Obesity in children

Obesity in children
Prevalence
and
Etiologies
Dr. Gaby Falakha
Management
and
Treatment
Dr. Ahlam Azar
Tripoli April 10th
, 2018

Obesity in children
Prevalence and Etiologies
GABY FALAKHA
PEDIATRICIAN -NEONATOLOGIST
DIU IN CHILD AND ADOLESCENT OBESITY
TRIPOLI APRIL 10TH
, 2018

Outline
1. Definition
2. Prevalence worldwide
3. Prevalence in Lebanon
4. Etiologies
 Genetic
 Endocrine
 Social and behavioral
5. Take home messages

Definition
 BMI : Body Mass Index
 BMI= Weight (in Kg) / Height2
(in meters)
 Overweight : BMI > 85th
percentile for age and gender
 Obesity : BMI > 95th
percentile for age and gender

Normal 18.5 - 25
Overweight 25-30
Obese > 30

Is there an increase in Obesity prevalence?

Obesity Trends* Among U.S. Adults
1985
No Data <10% 10%–14%
BMI ≥30

BRFSS, 1986
No Data <10% 10%–14%

BRFSS, 1987
No Data <10% 10%–14%

BRFSS, 1988
No Data <10% 10%–14%

BRFSS, 1989
No Data <10% 10%–14%

BRFSS, 1990
No Data <10% 10%–14%

BRFSS, 1991
No Data <10% 10%–14% 15%–19%

BRFSS, 1992
No Data <10% 10%–14% 15%–19%

BRFSS, 1993
No Data <10% 10%–14% 15%–19%

BRFSS, 1994
No Data <10% 10%–14% 15%–19%

BRFSS, 1995
No Data <10% 10%–14% 15%–19%

BRFSS, 1996
No Data <10% 10%–14% 15%–19%

BRFSS, 1997
No Data <10% 10%–14% 15%–19% ≥20%

BRFSS, 1998
No Data <10% 10%–14% 15%–19% ≥20%

BRFSS, 1999
No Data <10% 10%–14% 15%–19% ≥20%

BRFSS, 2000
No Data <10% 10%–14% 15%–19% ≥20%

BRFSS, 2001
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

BRFSS, 2002
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

BRFSS, 2003
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

BRFSS, 2004
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

BRFSS, 2005
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

BRFSS, 2006
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

BRFSS, 2007
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

BRFSS, 2008
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

BRFSS, 2009
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

BRFSS, 2010
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

2000
BRFSS, 1990, 2000, 2010
(*BMI ≥30, or about 30 lbs. overweight for 5’4” person)
2010
1990
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Age–standardized prevalence of obesity (based
on IOTF cutoffs), ages 2–19 years, males, 2013

Age–standardized prevalence of obesity (based
on IOTF cutoffs), ages 2–19 years, females, 2013

Study/Author Year
Nr. Of
subjects Age Results
IMC <85th
% 85th
%>IMC<95th
% IMC >95th
%
1 Falakha/Rachkidi 2000 484 3-11 ans
76.10% 15.20% 8.70%
2 Sibai 2003 399 -Garcons 3-19 ans
70% 22.50% 7.50%
3 Sibai 489 -filles 3-19 ans
80.70% 16.10% 3.20%
4 Chakar 2006 5529-Garcons 10-18 ans
60.80% 29.20% 10.10%
5 Chakar 2006 6770 -filles 10-18 ans
77.60% 18.70% 3.70%
6 Fazah 2007 1000 14-18
69.70% 22.50% 7.80%
7
Chemaitelly/
Falakha 2008 496-Garcons 13-18
61% 29% 10%
8
Chemaitelly/
Falakha 2008 554-Filles 13-18
77% 19% 4%
9 Samar Zawdeh 2017 429 6-12 52%
34% 14%
10 Samar Zawdeh 2017 506 12-18
60%
29% 11%

