CME article (Series 9) – Nutrition

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Treatment and prevention of childhood obesity

Ceylon Medical Journal 2011; 56: 77-80

Obesity is defined as accumulation of excess fat in In clinical practice body mass index (BMI) is used as
body associated with adverse health outcomes [1]. a convenient surrogate marker to diagnose obesity.
Although consensus is lacking, a body fat content of However, current BMI cut-off values are not sensitive in
more than 20-25% in boys and 25-32% in girls are detecting obesity in Sri Lankan children mainly due to the
associated with morbidity [2,3]. Socioeconomic high fat content South Asians have for any given BMI
advancements leading to nutritional transition from a compared to many other ethnic groups [5]. BMI "tracks"
traditional diet to a high fat, refined carbohydrate from about 6 years of age into adult life. A small increase
containing diet accompanied by sedentary behaviour has of BMI in childhood will lead to a larger difference during
made childhood obesity an emerging problem in many adult life and it is resistant to change [6]. The danger of
developing countries. childhood obesity is that it persists into adulthood and
related pathological changes begin from childhood leading
Effects of obesity are both physical and
to non communicable diseases and complications at a
psychological. It could affect any organ of the body either
younger age. Therefore early detection and correction of
metabolically (diabetes mellitus, cardiovascular disease,
childhood obesity is of paramount importance.
NAFLD/NASH, metabolic syndrome, glomerular disease,
polycystic ovarian syndrome, gall stones and
pseudotumour cerebri) or mechanically (slipped capital Diagnosis
femoral epiphysis, genu alga, tibia vara, flat foot, scoliosis Obesity is diagnosed when BMI is >95th centile (or
and osteoarthritis). Psychological effects are bullying, >2 SD). BMI between 85th to 95th centile (+1 to +2 SD) is
peer rejection, lack of friends, lack of self confidence and considered as overweight or at risk of obesity. Gender
low job opportunities [4]. Obesity occurs due to surplus specific BMI for age and WHO growth charts can be used
of energy being deposited as fat in the body. The only for calculation of BMI (http://www.who.int/childgrowth/
way of preventing excess calorie deposition is by utilising en/). Both groups need complete clinical evaluation and
them through physical activity. management (Figure 1).

 
BMI >85th centile 
(>1 SD) 

Abnormal   History and clinical  Normal 

evaluation 

Low height velocity,   Evaluate for obesity 
Signs of endocrine  related comorbidities  
Antipsychotic, 
disease or dysmorphism   antiepileptic use 

Initiate lifestyle changes  
Endocrine evaluation  Revise medication 
± Treat comorbidities   
Genetic evaluation  

Poor control of weight  Weight maintained or 
reduced 

Consider  Maintain support for 
Specific treatment   pharmacotherapy  
lifestyle changes   
(± Surgery)   

Figure 1. Diagnosis and management flow chart.

Vol. 56, No. 2, June 2011 77

CME article (Series 9) – Nutrition

Aetiology frequency of beverages, snacks, fast food and outside

meals taken are important in the management. Detailed
Majority of cases is due to excess calorie intake and
activity history should include frequency and duration
is known as simple obesity. Only a minority are due to
spent on physical activity both at home and school,
pathological causes. They could be due to a syndrome
amount of structured activities including participating in
(Bardet Biedel, Alstrom, Prader Willi, Down) or an endocrine
team sports and forms of physical activity engaged in day
disorder (hypothyroidism, growth hormone deficiency,
to day life. Another important aspect of activity history is
Cushing disease/syndrome, pseudohypoparathyroidism). information on sedentary behaviour (spent in front of
In simple obesity, both weight and height increase and television, video games and computers). It is a way of
the distribution in weight for age and height for age charts spending time with minimum consumption of energy. Drug
are similar similar (both above median). However, as a rule history is important as antipsychotic medication
of thumb, pathological obesity results in a short obese (risperidone) and antiepileptics (sodium valproate) are
child (height below median). Exceptions are adrenal tumour associated with obesity.
with concomitant hypersecretion of androgens and cortisol
Complete physical evaluation including waist
and the condition termed growth without growth hormone
circumference measurement (measured in the horizontal
which is a rare condition seen in central nervous system
plane at the level of midpoint between iliac crest and costal
pathologies [4]. Clinical history and examination will help
margin in the mid-axillary line), blood pressure
in identifying these conditions. Leptin deficiency, although
measurement using correct size cuff and interpreting using
a pathological condition, behaves like simple obesity as
appropriate tables, examining for acanthosis and clinical
the effects are brought by excess calorie intake. When it
features suggestive of endocrine or syndromic causes is
is clinically suggestive of simple obesity, investigations
useful in determining the aetiology and complications [7,8].
for pathological aetiology (genetic and endocrinological
evaluation) can be deferred.
Investigations
Clinical evaluation In an obese child (above 5 years) with the clinical
suspicion of simple obesity, basic investigations are
A complete clinical history including birth history performed to evaluate associated comorbidities rather than
(weight, maturity, maternal illnesses), family history to identify the aetiology. Fasting blood sugar, lipid profile
(obesity in parents and siblings, diabetes and and amino transferase levels (ALT and AST) are done
cardiovascular disease), medical history (sleep apnoea, after a 12-hour overnight fast. A load of anhydrous glucose
polydypsia, polyuria, recent weight loss, acne, hirsuitism 1.75 g/kg body weight to a maximum of 75 g is given
and menstrual history in a pubertal girl suggestive of dissolved in water (taken within 5 minutes) and blood will
polycystic ovary syndrome, school performance, day time be drawn for random blood sugar at the end of 2 hours
somnolence) are important to identify aetiology and (Table 1). Investigations in an obese child below 5 years
complications. Although unreliable and subject to error, of age are usually done only when there is severe obesity
detailed feeding history is important to outline the with strong family history of comorbidities or resistant to
management. Information about type, quantity and initial therapy.

