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Obesity in children DR GRK
1.
2. Obesity
is a condition of abnormal or excessive
fat
accumulation in adipose tissue to the
extent that
health may be impaired
DR GRK DSMCH 2
3. • An emerging problem reaching epidemic
proportions.
• A big health problem which affects not only their
childhood but also causes problems in their adult
life.
• Between 3-7% of total health care costs can be
attributed to overweight.
• It is prevalent not only in developed but also in
developing countries
DR GRK DSMCH 3
4. Indian Scenario
Increasing prevalence of obesity in adolescents
especially in urban affluent population (22%
overweight in affluent schools as compared to 4.5% in
poor section schools)
Pune Study: (1228 boys between 10-15 Years)
25.1% overweight and 8.1% obese
Delhi :
31% of children overweight and 7.5% obese
(Private schools)
29% overweight with BMI >25 (In 5000
children between 4-18 Years showed)
DR GRK DSMCH 4
5. • Thrifty genotype
• Sedentary lifestyle
• Good high calorie food
DR GRK DSMCH 5
Pathogenesis
6. • Fat cannot be measured.
• The best way to measure obesity is Body
Mass Index in Adults
DR GRK DSMCH 6
Measurement of obesity
7. Measurement of obesity
But in children age and gender reference charts of BMI
are available
BMI > 85th percentile – Overweight
BMI > 95th percentile (+2SD) – Obese
In children < 2 Years wt. for length charts are
used
Other methods to measure obesity:
Skin fold thickness
Waist hip ratio (more in adults)
Waist circumference (more in adults)
Some imaging studies (DEXA, USG, CT scan, MRI, Bioelectrical
impedance)
DR GRK DSMCH 7
9. Do obese children grow into
obese adults?
‘Tracking’ occurs throughout life
10-20% obese infants
40% obese children
60-80% obese adolescents
“Adiposity rebound”
DR GRK DSMCH 9
10. Types of Obesity
Android Obesity/
Central Obesity
- Fat accumulates in the
upper segment
- Apple shaped
distribution
- More likely to develop
related disorders like
NIDDM, HT, etc.
- WHR (waist hip ratio) >
0.8
Gynecoid Obesity
- More subcutaneous fat
- Accumulates over thighs
and lower segment
- Pear shaped
- Complications fewer
DR GRK DSMCH 10
13. Causes of Obesity
Endogenous causes comprise of genetic and
endocrine causes – responsible for less than 10%
cases
(<5%- Nelson 18e)
Should be ruled out before treating as exogenous
obesity
DR GRK DSMCH 13
16. Exo – versus Endogenous
Causes
Endogenous Obesity
1. Family history
uncommon
2. Short height
3. Low IQ
4. Retarded bone age
5. Physical defects
common
Exogenous Obesity
1. Family history of
obesity
2. Tall child
3. Normal IQ
4. Normal bone age
5. Normal physical exam
DR GRK DSMCH 16
17. Causes of Exogenous Obesity
Genetic
Environmental
Dietary
Neurochemical
Malnutrition
DR GRK DSMCH 17
18. Genetic Causes
Strong correlation between the bodyweight
of the child and biological parents
Resting energy expenditure genetically
determined – influences obesity
A number of genes shown to be involved
Discovery of leptin – big bang in the field of
obesity
DR GRK DSMCH 18
19. Genes for obesity
Ob Gene
Product – leptin
Reduces appetite, increases metabolic rate,
increases fat oxidation
Mutation results in decreased leptin output
leading to obesity
DR GRK DSMCH 19
20. Genes of Obesity – Contd..
db Gene
Regulates leptin binding site
Establishes ‘set point’
Agouti Gene
Product – agouti signaling protein
Suppresses appetite during weight gain [ - alpha
MSH]
Orexin A and B , Neuropeptide Y,melanin-
concentrating hormone – increases appetite.
POMC and alpha MSH decreases appetite.
