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? Earliest possible date US Soda Intake 52/gal/capita Definite date (2004) US Coffee Intake 46 gal/capita (1946) Modern Beverage Era 10,000 BCE - present Juice Concentrates (1945) 200,000BCE - 10,000 BCE US Milk Intake 45 gal/capita (1945)Pre-Homo Sapiens Origin of Humans Coca Cola (1886) Pasteurization (1860-64) Carbonation (1760-70) Liquor (1700-1800) Lemonade (1500-1600) Coffee (1300-1500) Brandy Distilled (1000-1500) (206 AD) Tea (500 BCE) Wine, Beer, Juice Wine (5400 BCE) (8000 BCE) Beer (4000 BCE) Milk (9000 BCE) 2000 BCEWater, Breast Milk 200000 BCE 200000 BCE Homo Sapiens Beginning 100000 BCE 10000 BCE of Time 0 BCE AD
Obesity is a major paediatric public healthproblem across the world, associated with riskof complications in childhood and increasedmorbidity and mortality throughout adult life.
FatStores ↑ 2% = 2.3 kg in a year
• More than 40% of the children eat out once or more in a week• 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week• 40% eat french fries once or more in a week• 60% eat noodles and drink colas once or more in a week Misra et al., Unpublished data, 2008
Obesity is a global public health problem,sparing only dramatically poor regions withchronic 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 anadditional 35% of adults are overweight. Inchildren, the prevalence of obesity increased300% over approximately 40 years.
Worldwide obesity has more than doubled since1980.In 2008, more than 1.4 billion adults, 20 andolder, were overweight. Of these over 200million men and nearly 300 million women wereobese.65% of the worlds population live in countrieswhere overweight and obesity kills more peoplethan underweight.More than 42 million children under the age offive were overweight in 2010. Close to 35 millionof these are living in developing countries.Obesity is preventable.
Childhood obesity, if not addressed, can lead tolifetime health consequences and contribute toadulthood obesity.A study found that 80% of obese children aged10-15 became obese adults (CDC, 2010).Untreated childhood obesity can lead tocardiovascular problems, as well as high bloodpressure, high cholesterol, and Type 2diabetes (CDC, 2010).At least 2.6 million people each year die as aresult of being overweight or obese.(WHO)
Prevalence of overweight/obesity among Adolescents (14-18 yrs), Delhi Government Age wise Public Schools Age wise Age Schools prevalence in Gender prevalence in(yrs) Overweight Overweight Government Public Schools % (N=2593) % (N= 955) Schools Male 29.7 12.9 14 32.6 12.7 Female 39.6 12.4 Male 23.3 11.8 15 29.9 11.5 Female 39.0 11.0 Male 28.0 7.8 16 25.1 8.4 Female 20.8 9.4 Male 27.0 9.4 17 25.3 11.0 Female 21.6 13.8 Total% 29.0 11.1 (N = 3548) OVERALL PREVALENCE = 24.2% Misra et al. Ann Nutr Metab.2011
Country/City Year PrevalenceGlobal 2004 10USA/UK 2000 20Australia 1995 20India/Chennai 2002 22India/Delhi 2004 16India/Delhi 2006 29 Misra et al., 2006
What is cut off value for OBESITY?
95th centile Author Range Year BMI values show Girls wide variations between regions, Vedavati 22-27 kg/m2 1998 and the period of the studies. Agarwal 23-27 kg/ m2 1988-1994 Pune study, age 10-13 years, BMI of boys have been Cole 24-29 kg/m2 1963-1993 even higher than the international values. 95th centile Khadilkar 24-27 kg/m2 2004 Delhi Agarwal’s Boys chart for the 85th Agarwal 22-27 kg/m2 1988-1994 and 95th centile show lower BMI Cole 23-28 kg/m2 1963-1993 values than the WHO values Local BMI values are collected on smaller samples and comparison between them and withinternational norms are not feasible.
obesityoverweight underweightNormal BMI
Conclusions: Contemporary cross-sectional age and sex specific BMI cut-offs forIndian children linked to Asian cutoffs of 23 and 28 kg/m2 for the assessment ofrisk of overweight and obesity, respectively are presented. KHADILKAR, et al.
