CHILDHOOD OBESITY

PEDIATRIC NUTRITION

Shweta kM.Sc. DIETETICS-II

Prevalence

The prevalence of overweight in children & adolescents in US has been increasing since the 1980s. Current estimates in children are 10.4% in 2 to 5 year-olds, 15.3% in 6 to 11 year olds, & 15.5% in 12 to 19 year olds.

Although the prevalence of obesity did not differ among racial/ethnic groups in the NHANES III survey of 1988-1994, in the NHANES 1999-2000 survey the prevalence of overweight was higher in non Hispanic black, & Mexican-American children & adolescents than in white children and adolescents.

Populations of children & adults with developmental disabilities such as myelomeningocele, Preder-Willi syndrome, & Down syndrome have been reported to have a higher prevalence of overweight than those in the general population.

Studies from Indian schools show a prevalence of 7.5%-10%. Overweight children tend to remain overweight during follow up periods of up to 20 years. They have increased risk for being overweight as adults & obesity related complications such as HTN, diabetes & CAD.

Definition

The child is considered obese when there is excess accumulation of fat in the subcutaneous tissue and other parts of the body.

Use of BMI for monitoring weight in a child requires a set of age & gender-dependent reference graphs.

‘overweight’ : BMI exceeds the 85th percentile for that age & sex.

‘obesity’: BMI exceeds 95th percentile for that age & sex.

• Median BMI values (kg/m2)Birth : 131 year : 176 years : 15.520 years : 20

Elevations of BMI correlate with BP, serum lipid levels, & has significant predictive value for adult obesity related morbidity & mortality.

Skin fold thickness: no reference standards, lot of inter-observer variation

W:H ratio : cut off > 0.9

Causes of Obesity

1. Exogenous causes 2. Endogenous causes

Exogenous causes 1) Dietary factors:

Not only on the total caloric intake but also on the frequency & the type of foodstuff consumed. Large infrequent meals rather than small frequent meals Switchover of diet to high calorie density junk foods.

2. Habits: The appetite may be increased due to

psychogenic causes such as parent child maladjustment & constant testing by peers.

Overeating becomes a behavior pattern. TV viewing has been an important culprit

responsible for the current epidemic of obesity. Studies showed a relation between the number of hours spent on viewing television & the development of obesity.

3. Decreased energy expenditure:Some investigators have shown that caloric intakes in overweight & normal adults are comparable leading to the hypothesis that the obese children actually have a ‘efficient’ metabolism. The tendency for decreased REE, which may be genetically determined, could be a contributing cause in such cases.

4. Genetic Factors:Parenteral obesity; the risk increasing when both parents are obese. Research is being done to identify human obesity genes. One such gene is ‘ob’ gene which codes for a protein called leptin which affects the appetite set point & also affect the metabolic rate.

Medical Causes of Obesity

Genetic SyndromesPreder-Willi syndromeRare congenital syndromesEndocrine DisordersHypothyroidismInsulin resistanceCushing’s syndrome

Medical Complications of ObesityAcuteSleep apnea with Pickwickian syndromeSlipped capital femoral epiplysisBlount’s diseaseGlucose intoleranceHypertension (also long term)

ChronicHyperlipidemiaHypercholesterolemiaHypertensionDiabetes

Management

Diet : reduced caloric intake Increased activity levelsBehavioral changesFamily involvementDrugsSurgery

Principles

a) To achieve healthy eating and activity pattern rather than IBW.

b) Weight maintenance vital as compared to weight loss, so that child grows into his weight. Sustained long term efforts needed.

c) Do not criticize, but empathise

Assessment and Diagnosis

Assessment: important in the treatment of childhood obesity. Persistence of the condition is based on a wide variety of factors, including age, sex, & family history of obesity, developmental stage, ethnicity, & social environment. Each of these factors will influence the treatment, & the course of therapy. Obesity is a complex disease &, even with excellent adherence to treatment recommendations, progress may be slow. Because of the extended time that children may need to be in treatment, the assessment must include a careful review of family lifestyle patterns & the child’s social environment.

Physical AssessmentEach overweight child should be given a complete physical

examination by a pediatrician or a pediatric nurse practitioner. The physical should begin with the child’s neonatal & birth history, with a view toward the possibility of an undiagnosed developmental disability. The child’s rate & pattern of weight gain should be carefully assessed.

A rapid & excessive weight gain in recent months may be due to a lifestyle change or an emotional reaction to a significant event. If the events paralleling the weight gain have not been weight control is initiated, to prevent failure in a weight control program.

Social AssessmentPsychological factors influence the etiology & maintenance of

obesity. A detailed social assessment, including a family interview at the onset of treatment, should be a key component of any weight control program designed for children. The purpose of the family interview is to gather as much information as possible about daily life in the family and to explore attitudes and beliefs about obesity and obesity treatment.

Sample Questions for Family Interview

Who prepares food in the family? Who shops, organizes meals? Are special foods prepared on holidays, at family events? How often does the family eat together? What does the family do for recreation? Who else in the family has a weight problem? Do parents feel that the obese child has a weight problem

or that he or she will “grow out of it”? How much weight should the child lose? What if the child doesn’t lose weight? Have there been previous attempts to lose weight? Who makes the rules about child behavior in the family? Who enforces them? What caused the child to become obese? Is there obesity elsewhere in your family (other relatives)? How close do you live to grandparents and other relatives? Who is the most independent member of your family? Who is the most dependent member of your family?