DR GRK DSMCH 20
24. Environmental Factors
In the first year – duration of feeding
- age of introduction of solid foods
Second year – maternal weight (reflects the
maternal influence on child’s intake and
expenditure)
DR GRK DSMCH 24
26. Dietary Factors
Reduced meal frequency and ‘gorging’
promotes weight gain, in contrast to ‘nibbling’
High calorie dense foods
DR GRK DSMCH 26
27. Neurochemical Causes
Feeding and appetite closely regulated –
imbalance may lead to obesity
Factors include insulin, neuropeptide Y,
dopamine and other monoamines, serotinin,
and gut hormones like CCK
DR GRK DSMCH 27
29. Malnutrition
Prenatal malnutrition predisposes to obesity –
due to altered development of hypothalamus
and the sympathetic system
Dutch famine of the Second WW
Undernutrition in later life – tendency to
accumulate fat more rapidly and intra
abdominally
DR GRK DSMCH 29
39. Psychosocial Complications
Most serious consequence
Lower self image, heightened self
consciousness, impaired social functioning
Negative stereotype attributed by peer group
and even trained physicians
Less likely to be successful in life
DR GRK DSMCH 39
40. Office evaluation of an obese child
Objective :
differentiate between Organic causes and
Idiopathic
obesity and early detection of complications
History
Physical Examination
Laboratory Studies
DR GRK DSMCH 40
41. History
Duration of disease
Previous attempts at weight reduction
Daily caloric intake and expenditure
Family history
- attitudes and practices
- weight status of parents and siblings
- meal patterns and recreational habits
DR GRK DSMCH 41
42. History
Family history of CHD, cancer, diabetes,
hypertension, hyperlipidemia and thyroid
disorders
History of complications
Psychosocial history and evaluation
DR GRK DSMCH 42
43. Physical Evaluation
Assessment of growth of the child
Distribution of fat - gynecoid or android
Sexual Maturity Rating (SMR) scoring
Blood Pressure
Other clinical features of organic causes
DR GRK DSMCH 43
44. Laboratory Studies
Evaluation of pituitary, adrenal, and thyroid
hormones for endocrine dysfunction
(selective)
Blood glucose and insulin levels
Plasma lipids
Serum cholesterol in all >2 years (NCEP
expert panel)
DR GRK DSMCH 44
48. Management of Obesity
Goals of treatment
Dietary management
Exercise
Behaviour modification
Other treatments
Complications of treatment
DR GRK DSMCH 48
49. Management of Obesity
Successful treatment of obesity is
challenging
Treatment goals vary- depending on
the age of the child and
the severity of complications
DR GRK DSMCH 49
50. Goals of Treatment
Achieve lifelong weight control
Avoid weight cycling
Maintain normal growth
Metabolically safe
Minimal hunger
Preserve lean body mass
No psychological problems
IAP
DR GRK DSMCH 50
52. Goals of treatment
In most children these goals can be attained by just
maintaining weight, rather than weight loss
Weight loss should be slow (1 lb or 0.5 kg or less/wk)
It should be attempted only in skeletally mature
children or in those with serious complications from
obesity.
An initial goal -10% reduction in weight
Once achieved, the new weight should be maintained
for 6 mo before further weight loss is attempted.
DR GRK DSMCH 52
53. Goals of treatment
Most successful approach to weight
maintenance or weight loss requires
substantial lifestyle changes that include
increased physical activity and
altered eating habits
DR GRK DSMCH 53
55. Dietary Management
Recommending healthy eating - should be
age specific and flexible enough
The parents should be educated about
approaches to deal with food refusals
Often more than 10 repeated exposures are
required to a new food before a child will
regularly accept it as part of the regular diet.
DR GRK DSMCH 55
56. Dietary Management
Simple measures:
For older than 2 yrs: Changing to skim milk,
exposure to a wide variety of less calorie-dense
foods and limitation of between-meal snacking.
Sweetened beverages should be limited and
parents should continue to offer healthy foods
DR GRK DSMCH 56
57. Dietary Management
Encouraging breakfast, decreasing
sweetened beverages, and teaching the
principles of balanced nutrition (eating
from all food groups) are useful strategies for
school going and overweight adolescent.
