Obesity in paediatrics

Presenter: Dr Preetham
Moderator: Dr Narayanappa

The Myth

“You are talking of obesity,
while malnutrition is
everywhere”

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 BCE
Water, Breast Milk

200000 BCE
200000 BCE

Homo Sapiens
Beginning

100000 BCE

10000 BCE
of Time

0

BCE
AD

Obesity is a major paediatric public health
problem across the world, associated with risk
of complications in childhood and increased
morbidity and mortality throughout adult life.

Fat
Stores

↑ 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Misra et al., Unpublished data, 2008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 with
chronic 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 an
additional 35% of adults are overweight. In
children, the prevalence of obesity increased
300% over approximately 40 years.

Worldwide obesity has more than doubled since
1980.
In 2008, more than 1.4 billion adults, 20 and
older, were overweight. Of these over 200
million men and nearly 300 million women were
obese.
65% of the world's population live in countries
where overweight and obesity kills more people
than underweight.
More than 42 million children under the age of
five were overweight in 2010. Close to 35 million
of these are living in developing countries.
Obesity is preventable.

Childhood obesity, if not addressed, can lead to
lifetime health consequences and contribute to
adulthood obesity.
A study found that 80% of obese children aged
10-15 became obese adults (CDC, 2010).
Untreated childhood obesity can lead to
cardiovascular problems, as well as high blood
pressure, high cholesterol, and Type 2
diabetes (CDC, 2010).
At least 2.6 million people each year die as a
result 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 Prevalence
Global 2004 10
USA/UK 2000 20
Australia 1995 20
India/Chennai 2002 22
India/Delhi 2004 16
India/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 with
international norms are not feasible.

obesity

overweight

underweight
Normal BMI

Conclusions: Contemporary cross-sectional age and sex specific BMI cut-offs for
Indian children linked to Asian cutoffs of 23 and 28 kg/m2 for the assessment of
risk of overweight and obesity, respectively are presented.

KHADILKAR, et al.

The National Health and Nutrition
Examination Survey (NHANES) IV, 1999-
2002, found 31% of children older than 2 yr to
be overweight or obese, and 16% of children
and adolescents 6-19 years were in the obese
range.
Children's risk varies by socioeconomic
status, race, maternal education level, and
gender
Across all racial groups, higher maternal
education confers protection against
childhood obesity.

A study conducted in mysore in 2009 shows
the prevalence of obesity and overweight
were 3.4%, 8.5% respectively. The prevalence
of obesity was maximum in the age group of
5-7 years and in those from private schools.

A study conducted in 2011 representing
upper, middle and lower socioeconomic
groups and the children aged 6-15 years of
age were interviewed. The prevalence of
obesity was 3.0% for boys and 5.3% for girls.
The prevalence of obesity (7.5%) and
overweight (21.9%) were highest among high
income group and lowest (1.5% and 2.5%)
among low income group.

Environmental changes
Genetic changes
Endocrine and neurological changes

Environmental changes
• Foods are increasingly
prepared by a “food
industry,” with high levels of
calories, simple
carbohydrates, and fat.
•The increased consumption
of high-carbohydrate
beverages, including sodas,
sport drinks, fruit punch, and
juice
•The dramatic increase in the
use of high-fructose corn
syrup to sweeten beverages

levels of physical activity in
children and adults have
declined 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 time
watching television, and a generally faster
pace of life has lead to decreased sleep which
increases risk for weight gain and obesity.

Rare single-gene disorders resulting in
human 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 syndrome
Cohen syndrome
Prader-Willi Syndrome
Pro-opiomelanocortin deficiency
Turner syndrome
Leptin or leptin receptor gene deficiency
Carpenter syndrome

Cushings syndrome
Growth hormone deficiency
Hyperinsulinism
Hypothyroidism

Complications of paediatric obesity occur during
childhood and adolescence and persist into
adulthood
More immediate co morbidities include type 2
diabetes, hypertension, hyperlipidemia, and non
alcoholic fatty liver disease
Insulin resistance increases with increasing
adiposity and independently affects lipid
metabolism and cardiovascular health.
Non alcoholic fatty liver disease occurs in 10-25%
of obese adolescents and can progress to
cirrhosis.

Conditions:
Metabolic syndrome
Polycystic ovary syndrome
Gallbladder disease
Blount disease (tibia varus)
Behavioural complications
Obstructive sleep apnea
Dyslipidemia
Type 2 diabetes mellitus

Overweight and obese children are often
identified as part of routine medical care, and
the child and family may be unaware that the
child has increased adiposity.
obesity intervention requires a chronic
disease management approach

Body Mass Index (BMI)
Waist Circumference
Waist-to-Hip Ratio
Skinfold Thickness
Bioelectric Impedance (BIA)

Underwater Weighing (Densitometry)
Air-Displacement Plethysmography
Dilution Method (Hydrometry)
Dual Energy X-ray Absorptiometry (DEXA)
Computerized Tomography (CT) and
Magnetic Resonance Imaging (MRI)

Consideration of possible medical causes of
obesity is essential, as endocrine and genetic
causes are rare.
Growth hormone deficiency, hypothyroidism,
and Cushing syndrome are examples of
endocrine disorders that can lead to obesity. In
general, these disorders manifest with slow
linear growth.
Polyuria and polydipsia may be noted if the
adolescent with obesity develops overt
diabetes.

