Obesity in Children

Dr. Bedangshu SaikiaRegistrar, Pediatrics and Neonatology

St Stephens Hospital, New Delhi

Obesity

is a condition of abnormal or excessive fat

accumulation in adipose tissue to the extent that

health may be impaired

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

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)

International Scenario

Pathogenesis

Thrifty genotypeSedantary lifestyleGood high calorie food

Measurement of obesityFat cannot be measured.

The best way to measure obesity is Body Mass Index in

adults

Measurement of obesityBut in children age and gender reference charts of BMI

are availableBMI > 85th percentile – OverweightBMI > 95th percentile (+2SD) – ObeseIn children < 2 Years wt. for length charts are usedOther methods to measure obesity:

Skin fold thicknessWaist hip ratio (more in adults)Waist circumference (more in adults)

Some imaging studies (DEXA, USG, CT scan, MRI, Bioelectrical impedance)

Do obese children grow into obese adults?

‘Tracking’ occurs throughout life

10-20% obese infants

40% obese children

60-80% obese adolescents

“Adiposity rebound”

Obese Adults

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

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

Endogenous causes

Endocrinal causes1. Cushing’s syndrome2. Hypothyroidism3. Hyperinsulinism4. Pseudo-

hyperparathyroidism5. Acquired

hypothalamic syndrome

Genetic Causes1. Prader Willi syndrome2. Alstrom3. Carpenter4. Cohen5. Laurence Moon Biedl

Diseases Associated with Childhood Obesity (Endogenous obesity)

Exo – versus Endogenous CausesEndogenous Obesity1. Family history

uncommon2. Short height3. Low IQ4. Retarded bone age5. Physical defects

common

Exogenous Obesity1. Family history of

obesity2. Tall child3. Normal IQ4. Normal bone age5. Normal physical exam

Causes of Exogenous Obesity

Genetic

Environmental

Dietary

Neurochemical

Malnutrition

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

Genes for obesity

Ob GeneProduct – leptinReduces appetite, increases metabolic rate, increases fat oxidationMutation results in decreased leptin output leading to obesity

Genes of Obesity – Contd..

db Gene Regulates leptin binding siteEstablishes ‘set point’Fat GeneProduces carboxypeptidasesCauses miss processing of insulin – competes with

leptin binding

Genes of Obesity - Contd..

tub GeneUnknown product – possibly mitochondrial

uncoupling proteinAgouti GeneProduct – agouti signaling proteinSuppresses appetite during weight gain

Pathway through which leptin acts to regulate appetite and body weight

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)

Environmental factors

Vigorous feeding

Sedentary lifestyle

TV viewing

- lowers the metabolic rate

- increased caloric intake during viewing

- Food advertisements and messages

Dietary Factors

Reduced meal frequency and ‘gorging’ promotes

weight gain, in contrast to ‘nibbling’

High calorie dense foods

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

Control of appetite

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

Complications of Obesity

Medical

Orthopedic

Dermatologic

Psychosocial

Endocrinologic

Medical Complications

Hypertension

Hyperlipidemias

Coronary heart disease

Cholelithiasis and steatohepatitis

Respiratory infections

Obesity hypoventilation syndrome

Obstructive sleep apnea

Orthopedic ComplicationsIN CHILDREN

Slipped femoral epiphysis

Legg-Calves-Perthes’ Disease

Genu valgum

IN ADOLESCENT

Blount disease (slipped tibia vara)

Slipped femoral epiphysis

Dermatologic Complications

Heat rash

Intertrigo

Monilial dermatitis

Striae

Acanthosis nigricans

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

Endocrinologic Complications

Hyperinsulinemia with insulin resistance

- Overt diabetes

- Stimulates lipogenesis and maintains obesity

- Hyperplasia and hypertrophy of fat cells

Endocrinologic Complications

Decreased SHBG (Sex hormones binding globulin)

↓ Increase free sex hormones

↓Early puberty and advanced skeletal age

Endocrinologic Complications

Increased urinary clearance of cortisol

↓Compensatory increase in ACTH

↓Increased adrenal sex steroids

↓Early adrenarche

Office evaluation of an obese childObjective :differentiate between Organic causes and Idiopathic

obesity and early detection of complications

History

Physical Examination

Laboratory Studies

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

History

Family history of CHD, cancer, diabetes,

hypertension, hyperlipidemia and thyroid disorders

History of complications

Psychosocial history and evaluation

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

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)

Simplified Laboratory Norms for Assessing Overweight Children

Comorbidity H & PE Testing

Management of Obesity

Goals of treatment

Dietary management

Exercise

Behaviour modification

Other treatments

Complications of treatment

Management of Obesity

Successful treatment of obesity is challenging

Treatment goals vary- depending on

the age of the child and

the severity of complications

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

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.

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

Proposed Algorithm for Weight Management

2-7 Yrs > 7 Yrs

BMI85-94 %ile

BMI> 95%ile

BMI85-94 %ile

BMI> 95%ile

Weightmaintenance

Complication

No Yes

Weight loss

Complication

No

Weightmaintenance

Yes

Weight loss

Multidisciplinary and community based management 1

Severely overweight children and adolescents with complications from

obesity are best managed by a multidisciplinary team.

Teams may include a physician, a psychologist, a dietitian, an exercise

specialist (physical therapist, exercise physiologist, educator), a nurse,

and counselors.

Management consists of dietary counseling, exercise therapy, and

behavioral management.

The treatment models used in most pediatric centers feature family-

based behavioral treatment, which is the only approach shown to have

long-term efficacy.

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.

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

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.

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)

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

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.

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

Dietary Management

ExerciseDecreasing 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

Exercise

Preserves lean body mass

Prevents the reduction in BMR associated with

weight loss

Improvement in mood

Promotes a more active lifestyle in adulthood

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

Behavior ModificationPsychologists 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.

Behavior ModificationTechniques

Changes in the home and family environment

Nutrition education

Self monitoring

Goal setting

Stimulus control procedures

Contracting

Parenting skills training

Positive reinforcement,,

Other Treatments

Anti-obesity drugs

Surgery

Leptin therapy

Medication of overweight children and adolescents is reserved for those with severe medical complications.

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

Bariatric Surgery Timing of surgical TreatmentSexual 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

LAGB

BPD

BPDDS

RYGB

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

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

Multidisciplinary and community based management 2

Community-based programs to inform families

regarding age-appropriate healthy

eating choices,

meal and portion size planning,

decreasing “screen time,” and

approaches to increasing physical activity provide an

important service for families with children at risk for

becoming overweight or mildly to moderately

overweight without comorbidities

Proposed Suggestions for the Prevention of Obesity

Proposed Suggestions for the Prevention of Obesity

Thank you