Prevalence of Obesity in Arab countries
Boys < 20 years
Overweight and Obese Obese
North Africa and Middle East 22.2(21.0-23.3) 8.4(7.9-8.9)
Qatar 33.5(29.3-38.0) 18.8(15.8-21.9)
Lebanon 33.1(28.9-37.9) 15.9(13.0-19.1)
Syria 32.9(28.6-37.5) 13.9(11.5-16.5)
Libya 32.5(28.5-36.9) 14.5(12.0-17.0)
Egypt 31.5(27.5-35.7) 12.7(10.7-15.2)
UAE 30.8(26.5-35.1) 12.2(9.8-14.7)
Palestine 27.9(23.8-31.9) 11.9(9.8-14.3)
Kuwait 24.6(21.1-28.5) 16.7(13.9-20.1)
Oman 24.5(20.5-28.5) 8.4(6.7-10.2)
Jordan 24.1(20.6-28.0) 8.0(6.4-9.9)
Saudi Arabia 23.5(20.2-26.8) 9.4(7.8-11.2)
Morocco 22.5(19.3-26.1) 7.9(6.4-9.6)
Bahrein 22.4(19.2-26.0) 9.3(7.3-11.4)
Algeria 21.7(18.5-23.3) 8.4(6.2-9.4)
Tunisia 17.7(15.0-20.8) 4.2(3.4-5.2)
Sudan 11.2(9.2-13.4) 5.7(4.6-6.9)
Yemen 8.4(6.9-10.0) 1.7(1.4-2.1)
Lancet. 2014 August 30; 384(9945)

Girls < 20 years
North Africa and Middle East 27.9(26.6-29.2) 10.2 (9.5-10.8)
Kuwait 45.5(40.1-50.9) 23.3(19.5-27.8)
Oman 42.3(37.4-47.5) 15.4(12.4-18.5)
Libya 41.7(36.3-46.8) 22.1(18.1-26.4)
Egypt 39.5(34.7-44.3) 14.4(11.9-17.6)
Saudi Arabia 37.4(32.8-42.5) 14.8(12.2-17.7)
Syria 33.3(28.8-38.3) 15.4(12.5-18.6)
Qatar 32.1(28.6-35.7) 18.5(12.6-23.6)
UAE 31.6(27.1-36.2) 12.6(10.0-15.7)
Palestine 30.6(26.4-35.5) 12.5(10.1-15.2)
Algeria 30.0(25.5-34.5) 15.3(12.5-18..6)
Lebanon 29.8(25.6-34.0) 12.5(10.2-15.4)
Yemen 26.9(22.9-31.4) 8.3(6.5-10.3)
Bahrain 26.7(22.5-30.8) 15.3(12.5-18.6)
Morocco 25.9(22.1-30.2) 9.1(7.3-11.3)
Jordan 25.4(21.8-29.3) 8.0(6.2-10.0)
Tunisia 23.4(19.6-27.5) 4.2(3.3-5.2)
Sudan 14.4(12.0-17.6) 5.8(4.5-7.1)
Lancet. 2014 August 30; 384(9945)

Girls < 20 years
North Africa and Middle East 27.9(26.6-29.2) 10.2 (9.5-10.8)
Kuwait 45.5(40.1-50.9) 23.3(19.5-27.8)
Oman 42.3(37.4-47.5) 15.4(12.4-18.5)
Libya 41.7(36.3-46.8) 22.1(18.1-26.4)
Egypt 39.5(34.7-44.3) 14.4(11.9-17.6)
Saudi Arabia 37.4(32.8-42.5) 14.8(12.2-17.7)
Syria 33.3(28.8-38.3) 15.4(12.5-18.6)
Qatar 32.1(28.6-35.7) 18.5(12.6-23.6)
UAE 31.6(27.1-36.2) 12.6(10.0-15.7)
Palestine 30.6(26.4-35.5) 12.5(10.1-15.2)
Algeria 30.0(25.5-34.5) 15.3(12.5-18..6)
Lebanon 29.8(25.6-34.0) 12.5(10.2-15.4)
Yemen 26.9(22.9-31.4) 8.3(6.5-10.3)
Bahrain 26.7(22.5-30.8) 15.3(12.5-18.6)
Morocco 25.9(22.1-30.2) 9.1(7.3-11.3)
Jordan 25.4(21.8-29.3) 8.0(6.2-10.0)
Tunisia 23.4(19.6-27.5) 4.2(3.3-5.2)
Sudan 14.4(12.0-17.6) 5.8(4.5-7.1)
Lancet. 2014 August 30; 384(9945)
11th

