Obesity in children, etio-pathology and management

1. SEMINAR ON OBESITY
IN CHILDREN AND
ADOLESCENTS

2. OBESITY IN
CHILDREN –
AN
OVERVIEW
Dr. Prashant (PG)
Dr. Dushyant (SR)
Dr. Ruchi Mishra
Assistant Professor(Paediatrics)
ESI PGIMSR, Basaidarapur, New
Delhi

3. What is obesity??
Grossly, overweight means excess body-weight for height. Overweight
& Obesity are objectively defined using age-specific & gender-specific
nomogram
Obesity is defined by WHO as excess in fat mass great enough to
increase the risk of morbidity, altered physical, psychological, or social
well-being and/or mortality
Weight Status Category Percentile Range
Underweight Less than 5th centile
Normal or healthy weight 5th-85th percentile
Overweight 85th-95th percentile
Obese 95th percentile or greater
Morbid obesity >120% of 95th percentile

4. Why to discuss obesity in children
• It has become a major global public challenge today.
• Complex, multifactorial, challenging and often, frustrating
problem that is escalating at an alarming rate in the
western world and paradoxically, also in developing
countries like India.
• 60-80% of obese adolescents are expected to remain
obese as adults.
• Cardiovascular diseases, Type II DM in young age,
Hypertension & Dyslipidemia, all are related to childhood
obesity.
• New issues like fatty liver disease, obstructive sleep
apnea, orthopaedic problems and psychological
abnormalities are also attributed to obesity in childhood.

5. Epidemiology
• Paediatric obesity continues to be a serious ongoing
health problem affecting 45 million children under 5
years worldwide(2010 data).
• Countries like us have a double whammy of trying to
prevent malnutrition at one end and finding nearly
1/5th of the population being obese.
• Combined prevalence of childhood obesity &
overweight in India is 19.3%(2010) as compared to
16.3% in (2001-2005).
• In 2016, an estimated 41 million children under the
age of 5 years were overweight or obese and over 340
million children and adolescents aged 5-19 year were
overweight or obese.

7. Etiology of Obesity in Children and
adolescents
Obesity in
children
Exogenous
Increased
caloric intake
Decreased
energy
expenditure
Endogenous
Endocrine
Monogenic
Syndromic
Hypothalamic

8. Endocrinal causes of obesity
Cushing Syndrome GH Deficiency
Hypothyroidism Hyperinsulinoma
Pseudohypoparathyroi
dism

9. Genetic causes of Obesity
1. Alstrom syndrome
2. Bardet-biedel
syndrome
3. Biemond syndrome
4. Carpenter syndrome
5. Cohen syndrome
6. Deletion 9q34
7. Down syndrome
8. ENPP1 gene
mutations
9. Frohlich syndrome
10. FTO gene
polymorphism
11. Leptin or leptin
receptor gene
deficiency
12. Melanocortin 4
receptor gene mutation
13. Prader-Willi
syndrome
14. POMC deficiency
15. Rohhad
16. Turner Syndrome

10. Etiology of Exogenous Obesity
Chronic imbalance between energy intake and expenditure
o Increased intake of processed and refined diet, sugar-sweetened
beverages, increased time spent on TV viewing, internet browsing
or playing electronic games, reduced physical activity, reduced
sleep
Medications
o Glucocorticocoids, TCAs, Risperidone
 Adverse metabolic programming (acts in conjunction
with diet and lifestyle factors)
o Infants born SGA, LGA, those born to mothers with obesity or
diabetes, and those with accelerated weight gain in infancy are
predisposed to obesity in childhood.