InterventionsRole of Schools: The schools should formulate & adhere to physical-

education & activity requirements & standards. Schools should facilitate changes to increase physical

activity & parent teacher associations can help to educate parents as to the dangers of childhood obesity.

Introduction of ‘nutrition & physical education’ in the school curriculum with these activities should become compulsory and /or a ‘scoring subject’ with marks to be added to total grades.

The parents/students are then likely to give the required attention & time to these activities in this competitive world of academics.

Role of Family: Everyone should be involved in planning meals, buying food

& coming up with ways to be active together.

Families should also make physical activity a family priority & establish rules or guidelines that encourage activity & limit leisure time in front of the TV or computer.

If you exercise and eat healthy, your child shall follow suit.

Role of Government authorities: Programs having a bearing on the diet lifestyle of children

should be devised. Regulate fast food advertisements aimed at children insist

on food labeling. Departments can influence the food industry to reduce the

levels of fat and sugar in foods targeted at children; & parent teacher associations can help to educate parents as to the dangers of childhood obesity.

Schools encourage a responsible approach to marketing of these foods.

Role of Pediatricians and IAP: It is important for us to think of ‘prevention of obesity’ at

all visits & incorporate relevant health education. BMI should be calculated & above 85th percentile should

be advised about lifestyle interventions while children with BMI >95th percentile should be screened for co-morbidities.

Encourage gradual weight control rather than crash dieting. The role of pharmacotherapy is still unclear.

The report on childhood obesity, called for a global strategy to stem the rising number of obese children everywhere.

A global strategy means keeping children active both at school & home, and making sure that foods that are energy-dense be limited.

Prevention of ObesityUniversal approach:

The public health approach to obesity focuses on those elements of the social, cultural, political, physical & structural environment as a whole by

improving the quality of available diet promoting the level of physical activity & adopting healthy

lifestyle increasing the population knowledge regarding childhood

obesity involvement of community; & monitoring & evaluation The issue of obesity should be addressed during every well

child examination. Parents should be counseled to respect the child’s appetite & not attempt to overfeed the child. Food should not be used for non-nutritive purposes like for comfort or reward. Sugared foods should be avoided & healthy diet with ample fiber should be encouraged. Finally parents should restrict the amount of TV viewing & encourage more physical activity, preferably by setting themselves as role models.

At Risk approach:

This approach is directed at high-risk individuals who are at particularly high risk obesity & its consequences. Selective prevention strategies may be initiated through schools, collages & primary care, or through any appropriate setting, which allows access to high-risk groups. The components of this approach are

prevention of weight gain promotion of weight maintenance management of health risks associated with obesity and Promotion of weight loss. For weight maintenance and for preventing at-risk

children from gaining weight, the approach should be geared toward healthier eating and a more active lifestyle. To induce weight loss, a temporary negative energy balance has to be created by either reducing intake or increasing energy expenditure, or both.

Management of associated diseases may require specific attention.

Parenting skill advice: Find reasons to praise the child’s behavior Never use food as a reward Establish daily family meal & snack times Offer only healthy options Remove temptations Be a role model Be consistent Parents/caregivers determine what food is offered & when

child decides whether to eat or not.

Drug therapy There is no ideal weight-reducing drug. To date,

all have had significant side-effects and all have only been useful in long-term weight-managed when used in conjugation with a well-managed behavioral management program. There are few reports of the effect of weight-reducing drug therapy in children or adolescents.

Research priorities relevant to child & adolescent obesity

These include-Regular population monitoring in order to track

trends in the prevalence of overweight & obesity. Improved understanding of the forces promoting

the development of obesity in different communities (e.g. the rise of sedentary pursuits and the changing food culture).

Effective clinical management of overweight and obesity in childhood & adolescence.

Effective population level strategies for the prevention of overweight & obesity.

Physical Activity An increase in the level of physical activity during

treatment is a long term predictor of maintain non obesity. The type of activity employed also appears to be important for sustain weight loss.

Obese children may not enjoy group physical activity, such as school sports, because of there performance not as good as there leaner peers. However, they or there families made to be encouraged to incorporate some opportunities for activities into there day to day life.

WHO recommendations:Prevention of obesity: 30 min moderate exercise + 20 min

vigorous exercise (running)Established obesity: minimum 1 hr per day.

Components of an Exercise ProgramWarm-Up and Cool-Down Exercises Breathing Head Rolls Side bends Hamstring StretchEndurance Exercises Biking Swimming Dancing Stair-Stepping Walking Jogging SkatingStrengthening Exercises Push-ups Sit-ups Bridges Leg lifts Leg ExtensionsFindings time-out for Exercises Pick a time of day Keep a written exercises activity record Plan a substitution for an outdoor activity ahead of time, in case of

inclement weather Keep exercise equipment or clothing in plain view

Conclusion

Childhood Obesity is a public health problem. Although current dietary guidelines provide reasonable recommendations for families to follow, there is the possibility that modifications to these guidelines may occur in the future. The management of the individual with obesity is difficult and resource intensive Public health and government policy interventions are essential for the ultimate control and prevention of obesity in populations.

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