Physical consequences of
childhood and adolescent obesity

Physical consequences of
childhood and adolescent obesity
 Pulmonary : Sleep apnoea, Asthma, Pickwickian syndrome
 Orthopaedic : Slipped capital epiphyses, Blount’s disease (tibia vara), Tibial
torsion, Flat feet, Ankle sprains, Increased risk of fractures
 Neurological : Idiopathic intracranial hypertension (e.g. pseudotumour
cerebri)
 Gastroenterological : Cholelithiasis, Liver steatosis / non-alcoholic fatty
liver, Gastro-oesophageal reflux
 Endocrine : Insulin resistance/impaired glucose tolerance, Type 2 diabetes,
Menstrual abnormalities, Polycystic ovary syndrome, Hypercorticism
 Cardiovascular : Hypertension, Dyslipidaemia, Fatty streaks, Left ventricular
hypertrophy
 Other : Systemic inflammation/raised C-reactive protein

Etiologies of Obesity ?
1. Genetic
2. Endocrine
3. Behavioral
4. Environmental

1. Genetic
2. Endocrine
3. Behavioral
4. Environmental
5%

1. Genetic
2. Endocrine
3. Behavioral
4. Environmental
95%

Leptin deficiency
Leptin receptor deficiency is
a condition that causes
severe obesity beginning in
the first few months of life.
Affected individuals are of
normal weight at birth, but
they are constantly hungry
and quickly gain weight.

Melanocortin-4 receptor gene mutation
• The most frequent single-gene
cause of Obesity
• MC4 receptors are involved in
suppression of food intake by
α-melanocyte-stimulating
hormone
• Leads to massive obesity
• Present in 5% of persons with
severe obesity

Mutations in POMC
• Lack of central appetite
signaling and therefore
hyperphagia.
• Affected patients have red
hair and adrenal
insufficiency

Albright's hereditary osteodystrophy
 Short stature
 Obesity
 Round face
 Subcutaneous
ossifications
 Brachydactyly

Bardet-Biedl Syndrome
 Short stature
 Developmental delay
 Retinitis pigmentosum
 Polydactyly

Alström syndrome
• Blindness
• Vision loss
• Hearing loss
• Hyperinsulinemia
• Obesity

Prader-Willi Syndrome
• Deletion in the proximal arm
of chromosome 15
• Diminished fetal activity
• Obesity
• Hypotonia
• Mental retardation
• Short stature
Hypogonadotropic
hypogonadism
• Strabismus
• Small hands and feet

Becwith-Wiedemann syndrome
 An overgrowth disorder usually present
at birth, characterized by an increased
risk of childhood cancer and certain
congenital features.
 Macroglossia
 Macrosomia
 Microcephaly
 Midline abdominal wall defects
(omphalocele/exomphalos, umbilical hernia,
diastasis recti)
 Ear creases or ear pits
 Neonatal hypoglycemia
 Hepatoblastoma

Endocrinologic causes of childhood obesity

Ecological model of predictors of childhood obesity.

IntakeOutput
BMR +
Activity
Prot, Lip, CHO
1400+1100=2500 Kcal
2500 Kcal
70 Kg adult
The energy balance

IntakeOutput
BMR +
Activity
Prot, Lip, CHO
2200 Kcal
70 Kg adult
1400+1100=2500 Kcal
The energy balance

IntakeOutput
BMR +
Activity
Prot, Lip, CHO
2200 Kcal
1100+1100=2200
The energy balance

The human “leptinostat”
a long evolutionary adaptation

Serum Immunoreactive-Leptin
Concentrations in Normal-Weight and
Obese Humans
R. Considine, N Engl J Med 1996; 334:292-295

Hunger
after
weight
loss
Priya Sumithran et al, N Engl J Med 2011;365:1597-604.