11. Nutritional obesity
Normal examination and
development with normal/linear
growth
1. Genetic predisposition
2. Higher socioeconomic status
3. Intrauterine factors
a) IUGR with rapid postnatal
catch-up weight gain
b) Excess maternal weight gain
c) Large for gestational age
d) Gestational diabetes
4. Nutritional
a) Formula (rather than breast)
feeding

12. Exogenous
• Chronic imbalance
between energy intake
and expenditure
• Increased intake of
processed and refund
diet, sugar-sweetened
beverages, increased
time spent on TV
viewing, internet
browsing or playing
electronic games,
reduced physical
activity, reduced sleep
Endogenous
• Monogenic causes –
Defects in genes
encoding melanocortin 4
receptor(MCAR), Leptin
receptor(LEP), pro-
opiomelanocortin(POMC)
etc

13. Exogenous
• Medications –
Glucocorticoids, TCAs,
Risperidone
• Adverse metabolic
programming (acts in
conjunction with diet and
lifestyle factors)
• Infants born SGA, LGA,
those born to mothers
with obesity or diabetes,
and those with
accelerated weight gain
in infancy are
predisposed to obesity
in childhood.
Endogenous
• Genetic syndromes –
Alstrom, Bardet-Biedel ,
Prader Willi, Beckwith-
Wiedmann, carpenter,
cohen, Albright
hereditary
osteodystrophy etc.
• Endocrinal causes –
Hypothyroidism,
Cushing syndrome,
hypothalamic obesity,
growth hormone
deficiency, persistent
hyperinsulinism

14. Poor start to life
Mismatch
pathway-IUGR
Developmenta
l pathway-
GDM,
hormonal,
epigenetic
Rapid growth
in infancy,
childhood
Poor PA
Calorie-dense
diet
Catch-up fat
Sedentary
lifestyle in
adolescence
Sarcopenia
Adiposity
IR
Young adults
Met S
IR, IGT, GDM
T2D
CAD
NAFLD
Obesity begets obesity
 Shared behaviours
 Shared biology in
families

18. Hypothyroidism
• Hypothyroidism - associated with decreased
thermogenesis and decreased metabolic rate
• Decrease in energy expenditure
• Decrease in linear growth, causing the increase in
BMI
• There is increased permeability of capillaries
• Weight gain is mostly due to fluid retention ,not due
to fat deposition

20. Prader Willi Syndrome
• Loss of expression of paternally
expressed genes on chromosome
15q11.2-q13
• Hypotonia, feeding difficulties and
failure to thrive in infancy
• Hyperphagia with food foraging
behaviour, rapid weight gain, after 1st
year
• IQ between 60-70, behavioural
problems
• Small facial features, almond shaped
eyes, small hands with slender
tapering fingers
• Hypogonadism
• Diagnosis: FISH or methylation
specific PCR

21. Bardet Biedel Syndrome
• Developmental delay, retinitis pigmentosa, postaxial
polydactyly, truncal obesity and renal abnormalities
• Onset of obesity within 1st year of life
Albright Hereditary Osteodystrophy
• Rounded facies, short stature
• PHP 1a, low Ca, high P, high PTH
• Short 4th & 5th metacarpal; metatarsal

23. Hypothalamic Obesity
• The VMH, ARC, PVN, DMH, and LHA are involved in
control of appetite and energy expenditure.
• These areas produce several neuropeptides involved in
appetite regulation, including orexigenic peptides like
neuropeptide Y and anorexigenic peptides like the
melanocortins
• Injury or malformation may also affect binding of
peripheral intake-related signals, including cholecystokinin
(CCK), glucagon-like peptide (GLP-1), ghrelin, insulin,
and leptin.
• These peptides cross the blood brain barrier and bind to
their receptors in the hypothalamus to regulate appetite.

24. Monogenic obesity
• Recessive or co-dominant single gene mutation disrupting
leptin melanocortin pathway in the hypothalamus,
important for satiety regulation cause hyperphagia and
severe obesity
• LEP, LEPR, MC4R, others

25. Exogenous Obesity and its
comorbidities

26. Exogenous Obesity
• Chronic imbalance between caloric intake
and energy expenditure which includes
unhealthy eating patterns resulting in
energy excess and lack of physical
exercise

27. How to Measure Obesity
• BMI is important and commonly used
surrogate marker of obesity.
• Commonly used in children more than 2
year of age.

