| Till age four, AT was a lean child. Then an episode of fever led to serious weight loss. On recovery, her parents made it their primary responsibility to feed her. Within a year, she put on so much weight that she was euphemistically referred to as "healthy". AT, never too keen on sport, started spending more time on "computer games" and "chatting" on the Net. By the time she came to me as a patient, she was 10 and weighed a worrying 72 kg. Is she a rare entity in today's urban India? The answer is a resounding and deafening 'No'. Studies from across the country, especially among urban middle and upper classes, demonstrate that between 20-25 per cent children are either overweight or obese. Over a period of two decades, the average weight of children has increased by over five kg, which in public health terms is equivalent to an "epidemic". Our own study, from the All India Institute of Medical Sciences (AIIMS) among schoolchildren in Delhi, showed that about one-quarter weighed more than their suggested ideal. The problem seemed to start early, with 10 per cent of even five-year-olds being overweight or obese. And it peaked with onset of puberty in both boys and girls. The time trends of childhood obesity unequivocally mirror the surge in economic growth in India. A serendipitous confluence of biological, developmental and technical components have contributed to the emerging epidemic that we see today. From a time when food scarcities were a norm to now, when there is abundant food availability at least among the affluent, coupled with a decline in energy expenditure for activities of daily living-the shift in energy balance has been huge. Extreme endocrine and genetic disorders (a minute proportion of this entity), enhanced caloric consumption, declining physical activity, dramatic increase in sedentary activities (including working or playing on computers, watching television) and a rapid socio-economic and nutrition transition combined with easy access to consumer goods-consumables and energy saving-all contribute to the problem. For AT, parental concern over her weight loss led to her spiralling weight gain. To them, the term "healthy" denoted the misconception that a few extra kilograms have a positive health connotation. An inappropriate health notion that finds currency across the country. Is there more to overweight in a child than merely a cosmetic issue? The unfortunate reality is that the significant health implications of childhood obesity are yet to be universally recognised, even among the medical fraternity. When we evaluated more than 500 overweight and obese children in Delhi, 10 per cent had abnormalities of glucose metabolism (with frank diabetes among one per cent); nearly two of every five children had abnormal cholesterol levels. This data was reaffirmed recently by a larger study involving over 3,000 children-with a similar proportion having elevated cholesterol. A striking majority had high "bad cholesterol" (LDL) and low levels of "good cholesterol" (HDL). Childhood obesity begets adult obesity with its attendant risk. But, even before that, childhood obesity has immediate health implications: diabetes, high cholesterol, high blood pressure (BP), fatty liver disease and perhaps maximally (less quantifiable but equally critical) psychosocial complications. Studies in the developed world have clearly linked childhood obesity with poor school performance and unhealthy or risky behaviour, including alcohol and tobacco use. Obesity in childhood and adolescence sets off the process of atherosclerosis and is linked to cardiovascular mortality in adults. Lung disorders, such as asthma and obstructive sleep apnea (snoring), are more prevalent among obese children. While obesity reflects increased energy intake, several micro-nutrient deficiencies, namely iron and vitamin D, are much more common in such children. An additional problem, often described from low and middle income countries like India, is when babies born small rapidly gain weight in childhood and adolescence. This has now clearly been shown to be associated with a higher prevalence of diabetes, high bp, lipid abnormalities and other metabolic disturbances. A recent study, following a group of individuals born in south Delhi 40 years ago, shows the implication of this transition from low birth weight to increased weight in young adulthood. The best strategy to counter this problem is a vexed and contentious issue. The ideal approach would be to prevent weight gain. But this is easier said than done. Prevention has to be done at multiple levels-individual, household, school and community. While it is important for the child to be counselled, home and school-based interventions are critical. Parents should be encouraged to offer appropriate food portions and encourage physical activity. And they have to ensure that such advice is followed by all members of the household. It does not help if a child finds others in the family are exempt from the "regimentation" being "imposed" on him or her. A "healthy" school environment is equally important-from suggested food items to be brought in "tiffin" to ensuring adequate sporting facilities. AT's parents had started dragging her to nutrition experts and personal trainers, swimming and aerobic classes. But the child showed limited, if any, enthusiasm. Fortunately, her metabolic parameters did not reveal major derangement. We started a prolonged and gradual intervention programme, through multiple interactions with doctors and nutritionists, where she was encouraged to express her views. As rapport and trust developed between the child and her medical team, she embarked on a self-driven and self-targeted programme of weight loss. Over a period of one year, she lost weight and is now a trim, energetic, physically fit and outgoing 12-year-old. Unfortunately, others are often not as lucky. |
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