OBESITY is a major public health crisis, and the prevalence and incidence of obesity has reached epidemic proportions globally. Childhood obesity is one of the most serious public health challenges of the 21st century, and it has increased eight-fold since 1975. The problem is global and is steadily affecting many low and middle-income countries, particularly in urban settings. The prevalence has increased at an alarming rate. Globally in 2016, the number of overweight children under the age of five, is estimated to have been over 41 million.
Overweight and obese children are likely to stay obese into adulthood and are more likely to develop non-communicable diseases (NCDs) such as diabetes and cardiovascular diseases at a younger age. Today, more and more children are being diagnosed with diabetes, hypertension and other co-morbid conditions associated with obesity and morbid obesity. NCDs have reached crisis levels in the Pacific, and obesity is one of the most visible indicators of that crisis. Overweight and obesity, as well as their related diseases, are largely preventable. Prevention of childhood obesity therefore needs high priority.
Childhood obesity in Pacific Island countries
Among the top ten countries with the highest prevalence of obesity globally, nine are Pacific Island countries (World Health Organization, 2015), and an estimated 43 per cent of adults in Pacific Island countries are obese, based on 2016 data from the WHO. That’s more than three times the global average. Overall, the Pacific region is home to seven out of 10 of the world’s most obese countries.
Statistics show that childhood obesity is on the rise in Fiji. The prevalence increases with age with 12-14 per cent of 10–14-year-olds classified as overweight. About 8.1 per cent of children between the ages of 15 and 17 top the list among children in Fiji for being overweight.
Survey results of the obesity prevention in children (OPIC) project indicated high rates of overweight and obesity in adolescents aged between 13 and 15 years. Prevalence of obesity among younger children aged 11 years and below is also an emerging public health concern and this is a bad situation and a slow-motion disaster.
Definition of childhood obesity
Although definition of obesity and overweight has changed over time, it can be defined as an excess of body fat that presents a risk to health. The range of weights for individuals if greater than the ideal weight, which is considered healthy for the particular height, is termed as either overweight or obese. There is no consensus on a cut–off point for excess fatness of overweight or obesity in children and adolescents.
Body mass index (BMI) is a simple index of weight-for-height that is commonly used to classify overweight and obesity in adults. It is defined as a person’s weight in kilograms divided by the square of his height in metres (kg/m2).
Evaluation of obesity begins with calculation of body mass index (BMI), which has clinical validity because it correlates with adiposity, adult adiposity, cardiovascular risk factors and long-term mortality. Unfortunately, there is no perfect cut-point for BMI that identifies all children with elevated body fat. Because BMI norms change with age and differ between boys and girls, absolute BMI is not an appropriate screen in children.
The Centre for Disease Control (CDC) and Prevention, USA defined overweight as at or above the 95th percentile of BMI for age and “at risk for overweight” as between 85th to 95th percentile of BMI for age. European researchers classified overweight as at or above 85th percentile and obesity as at or above 95th percentile of BMI.
An Indian research study has defined overweight and obesity as overweight (between ≥85th and obesity (≥95th percentile). Another study has followed World Health Organization growth reference for defining overweight and obesity.
Causes of childhood obesity
There is no single element causing this epidemic, but obesity is due to complex interactions between biological, developmental, behavioural, genetic and environmental factors. The role of epigenetics and the gut microbiome, as well as intrauterine and intergenerational effects, have recently emerged (Kansra et al). Other factors including small for gestational age status at birth, formula rather than breast feeding in infancy and early introduction of protein in infant’s dietary intake have been reportedly associated with weight gain that can persist later in life. The most common cause of obesity throughout childhood and adolescence is an inequity in energy balance; that is, excess caloric intake without appropriate caloric expenditure.
Even though there are genetic predispositions that contribute to the development of obesity, several researchers argue that environmental factors, in particular the changes in recent years that have led to a so called “obesogenic environment”, are responsible for the dramatic increase in obesity In the Pacific Island countries, extensive dietary changes have been occurring, leading to obesity. The reliance on traditional foods has declined and the reliance on imported and processed foods has increased. Apart from this, physical activity among Pacific Islanders has decreased.
Genetic factors
There are certain genetic factors which may lead to obesity in children. These genetic factors increase the child’s susceptibility for obesity. Genetic factors may influence the metabolism, by changing the body fat content and energy intake and energy expenditure. Heritability of obesity from parents also influences obesity in children.
Behavioural factors:
There are some behavioural factors which can cause obesity. Sometimes children eat more or consume more energy via food and beverages which are not utilised appropriately. Children may eat large portions of food, foods high in sugar and energy-rich foods. If energy intake is higher than energy expenditure, it may lead to weight gain in children.
