Opinion: Childhood Obesity – One Of The Major Public Health Challenges Of The 21st Century

New Delhi: Globally, the prevalence of child obesity has reached epidemic levels alarmingly both in developed as well as in developing countries.But India has a double nutritional burden of undernutrition and obesity. As per the World Health Organization report, it has been estimated that over 41 million children under five years of age are overweight and almost half of these children live in Asia. UNICEF reports that the number of children aged 5-19 years who are overweight has nearly doubled over the past 15 years.

India has 14.4 million children with obesity and is the home to the 2nd highest number of obese children in the world after China. It is obvious that India is battling a full-blown crisis of obesity which is only anticipated to worsen in the years to come. The fundamental reason for this problem is the energy imbalance between the amount of calories consumed and the calories spent. Today, even amongst children, there is a global shift in the dietary pattern towards increasing intake of energy dense foods that are rich in fat and sugar and low in vitamins, minerals and other useful micronutrients. In addition there is also a trend towards decreased level of physical activity due to increasing sedentary nature of recreation, changing modes of transportation using vehicles and rapid urbanization.

The problem of overweight and obesity in children is likely to continue into adulthood. Infants with excessive weight gain have more adipose cells laid down in their body (hyperplastic obesity) than normal infants. It is a well-established fact that most adipose cells are formed early in life. This leads to hyperplastic obesity in adults which is difficult to treat. The Childhood obesity increases the risk of non-communicable diseases like diabetes, hypertension and coronary artery disease at an younger age. In addition childhood obesity affects the child’s social and emotional well-being and self esteem. Depression and social withdrawal is more often seen in the children.

ASSESSMENT OF CHILDHOOD OBESITY

Although obesity can be made out at the first sight, a precise assessment has to be made with measurements and use of reference standards and charts:

Body weight
Body Mass Index(BMI): Weight (Kg) / Height2 (m)

Broca index:
Height (cm) -100

For example if a person’s height is 160 cm his ideal weight is 160 -100= 60 Kg

Skin fold thickness: A large proportion of body fat is located under the skin and is most accessible for measurement. The Harpenden skin calipers are used to measure body fat at the mid triceps level. The main drawback of skin fold thickness measurement has poor reproducibility.

Waist circumference: This is measured at the midpoint between the lower costal margin and the iliac crest, It is an indicator of intra abdominal fat mass which indicates an increased risk for metabolic syndrome.

Waist-hip ratio: An increased ratio again indicates increased abdominal fat accumulation.

Waist circumference can be used as a measure of central obesity which is a risk factor for type 2 diabetes and coronary artery disease.

Other methods: Estimation of body fat.It can be defined as an excess of body fat of over 25% for males and 30% for females. The technique is relatively complex and hence, cannot be used for routine clinical or epidemiological purposes.

DEFINITION OF CHILDHOOD OBESITY

The Centre for Disease Control and Prevention (CDC) has defined childhood obesity in terms of body mass index (BMI). The World Health Organization (WHO) 2006 growth charts and BMI have been introduced subsequently.

Overweight is defined as BMI ≥ 85th percentile and obesity as BMI ≥ 95th percentile in the chart.

THE MAGNITUDE OF CHILDHOOD OBESITY

The past four decades have seen almost a 10 fold increase in the number of children and adolescents with obesity, and this in turn could lead to a decline in life expectancy in the future. As per the UNICEF data, the global prevalence of childhood obesity has increased from 4.2% in the 1990s to 6.7% in 2010 and is further anticipated to raise to 9.1% by 2020.

Similarly in the adolescent age group of 12-19 years obesity prevalence has increased from 5 to 18.1%.

In India the key studies are from the National Family Health Surveys (NFHS) and National Nutrition Monitoring Bureau (NNMB) surveys. It was found that the prevalence of childhood and adolescent obesity was higher in the North when compared to South India. The overall prevalence of childhood obesity in 2010 was estimated to be 19.3% of and this has significantly increased.

FACTORS INFLUENCING CHILDHOOD OBESITY

The etiology of childhood obesity is multifactorial.

Genetic factors:

Obesity amongst parents influences obesity in children. Twin studies have shown a close correlation between weight of identical twins even when they are brought up in different environments. There is a genetic predisposition to obesity. The following genes have been studied namely the fat mass and obesity-associated (FTO) gene, leptin gene and its receptor, tumor necrosis factor alpha (TNF-α), the melanocortin 4 receptor gene (MC4R), Ectoenzyme nucleotide pyrophosphatase phosphodiesterase 1 (ENPP1) genes.

The roles of these genes are complex and interdependent, being linked to different cornerstones in obesity development, such as appetite behavior, control of food intake and energy balance, insulin signaling, lipid and glucose metabolism, metabolic disorders, adipocyte differentiation, and so on.

There is a compelling evidence to show that regular physical activity is protective against obesity. Television viewing amongst children and adolescents has increased dramatically over the recent years. Every extra hour of television viewing increase the prevalence of obesity by 2%. In addition children watching television also consume advertised goods that includes sweetened cereals, beverages and salty snacks leading to obesity.

