Childhood obesity

Dr.Sid Kaithakkoden MD
MBBS, DCH,DipNB, MD, MRCPCH, FCPS
alavisaid@aol.com

 Increasingly common problem in children
 Difficult to treat
 The adverse consequences of childhood obesity,
such as development of hypertension,
hyperlipidaemia and type 2 diabetes, are under-
recognised
 The tendency for childhood obesity to persist
into adult obesity
 The prevention of childhood obesity is not
adequately addressed despite a rapid rise in its
prevalence
 Treatments have only limited success, resulting
in a negative approach to treatment strategies
03/02/15 2

 Obesity in children is different from obesity in adults
- all children and adolescents need to grow; for
example during puberty, a child’s weight will double
and their height increase by 20%
 Simple measures of obesity such as the body mass
index (BMI) cannot be used in isolation, instead they
should be expressed as a BMI percentile in relation to
an age and sex matched population
 In the prevention and treatment of childhood obesity,
dietary energy restriction, increases in activity and
decreases in sedentary behaviour must not
compromise normal growth and development
 weight maintenance is often a suitable goal, rather
than weight loss
03/02/15 3

 The aetiology lies in deranged energy
balance
 In children, growth is only possible if energy
intake (as food and drink) exceeds energy
output (resting metabolic rate and activity)
 Excess energy is stored in new tissue, excess
adipose tissue will be formed and stored
03/02/15 4

 In UK, a rapid rise in the prevalence of
obesity - due to environmental and
behavioural changes relating to diet and
inactivity
 Particularly due to increased intake of high
fat foods - they are readily available, very
palatable and energy-dense, but may not
satisfy the appetite as quickly as high
carbohydrate foods
 The marked rise in obesity prevalence has
coincided with a major change in how
children spend their time, resulting in both a
decrease in physical activity and a rise in
sedentary behaviour
03/02/15 5

 There has been a general reduction in
activity during daily living (less walking,
greater use of cars, more use of escalators
and lifts), and also reductions in the amount
of physical education and sport carried out
at school and at home
 The marked rise in sedentary behaviour
-increased time spent watching television,
playing computer games, surfing the internet
and using the telephone
03/02/15 6

 Societal and political context to these
changes
 loss of school playing fields
 lack of a safe environment in which to walk or
cycle to school or for physical play at the home
 transport policies that favour driving above
cycling or walking
 a food industry that targets children with
advertisements for high energy foods
 health promotion policies that fail to target
appropriate dietary change or address issues of
health inequality
03/02/15 7

 Body Mass Index (BMI: weight in kilograms
divided by the square of height in metres:
kg/m2), obesity - BMI >30.0 kg/m2
 For children and young people <18 years, BMI
is not a static, varies from birth to
adulthood, different between boys and girls
 Interpretation of BMI values in children and
young people therefore depends on
comparisons with population reference data,
using cut-off points in the BMI distribution
(BMI percentiles)
03/02/15 8

 For clinical use:
obese children are those with a BMI >98th
centile of the UK 1990 reference chart for age
and sex
overweight children are those with a BMI >91st
centile of the 1990 reference chart for age and
sex
 For epidemiological (research) purposes:
overweight should be defined as BMI >85th
centile of the 1990 reference data
obesity should be defined as BMI >95th centile
of the 1990 reference data for age and sex
03/02/15 9

 Increasing worldwide
 USA - one in five children are overweight
 UK - 11% of 6 year olds and 17% of 15 year
olds (Health Survey for England 1996) had a
BMI >95th centile
03/02/15 12

 Cardiovascular Risk Factors, Metabolic &
Endocrine Complications:
 increase in the prevalence of adolescent type 2
diabetes
 Atherosclerosis (level 3 evidence)
 Coronary artery diseases
 increased blood pressure
 adverse lipid profiles
 adverse changes in left ventricular mass
 Hyperinsulinaemia (evidence level 2)
03/02/15 13

 Psychological Consequences
 poor self esteem, being perceived as
unattractive, depression, disordered eating,
bulimia and body dissatisfaction (level 2)
 Other Medical Problems
 the risk of developing asthma and the
exacerbation of pre-existing asthma
 abnormalities of foot structure and function
 increased risk of type 1 diabetes (evidence level
2+)
03/02/15 14