Lack of physical activity also plays an important role in obesity. Energy gained should be properly balanced by energy expenditure. It is seen that sedentary lifestyle is an important factor for obesity, as many children spend most of their time in front of television, play video games and watch computers and mobile phones. Children are prone to sedentary lifestyle such as watching television, consuming more energy-dense foods or snacks with large portion sizes, and having reduced physical activity, giving rise to obesity. In addition, the television and social media advertisements of energy-rich and sugar-rich foods influence children to make unhealthy choices. These unhealthy food choices may lead to weight gain and obesity.
Environmental factors
Environmental factors are those that surround the children and influence their food intake and physical activity. These factors are seen in various settings such as at home, in school, and in the community. At home, the parent-child interaction is very crucial as parents can influence children food choices and motivate them to have a healthy lifestyle. Children spend most of their time at school, so school can promote healthy food choices and physical activity among them. Community’s lack of accessibility and affordability of healthy food can affect the nutrition of these children. Their lack of physical activity may be because of lack of facilities such as safe side walks, bike paths, and safe parks.
Consequences of childhood obesity Growth and puberty:
Excess weight gain in children can influence growth and pubertal development. Childhood obesity can cause prepubertal acceleration of linear growth velocity and advanced bone age in boys and girls. Hyperinsulinemia is a normal physiological state during puberty, but children with obesity can have abnormally high insulin levels. Excessive weight gain can initiate early puberty and menstrual irregularities in adolescent girls due to altered hormonal parameters.
Sleep disorders:
Obesity is an independent risk factor for obstructive sleep apnoea (OSA) in children and adolescents. In children, abnormal behaviours and neurocognitive dysfunction are the most critical and frequent end-organ morbidities associated with OSA. In adolescents, obesity and OSA can independently cause oxidative systemic stress and inflammation, and when this occurs concurrently, it can result in more severe metabolic dysfunction and cardiovascular outcomes later in life.
Psychological issues:
Obese children and adolescents may experience psychosocial sequelae, including depression, bullying, social isolation, diminished self-esteem, behavioural problems, dissatisfaction with body image, and reduced quality of life.
Other health risks:
Obesity is related to a clinical spectrum of liver abnormalities such as non-alcoholic fatty liver disease (NAFLD), the most important cause of liver disease in children. NAFLD is closely associated with metabolic syndrome including central obesity, insulin resistance, type 2 diabetes, dyslipidaemia and hypertension.
The physical effects may also reflect on musculoskeletal system causing discomfort due to increased weight on joint, causing muscle and bone disorder.
Prevention of childhood overweight and obesity
Even though there are genetic predispositions that contribute to the development of obesity, several researchers argue that environmental factors, in particular the changes in recent years that have led to a so called “obesogenic environment”, are responsible for the dramatic increase in obesity In the Pacific Island countries, extensive dietary changes have been occurring, leading to obesity. The reliance on traditional foods has declined and the reliance on imported and processed foods has increased. Apart from this, physical activity among Pacific Islanders has decreased.
Overweight and obesity, as well as related non-communicable diseases, are largely preventable. It is recognised that prevention is the most feasible option for curbing the childhood obesity epidemic since current treatment practices are largely aimed at bringing the problem under control rather than effecting a cure. The goal in fighting the childhood obesity epidemic is to achieve an energy balance which can be maintained throughout the individual’s life span.
There are three levels of prevention in dealing with childhood obesity:
- Primordial prevention: deals with keeping a healthy weight and a normal BMI throughout childhood and into the teens.
- Primary prevention: aims to prevent overweight children from becoming obese.
- Secondary prevention: directed toward the treatment of obesity so as to reduce the comorbidities and reverse overweight and obesity if possible.
Behavioural intervention:
The complications caused due to childhood obesity are severe and could continue to affect the health of a child even in adulthood. Hence, there is need to address this problem at every possible step through effective interventions and motivation strategies. The recommended initial treatment for children and adolescents with obesity is behavioural counselling and compliance with behavioural change that increases the likelihood of sustained weight loss.
Parents’ understanding for a convenient behavioural intervention to promote healthy weight management for families is vital. Interventions should incorporate the perspectives of parents, particularly the barriers faced by families from poor and underserved communities, to develop sustainable and feasible behavioural interventions for the treatment of childhood obesity. Family-based cognitive behavioural interventions, which focus on increasing healthy eating behaviours and physical activity and decreasing unhealthy eating and sedentary behaviours, are critical for these children.