28. BODY MASS INDEX (BMI)
• Correlates well with fat mass
• >2 years
 Overweight - BMI>85th centile
but <95th centile
 Obese - >95th centile
 Extreme - > 120% of 95th
centile
• < 2 years
• Sex specific weight for recumbent
length is >97.7 centile of WHO
growth charts.

29. Considerations using BMI
• Doesn’t differentiate between fat mass and lean mass
• Fat mass prediction based on BMI is different for
Asians,
• - Have higher fat mass as compared to Caucasians for
same BMI
• - Fat distribution is more central so waist maybe a
better marker.
• Indian children recommended to use WHO charts for
< 5 years and IAP charts > 5 years

30. Other Indicators of Obesity
1. Age specific growth charts
2. Skin fold thickness
3. Waist circumference
4. Waist-hip ratio
5. Waist-height ratio
6. Body fat measurement techniques like DEXA, CT,
MRI, USG for subcutaneous and intra-abdominal fat.

31. IMPLICATIONS OF
CHILDHOOD OBESITY
Obesity-related diseases rarely seen in children in
the past, including obesity-associated sleep apnea,
NAFLD with resultant cirrhosis, and type 2 diabetes
are increasingly diagnosed in pediatric patients.

33. Complications of childhood obesity
Psychological Poor self-esteem, Depression, Eating
disorder
Pulmonary Sleep apnea, Asthma, Exercise
intolerance
Gastro-intestinal Gall stones, Steatohepatitis
Renal Glomerulosclerosis
Neurological Pseudotumour cerebri, migraine
Musculoskeletal Flat feet, forearm fracture, slipped capital
femoral epiphysis, Blount disease
Cardiovascular Dyslipidemia, Hypertension,
Coagulopathies, Chronic inflammation
Endocrinal Type 2 DM, Precocious puberty, PCOD,
Hypogonadism

34. Screening for complications
• Above 10 years: All obese/ overweight children
• < 10 years: Overweight/ obese with additional risk markers:
-Family history of obesity, dyslipidemia, GDM, T2DM or early CVD
-Acanthosis nigricans
-LBW with rapid catch-up growth in early childhood
Waist to height ratio>0.5
Waist to height ratio, BMI and waist circumference for screening paediatric
cardio-metabolic risk factors
What should be tested?
 BP
 Fasting blood glucose, consider OGTT if high risk
 TG, HDL-C
 ALT for NAFLD
 PCOS, if hirsutism or oligomenorrhea in pubertal girls

35. Normal Laboratory Values for
recommended tests
Test Normal Range
Glucose < 110 mg/dL
Insulin < 15 mU/L
Hemoglobin A1c < 5.7%
AST (age 2-8 yr) < 58 U/L
AST (age 9-15 yr) < 46 U/L
AST (age 15-18 yr) < 35 U/L
ALT < 35 U/L
Total cholesterol < 170 mg/dL
LDL < 110 mg/dL
HDL > 45 mg/dL
Triglycerides (age 0-9 yr) < 75 mg/dL
Triglycerides (age 10-19 yr) < 90 mg/dL

36. NAFLD
• Surrogate marker is ALT.
• Interpretation is age/sex specific
• Persistently high ALT ( >2 times the normal for more than 3
months → Investigate for NAFLD
• ALT > 80 – increased concern → Exclude other causes
• Liver biopsy is confirmatory.
• Early changes are reversible by dietary management
NAFL NASH
NAFLD with
fibrosis
NAFLD with
cirrhosis

37. Type II DM
Diagnosis
• HbA1c > 6.5%
or
• FBG >126
or
• 2 hr PL Gl > 200
or
• RBG > 200
Treatment
• If HbA1c > 6.5%-
Metformin
• If HbA1c is between 6.5-
9.0 – Metformin + Dietary
& behaviour changes
• If HbA1c > 9.0 or with
metabolic
decompensation– Insulin
+ metformin