DR GRK DSMCH 57
58. Dietary Management
Diet must provide all essential nutrients
Calculate caloric intake on the principle that
O.5 Kg of wt loss = 3500 kcal deficit
Replace fat with complex carbohydrates
(Low glycemic Index)
Increase fiber (intake = age + 5-10 gm/day)
DR GRK DSMCH 58
59. Dietary Management
Special Diets:
1. Balanced Hypocaloric diet
- Provide 30-40% less than usual intake with
lower fat (25-30%),
more (50-55%) complex carbohydrate, and
sufficient protein (20-25%)
- ensures normal growth with weight loss of
upto 0.5 kg/week
DR GRK DSMCH 59
60. Dietary Management
Special Diets: for severe obesity
2. Restrictive protein sparing modified fast diet
(ELCD)
- Provides only 600-800 kcal/day (1.5-2 g/kg
protein, 2 L water, 2-4 cup low starch veg
- Achieves faster weight loss
- More side effects like orthostatic hypotension,
arrhythmias, hair loss etc.
DR GRK DSMCH 60
62. Dietary Management
Needs a multidisciplinary approach:
identify problem areas in a child's and family's regular
diet
teach them about healthier alternatives and eating
patterns
Traffic light or stoplight diet:
successful approach used in preschool and
preadolescent children.
limit calories
achieve good nutrient balance and
easily adaptable to fit particular ethnicities and
nutrition plans DR GRK DSMCH 62
64. Exercise
Decreasing sedentary activity is essential for achieving
weight
control.
Increased activity not only increases calorie use but also
appears to decrease appetite.
Children younger than 2 yrs,
avoiding television and computers
Children 2–18 yr of age
should have <2 hr/day of “screen time” (television, video
games, computer), and televisions should be removed from
children's bedrooms
DR GRK DSMCH 64
65. Exercise
Preserves lean body mass
Prevents the reduction in BMR associated
with weight loss
Improvement in mood
Promotes a more active lifestyle in
adulthood
DR GRK DSMCH 65
66. Exercise – Contd..
Long term compliance poor with vigorous exercise
Better option to decrease inactivity
- Less time on computer/ TV
- Using stairs in place of elevators
- Walking to perform daily errands
- Playing outdoor games
In the severely overweight, problems of exercise
tolerance, referral to an experienced physical or
exercise therapist for a safe and graded exercise
regimen
DR GRK DSMCH 66
67. Behavior Modification
Psychologists screen families for underlying
problems that led to
child's overweight,
problems arising from health complications of
overweight, and
barriers to successful adaptation of a healthier
lifestyle.
Once problems are identified, psychologists and
counselors can use cognitive behavioral and family
therapy to address such issues.
The treatment models used was family-based
behavioral treatment, which is the only approach
shown to have long-term efficacy.
DR GRK DSMCH 67
68. Behavior Modification
Techniques
Changes in the home and family environment
Nutrition education
Self monitoring
Goal setting
Stimulus control procedures
Contracting
Parenting skills training
Positive reinforcement,,
DR GRK DSMCH 68
71. Bariatric Surgery
Surgery to be considered only in children
with a
BMI > 40 and
a medical complication of obesity after they
have failed 6 mo of a multidisciplinary weight
management program.
American Pediatric Surgical Association Guidelines
Monitoring for nutritional complications is
mandatory Deficiencies of iron, vitamin B12,
folate, thiamine, vitamin D, and calcium have
been reported
DR GRK DSMCH 71
72. Bariatric Surgery
Timing of surgical Treatment
Sexual maturation –Tanner 3 or 4
Skeletal maturation – Age 13 – 14 girls, 15-16 boys or
has attained mid parental height.
Congenital maturation – acquired formal operations
– thinking about possibilities consequences
Contradictions:
Substance abuse
Psychiatric disabilities include severe eating
disorders
Inability or unwillingness to follow medical or
nutritional recommendations
DR GRK DSMCH 72
74. Complications of Treatment
Gall bladder disease in cases of rapid weight
loss
Slowing of linear body growth
Loss of lean body mass
Eating disorders
Emotional and psychological problems
DR GRK DSMCH 74
75. Prevention of Obesity
Treating difficult so prevention better
Parents taught to respect the child’s appetite
Food not to be used for comfort or reward
Avoid sugared foods and encourage fiber
intake
Restrict sedentary activities like TV viewing
Promote healthy lifestyle by acting as role
models
DR GRK DSMCH 75
