World obesity day: Obesity in Children-Growing Concern!!!
Gastroenterologist & Lifestyle Medicine Physician
Paediatric Obesity: Growing Concern
Growing incidence of overweight and obesity in childhood, 4% in 1975 to 18% in 2016, with persisting obesity complications into adulthood -> harmful ->increasing the incidence of severe MAFLD at an earlier age. India is becoming the epicenter of epidemics of both adult and childhood obesity with the third-highest level of obesity in the world. Global Burden of Disease study 2013 : 5.3% of males and 5.2% of female < 20 yr in India were overweight.Currently, MAFLD is the leading form of chronic liver disease in children and adolescents, with a global prevalence of 3 to 10%. Most children with MAFLD have been diagnosed between the ages of 10 and 13. At the time of diagnostics, 10–25% of them have advanced steatosis (NAFL) and 20–50% have NASH .
Causes of rising obesity –
Convenience foods : low in fiber, micronutrients and antioxidants and contain dietary components that affect risk of heart diseases, cardiovascular events and diabetes in children.
A positive energy balance of only (120 kcal) per day (approximately one serving of sugar-sweetened soft drink) 50 kg increase in body mass over 10 years.
A large meal of this type i.e., double cheeseburger, French fries, soft drink and a dessert, is likely to contain 9,200 kJ (2,200 kcal), which, at 350 kJ (85 kcal) per mile, would require a full marathon to eliminate the body fat.
Maternal obesity & Paternal Obesity
• Australian longitudinal birth cohort :2900 offspring,
a maternal BMI >30 before pregnancy --> MAFLD risk in offspring.
• More alarming as the prevalence of obesity and MAFLD in pregnant women continues to rise.
• Paternal obesity can promote programmed phenotypes in offspring via epigenetics.
• Paternal obesity increase in sperm’s oxidative stress and greater susceptibility of a DNA methylation and histone modifications defect in embryonic development --affects early hepatic programming of offspring hepatocytes
The impact of the COVID-19 pandemic: on obesity prevalence in children is of great concern at least a 3–4% weight gain in children during the COVID-19 pandemic. It was estimated that 22% of children and adolescents had obesity in August 2021 which was increased from 19% one-year prior. During the COVID-19 pandemic, obesity was ranked as either the 1st, 2nd or 3rd demographic factor in children with severe disease requiring ICU admittance. In addition, obesity was associated with disease severe enough to require mechanical ventilation.
Early diagnosis and intervention is essential as children with obesity are at higher risk for several medical conditions such as
1.Metabolic syndrome
2.Insulin resistance
3.High blood pressure
4.Hyperlipidemia.
5. Prediabetes and diabetes.
For youth who develop T2DM there is at least a 50% chance that the disease will progress despite treatment.
Other comorbidities
Nonalcoholic fatty liver disease
Obstructive sleep apnea
Premature puberty
Irregular menstruation
Polycystic ovary syndrome (PCOS)
Orthopedic conditions such as SCFE and Blount's disease.
Furthermore, children with obesity are more likely to become adults with obesity, with development of associated health problems including type 2 diabetes, stroke, and ischemic heart disease later in life.
Children with a BMI percentile at the >95th percentile have a greater chance of maintaining obesity into adulthood.
The tragedy is that many children are unable to receive medical treatment for obesity, and for those who do receive treatment, options are limited.
Management:
· Lifestyle modifications to improve diet and increase physical activity : first-line treatment for all children.
· Avoidance of sugar-sweetened beverages is recommended as a strategy to decrease adiposity.
· Increasing moderate to high intensity physical activity and limiting screen time activities to < 2 hours per day is recommended for all children including those with NAFLD.
· No currently available medications or supplements are recommended to treat NAFLD because none have been proven to benefit the majority of NAFLD patients.
Preventive and therapeutic value of lifestyle intervention:
In case of overweight/obese subjects: hypocaloric diet -25-30 cal/kg per day
Normal-body-weight children: isocaloric diet - 40-45 cal/kg per day
The amount of calories prescribed also takes into account physical activity and daily routines.
Diet composition consists of
Low gastrointestinal carbohydrate (50%-60%),
Protein (15%-20%)
Fat (23%-30%): 2/3rd unsaturated and 1/3rd saturated
ω6/ω3 ratio - 4:1
• Based upon knowledge of NAFLD pathogenesis, a proper diet might be a low-glycemic index diet; in fact, a similar diet may lead to reduction in serum ALT and hepatic steatosis.
Pharmacothearpy:
In regards to pharmacotherapy options available:
Orlistat, an enteric lipase inhibitor which prevents breakdown and absorption of fat is approved for children ≥ 12 years, but is rarely used in clinical practice due to the side effect of abdominal distress and greasy stools.
Phentermine is FDA approved for weight loss only for > 16 years.
Topiramate has been used for seizure control in children for years and is commonly used off label for treatment in children with obesity but is not FDA approved for this use.
Metformin is commonly utilized in the population of children and adolescents, although FDA approved only in children ≥10 years with T2DM. However, metformin has been prescribed by obesity medicine specialists for polycystic ovary syndrome or severe insulin resistance with or without impaired glucose tolerance, with multiple trials showing a small amount of weight loss associated with metformin use, particularly in the first few months of medication initiation
Role of genetic testing
Currently, there at least 10 different laboratories offering genetic testing.
Tests performed range from 2 to 79 different genetic mutations associated with individuals at risk for obesity. Some testing is offered free of charge to the patient and if the patient has a suspect mutation, family members may also be offered testing for free. Indications for testing are broad, but the underlying clinical suspicion is in those who present with obesity at younger than 5 years of age, defined as the criteria for early onset obesity.
Role of Surgery
The most common procedure practiced is the laparoscopic gastric sleeve. Outcomes seen are similar to those in adults. It is a safe and effective procedure in most youth. Health-related quality of life metrics are dramatically improved and five-year outcomes have also been positive. In the 5 year Teen Labs Study, there was 96% follow-up at 5 years with a mean percentage weight loss of 26%. In regards to comorbidities, 68% normalized blood pressure, and 81% normalized triglycerides, with 86% of patients with T2DM in remission .
Conclusion:
Diet and Lifestyle modification is mainstay of treatment
• Comprehensive approach to weight management in the school and home surroundings, can reduce the public health impact of pediatric obesity & NAFLD.
• Timely diagnosis and close surveillance of most patients with NAFLD and aggressive management in a subset of them is highly recommendable.
• Pharmacotherapy in children and adolescents currently not recommended due to insufficient evidence.
• Future research needed.
Home-based interventions
• Set firm limits on television and other media early in the child's life, and establish habits of frequent physical activity.
• TV/computer time to be restricted to maximum 2 h/day
• Mandatory 60 min of physical activity daily to be supervised by parents
• Restriction on eating out at weekends and restricting availability of junk foods at home.
School-based interventions
• High importance on physical activity
• Making healthier choice available and banning un-healthy food in cafeteria, (sweetened beverages and energy-dense junk food).
• Training of teachers regarding nutrition education
• Incorporation of more knowledge about nutrition and physical activity and nutrition related diseases in school curriculum.
Policy formulation
• Creation of national task force for obesity
• Decrease in taxes and prices of fruits and vegetables
• Proper Food labeling practices and quality monitoring
• More playgrounds, parks and walking and bicycle tracks
• Restriction on advertisement of commercial foods on television at prime time and during children's programs
• Ban on unfair nutrition claims for commercial products
• Encourage food companies to manufacture healthy snacks
• Prohibition of promotional gifts with junk foods
Ban on monetary sponsorship of youth festivals by cola companies
Nice information Doctor
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