Chairman

Institute of Minimal Access, Metabolic & Bariatric Surgery (iMAS) Sir Ganga Ram Hospital | New Delhi

Medical Director

Bhatia Global Hospital & Endosurgery InstitutePaschim Vihar | New Delhi
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Media & Press Coverage

Surgery on the rise for obese teens. 25-Aug-2013 \"If the child is showing comorbidities like diabetes and hypertension, has reached puberty and achieved certain growth milestones then su

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Obesity prompts more cases of bariatric surgeries. 28-Jul-2013 \"By 2020 we will become the diabetic capital of the world. Its alarming.\" says Dr. Parveen Bhatia, Chairman of iMAS at Sir Ganga Ram H

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Childhood Obesity

Obesity is now among the most widespread medical problems affecting children and adolescents living in the United States and other developed countries. Childhood obesity represents one of the  greatest health challenges. These overweight adolescents have a 70% chance of becoming overweight or obese adults and without major lifestyle changes, these kids face a 10 to 20 years shorter life span and will develop health problems in their 20s that is typically seen in 40-to-60-year-olds. 

About 17 percent of children and adolescents are affected and the numbers are expected to continue increasing.  The percentage of children aged 2 to 5 who are obese has increased to 12.4 % in 2006 from 5 percent in 1980. Obesity in teenagers is even higher than that of younger children at 18%. Of these almost 7 percent of boys and 5 percent of girls were extremely obese, as were more than 2 percent of all children under 5 years old.

Determinants and risk factors for Obesity

Although there are some genetic and hormonal causes of childhood obesity, most of the time it’s caused by kids eating too much and exercising too little.

• Diet Regularly taking high-calorie foods, such as fast foods, baked goods and vending machine snacks, loading up on soft drinks, candy and desserts cause tremendous weight gain.

• Lack of exercise Children who don’t exercise much are more likely to gain weight. Inactive leisure activities, such as watching television or playing video games, contribute to the problem.

• Family history If a child comes from a family of overweight people, he or she may be more likely to put on excess weight, especially in an environment where high-calorie food is always available, and physical activity is not encouraged.

• Psychological factors Some children overeat to cope with problems or to deal with emotions, such as stress, or to fight boredom. Their parents may have similar tendencies.

• Family factors If many of the groceries we buy are convenience foods, such as cookies, chips and other high-calorie items, this can contribute to a child’s weight gain. If we can control our child’s access to high-calorie foods, we may be able to help our child lose weight.

• Socioeconomic factors. Children from low-income backgrounds are at greater risk of becoming obese. It takes both time and resources to make healthy eating and exercise a family priority.

• Diseases associated with Obesity eg.  Prader-Willi syndrome, Cushing’s syndrome.

Diagnosis of Obesity

Tests to determine this include:

Weight-to-height tables define obesity in children as body weight at least 20% higher than a healthy weight for a child of that height. The tables, however, do not take into account the individual characteristics of each child like children gaining weight before a growth spurt. 

Body fat percentage This is a good marker of obesity. Boys over 25% fat and girls over 32% fat are considered obese. Body fat percentage is difficult to measure accurately, however.  Measuring skin fold thickness is not reliable unless it is done correctly by a trained and experienced technician.

Body mass index (BMI) is defined as weight in kilograms divided by height in meters squared (kg/m 2). BMI is the standard for defining obesity in adults, but its use in children is not accepted universally. The Centers for Disease Control and Prevention (CDC) suggests two levels of concern for children based on the BMI-for-age charts.
• BMI-for-age between 85th and 94th percentiles — at risk of overweight
• BMI-for-age 95th percentile or above — Overweight 

Waist circumference (WC) This measurement in a child or adolescent correlates closely with the future risk of developing type 2 diabetes mellitus and related complications of the a metabolic syndrome. The assessment is made with a tape measure stretched across the widest abdominal girth and any value over the 90th percentile for age and gender carries the highest risk.

