It is a usual scenario in my practise when the parents describe their obese child like ‘She has been healthy like this since beginning’. Even we doctors use the word ‘healthy’ very loosely to describe fattiness. It is not right to discriminate obese children in the society, but in medical practise, a line between healthy and fatty needs to be drawn. To do so, we must understand that obese is ‘not healthy’.
The prevalence of over-weight and obesity has been
increasing exponentially over the last decade. Various cities in our countries
are coming up with pediatric obesity prevalence figures between 6-22%. Obesity,
just like type 2 diabetes, is no longer a disease of the rich. The prevalence
in increasing in economically challenged as well.
What is Obesity and Overweight in pediatric age group?
We do not follow absolute BMI values in pediatric age group.
A BMI of 20 is normal for a 14 year old; but it is high for a 5 year old child.
For given age and sex, if the body mass index falls between 85th to
95th percentiles, the child is said to be overweight. If it is above
95th percentile, the child is obese. In simple terms, when the
weight percentile is much above the height percentile on a growth chart, the
child is probably obese.
What are the usual culprits in Pediatric Obesity?
Most of the pediatric obesity is exogenous and lifestyle
related. Reduced outdoor play, increased consumption of calorie dense foods, increased
screen time [TV, computers, PS3s etc] are the common causes. Media plays a
direct and indirect role in causing pediatric obesity by promoting fast food
culture and reducing calorie expenditure due to inactivity.
Endocrinal causes like Cushing’s [exogenous/endogenous] and
pseudohypoparathyroidism are rare. Obesity in operated CNS tumors like
craniopharyngioma can be due to excess steroid replacement or Growth hormone
deficiency. Physiological doses of steroid replacement [9-12mg/m2 of
hydrocortisone] usually do not cause obesity.
Hypothyroidism does not cause obesity; it causes edema and
mild weight gain. Most of the obesity associated with mild hypothyroid is
actually lifestyle related and hypothyroid is only the tip of the iceberg of
weight gain. That is the reason such children do not lose weight even after
starting thyroid supplementation.
Genetic causes such as MC4R mutation, Prader Willi, Laurence
Moon Biedl, ACTH deficiency, Leptin deficiency are rare causes of hypothalamic
obesity. They cause rapid weight gain during infancy and early childhood due to
problem in the energy homeostasis.
Why Obesity is bad for children?
Pediatric obesity is associated with co-morbidities like
metabolic syndrome, Polycystic Ovary syndrome, Type 2 diabetes [T2DM], Non Alcoholic
Steato-Hepatitis, Gall stones, and increased risk for cardiovascular disease. Prevalence
of T2DM in children is rapidly increasing in India due to obesity. Skeletal
problems like Slipped capital femoral epiphysis, Blount’s disease and osteoarthritis
are seen in obese children. Obese children are likely to get psychosocial
problems in the school. Obstructive Sleep Apnea can cause day time sleepiness,
headaches and poor concentration in studies. These children are ten times more
likely to get glomerulonephritis.
What is the minimum that a family physician can do?
We can ask the parents to monitor the intake of their child.
Starving is a bad choice for weight reduction. A child needs 3 meals
[Breakfast, lunch and dinner] and 2 snacks in a day; however, grazing in
between the meals needs to be avoided. Buffalo milk can be substituted by
either ‘low fat’ or cow’s milk. Sensitize the mother about keeping an eye on
the monthly oil consumption; that way the dietician will get realistic figures.
Plotting a child’s weight and height during each visit is the least we can
do. This helps in ruling out or
considering many hormonal disorders like Cushing’s syndrome. Motivating the
family towards lifestyle modification is a continuous process, beginning with
the family physician. Identify the risk factors such as Acanthosis Nigricans
[thick blackish skin over nape of neck, axillae and groins], high blood
pressure, history of menstrual irregularity, family history of
T2DM/cardiovascular disease/hyperlipidemia.
Which patient needs a referral to endocrinologist?
In the age of specialization, the role of family physicians
is crucial in screening patients and identifying the need for referral. A child, who is short and obese, definitely
warrants urgent evaluation by a pediatric endocrinologist. Sudden onset rapidly progressive obesity,
obesity during infancy, obesity with delayed milestones or mental retardation,
family history of hyperlipidemia/ type 2 diabetes/ sudden cardiac death, signs
and symptoms of Cushing’s syndrome, early or delayed puberty are the scenarios
which need detailed evaluation by a team of endocrinologist, dietician and a counselor.
What an endocrinologist does for an obese child?
The purpose of endocrinologist referral is not just ruling
out endocrinological/genetic causes, but also to stratify the risk of getting
endocrinal manifestations secondary to obesity. Lipid profile, liver enzymes
and blood sugars are the minimum tests required for co-morbidities, along with
multiple blood pressure recordings. Endocrine work-up is needed in selected
cases.
Individual child is
given weight targets and diet plan for short interval of time. Pharmacotherapy
in pediatric obesity has a limited role and needs to be accompanied by
intensive lifestyle modification. Drugs like metformin and orlistat have
statistically significant, yet modest role in weight reduction in children
beyond 8 and 12 years of age. These are given when the lifestyle modification
alone is not helping or there are associated significant co-morbidities or risk
factors. Other drugs are not licensed. Repeated assessment of the compliance
and response is essential is a successful and sustainable weight control.
The initial approach in any obese child is to identify the
treatable causes and modifiable factors in the lifestyle. A frequent follow up
at 3-6 months for assessment is needed. Weight loss is recommended only for
moderate to severe obesity or when the simple lifestyle changes have failed.
Bariatric surgery is reserved for morbid obesity associated with co-morbidities
and non-responsive to standard management. Such surgeries are not done until
the skeletal and sexual growth is complete.
Finally, the management of pediatric obesity is a team-work.
Successful and sustainable weight control needs continuous support from the
family. Family members need to take part in the treatment by changing the diet
for the entire family, sacrificing on their television hours and setting
examples by promoting healthy lifestyle.
-Dr.Tushar R Godbole
MBBS, DCH,
DNB, PDCC, MNAMS
Consultant
Pediatric and Adolescent Endocrinologist,
Lecturer in
Pediatrics, Dr.Vasant Pawar Medical College Nashik
Consultant
at Six Sigma Hospital, Nashik and Niramay Pediatric Superspeciality Hospital,
Aurangabad.