 Long Term Morbidity & Mortality
 increased 32-year mortality risk (relative risk
1.95, confidence intervals 1.41 - 2.69) for men
with BMI >26 at age 18 years (Evidence level 2++)
 Socioeconomic associations
 Two good quality studies, one from the UK and
one from the USA show adverse associations
between childhood obesity and educational
attainment and income in women(evidence level
2+)
03/02/15 15

 Children at high risk of developing obesity:
 Syndromes like Prader Willi
 Hypothyroidism
 Socioeconomic status: relationship between
prevalence of childhood obesity and deprivation
(defined by Townsend score), survey of 5 to14
year olds from 1994 to 1996 in Plymouth - found
a significant relationship between degree of
deprivation and increased prevalence of
childhood obesity. (evidence level 3)
03/02/15 16

 GENDER - None
 AGE
 Obesity was found to be more prevalent with increasing age in
British children. Evidence level 2+,3
 PARENTAL OBESITY
 No published, recent, UK study has evaluated the role of
parental obesity as a risk factor for childhood obesity in a
cohort or cross-sectional survey
 DIET
 No published UK study has evaluated the role of diet in a
cohort of children prior to the development of obesity.
 PHYSICAL ACTIVITY
 No published UK study has evaluated the role of physical
activity in a cohort of children prior to the development of
obesity.
 PHYSICAL INACTIVITY AND TELEVISION VIEWING
 There is increasing evidence that physical inactivity,
particularly increased TV viewing, is a risk factor for the
development of obesity in children and adolescents. There are
currently no published studies on this topic from the UK.
03/02/15 17

 School, family and societal interventions
to prevent obesity:
 the child and family are perceived to be
ready and willing to make the necessary
lifestyle changes
 Weight maintenance:
healthier eating
increasing habitual physical activity (brisk
walking) to a minimum of 30 mins day. In
healthy children, 60 minutes of moderate-
vigorous physical activity/day has been
recommended
reducing physical inactivity (watching
television and playing computer games) to <2
hours/day on average or the equivalent of 14
hours/week
03/02/15 18

 Possible approaches to implementing
behavioural changes:
 encouraging children and their families to make
a few small, permanent changes in behaviour at
a time
 developing family awareness of eating, activity,
and parenting behaviours
 encouraging a family to improve their monitoring
of their eating and activity habits
03/02/15 19

 When to refer:
children who may have serious obesity-related
morbidity that requires weight loss (benign
intracranial hypertension, sleep apnoea;
obesity hypoventilation syndrome, orthopaedic
problems and psychological morbidity)
children with a suspected underlying medical
(endocrine) cause of obesity including all
children under 24 months of age who are
severely obese (BMI >99.6th centile)
all children with BMI >99.6th centile (who are
at higher risk of obesity-related morbidity)
Suspect an underlying medical cause of obesity
if a child is obese and also short for their age
03/02/15 20

 Role of secondary care:
 The primary purposes of referral - to exclude
underlying medical causes of obesity and to treat
comorbidity
 Most patients will not have an underlying
medical cause and should be discharged back to
management in the community
 In patients with no underlying medical causes but
with serious obesity-related comorbidity,
treatment of the comorbidity may be indicated
03/02/15 21

 In secondary care, treatment
should follow the principles, but
weight loss, rather than weight
maintenance may be the
appropriate aim
For obese children over the age of
seven years, who can demonstrate
prolonged weight maintenance and
who are cared for by secondary care
services, modest weight loss (no more
than 0.5kg/month) advised
03/02/15 22

 Obesity in children is becoming more
common
 Obesity is due to an imbalance between
energy consumption and energy
expenditure. Obese children do not have
low energy needs. They have high energy
needs to support their high body weight
 Obesity is a health concern in itself and
also increases the risk of other serious
health problems such as high blood
pressure, diabetes and psychological
distress
03/02/15 23

 An obese child tends to become an obese
adult
 There is no evidence that any drug
treatment is effective in treating obesity
in children Obesity in children may be
prevented and treated by making lifestyle
changes such as:
increasing physical activity
decreasing physical inactivity (eg TV watching)
 Encouraging a well balanced and healthy
diet
03/02/15 24