Neck Size: Measuring a child’s neck size is a relatively new method of screening for childhood obesity and is more accurate and easier to obtain than BMI and can be used to identify overweight and obesity in boys and  girls ages 6 to 18. The technique isn’t routinely used yet and further research is needed.

Why is childhood obesity considered a health problem?

Some health problems are much more likely to affect obese children than non-obese children. 
• Asthma, especially severe asthma and other breathing problems. The extra weight on the child’s body can cause problems with the development and health of the child’s lungs, leading to asthma or other breathing problems.
• Diabetes, type 2
• High blood pressure and High cholesterol 
• Heart failure
• Liver problems (“fatty liver”)
• Bone and joint problems in the lower body
• Growth abnormalities
• Early puberty or menstruation. Being obese can create hormone imbalances for the child. These imbalances can cause puberty to start earlier than expected.
• Breathing problems such sleep apnea, a condition in which the child may snore or have abnormal breathing when he or she sleeps.
• Emotional and social problems: Children often tease or bully their overweight peers, who suffer a loss of self-esteem and an increased risk of depression as a result.
• Behavior and learning problems. Overweight children tend to have more anxiety and poorer social skills than normal-weight children have. At one extreme, these children may be aggressive and disrupt their classrooms and at the other, they may be socially withdrawn. Stress and anxiety also interfere with learning, causing declining academic performance.
• Rashes or fungal infections of the skin, acne.

Obese children also are much more likely to have these and other obesity-related health problems in adulthood: 
• Heart disease, Stroke
• Certain types of cancer
• Osteoarthritis, Gout
• Gallbladder disease
• Infertility due anovulation, poor response to infertility treatments including IVF
• A pregnancy complicated by obesity is high risk for the mother and the baby.

Prevention of Childhood Obesity

What can parents do about obesity? Some factors that influence early childhood obesity begin during pregnancy. We know that pre-pregnant weight, excessive weight gain during pregnancy, tobacco use during pregnancy, and diabetes during pregnancy, all contribute to early-childhood obesity.

During pregnancy:

• Babies whose mothers smoked during pregnancy are at risk of becoming obese, even though the babies are usually small at birth. Counsel against excessive smoking during pregnancy.
• If the woman is overweight , encourage to lose weight before pregnancy rather than after, to cut the risk of obesity and diabetes in their children;  
• Siblings born after the mother developed Type 2 diabetes had a higher body mass index throughout childhood and were almost four times as likely to develop diabetes as siblings born before the diagnosis. Keeping blood sugar under control throughout pregnancy has a role in preventing Macrosomia and later development of childhood Obesity. The intrauterine environment of a woman with diabetes over nourishes the fetus, and may reset the offspring’s satiety set point, and make them predisposed to eat more.

After Birth

• In infancy, breastfeeding and delaying introduction of solid foods may help prevent obesity.
• In early childhood, children should be given healthful, low-fat snacks and take part in vigorous physical activity every day. Increase fruit and vegetable intake as these are very filling and decrease satiety.
• Older children can be taught to select healthy, nutritious foods and to develop good exercise habits.
• Reduce television time, and particularly keeping televisions out of children’s bedrooms.

Non Pharmacological Management of Childhood Obesity

Non-pharmacological approaches should be the foundation of all obesity treatments, especially in children, and should always be considered as first-line therapy.
Treatment for children under age 7 and have no other health concerns, the goal of treatment should be weight maintenance rather than weight loss. This strategy allows the child to add inches in height but not pounds, causing BMI-for-age to drop over time into a healthier range. 

Treatment for children 7 years of age and older: Weight loss is typically recommended for children over age 7 and for those having related health concerns. Weight loss should be slow and steady — anywhere from 1 pound (about 0.5 kilograms) a week to 1 pound a month, depending on child’s condition.

Advice 

Healthy eating

- When buying groceries, choose fruits and vegetables.
- Limit sweetened beverages
- Limit the number of times you eat out, especially at fast-food restaurants. Many of the menu options are high in fat and calories.
- Discourage eating in front of a screen, such as a television, computer or video game.