Examples of problematic social trends
 Increase in use of motorized transport, e.g. to school.
 Fall in opportunities for recreational physical activity.
 Increased sedentary recreation.
 Multiple TV channels around the clock, smartphones.
 Greater quantities and variety of energy dense foods available.
 Rising levels of promotion and marketing of energy dense foods.
 Use of candies as a reward system
 Larger portions of food offering better ‘value’ for money.
 Rising use of soft drinks to replace water, e.g. in schools.
 Air conditionning?
Obesity in children and young people: a crisis in public health
T. Lobstein, et al. for the IASO International Obesity Task Force

Marketing
 Kellogg spent $22.2 million just on media advertising to
promote 139.8 million dollars' worth of sales in 2004
 McDonald's spent $528.8 million on marketing to support
$24.4 billion in sales.
 Budget for education about the risk hazards of obesity
“1 million dollars”
 Since 1994, U.S. companies have introduced about 600 new
children's food products; half of them have been candies or
chewing gums, and another fourth are other types of
sweets or salty snack

Relation between energy density and energy cost

POSSIBLE ROLE OF ADDED SUGARS IN CHILD OBESITY
 The largest contributors of added sugars to American’s diets are
sugar-sweetened beverages (SSBs), and adolescents are the highest
consumers.
 Total energy consumed by Americans ages 2 years and older comes
from added sugars : - 13.1 % in 1977
- 19.7 – 22.3 % in 1999
- 5-10% (recommended)
Mechanisms are :
1. Increased caloric intake
2. Insulin resistance
3. High glycemic index, rebound hyperinsulinemia and hypoglycemia

US trends in per capita calories from beverages
among children
F.B. Hu, V.S. Malik / Physiology & Behavior 100 (2010) 47–54 49

Screen time
 A 2009 study on video game use found that the length of
game play time in a single sitting, frequency of video
game playing, and years of video game playing were
each correlated with less exercise and higher BMI
1. Decreased Energy Expenditure
2. Increased Consumption of Calories
3. Food advertising and product placement
4. Presence of TV in the bedroom
Ballard M, Gray M, Reilly J, et al. Correlates of video game screen time among
males: body mass, physical activity, and other media use. Eat Behav 2009; 10(3):161–7.

BMI and television viewing among over 2500
children aged 6–17 years in northern Greece
Krassas GE et al. Determinants of body mass index in Greek children and adolescents. J
Pediatr Endocrinol Metab 2001; 14 (Suppl. 5): 1327–1333.

• Mice receiving Penicillin
during weaning gained total
mass and fat mass in adult
age
• Mice receiving penicillin-
altered microbiata from 18
week-old penicillin treated
mice to 3 week-old Germ Free
Mice gained fat mass at a
significantly faster rate
Altering the intestinal microbiota during a critical
developmental window has lasting metabolic consequences
Cox et al. Cell. 2014 Aug 14;158(4):705-721

Factors causing dysbiosis and affecting health

Obesity and Antibiotics prescription

BPA : a chemical found in baby bottle
linked to increased risk of obesity
 Analysing 61 studies investigating the link between BPA
exposure and weight and fat deposition, researchers from
Brunel University London, New York University and Vrije
University in Amsterdam discovered that exposure to BPA
during the development of mice and rats significantly
raised their risk of being overweight later in life.

The Lancet Planetary Health
Bisphenol A substitutes and obesity in US adults: analysis of a
population-based, cross-sectional study
Volume 1, Issue 3, June 2017, Pages e114-e122
Methods:
We included participants aged 20 years or older, who had available data on
concentrations of BPA, BPF, and BPS (n=1709), from a cross-sectional study,
the National Health and Nutrition Examination Survey 2013–14
Findings:
1521 participants were included in the analysis.
Higher BPA, BPF, and BPS concentrations were observed in adults who
were obese than adults who were not obese.
After adjustment for demographic, socioeconomic, and lifestyle factors,
and urinary creatinine concentrations, BPA, but not BPF or BPS, was
significantly associated with obesity (The OR for general obesity was 1·78)

Take home message
1. BMI should be measured periodically in all children
2. Child obesity is reaching alarming rates
3. Obesity is a multifactorial disease
4. Genetic and endocrine causes represent only 5% of all
etiologies
5. Social and behavioral etiologies are the main culprit.
6. Educating parents is an essential responsibility of
pediatricians
7. Better prevent than treat

Thanks for your attention
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Obesity in children

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