 Lifestyle change involves making small
gradual changes to behaviour
 Family support is necessary for treatment
to succeed
 The aim of treatment is to help children
maintain their weight (so they can “grow
in to it”)
 A medical cause of obesity is more likely
in the child who is obese and short for
their age
 Most children are not obese because of an
underlying medical problem but as a
result of their lifestyle
03/02/15 25

 Birth to 5 yrs:
 Breast milk food of choice
 Introduction of solid foods should be avoided
until infants are at least four to six months of
age.
 Weaning is best done gradually, starting with
small amounts of pureed fruit or vegetables, or
rice or other gluten free cereal
03/02/15 26

 From six months:
 full fat versions of dairy products recommended
 starchy foods very high in fibre should be avoided
 From two years:
 gradual introduction of low fat dairy products so
that by the age of 5 most children are eating in
accordance with the ‘Eating for Health’ plate
model
 Children from approximately one year would
normally be expected to eat three meals a
day and two between-meal snacks
 Foods particularly high in fat and sugar are
not necessary
03/02/15 27

 Over 5 yrs:
 One third of a child’s intake by volume should
comprise starchy carbohydrate foods, one third
fruits and vegetables, with smaller amounts of
foods from the meat, fish and alternatives group
and low fat dairy products
 fatty, sugary foods in small amounts can be part
of a normal healthy diet
 adequate fluid intake is also important (water,
low fat milk, very well diluted low calorie
diluting juices and diluted fruit juice)
03/02/15 28

 Eat regularly
 Include bread, pasta, cereals, rice or potatoes at
every meal
 Eat some form of fruit and vegetables at each
meal
 Limit foods high in sugar such as sweets and
chocolate
 Limit foods high in fat such as crisps, chips and
pastries
 Limit fried foods (including deep fried foods)
03/02/15 29

 Take plenty of exercise & limit time spent
watching TV or playing computer games
 Provide meals and snacks at regular
times; avoid grazing all day long
 Separate eating from other activities such
as watching TV or doing schoolwork
 Offer healthy options but agree one to
two treats a week
 Encourage the child to listen to internal
hunger cues and to eat to appetite
03/02/15 30

 Instead of offering food as a reward to a
child, try alternatives such as giving stickers,
going to the cinema, a new book or toy, or
having a friend to stay overnight
 Comfort with attention, listening and hugs
instead of food
 Ask for help from friends and family in
supporting behaviour changes
 Keep foods that the child should be avoiding
out of the house
 Avoid classifying foods as good or bad
 The approach a parent takes to a child’s
behaviour should always be consistent
03/02/15 31

 More physical activities (30 min/day)
 walking instead of taking the bus
 using stairs instead of escalators or lifts
 going for walks, visits to parks and playgrounds
 swimming, cycling, rollerblading
 team activities such as football, dancing,
Brownies/Cubs and Guides/Scouts
 attending PE lessons/outdoor education.
03/02/15 32

 The Behavioural Health Centre, The
Children's Hospital of Philadelphia and the
University of Pennsylvania School of Medicine
 498 participants 12 to 16 years of age with a
body mass index (BMI) that was at least 2
units more than the U.S. weighted mean of
the 95th percentile based on age and sex
 CONCLUSIONS: Sibutramine added to a
behaviour therapy program reduced BMI and
body weight more than placebo and
improved the profile of several metabolic
risk factors in obese adolescents
03/02/15 33

E Stamatakis, P Primatesta, S Chinn et al
UCL & King’s College London
Archives of Disease in Childhood, October 2005;90:999-1004

 Individuals from lower socioeconomicstrata
 have diets rich in low cost energy dense foods
 participate less in sports or physical activity
 have lower weight control awareness
 Lower SES is linkedto lower control over one’s
life and this does not encouragesthe adoption of
healthy lifestyles for a given individual andtheir
children
03/02/15 36

 To examine the childhood overweight and
obesity prevalencetrends between 1974 and
2003
 Assess whether these trendsrelate to
parental social class and household income
03/02/15 37