The National Health and NutritionExamination Survey (NHANES) IV, 1999-2002, found 31% of children older than 2 yr tobe overweight or obese, and 16% of childrenand adolescents 6-19 years were in the obeserange.Childrens risk varies by socioeconomicstatus, race, maternal education level, andgenderAcross all racial groups, higher maternaleducation confers protection againstchildhood obesity.
A study conducted in mysore in 2009 showsthe prevalence of obesity and overweightwere 3.4%, 8.5% respectively. The prevalenceof obesity was maximum in the age group of5-7 years and in those from private schools.
A study conducted in 2011 representingupper, middle and lower socioeconomicgroups and the children aged 6-15 years ofage were interviewed. The prevalence ofobesity was 3.0% for boys and 5.3% for girls.The prevalence of obesity (7.5%) andoverweight (21.9%) were highest among highincome group and lowest (1.5% and 2.5%)among low income group.
Environmental changesGenetic changesEndocrine and neurological changes
Environmental changes• Foods are increasinglyprepared by a “foodindustry,” with high levels ofcalories, simplecarbohydrates, and fat.•The increased consumptionof high-carbohydratebeverages, including sodas,sport drinks, fruit punch, andjuice•The dramatic increase in theuse of high-fructose cornsyrup to sweeten beverages
levels of physical activity inchildren and adults havedeclined 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 timewatching television, and a generally fasterpace of life has lead to decreased sleep whichincreases risk for weight gain and obesity.
Rare single-gene disorders resulting inhuman 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 syndromeCohen syndromePrader-Willi SyndromePro-opiomelanocortin deficiencyTurner syndromeLeptin or leptin receptor gene deficiencyCarpenter syndrome
Complications of paediatric obesity occur duringchildhood and adolescence and persist intoadulthood More immediate co morbidities include type 2diabetes, hypertension, hyperlipidemia, and nonalcoholic fatty liver diseaseInsulin resistance increases with increasingadiposity and independently affects lipidmetabolism and cardiovascular health.Non alcoholic fatty liver disease occurs in 10-25%of obese adolescents and can progress tocirrhosis.
Overweight and obese children are oftenidentified as part of routine medical care, andthe child and family may be unaware that thechild has increased adiposity.obesity intervention requires a chronicdisease management approach
Body Mass Index (BMI)Waist CircumferenceWaist-to-Hip RatioSkinfold ThicknessBioelectric Impedance (BIA)
Consideration of possible medical causes ofobesity is essential, as endocrine and geneticcauses are rare.Growth hormone deficiency, hypothyroidism,and Cushing syndrome are examples ofendocrine disorders that can lead to obesity. Ingeneral, these disorders manifest with slowlinear growth.Polyuria and polydipsia may be noted if theadolescent with obesity develops overtdiabetes.
Children who consume excessive amounts ofcalories tend to experience accelerated lineargrowth.Genetic disorders associated with obesity canhave coexisting dysmorphic features, cognitiveimpairment, vision and hearing abnormalities,or short stature.Children with congenital disorders such asmyelodysplasia or muscular dystrophy, lowerlevels of physical activity can lead to secondaryobesity
A history of damage to the central nervoussystem (CNS) (eg, infection, trauma,hemorrhage, radiation therapy, seizures)suggests hypothalamic obesity with or withoutpituitary growth hormone deficiency or pituitaryhypothyroidism. A history of morningheadaches, vomiting, visual disturbances, andexcessive urination or drinking also suggests thatthe obesity may be caused by a tumor or mass inthe hypothalamus.