Physical activity

-  Limit recreational computer and TV time to no more than 2 hours a day.
-  Emphasize activity, not exercise: the objective is just to get him or her moving. Free-play activities, such as playing hide-and-seek, tag or jump-rope, can be great for burning calories and improving fitness.
-  Find activities your child likes to do.
-  If you want an active child, be active yourself. Find fun activities that the whole family can do together. Never make exercise seem a punishment or a chore.

Pharmacological agents for managing Childhood obesity

Prescription weight-loss medication isn’t often recommended for adolescents. The risks of taking a medication long term is still unknown, and its effect on weight loss and weight maintenance is still questioned.  However, these  agents provide modest to moderate, short-term reduction in body weight and may be good options when lifestyle modifications alone do not work.

Orlistat  is a potent and irreversible inhibitor of gastric, and pancreatic carboxyl ester lipases, thus decreasing the hydrolysis of the ingested triglycerides. It produces a dose-dependent reduction in dietary fat absorption. Orlistat has also been shown to reduce the percentage of subjects with impaired glucose tolerance who progress to develop overt diabetes mellitus. However, its role is limited by the FDA for adolescents 12-18 years old and having BMI more than 2 units above the 95th percentile for the age and gender. The use is limited due to the severe side-effects such as fatty or oily stools along with a risk of possible malabsorption of fat soluble vitamins like Vitamin D leading to increased bone turnover and osteopenia and risks of gall bladder disease. Binge eating, a psychiatric condition leading to obesity has also been managed by using orlistat.

Sibutramine This drug has been approved by FDA and registered in many countries. It is a serotonin and noradrenaline reuptake inhibitor. The drug  associated weight loss occurs within the first 6 months of treatment, and it may be maintained for at least 2 years. It may have favorable effects on cardiovascular risk factors, as well as improving glucose control in patients with diabetes.  But there are concerns about tachycardia and increase in blood pressure, given the high rates of systolic hypertension among obese adolescents. Other side-effects are dry mouth, constipation , dizziness and insomnia. 

Larger and longer studies are needed to assess the benefits and hazards of sibutramine treatment in obese adolescents.

Rimonabant, a cannabinoid receptor antagonist, caused mean weight loss of 3-6 kg over 1-year follow-up at doses of 5-20 mg/d.  Side effects include Gastro intestinal distress, Psychiatric and nervous system disorders like anxiety, depression, dizziness, insomnia. Suicidal ideation has also been reported. 

Statins if the child has high cholesterol, sometimes statin medication may be recommended.  Statins help lower cholesterol, but their use in children remains controversial, since it’s uncertain what long-term side effects they might have.

Bariatric Surgeries for Surgical management of obesity

Weight-loss surgery can be a safe and effective option for some severely obese adolescents who have been unable to lose weight using conventional weight-loss methods. However, as with any type of surgery, there are potential risks and long-term complications. The surgical mortality rate is less than 0.5% at centers specializing in bariatric surgery. But, the long-term effects of weight-loss surgery on a child’s future growth and development are largely unknown.

Among the standard bariatric procedures are:

• Roux-en-Y gastric bypass reduces stomach size and is the most common procedure performed.

• Biliopancreatic diversion with duodenal switch is similar in some ways to Roux-en-Y gastric bypass, but keeps some stomach function intact while bypassing most of the intestine.

• Laparoscopic Adjustable Gastric banding involves placing an inflatable band around the upper portion of the stomach to restrict the amount of food one can consume. This minimally invasive procedure is adjustable and reversible.

• Jejunoileal bypass procedures

• Sleeve gastrectomy involves surgically removing the left side of the stomach, leaving a much smaller stomach about the size and shape of a banana.

Bariatric Surgeries are done mostly using minimally invasive (laparoscopic) surgery, which can help decrease hospital stay time and speed up recovery.