 A school based and a general population
health survey:the National Study of Health
and Growth in 1974, 1984, and 1994,and the
Health Survey for England, yearly from 1996
to 2003
 Participants:
 14587 white boys and 14014 white girls aged5–10
years
 Ethical Approval:
 by London Medical Research Ethics Council
03/02/15 38

 Physical Measurements:
Exact age
Height & Weight
 Overweight and obesity prevalence:
calculatedusing UK specific as well as
international age & sex specific body mass
index cut-offs - Wt(kg)/Ht(m2
)
 Socioeconomic status:
measured using the RegistrarGeneral’s social
class; household income (1997 onwardsonly)
was adjusted for household size
03/02/15 39

 Total of 14587 boys and 14014 girls
aged5–10 years
 The prevalence of obesity in boys
increased from 1.2% in 1984 to 3.4%
in 1996–97and 6.0% in 2002–03
03/02/15 40

 In girls, obesity increased from1.8%
in 1984 to 4.5% in 1996–97 and 6.6% in
2002–03
 Obesity prevalence has been
increasing at accelerating ratesin the
more recent years
03/02/15 41

 Children from manual social classeshad
marginally higher odds (OR 1.14, 95% CI 0.98
to 1.33) andchildren from higher income
households had lower odds (OR 0.74,95% CI
0.61 to 0.89) to be obese than their peers
from non-manualclass, and lower income
households
03/02/15 42

03/02/15 43Copyright ©2005 BMJ Publishing Group Ltd.
Stamatakis, E et al. Arch Dis Child 2005;90:999-1004
Figure 1: Obesity prevalence trends from 1997 to 2002-03 by
income category and sex (Lower income: bottom 50% of income
distribution of each individual year; higher income: top 50% of
income distribution of each individual year)

03/02/15 44Copyright ©2005 BMJ Publishing Group Ltd.
Stamatakis, E et al. Arch Dis Child 2005;90:999-1004
Figure 2: Obesity prevalence trends from 1997 to 2002-03 by
income group and social class for boys and girls combined.

 Results showed that the upward trends in
overweight andobesity in children noted by
other authors over the1990s are continuing
into the 2000s
 Alarmingly, the rate of increase has
accelerated over the last decade
 15 fold increase in the average annual rate
of change in boys and 5 fold increase in girls
03/02/15 45

 Family social class at birth & in infancy have
a long term effect on BMI
 Obesity among children from manual classes
and children from lower income households
seems to be increasing more rapidly than
among children from non-manual classes and
higher income households
03/02/15 46

 Both material deprivation and other early
social influences such as parental occupation
are closely related to the development of
obesity in childhood
 Social class and especially income
inequalities should be tackled, and
interventions aimed at relieving economic
hardship may reduce the risk of behaviors
damaging health from childhood
03/02/15 47

 Childhood obesity is increasing rapidly
into the2000s in England
 These increases are more marked among
childrenfrom lower socioeconomic strata
 Considering the calamitousconsequences
of obesity, there is an urgent need for
actionto halt and reverse this rapid
upward trend among English children,
especially among those from lower
socioeconomic strata
03/02/15 48

 Psychological consequences
 obese children are more likely to experience
psychological or psychiatric problems than non-
obese children
 girls are at greater risk than boys
 risk of psychological morbidity increases with age
 Low self esteem and behavioral problems were
particularly commonly associated with obesity
 34% of obese (defined as BMI >95th centile), white,
13–14 year old girls had low self esteem (defined as
<10th centile) compared to 8% of non-obese white
girls
03/02/15 50

 Cardiovascular risk factors in childhood
 high blood pressure
 dyslipidaemia
 abnormalities in left ventricular mass and/or function
 abnormalities in endothelial function
 hyperinsulinaemia and/or insulin resistance
03/02/15 51

 Social and economic effects
 obesity in adolescence/young adulthood has
adverse effects on social and economic outcomes
in young adulthood (income, educational
attainment)
 Persistence of obesity from childhood
 Impact of childhood obesity on adult
morbidity and risk of premature mortality
 Cardiovascular risk factors in adulthood
03/02/15 52

 the promotion of active lifestyles
 the restriction of television viewing
 the promotion of fruit and vegetable
consumption
 the restriction of energy dense and sugary foods
and drinks
03/02/15 53

Childhood obesity

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