The appearance of signs of sexual development atan early age suggests that the weight gain iscaused by precocious puberty . However,excessive facial hair, acne, and irregular periods ina teenage girl suggest that the weight gain maybe caused by cortisol excess or polycystic ovarysyndrome (PCOS). Hip or knee pain can be caused by secondaryorthopedic problems, including Blount diseaseand slipped capital femoral epiphysisAcanthosis nigricans can suggest insulinresistance and type 2 diabetes
The objective of interventions in overweightand obese children and adolescents is theprevention or amelioration of obesity-relatedco-morbiditiese.g. glucose intolerance and T2DM, metabolicsyndrome, dyslipidemia, and hypertension.
Diabetes Respiratory Hypertension Problems Depression Gall Bladder disease Obesity andHeart Diseases Cancer Health risks Osteoarthritis Infertility Optical disorders Renal Disease Stroke
Office visit modelSymptoms Diagnosis Treatmentand signsHeadaches with Migraines MedicationnauseaSoda, fast food, school Education, Obesity motivation,food, video games,poverty, unsafe parenting skills,neighbor-hood, single social work, screenmother, poor and addressparenting, depression 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 “fastfood,” and calorie-dense snacks)Increasing the intake of dietary fiber, fruits, andvegetables.Eating timely, regular meals, particularlybreakfast, 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 physicalactivity for at least 60 minutes per day.
Educate parents aboutthe need for healthyrearing patterns relatedto 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 combinationwith lifestyle modification) beconsidered if a formal program ofintensive lifestyle modification hasfailed to limit weight gain or tomollify comorbidities in obesechildren.Overweight children should not betreated with pharmacotherapeutic agents unlesssignificant, severe co-morbiditiespersist despite intensive lifestylemodification.
Bariatric surgery be considered only under thefollowing 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/m or has BMI 2 above 35 kg/m and significant, severe co morbidities. 2
Severe obesity and co-morbidities persist despite aformal program of lifestyle modification, with orwithout a trial of pharmacotherapyThere is access to an experienced surgeon in amedical center employing a team capable of longterm follow-up of the metabolic and psychosocialneeds of the patient and familyThe patient demonstrates the ability to adhere tothe 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.
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 childrens 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 ofSouth 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 diabetesand obesity among children and adultsand to thus act as change agents for betterlifestyles and prevention of diabetes Initiative of National Diabetes, Obesity, and Cholesterol Diseases Foundation & Emcure Pharmaceutical (India) Pvt. Ltd March 5, 2011
Objectives Specific Objectives• To enhance awareness among school children, and adults 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 November 14, 2011 – World Diabetes Day • Distribution of printed education material to children and adults • Message dissemination through media Initiative of National Diabetes, Obesity, and Cholesterol Diseases Foundation & Emcure Pharmaceutical (India) Pvt. Ltd March 5, 2011
Participating Teams Across 50 cities in IndiaInitiative of National Diabetes, Obesity, and Cholesterol Diseases Foundation & Emcure Pharmaceutical (India) Pvt. Ltd March 5, 2011
Initiatives being implemented in various cities of India New Delhi Dehradun Mumbai Allahabad Jaipur Bangalore Agra Pantnagar Chandigarh Pune Vadodara Lucknow Noida Bhubaneshwar
“MARG” (The Path) Medical education for children/ Adolescents for Realistic prevention ofobesity 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: 1. changing the individual (children, family, teachers) 2. 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 Diabetes Foundation (India)
“CHETNA” Children’s Health Education ThroughNutrition and Health Awareness Program A Project of Diabetes Foundation (India) 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