Children who consume excessive amounts of
calories tend to experience accelerated linear
growth.
Genetic disorders associated with obesity can
have coexisting dysmorphic features, cognitive
impairment, vision and hearing abnormalities,
or short stature.
Children with congenital disorders such as
myelodysplasia or muscular dystrophy, lower
levels of physical activity can lead to secondary
obesity

A history of damage to the central nervous
system (CNS) (eg, infection, trauma,
hemorrhage, radiation therapy, seizures)
suggests hypothalamic obesity with or without
pituitary growth hormone deficiency or pituitary
hypothyroidism. A history of morning
headaches, vomiting, visual disturbances, and
excessive urination or drinking also suggests that
the obesity may be caused by a tumor or mass in
the hypothalamus.

The appearance of signs of sexual development at
an early age suggests that the weight gain is
caused by precocious puberty . However,
excessive facial hair, acne, and irregular periods in
a teenage girl suggest that the weight gain may
be caused by cortisol excess or polycystic ovary
syndrome (PCOS).
Hip or knee pain can be caused by secondary
orthopedic problems, including Blount disease
and slipped capital femoral epiphysis
Acanthosis nigricans can suggest insulin
resistance and type 2 diabetes

The objective of interventions in overweight
and obese children and adolescents is the
prevention or amelioration of obesity-related
co-morbidities
e.g. glucose intolerance and T2DM, metabolic
syndrome, dyslipidemia, and hypertension.

Complications of Obesity
Pulmonary disease Idiopathic intracranial
abnormal function hypertension
obstructive sleep apnea Stroke
hypoventilation syndrome
Cataract
Nonalcoholic fatty liver Coronary heart disease
disease
Diabetes
steatosis
Dyslipidemia
steatohepatitis
cirrhosis Hypertension

Gall bladder disease Severe pancreatitis

Gynecologic abnormalities Cancer
abnormal menses breast, uterus, cervix
infertility colon, esophagus, pancreas
polycystic ovarian syndrome kidney, prostate
Osteoarthritis
Phlebitis
Skin venous stasis
Gout

Diabetes Respiratory
Hypertension
Problems

Depression Gall Bladder
disease
Obesity
and
Heart Diseases Cancer
Health
risks

Osteoarthritis Infertility

Optical
disorders Renal Disease
Stroke

Office visit model

Symptoms Diagnosis Treatment
and signs

Headaches with Migraines Medication
nausea

Soda, fast food, school Education,
Obesity motivation,
food, video games,
poverty, unsafe parenting skills,
neighbor-hood, single social work, screen
mother, poor and address
parenting, 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 “fast
food,” and calorie-dense snacks)
Increasing the intake of dietary fiber, fruits, and
vegetables.
Eating timely, regular meals, particularly
breakfast, 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 physical
activity for at least 60 minutes per day.

Educate parents about
the need for healthy
rearing patterns related
to 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 combination
with lifestyle modification) be
considered if a formal program of
intensive lifestyle modification has
failed to limit weight gain or to
mollify comorbidities in obese
children.
Overweight children should not be
treated with pharmaco
therapeutic agents unless
significant, severe co-morbidities
persist despite intensive lifestyle
modification.

Bariatric surgery be considered only under the
following 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 a
formal program of lifestyle modification, with or
without a trial of pharmacotherapy
There is access to an experienced surgeon in a
medical center employing a team capable of long
term follow-up of the metabolic and psychosocial
needs of the patient and family
The patient demonstrates the ability to adhere to
the 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.

Mixed procedures
Gastric bypass surgery:
▪ MC- Roux-en-Y gastric bypass

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 children's 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 of
South 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 diabetes
and obesity among children and adults
and to thus act as change agents for better
lifestyles and prevention of diabetes

& 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
March 5, 2011

Participating Teams

Across
50 cities
in India

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 of
obesity 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

“CHETNA”
Children’s Health Education Through
Nutrition and Health Awareness Program

A Project of
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

Study
School-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, anthropometric
measurements, 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 Design

1. Intensive intervention vs. usual intervention
2. 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 School

Sweetened carbonated drinks > 3 times/w 15.4% 7.9%
Western ‘energy-dense’ foods (Burgers, 9.2% 1.4%
pizzas, french fries, noodles) > 3 times/w

Chips/ Namkeen/Maggi > 3 times/w 8.3% No change
Indian ‘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


% 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/d

All differences are statistically significant


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 Control
P< 0.05 in Control SAD
P< 0.001 in Case biceps

% Change in Metabolic Parameters

Variable Case School Control School
Fasting Glucose -4.9%* -2.2%
HDL-C 2.2% -2.3%

*p < 0.001


% 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 arteries
starts 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 little
time 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 to
educate children. Healthy snacks are not
prepared at home. Many parents and teachers
are obese themselves! No cohesive intervention
program 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

THANK YOU FOR PATIENT HEARING ☺

Obesity in paediatrics

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