obesity in paediatrics
DESCRIPTION
TRANSCRIPT
Presenter: Dr Preetham
Moderator: Dr Narayanappa
The Myth
“You are talking of obesity,
while malnutrition is
everywhere”
Reality: The Double Jeopardy
Remarkably Short History for Caloric Beverages:
Might the Absence of Compensation Relate to This Historical Evolution?
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Earliest possible date
Definite date
Water, Breast Milk2000 BCE
Milk (9000 BCE)
Beer (4000 BCE)
Wine (5400 BCE)Wine, Beer, Juice
(8000 BCE)
(206 AD)Tea (500 BCE)
Brandy Distilled (1000-1500)
Coffee (1300-1500)
Lemonade (1500-1600)
Liquor (1700-1800)
Carbonation (1760-70)
Pasteurization (1860-64)
Coca Cola (1886)
US Milk Intake 45 gal/capita(1945)
Juice Concentrates (1945)
US Coffee Intake 46 gal/capita (1946)
US Soda Intake 52/gal/capita (2004)
� 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.
FatStores
↑ 2% = 2.3 kg ina 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
weekMisra et al., Unpublished data, 2008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
AgeGender
(yrs)
Male
Female
Male
Female
Male
Female
Male
Female
Public Schools
Overweight
% (N=2593)
29.7
39.6
23.3
39.0
28.0
20.8
27.0
21.6
Age wise
prevalence in
Public Schools
GovernmentSchools
Overweight
% (N= 955)
12.9
12.4
11.8
11.0
7.8
9.4
9.4
13.8
11.1
Age wise
prevalence in
GovernmentSchools
12.714 32.6
15 29.9 11.5
16 25.1 8.4
17 25.3
29.0
11.0
Total%(N = 3548)
OVERALL PREVALENCE = 24.2%
Misra et al. Ann Nutr Metab.2011
Country/City
Global
USA/UK
Australia
India/Chennai
India/Delhi
India/Delhi
Year
2004
2000
1995
2002
2004
2006
Prevalence
10
20
20
22
16
29
Misra et al., 2006
What is cut off value for
OBESITY?
95th centile
Girls
Author Range Year
Vedavati 22-27 kg/m2 1998
Agarwal 23-27 kg/ m2 1988-1994
Cole 24-29 kg/m2 1963-1993
95th centile
Boys
Khadilkar 24-27 kg/m2 2004
Agarwal 22-27 kg/m2 1988-1994
Cole 23-28 kg/m2 1963-1993
� BMI values show wide variations between regions, and the period of the studies.
� Pune study, age 10-13 years, BMI of boys have been even higher than the international values.
� Delhi Agarwal’schart for the 85th and 95th centileshow lower BMI 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
Normal BMI
underweight
KHADILKAR, et al.
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.
�
�
� 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 ObesityPulmonary disease
abnormal function
obstructive sleep apnea
hypoventilation syndrome
Nonalcoholic fatty liver
disease
steatosis
steatohepatitis
cirrhosis
Gall bladder disease
Gynecologic abnormalities
abnormal menses
infertilitypolycystic ovarian syndrome
Osteoarthritis
Skin
Gout
Idiopathic intracranial
hypertension
Stroke
Cataract
Coronary heart disease
Diabetes
Dyslipidemia
Hypertension
Severe pancreatitis
Cancerbreast, uterus, cervix
colon, esophagus, pancreas
kidney, prostate
Phlebitis
venous stasis
Hypertension
Depression
Heart Diseases
Diabetes RespiratoryProblems
Gall Bladderdisease
Cancer
Obesity
and
Healthrisks
Osteoarthritis
Opticaldisorders
Infertility
Renal DiseaseStroke
Office visit model
Symptoms
and signsDiagnosis Treatment
Headaches with
nauseaMigraines Medication
Soda, fast food, school
food, video games,
poverty, unsafe
neighbor-hood, single
mother, poor
parenting, depression
ObesityEducation,
motivation,
parenting skills,
social work, screen
and address
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 pharmacotherapeutic 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/m2 or has BMI
above 35 kg/m2 and significant, severe co morbidities.
� 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 adultsand to thus act as change agents for better
lifestyles and prevention of diabetes
Initiative of National Diabetes, Obesity, and Cholesterol Diseases Foundation
& Emcure Pharmaceutical (India) Pvt. LtdMarch 5, 2011
Objectives
Specific Objectives
• To enhance awareness among school children, andadults 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 November14, 2011 – World Diabetes Day
• Distribution of printed education material to children andadults
• Message dissemination through media
Initiative of National Diabetes, Obesity, and Cholesterol Diseases Foundation
& Emcure Pharmaceutical (India) Pvt. LtdMarch 5, 2011
Participating Teams
Across
50 citiesin India
Initiative of National Diabetes, Obesity, and Cholesterol Diseases Foundation
& Emcure Pharmaceutical (India) Pvt. LtdMarch 5, 2011
Initiatives being implemented in
various cities of India
New DelhiMumbai
JaipurAgra
Chandigarh
VadodaraNoida
DehradunAllahabad
BangalorePantnagar
Pune
LucknowBhubaneshwar
“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.
