrosis and cirrhosis. 15 Most cases of paediatric NASH are described in older children and adolescents. Elevated serum transaminase levels should raise suspicion of NASH in an obese child or adolescent. If NASH is suspected, referral to a centre specialising in the management of childhood obesity is recommended. </li></ul>
  21. 21. Cardiac risk factors <ul><li>Include a family history of early cardiovascular disease, high cholesterol and blood pressure levels, cigarette smoking, the presence of diabetes mellitus and decreased physical activity. Obesity in childhood is known to be associated with abnormal indices of lipolysis, including high cholesterol levels (greater than 170 mg per dL [4.40 mmol per L]), high triglyceride levels and low levels of high-density lipoprotein.17-19 The National Cholesterol Education Program Expert Panel on Blood Cholesterol Levels in Children and Adolescents20 therefore recommends that physicians consider screening all obese children over two years of age for elevated cholesterol levels. </li></ul>
  22. 22. Contd. <ul><li>Obese children also have increased average blood pressure, heart rate and cardiac output when compared to non-obese peers </li></ul>
  23. 23. ORTHOPEDIC PROBLEMS <ul><li>These include tibial torsion and bowed legs, slipped capital femoral epiphysis (especially in boys) and symptoms of weight stress in the joints of the lower extremities. </li></ul>
  24. 24. SKIN DISORDERS <ul><li>Heat Rash </li></ul><ul><li>Intertrigo </li></ul><ul><li>Monilial Dermatitis </li></ul><ul><li>Acanthosis Nigricans </li></ul>
  25. 25. PSYCHIATRIC PROBLEMS <ul><li>Depression </li></ul><ul><li>Poor Self-esteem </li></ul><ul><li>Negative self-image </li></ul><ul><li>Withdrawal from peers </li></ul>
  26. 26. Assessment and management of the obese child or adolescent
  27. 27. Conventional management of childhood obesity <ul><li>Dietary change </li></ul><ul><li>Avoid severe food restriction </li></ul><ul><li>Reduce energy intake </li></ul><ul><li>Reduce portion size </li></ul><ul><li>Select foods with lower fat content and low glycaemic index </li></ul><ul><li>Increase vegetable and fruit intake </li></ul><ul><li>Reduce high-sugar foods and drinks </li></ul><ul><li>Use water as the main beverage </li></ul>
  28. 28. Increased physical activity <ul><li>Incidental activity </li></ul><ul><li>Lifestyle activity </li></ul><ul><li>Exercise programs </li></ul><ul><li>Active transport (walking, cycling ) </li></ul>
  29. 29. Decreased sedentary behaviour <ul><li>Reduce time spent watching television, playing computer games, using other electronic media </li></ul><ul><li>Encourage alternatives to motorised transport </li></ul>
  30. 30. Behaviour modification <ul><li>Build confidence </li></ul><ul><li>Assess readiness for change </li></ul><ul><li>Change habits associated with eating and physical activity </li></ul><ul><li>Set realistic goals for lifestyle change </li></ul>
  31. 31. Family Involvement <ul><li>It is important to involve the entire family when treating obesity in children. Many studies have demonstrated a familial aggregation of risk factors for obesity, and the family provides the child's major social learning environment. It has been demonstrated that the long-term (10-year) effectiveness of a weight control program is significantly improved when the intervention is directed at the parents as well as the child, rather than aimed at the child alone. </li></ul>
  32. 32. Drug therapy <ul><li>Sibutramine, Orlistat </li></ul><ul><li>: The NHMRC guidelines suggest that use of both sibutramine and orlistat in obese adolescents with complications should take place only in a specialist centre, and only when there is a reasonable expectation of benefit over risk. </li></ul><ul><li>Metformin: metformin therapy should be considered in obese adolescents with significant hyperinsulinaemia and a family history of diabetes. </li></ul>
  33. 33. Obesity (bariatric) surgery <ul><li>The NHMRC guidelines consider bariatric surgery as a last possible option in a severely obese adolescent with obesity-related comorbidity. </li></ul>
  34. 34. Preventing Obesity: Tips for Parents <ul><li>• Respect your child's appetite: children do not need to finish every bottle or meal. </li></ul><ul><li>• Avoid pre-prepared and sugared foods when possible. </li></ul><ul><li>• Limit the amount of high-calorie foods kept in the home. </li></ul><ul><li>• Provide a healthy diet, with 30 percent or fewer calories derived from fat. </li></ul><ul><li>• Provide ample fiber in the child's diet. </li></ul><ul><li>• Skim milk may safely replace whole milk at 2 years of age. </li></ul><ul><li>• Do not provide food for comfort or as a reward. </li></ul><ul><li>• Do not offer sweets in exchange for a finished meal. </li></ul><ul><li>• Limit amount of television viewing. </li></ul><ul><li>• Encourage active play. </li></ul><ul><li>• Establish regular family activities such as walks, ball games and other outdoor activities. </li></ul>
  35. 35. AYURVEDIC CONCEPT Termed as sthaulyaroga or medoroga There are references to obesity in almost all ayurvedic texts like charak samhita,susruta samhita etc.