Eating habits:

Dietary factors have been studied extensively and has been proved to contribute to childhood obesity. The factors that have examined are fast food consumption, sugary beverages, snack foods and portion sizes.

Fast food consumption:

Increased fast food consumption in the recent years has been linked to increased prevalence of obesity. Children from families where both parents are working are given fast foods more often as they find most convenient.

Sugary beverages:

Sugary drinks is an another factor that has been associated with obesity. Sugary drinks not only includes soda, but also juices and other sweetened beverages. Sugary drinks are less filling and hence consumed in larger amounts which results in higher calorie intake.

Snack foods:

Snack foods are another factor which contributes to childhood obesity. Snack foods include chips, baked foods and candies.

Infant feeding:

The inappropriate use of bottles for feeding infants and early introduction of solid foods before 4 months of age increase the risk of childhood obesity .

Environmental factors:

Children should be given opportunities to walk or take their bike to school.Children living in unsafe areas who do not have access to safe walking paths have fewer opportunities to be physically active contributing to obesity.

Social cultural factors:

In many societies including ours, food has been used as a reward, as a way to control others, as part of socialization. This practice increases the risk of developing obesity amongst children.

Family factors:

Family factors play an important role in the cause of obesity.The food that is available in the household, the food preferences of the family members can influence the food that the child consumes. Studies have shown children with an overweight mother and living in a single parent household have increased risk of becoming obese. In addition family habits, whether the family members are sedentary or physically active can influence the child’s level of activity.

Psychological factors:

Depression may be the cause of obesity and it could also be the consequence of obesity.Adolescents having depression are more likely to overeat or make poor food choices, tend to avoid exercising, and become more sedentary, all of which contribute to obesity.

Ethnicity:

Certain ethnic groups are susceptible to the development of obesity and this becomes apparent when they become exposed to a more affluent lifestyle.

Drugs:

Long term use of certain drugs like corticosteroids can promote excessive weight gain.

PROBLEMS OF CHILDHOOD OBESITY

The health-related problems associated with obesity in children include physical, psychological and social.

Psychological and social issues: Children who are obese tend to have lower self-esteem. They are depressed and withdrawn. This in turn, reflects in poor academic performance and socialization.

Physical problems: The physical problems of childhood obesity are many. Obese children are at increased risk of developing cardiovascular disease, hypertension and dyslipidemia. There is also an increase the risk of developing type 2 diabetes. Respiratory conditions like Asthma tends to be exacerbated with increasing obesity. Extreme obesity can cause obstructive sleep apnoea. Increase weight on musculoskeletal system can lead to joint pains. Obesity may also result in fatty degeneration of the liver.

Family Based Interventions

Suggestions for promotion of good nutrition For infants and young children

• promotion of exclusive breastfeeding for the first six months of life
• continuation of breastfeeding until two years and beyond
• introduction of complementary feeds which are adequate, safe and nutritious from six months of age

For children and adolescents

• Provision of healthy breakfast every day before school
• Provision of healthy school snacks containing grains, nuts, green vegetables and fruits
• Restriction of packaged snacks
• Restriction of sugar sweetened soft drinks

Suggestions for promotion of physical activities

• reduction of non-active time example television viewing and computer at home
• encouraging walking or bicycling to school
• playing active games as part of daily routine at least 30 minutes a day for children

School Based Interventions

Children spend a large portion of the time in schools.

• schools can encourage children to make healthy food choices
• schools can involve children in physical activities like lengthening the time for physical activity
• children should be encouraged in various physical activities like dances, games and sports

Community Based Interventions

The term community includes the environment in which the child lives. Communities can organize

• social events like healthy food festivals
• conduct education programmes on healthy eating
• encourage people to adopt healthy lifestyles
• provide a safe neighbourhood for children to play like having safe playgrounds and bike paths

NATIONAL HEALTH PROGRAMS

India has launched numerous campaigns in the recent months to address this crisis. The Eat Right India movement promotes the value of health and emphasis the importance of a balanced, adequate and nutritious diet . The Food Safety and Standards Authority of India (FSSAI) is moving towards eliminating trans fats from the country’s food supply by the year 2022. Our Prime Minister has launched a Fit India movement to encourage Indians to participate in more exercise

Childhood obesity is a major public health problem not only in India, but all over the world. Childhood obesity crisis can be addressed by educating children and their parents about healthy nutrition and encouraging them to stay physically active. The rising trend of childhood obesity is worrying. Inventions need to be done at the family, community, national and international level to address this pandemic. Sustainability of these interventions is vital. This will lead to a nationwide healthy future for our children and the generations to come.

About The Author: Prof Dr. R. Somasekar, MD, DCH, FIAP; Prof of Paediatrics, Sree Balaji Medical College & Hospital; Dean (Retd) Kanyakumari Govt Medical College & Hospital; Former Prof of Paediatrics, Madras Medical College; Past President IAP- Chennai City Branch

Disclaimer: The opinions expressed within this article are the personal opinions of the author. The facts and opinions appearing in the article do not reflect the views of NDTV and NDTV does not assume any responsibility or liability for the same.

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