2.
changing the individual
(children, family, teachers)
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
Diabetes Foundation (India)
“CHETNA”Children’s Health Education Through
Nutrition and Health Awareness Program
A Project of
Diabetes Foundation (India)
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
Poster Making Competition
Poster Making Competition
Cooking Competition
Skit Competition
Extempore Competition
Quiz Competition
StudySchool-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
Intervention Trial (6 months):
Case Control Design
1. Intensive intervention vs. usual intervention
2. Improvements in the following aspects:a.
b.
c.
d.
e.
f.
g.
Knowledge levels
Dietary habits
Anthropometric measurements
Body fat composition
Glycemic indicators
Insulin levels, CRP levels
Lipid profile
Key Activities:
Phase 2:Interventions
Weekly individual counseling of children
LecturesActivities: Skits, quiz competition, extempore, focused groupdiscussions
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 morningassembly on important days like the World Food Day
Quiz competition in class
Paragraph writing on topics like: Ways in which you canprevent yourself from diabetes and heart disease in the next 5-8years, healthy alternatives to junk food, planning a day’s diet forthemselves, planning their own tiffins for a week
Checking tiffins of younger classes in their school by theintervention group
% Decrease in Consumption Patterns of ‘Energy-Dense Foods”
Consumption of Food Articles
Sweetened carbonated drinks > 3 times/w
Western ‘energy-dense’ foods (Burgers,
pizzas, french fries, noodles) > 3 times/w
Chips/ Namkeen/Maggi > 3 times/w
Indian ‘energy-dense’ food > 3 times/w
All differences are statistically significant
Case School
15.4%
9.2%
8.3%
6.3%
Control School
7.9%
1.4%
No change
2.2%
Singhal N, Misra A, Shah P, Gulati S. Eur J Clin Nutr, in press
Consumption of Fruits (brought in Tiffin)
Case School
Baseline
Follow-up
*Statistically significant
Control School
29.8%
25.9%
10.1%
40.4%*
Singhal N, Misra A, Shah P, Gulati S. Eur J Clin Nutr, in press
% Change in Time Spent in TV Viewing
and Physical Activity
Variables
TV Viewing > 2 h/d
Physical Activity
30-60 min/d
All differences are statistically significant
Singhal N, Misra A, Shah P, Gulati S. Eur J Clin Nutr, in press
Case
School
5.2%
9.8 %
Control
School
2.4%
3.7%
Pre- and Post Surveys Show significant Increase in Knowledge
80
70
60
50
40
30
20
10
0
Healthy
living
Junk
food
Obesity Diet and
DM
Knowledge, Attitude and Practice about
Nutrition, Obesity and Diabetes:
Pre
Post
Shah P, Misra A et al., Br J Nutr 2010
% Change in Anthropometric Parameters
4%
2%
0%
-2%
-4%
-6%
-8%
-10%
-12%
-14%
WC Mid -thigh SAD Triceps Biceps
P< 0.05 in Control SAD
P< 0.001 in Case biceps
Case Control
Singhal N, Misra A, Shah P, Gulati S. Eur J Clin Nutr, in press
% Change in Metabolic Parameters
Variable
Fasting Glucose
HDL-C
*p < 0.001
Case School
-4.9%*
2.2%
Control School
-2.2%
-2.3%
Singhal N, Misra A, Shah P, Gulati S. Eur J Clin Nutr, in press
% Change in Fasting Serum Insulin and CRP
13
47
6.2
CONT.INT. CONT.
-21.6
Insulin
Misra et al., Unpublished data
Hs-CRP
Summary
• Rising childhood obesity in urban India and inother Developing Countries is of great concern,and would fuel the diabetes and the metabolicsyndrome epidemics further.
• Overall, it is more in urban areas (vs. rural), andpublic schools.
• Its consequences, insulin resistance, PCOS,hirsutism, type 2 diabetes, subclinicalinflammation and hepatic steatosis are nowfrequently seen in children .
• Countrywide programs, akin to our program“MARG” in schoolchildren are urgently needed.
The Myths
“What will happen if a child isfat. He/she will not have any
diseases”
Reality:
• Diabetes may strike early
• Polycystic ovaries, excess facial hair andinfertility may occur in girls
The Myths
“Heart Disease startsat old age”
Reality:
Hardening and blockage of the arteriesstarts at 11 years in boys and 15 years
in girls
The Myths
“A fat child isotherwise healthy”
Reality:
28% of urban children have syndrome X, onestep away from diabetes and 2 steps away
from heart disease
The Myths
“A child does notdevelop high bloodpressure or high
cholesterol”
Reality:
Many children will have high blood pressure andlow good cholesterol
The Myths
“A child should enjoy,and eat and relax. Suchtime will not come again
later”
Reality:
Parents do not realize, but children are eatingjunk food all the time.
The Myths
“All children are doingrequired physical
activity”
Reality:
Time on TV, internet and studies leaves littletime 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 toeducate children. Healthy snacks are notprepared at home. Many parents and teachersare obese themselves! No cohesive interventionprogram in India
The Myths
“So what if there aremetabolic abnormalitiesor diseases, these can
be easily treated”
Reality:
Most of these diseases are catastrophicand have complications that cannot bereversed. Most will shorten lifespan
THANK YOU FOR PATIENT HEARING ☺