38. Hypertension
Blood Pressure Stages of Hypertension
< 90th percentile Normal
> 90th percentile Elevated BP
> 95th percentile or 130/80 – 139/89
mm Hg
Stage 1 hypertension
> 95th percentile + 12 mm Hg Stage 2 hypertension

39. Hypertension
• Three main pathophysiological mechanisms:
a) Disturbances in autonomic function (increased heart rate
variability due to an altered balance between
parasympathetic and sympathetic activity)
b) Insulin resistance (insulin resistance associated with
obesity may prevent insulin-induced glucose uptake but
leave the renal sodium retention effects of insulin relatively
preserved, thereby resulting in chronic volume overload
and high BP)
c) Abnormalities in vascular structure and function
(increased intimal-medial thickness)

40. Dyslipidemia of Obesity
• ↑ TG & FFA
• ↓ HDL-c with HDL dysfunction
• Normal or ↑ ed LDL-c
• ↑ ed apolipoprotein B

41. Hypertension
Rule out secondary causes of HTN
ARBs, CCB, Beta-blockers and diuretics may be used
Target BP<95th percentile in absence of comorbidities
and <90th percentile in presence of comorbidities.
Dyslipidemia
Primary target is LDL-c ≤95th percentile
Statins –drug of choice, indicated in >10 yrs of age
LDL-c of ≥190 mg/dL after a 6 month trial of lifestyle
management
LDL-c between 160-198 mg/dL, drug treatment
indicated in presence of other risk factors
Fibrates indicated if TG>500 mg/dL

42. Metabolic Syndrome
1. Waist circumference, ↑ TG, HDL, fasting glucose
and blood pressure measurements have been
associated with metabolic syndrome
2. There is accumulation of cardiovascular and
metabolic factors which predispose to type II DM in
future
3. It includes presence of central obesity & only 2 of
these-
- hypertension
- impaired fasting glucose
- high TG
- low HDL

43. Screening for Metabolic syndrome
• Look for abnormal fat distribution
• Impaired glucose tolerance test
• Hypertension
• ↑ fasting insulin/ HOMA IR
• Elevated FFA
• ↑ CRP
• ↑ Adiponectin
• ↑ Inflammatory cytokines

44. MANAGEMENT OF OBESITY
• Prevention is best management.
• Education of child and family, both are required.
• Also steps taken by government and authorities for
restrictions on advertisements of unhealthy food.
• Initiation of Sugar tax.
• Clear labelling of calorie & nutritional content on
every foodpack
• Education on reading labels & controlling portion
size.

45. MANAGEMENT OF OBESITY (contd.)
• Easy & pocket friendly access to healthy food.
• Increasing physical activity, both at home & school.
• Health education at school
• Nutrition as part of regular curriculum
• Physical education at school
• Safe and easy access to play area for children

46. Early childhood diet and physical activity
Infancy
 Exclusive breastfeeding for first 6 months
 Complementary feeding with home-based foods
Childhood
 Avoid overfeeding and force feeding
 Discourage juices, soda and junk foods
 Daily physical activity for atleast 1 hr.
 Regular monitoring of height, weight, BMI
 TV/ computer time restricted to <2 hours/day
 Discourage grazing
 Snacks= Fruits, salads, low fat milk, sprouts
Adolescents
 Encourage adequate & regular meals, avoid meal skipping
 Activity-aerobic and muscle strengthening
 Body image, emotional needs

47. Treatment of Obesity
• Target weight loss: Depends on age and BMI
-6-<10 Year : 0.5 kg/week
- ≥10 year : 1 kg/week,setting goal for 10% weight loss
• Diet and lifestyle modification
-Caloric intake below energy expenditure levels
-Elimination of sugared beverages, high intake of water
& fiber.
-Emphasis on regular structured meals(6 meal pattern)
-Involvement of whole family, group sessions.

