Published in Panorama
A Chubby child, a Healthy child ????
Fat is unhealthy and unwanted as a matter of societal norms! While it is true that a chubby child is “cute and sweet” to cuddle, there is 80% chance that he or she grows up to be a fat adult, often ridiculed by peers and those around. While it is true that not all obese infants become obese children, and not all obese children become obese adults, the incidence of childhood obesity developing into adult obesity is very much on the rise. The health hazards apart, obesity gives rise to severe social and psychological problems particularly in children, eroding their self-esteem and confidence.
What is obesity and how does one measure it? Obesity is body weight more than normal for that particular age, sex and height. Simply put, it implies increased input and decreased output or decreased energy expenditure, says Dr.Prakash Pania, Specialist Endocrinologist, Indian Specialist Medical Center, Dubai. “Body Mass Index (BMI) is the commonest measure of obesity: it’s the ratio of a person’s weight in kilograms to height of the person in metres square. BMI between 20-25 kg/metre square is considered normal weight; between 25-30 kg/metre square is overweight; 30 and above is obese and 40 kg/metre square and above is morbidly obese. A second measure used in tandem with BMI is a skin fold thickness. These measures apart, height and weight charts would indicate whether a child is obese, overweight or normal.” About 20-27% of the paediatric population in the developing world, is obese. The rate is over 30% in the USA, claims Dr.Pania.
What are the causes of obesity? “Obesity is a multifactorial problem, involving several contributory factors. It’s a challenging problem and a frustrating one at that,” admits Dr.Pania. “It could be straightforward hereditary or constitutional obesity which accounts for roughly 30% of all obesity,” explains Dr.Pania. “For instance, if both parents are obese, the chances of having an obese child are much higher than if only one of the parents or neither parents were obese. Even adoption studies indicate this trend in that, children are likely to take after their biological parents in respect of obesity. In the case of constitutional obesity, the onset of puberty is likely to be delayed.”
Dr.Pania enumerates the other causes of obesity as:
• Certain rare Dysmorphis Syndromes wherein the children will have certain somatic and facial abnormalities which one can identify. Invariably most of these children are short; they have associated mental retardation in varying degrees, though not always. They may have flat nasal bridge, multiple fingers, blindness because the retina is pigmented, almond shaped eyes, more obesity on the upper arm and thigh but slender fingers. These are some of the ways in which you can gauge that the obesity may be syndrome-related. These children are usually moderately to severely obese, crossing a BMI of 35!
• Endocrine causes: These may contribute to less than 5% of all obesity cases. The commonest of these is hypothyroidism, which results in mild to moderate obesity, never severe. These children are likely to be short and be scholastically backward. Cushing’s Syndrome is another endocrine cause occurring due to an excess steroid production in the body. These children are also short but are overachievers. Other symptoms to look for in Cushing’s Syndrome is that the child will be moon-faced, will have acne, may have a buffalo hump and he may have certain purplish stri over his abdomen. Whereas in obesity not related to Cushings, the stri marks are pallid or white. Then you have the Turner Syndrome in females and Klinefelter’s Syndrome in males which involve chromosomal abnormalities resulting in the ovaries and testes becoming non functional. These girls and boys have delayed puberty and delay or absence of secondary sexual characters. Because of the absence of androgens, these children will be obese.
• Environmental factors can lead to obesity. This is because children indulge in junk food, in overeating and in following sedentary lifestyles with little or no exercise.
• Then there are some CNS (Central Nervous System) causes of obesity. The satiety center which is present in the hypothalamus gets destroyed or compressed because of certain tumours, infection, surgery or trauma. Irrespective of what and how much the child eats, the satiety center is not stimulated. The tendency is for the child to keep on eating; hence obesity. These are children with ravenous appetites and who will most likely be morbidly obese.
• Certain psychological problems like depression and psycho-social deprivation can contribute to obesity.
• Anti-psychotic, anti-sizure drugs, glucocorticoids can cause obesity. Any of the chronic ailments in childhood which would require treatment with steroids, like asthma or any kidney-related disease, would cause Cushing’s Syndrome and can lead to obesity.
• Leptin related abnormalities in appetite regulation can lead to obesity.
What are the complications of obesity? “Obesity can lead to many complications,” explains Dr.Pania. “10-12% of obese children may have hypertension. They may have type 2 diabetes as early as at the age of 10. They may have high levels of uric acid. Because of obesity, one may have osteo-arthritis and joint problems. Sleep apnea is also common in these children. I don’t need to over-emphasize the cardio-vascular problems associated with obesity. There is increased danger of premature athero-sclerosis and ischemic heart diseases. Obese girls may develop polycystic ovary disease which can lead to excess hair over the body and problems with their monthly cycles, even leading to infertility in adult life.”
How does one approach a patient with obesity? A detailed family history is the first step in examination, says Dr.Pania. “The history of the child since birth is very important, as are his/her dietary habits, scholastic performance. It is important to know if the child attained milestones at regular intervals as normal children do because even if there is some amount of mental retardation, you could pick up the diagnosis from that. Detailed physical examination of the child would be the second step. This includes measuring height, weight BMI and observing other indicators like buffalo hump, stri marks, acne, et al. After taking detailed history and physical examination, one can more or less draw a conclusion on the nature of obesity, its underlying cause. To confirm diagnosis, it is mandatory to go in for a trio of basic investigative procedures in all such children. These include the thyroid function test, lipid profile test and an X-ray of the hands to determine the bone age. Where other disorders are suspected to be involved in causing the obesity, specific investigations would be in order.”
The cornerstone for therapy in obesity is three pronged, enumerates Dr.Pania. “Diet, Exercise and Behaviour Modification. Drugs and surgery to correct obesity in children are not considered. Energy-dense or junk foods should be completely avoided. A balanced hypo-caloric, low-fat, fibre-rich diet is in order. High proteins, high calcium and high complex carbohydrate diet should be maintained to allow for the child’s normal and healthy growth. A dietician should be involved in charting out a diet regimen which should be strictly followed. Meals should be frequently spaced out in small quantities and supervised. While eating, there should be no stimulus like TV, to ensure that there is no over-eating.”
“Outdoor activities are a must and should be undertaken on a daily basis. 30 –60 minutes of any exercise like brisk walking, swimming, jogging, skipping, aerobics, cycling besides taking active interest in sporting activities like tennis, badminton, cricket. The best activity however, would be swimming because in addition to bringing calorie levels down, it can also tone the muscles.”
Dr.Pania explains, “As regards behaviour modification, we need to have team work involving the child, parents, teachers, healthcare-providers and dieticians. It requires boosting a child’s morale, self confidence and self esteem. Set realistic goals for the child to achieve. Avoid talking about the problem in the presence of the child.”
Dr.Pania advocates a slow and gradual reduction in weight rather than a rapid weight loss, “Because the faster he loses, chances are that he may regain the weight. A target of half a kg weight loss per week, should suffice.”