Poster Making 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, anthropometricmeasurements, 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
Key Activities: Intervention Trial (6 months): Case Control Design1. Intensive intervention vs. usual intervention2. Improvements in the following aspects: a. Knowledge levels b. Dietary habits c. Anthropometric measurements d. Body fat composition e. Glycemic indicators f. Insulin levels, CRP levels g. Lipid profile
Phase 2: Interventions Weekly individual counseling of children Lectures Activities: Skits, quiz competition, extempore, focused group discussions 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 morning assembly on important days like the World Food Day Quiz competition in class Paragraph writing on topics like: Ways in which you can prevent yourself from diabetes and heart disease in the next 5-8 years, healthy alternatives to junk food, planning a day’s diet for themselves, planning their own tiffins for a week Checking tiffins of younger classes in their school by the intervention group
% Decrease in Consumption Patterns of ‘Energy-Dense Foods”Consumption of Food Articles Case School Control SchoolSweetened carbonated drinks > 3 times/w 15.4% 7.9%Western ‘energy-dense’ foods (Burgers, 9.2% 1.4%pizzas, french fries, noodles) > 3 times/wChips/ Namkeen/Maggi > 3 times/w 8.3% No changeIndian ‘energy-dense’ food > 3 times/w 6.3% 2.2%All differences are statistically significant Singhal N, Misra A, Shah P, Gulati S. Eur J Clin Nutr, in press
Consumption of Fruits (brought in Tiffin) Case School Control School Baseline 10.1% 29.8% Follow-up 40.4%* 25.9%*Statistically significant Singhal N, Misra A, Shah P, Gulati S. Eur J Clin Nutr, in press
% Change in Time Spent in TV Viewing and Physical Activity Variables Case Control School School TV Viewing > 2 h/d 5.2% 2.4% Physical Activity 9.8 % 3.7% 30-60 min/dAll differences are statistically significant Singhal N, Misra A, Shah P, Gulati S. Eur J Clin Nutr, in press
Knowledge, Attitude and Practice about Nutrition, Obesity and Diabetes:Pre- and Post Surveys Show significant Increase in Knowledge 80 70 60 50 Pre 40 Post 30 20 10 0 Healthy Junk Obesity Diet and living food DM Shah P, Misra A et al., Br J Nutr 2010
% Change in Anthropometric Parameters 4% 2% 0% -2% WC Mid -thigh SAD Triceps Biceps -4% -6% -8% -10% -12% -14% Case ControlP< 0.05 in Control SADP< 0.001 in Case biceps Singhal N, Misra A, Shah P, Gulati S. Eur J Clin Nutr, in press
% Change in Metabolic Parameters Variable Case School Control SchoolFasting Glucose -4.9%* -2.2% HDL-C 2.2% -2.3%*p < 0.001 Singhal N, Misra A, Shah P, Gulati S. Eur J Clin Nutr, in press
% Change in Fasting Serum Insulin and CRP 13 47 6.2 CONT. INT. CONT. -21.6 Insulin Hs-CRP Misra et al., Unpublished data
Summary• Rising childhood obesity in urban India and in other Developing Countries is of great concern, and would fuel the diabetes and the metabolic syndrome epidemics further.• Overall, it is more in urban areas (vs. rural), and public schools.• Its consequences, insulin resistance, PCOS, hirsutism, type 2 diabetes, subclinical inflammation and hepatic steatosis are now frequently seen in children .• Countrywide programs, akin to our program “MARG” in schoolchildren are urgently needed.
The Myths “What will happen if a child is fat. He/she will not have any diseases” Reality:• Diabetes may strike early• Polycystic ovaries, excess facial hair and infertility may occur in girls
The Myths “Heart Disease starts at old age” Reality:Hardening and blockage of the arteriesstarts at 11 years in boys and 15 years in girls
The Myths “A fat child is otherwise healthy” Reality:28% of urban children have syndrome X, one step away from diabetes and 2 steps away from heart disease
The Myths “A child does not develop high blood pressure or high cholesterol” Reality:Many children will have high blood pressure and low good cholesterol
The Myths “A child should enjoy, and eat and relax. Such time will not come again later” Reality:Parents do not realize, but children are eating junk food all the time.
The Myths “All children are doing required 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 are metabolic abnormalities or diseases, these can be easily treated” Reality:Most of these diseases are catastrophic and have complications that cannot be reversed. Most will shorten lifespan