48. Weight management and treatment goals based on
BMI percentiles and health status
BMI Status Classification Treatment goal
< 85th percentile Normal weight for height Maintain BMI percentile to
prevent obesity
85th-95th percentile At risk for overweight Maintain BMI with ageing
to reduce BMI to < 85th
percentile; if BMI > 25
kg/m2, weight
maintenance
95th percentile Overweight weight maintenance
(younger children) or
gradual weight loss
(adolescents) to reduce
BMI percentile

49. Weight management and treatment goals based on
BMI percentiles and health status
BMI Status Classification Treatment goal
30 kg/m2 Adult obesity cut-off
point
Gradual weight loss (1-2
kg/month) to achieve
healthier BMI
95th percentile and co-
morbidities present
Overweight with co-
morbidities
Gradual weight loss (1-2
kg/month) to achieve
healthier BMI; assess
need for additional
treatment of associated
conditions

50. Pharmacotherapy
-Very limited role
-Orlistat (gastrointestinal lipase inhibitor)
-In children ≥12 yrs of age
-Discontinue treatment if <5%
weight loss in 3 month
-Metformin: Useful in insulin resistant
condition, not as an anti-obesity agent

51. Behavioral Treatment Strategies for
Obesity during Childhood and
Adolescence
Dietary Approaches
1) Encourage intake of ≥5 servings of fruits &
vegetables daily
2) Decrease intake of calorie-dense foods such as
saturated fats, salty snacks and high glycemic foods
such as candy
3) Minimize intake of sugar-containing beverages.
4) Minimize eating outside home and fast-food in
particular
5) Eat breakfast daily
6) Avoid skipping meals

52. Behavioral Treatment Strategies for
Obesity during Childhood and
Adolescence
Physical Activity
1) Decrease sedentary behaviour such as watching
TV, internet browsing and playing video games for
>2 hr/day
2) Engage in fun and age-specific exercise that is
appropriate to the individual’s abilities
3) Increase intensity, frequency and duration of
exercise gradually as tolerated
4) More than 1 hr of physical activity daily

53. Indications of Medical Treatment
• Only after a formal program of lifestyle intervention
has failed
• Only to be used in conjunction with high intensity
lifestyle modification program
• Should re-evaluate or reconsider if patients does not
have 4% reduction in BMI/BMI z score reduction after
12 weeks of therapy

54. Bariatric Surgery
• Attained near final height and Tanner stage 4 or 5 with
BMI>40 or BMI>35 with significant co-morbidities.
• Extreme obesity and co-morbidities persist despite
compliance with formal lifestyle modification
program.
• Full psychological evaluation of family for support.
• Ability to adhere to exercise and dietary program
• ONLY by An EXPERIENCED SURGEON and TEAM

55. FOOD FOR THOUGHT
Food Calories(kcal)
Double cheese burger 440
Single cheese burger 300
French fries 230
Regular pizza 714
Choco lava cake 500
Chhole bhature 511
Aloo parantha 175
1 packet maggie(medium) 360
1 bowl momos 366

56. CASE - 1
RAHUL
12 Years ,Male
Excessive weight gain – 1 year
Weight of the child - 45 kg
Height of the child – 140 cm
BMI = ???
Weight (kg)/ height(m2 )
22.95
Overweight

57. DIET CHART

58. TIME FOOD ITEM QUANTITY CALORIE
VALUE
PROTEIN
CONTENT
7:00 AM Parantha
Dal
Buffalo milk
2
1 katori
1 glass
(250ml)
240 + 90
86
238
4
6
11
11:00 AM Parantha
Potato Sabzi
2
1 katori
240 + 90
90
4
2
02:00 PM Rice
Dal
2 katori
1 katori
172
86
4
6
once in two
days
Ice cream 1 cup 102 2.5
once in two
days
Maggi/macroni 1 plate 110 2.5
08:00 PM Rice
Dal
2 katori
1 katori
172
86
4
6
11:00 PM Buffalo milk
Bournvita
1 glass
(250ml)
2 tsf
238
50
11
2
TOTAL 2090 65