Family-based lifestyle intervention:
Family bonding is a strong structure in the behavioural moulding of the child. Hence, effective interventions in a family setting can be beneficial to change child’s behaviour of overeating and unhealthy choice of food. It is essential that parents are aware of the potential risk the child is facing due to obesity and take actions to control the problem. The engagement of the whole family in a weight management intervention is important.
School-based intervention:
Children spend most of their time in schools. Hence, school plays an important role in the life of the child. There are many school-based intervention strategies. Some interventions focus on nutrition-based or physical-based aspect of weight-control independently, while others jointly focus on both aspects of nutrition and physical activity. Schools can encourage kids to make a healthy food choice like reducing the intake of carbonated drinks or sugary foods, encourage kids to drink healthy fruit juices, water, vegetables, and fruits. Schools which provide meals can have healthy nutritious food items with emphasis on a balanced diet. Schools can involve kids in physical activity by strategies like lengthening the time of physical activity; involving them in moderate to vigorous physical activity for short durations, encouraging them to walk or active commuting, and taking stairs instead of elevators.
Community-based intervention:
Community plays a crucial role in healthy lifestyle of children. Community can help children to get affordable and accessible healthy food options and encourage healthy nutrition. Community organisations along with parents can promote nutrition and physical activity-based programs for children. Community can make the neighbourhood safe and accessible to children and motivate them to increase physical activity and provide children with easily accessible facilities like gymnasiums and supervised physical education with strategies such as music for physical activities. Other programs such as providing play groups with safe play grounds and bike paths for kids to play outside will reduce their time spent in front of television sets and with mobile phones. Community can influence media or local entertainment to promote healthy educational programs for parents and children.
Role of primary care
provider/family physician:
Primary care providers/family physicians play a unique role in the prevention of obesity as they see the same patients and families on a regular basis. This gives them the opportunity to provide anticipatory guidance and counselling that can influence families’ nutrition and physical activity habits. It is well established that there are strong familial links to obesity, both genetic and environmental. These influences do not dictate fate however. By recognising risk factors early in a child’s life, primary care providers can help families make positive changes that will improve a child’s weight trajectory.
WHO recommends the following
to reduce and prevent childhood
overweight and obesity:
Promotion of healthy foods and beverages: increase consumption of fruit and vegetables, as well as legumes, whole grains and nuts and discouraging/reducing the intake of carbonated drinks or sugary foods.
- Availability of healthy foods
- Limit energy intake from total fats and shift fat consumption away from saturated fats to unsaturated fats
- Limit the intake of sugars
- Physical activities in schools and day-cares
Be physically active and accumulate at least 60 minutes of regular, moderate, to vigorous intensity activity each day that is developmentally appropriate
- Maintenance of safe neighbourhoods that encourage physical activity
Conclusion
Childhood obesity is a serious health problem that has adverse and long-lasting consequences for individuals, families, and communities. The magnitude of the problem has increased dramatically during the last three decades. Obesity increases the risk of developing early puberty in children, menstrual irregularities in adolescent girls, sleep disorders such as obstructive sleep apnoea, cardiovascular risk factors that include Prediabetes, Type 2 Diabetes, High Cholesterol levels, Hypertension, NAFLD and Metabolic syndrome. Additionally, obese children and adolescents can suffer from psychological issues such as depression, anxiety, poor self-esteem, body image and peer relationships, and eating disorders. Overweight and obesity, as well as their related diseases, are largely preventable. Prevention of childhood obesity therefore needs high priority.
Among the top ten countries with the highest prevalence of obesity globally, nine are Pacific Island countries. In the Pacific Island countries, extensive dietary changes have been occurring, with declining reliance on traditional foods and increasing reliance on imported and processed foods. Environmental factors, in particular the changes in recent years that have led to a so called “obesogenic environment”, are the major reasons responsible for the dramatic increase in obesity In the Pacific Island countries, extensive dietary changes have been occurring, leading to obesity. The main factors contributing to obesity in Pacific Island countries were globalization, increased international trade, urbanization, physical inactivity, changing eating patterns and culture.
The management of obesity must include the patient, family, school, community and even government for policy changes. Lifestyle changes are the mainstay of prevention and treatment including a healthy diet and increased physical activity. Community and policy changes concerning food and physical activities may facilitate practical strategies against the increasing obesity epidemic.
- Dr Sivaselvam Sivakumar is the laboratory head/transfusion services and consultant pathologist at Oceania Hospitals Pte Ltd. The views expressed are the author’s and do not reflect the views of this newspaper.