  36. 36. NIDAN (Ref.C.S. 21/4) <ul><li>Over intake </li></ul><ul><li>Intake of heavy,sweet,cool and unctuous food </li></ul><ul><li>No physical exercise </li></ul><ul><li>Day-sleep </li></ul><ul><li>Uninterrupted cheerfulness </li></ul><ul><li>Lack of mental exercise </li></ul><ul><li>Heredity </li></ul>
  37. 37. SAMPRAPTI (C.S.21/5-9),S.S15/37) <ul><li>SAMPRAPTI GHATAK </li></ul><ul><ul><ul><ul><ul><li>Dosha: kapha pradhan </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Dusya: meda </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Adhisthana: sarvasharira,nitamba,udara,stana </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Srotas: medovaha </li></ul></ul></ul></ul></ul>
  38. 38. <ul><li>NIDANA </li></ul><ul><li>ATIMADHURA-SNIGDHA,ANNARASA PRODUCTIONS </li></ul><ul><li>MEDOVRDDHI </li></ul><ul><li>ANYADHATU APOSHANA VATAVRDHII </li></ul><ul><li>VRDHVATA GOES INTO STOMACH </li></ul><ul><li>AGNIVRDDHI </li></ul><ul><li>ONLY MEDOVRDDHI INCREASED APPETITE & INTAKE OF </li></ul><ul><li>EXCESSIVE FOOD </li></ul><ul><li>STHAULYAROGA </li></ul>
  39. 39. LAKSHANA (C.S.21/4,S.S.15/32) <ul><li>Charak has included “Atisthula” persons while describing “Astanindita purusas”. </li></ul><ul><li>Distinctive features of “Atisthula” are: </li></ul><ul><li>Ayushohrasa (deficient in longevity) </li></ul><ul><li>Javoparodha (slow in movement) </li></ul><ul><li>Krichvyavayata (Difficult to indulge in sexual intercourse) </li></ul><ul><li>Daurbalya (weak) </li></ul><ul><li>Daurgandhya (emits bad smell from the body) </li></ul><ul><li>Swedabadha (perspiration) </li></ul><ul><li>Kshudhatimatra (excessive appetite) </li></ul><ul><li>Pipasatiyoga (excessive thirst) </li></ul>
  40. 40. AYURVEDIC MANAGEMENT <ul><li>Principle : “Guru cha aptarpanam chestam sthulanam karshanam prati” </li></ul><ul><li>Aptarpan(depleting therapy) includes specific regimen in food , activities (ahara–vihara) and medicines(ausadhi) that could control dosas like vata& kapha, thereby check the aetiopathogenesis of the disease. </li></ul>
  41. 41. MAIN TREATMENT METHODS <ul><li>Nidanaparivarjana </li></ul><ul><li>Satvavajaya </li></ul><ul><li>Upavasa </li></ul><ul><li>Samshodhan & karshan </li></ul><ul><li>Soshana-ahara </li></ul><ul><li>Vyayama & Yoga </li></ul><ul><li>Ausadhis </li></ul>
  42. 42. SAMSODHANA CHIKITSA Administration of Bhadradi asthapan vasti & lekhanavasti <ul><li>SAMANA CHIKITSA </li></ul><ul><li>Bahya </li></ul><ul><li>Antarika </li></ul>
  43. 43. BAHYA : <ul><li>Sirisadi pragarsha </li></ul><ul><li>Haritakyadi pralepa </li></ul><ul><li>Patradi pradeha </li></ul><ul><li>Shalaiye udvartanam </li></ul>
  44. 44. ANTARIK <ul><li>Agnimantha kwath </li></ul><ul><li>Vidangadi churna </li></ul><ul><li>Vidangadi lauha </li></ul><ul><li>Navaka gugglu </li></ul><ul><li>Amratadya guggulu </li></ul><ul><li>Loharishta </li></ul><ul><li>Triphalataila(for intake,vasti & massage) </li></ul><ul><li>Takrarishta </li></ul><ul><li>Yavamlaka churna </li></ul>
  45. 45. YOGA <ul><li>Yoga has considered all aspects of Obesity (physical, emotional and mental) </li></ul><ul><li>Regular practice of Yoga and controlled life style reduces obesity (weight is reduced). </li></ul><ul><li>Yoga makes human being agile, efficient and slim. </li></ul><ul><li>Yoga is suitable for people in any age group. </li></ul><ul><li>Yoga helps achieve control over mind and behavior (one can easily control food habits and change life style to reduce the obesity.) </li></ul><ul><li>Yoga has different effect on obesity, which is permanent in nature than other techniques for obesity reduction. Weight loss is permanent but one needs to practice few important techniques regularly. </li></ul>
  46. 46. THE SUN SALUTATION - Suryanamaskar <ul><li>  The Sanskrit word surya means sun. Namaskar is the Hindi word for Namaste, from the root nam , to bow. Namaskar means salutation, salute, greeting or praise </li></ul>
  48. 48. PRANAYAM
  49. 49. ASANAS <ul><ul><ul><ul><ul><li>NAUKASANA </li></ul></ul></ul></ul></ul>
  50. 50. Contd. <ul><ul><ul><li>Ustrasana Udarakarshasan </li></ul></ul></ul>
  51. 51. Contd. <ul><li>Katichakrasana Dhanurasana </li></ul>
  52. 52. PATHYA (wholesomeness) <ul><li>Acrid, bitter & astringent tastes drugs </li></ul><ul><li>Sali rice, mudga , kulattha, chana, masura, yava, kodrava, madhu, takra, sura, mustard oil, sesame oil, leafy vegetables, warm water for drinking (prefer before meal) etc. </li></ul>
  53. 53. THANK YOU