59. ACTIVITY & SLEEP
Cricket 30 mins twice or thrice a week
Playing mobile games 1 – 2 hours
T.V. Watching 1 - 2 hour
Screen time = 2 – 4 hours
Sleeps for about 7- 8 hours

60. INVESTIGATIONS
B sugar (Fasting) – 85 mg/d (<110mg/dl)
T cholesterol – 112 (<170mg/dl)
Triglycerides – 95 (<90 mg/dl)
HDL – 47 (27-67 mg/dl)
T bil – 0.6 (0.1-1.1 mg/dl)
AST – 75 (<46 IU/L)
ALT – 80 (<35 IU/L)
ALP – 717 (<800 IU/L)
T protein & Albumin – 8.5 & 4.6 (6-8 gm/dl ; 3.7-5.3 gm/dl)
S Insulin – 1.2 (< 15 mU/L )
S Cortisol – 155.5 (50-230 ng/ml @ 8 am)
HbA1c – 5.6% (4.2-6.2% - non diabetic)
USG abdomen – grade 2 fatty liver

61. Recommended calorie intake for males (9-13 yr) for
relatively sedentary level of activity is 1800 kcal ;
moderate level – 1800-2200 kcal ; for active – 2200-2600
kcal
The child is taking 2090 calories which is in excess to his
requirement for that level of activity
Also his diet is rich in fatty food and deficient in fruits and
vegetables.

62. CASE - 2
TRILOK
11 Years ,Male
c/o Gaining weight – 1-2 years
Hypogonadism
Weight of the child - 57 kg
Height of the child – 143 cm
Waist circumference– 83cm
BMI = ???
27.87
Obese

63. Waist to height ratio ???
0.58
Stretched penile length – 4 cm
Testicular volume – 5 cc

64. DIET CHART

65. TIME FOOD ITEM QUANTITY CALORIE
VALUE
PROTEIN
CONTENT
7:00 AM Tea
Biscuit
1 cup
1 packet
60
250
1
5
11:00 AM Dalmoth
Juice
50 gms
1 glass
370
61
8
1
02:00 PM Parantha
Potato Sabzi
2
1 katori
240
90
4
2
During tution
hours
Soya sticks 1 packet 554 7.5
Street food
(daily)
Chowmein/
Pav Bhaji
1 full plate/
2 pav & sabzi
470 12
9:00 PM Rice
Dal
1 katori
1 katori
86
86
2
6
TOTAL 2267 48.5

66. Activity & Sleep
2 kms walk to school & Tution nearby – Total 30 min daily
Playing mobile games - Around 30 mins
T.V. Watching – 3 hours (1:00 pm – 3:00 pm & 8:00pm –
9:00 pm)
Screen time = 3.5 hours
Sleeps for about 8 hours

67. INVESTIGATIONS
B sugar (PP) – 95 mg/dl (<110mg/dl)
T cholesterol – 152 (<170mg/dl)
Triglycerides – 79 (<90 mg/dl)
HDL – 46 (27-67 mg/dl)
T bil – 0.4 (0.1-1.1 mg/dl)
AST – 35 (<46 IU/L)
ALT – 27 (<35 IU/L)
ALP – 728 (<800 IU/L)
LH – 0.9 (1-10 U/L in males)
FSH – 4.2 (1-10 U/L in males)
S Progesterone - <0.05 (0-20 ng/ml in males)
S testosterone - <0.02 (3-12 ng/ml in males)

68. Reports awaited
S Insulin
S Cortisol
HbA1c
USG abdomen

69. Recommended calorie intake for males (9-13 yr) for
relatively sedentary level of activity is 1800 kcal ;
moderate level – 1800-2200 kcal ; for active – 2200-2600
kcal
The child is taking 2267 calories which is in excess to his
requirement for that sedentary life style
Also daily intake of street foods and junk foods has made
him obese.
The screen time should be reduced to less than 2 hours
per day/

72. Pulmonary Complications

73. Pulmonary Complications
Abnormal
ventilatory
drive
OSAS

74. Insulin Resistance

75. Insulin Resistance