Table 1. Cutoff values for diagnosing impaired glucose homeostasis and dyslipidaemia

Comorbidity Cutoff value

Impaired fasting glucose FBS >100 mg/dl but <126 mg/dl

Impaired glucose tolerance 2-h OGTT >140 but <200 g/dl
Diabetes mellitus FBS ≥126 mg/dl or 2-h OGTT ≥200 mg/dl
Dyslipidaemia
Triglyceride ≥160 mg/dl 90th centile
≥150 mg/dl (cutoff for metabolic syndrome[13])
Total cholesterol ≥200 mg/dl (90th centile)
LDL cholesterol ≥130 mg/dl (90th centile)
HDL cholesterol ≤35 mg/dl (25th centile)

Conversion of mg/dl to mmol/l; glucose × 0.5555, cholesterol ×0.0259, triglyceride ×0.0113

78 Ceylon Medical Journal

 CME article (Series 9) – Nutrition

Ultrasound scan of abdomen will help in detecting among other members as well. Taking the meals at a regular
hepatic steatosis or non alcoholic fatty liver disease time with whole family together is important. Meal times
(NAFLD) and in the presence of an elevated ALT and should be short and "grazing" throughout the day should
high ALT: AST ratio it is suggestive of non alcoholic steato be avoided. Fizzy sweetened beverages should be replaced
hepatitis (NASH), provided there had been no other illness by water. This will not only help in reducing obesity, but
accountable for hepatitis within the recent past. also improve dental health.
Persistence of elevated ALT for more than 6 months
requires further investigations for an underlying liver
Physical activity
pathology and warrants a liver biopsy for a definitive
diagnosis. Features suggestive of a genetic or endocrine Physical activity will not only help in reducing weight
disorder warrants special investigations and /or referral but also improve body composition and cardiovascular
to a specialised centre. Bone age is advanced in simple fitness. Minimum of 60 minutes of moderate to vigorous
obesity but matches the height age of the child. physical activity is recommended [4]. At the onset many
Investigations need to be repeated once in every 6-12 children would be unable to engage in physical activity
months depending on the degree of abnormality and for such an extent of time due to fatigue and would give
response to management. up. The thick subcutaneous fat layer prevents dissipation
of heat leading to easy fatigue. Therefore in the initial
stages they should engage in physical activity for short
Management
time spells alternating with relaxation. However, the
The mainstay of management is behaviour exercise session should continue for the entire period (60
modification and it should involve the whole family. minutes) although the cumulated exercise time would be
Targets need to be set and would depend on the pubertal well under 60 minutes. Once the subcutaneous fat layer
stage. Ultimate goal of management is to achieve an thins and endurance builds up children will be able to
appropriate weight for height (BMI) and control/prevent engage in physical activity for longer periods with less
any complications. The initial target for children who have relaxation. Physical activity alone does not bring down
not undergone the pubertal growth spurt (Tanner stage the weight. Calorie restriction is important and they should
≤2 in girls and 3≤ in boys) is to maintain weight till the not be given calorie rich beverages and snacks especially
pubertal growth spurt occurs (minimum of 2 years). When after exercise. Similarly children engaged in competitive
the pubertal growth spurt occurs while maintaining the sports should cut down calories during the off season.
weight, the BMI will decrease. However, if weight could
be reduced it is a bonus. The BMI should reach below As much as engaging in physical activity, limiting all
85th centile (1SD). Children who have passed the pubertal sedentary activity (TV viewing, computer and play station
growth spurt need to lose weight to achieve a satisfactory usage) to a maximum of 1-2 hours per day is important. It
BMI. Although most of the targets are achieved during is important for children to get involved in day to day
the initial phase of management, sustaining them over a household activities and restrict the use of automated
long period of time is not easy. Therefore a gradual change appliances.
in behaviour over a long period of time is more practical
and should involve changes in the whole family. Psychosocial issues
As children are growing it is important to provide Main difficulty in management of obese children is
adequate calories to prevent protein catabolism. motivating them as well as parents to adhere to the
Micronutrient deficiencies as well as essential fatty acid management plan. Parents should be educated about
deficiencies should be avoided. Providing about 80% of healthy rearing practices related to diet and activity. It will
the normal calorie requirement is appropriate. Selecting help not only treating the patient but preventing obesity
high fiber diet with low glycaemic index food is important. in other members of the family and improving the quality
Fruit and vegetable intake, minimum of 5 portions a day, of life of entire family. Parents should set an example of
should be increased. Intake of refined carbohydrates and behaviour (food and physical activity) for children to
fatty foods should be restricted. Non fat milk is follow. It is important to teach children coping skills as
recommended above 2 years of age as children under 2 they are constantly being bullied by peers.
years are more prone to develop essential fatty acid
deficiencies. A dietician's advice would be useful.
Pharmacological therapy
Rather than banning food items, the policy should
be to allow them in a restricted manner. Food based portion Pharmacotherapy is indicated only when behaviour
sizes can be used as a guide to determine the amount of modification programmes have failed to achieve any
food that each child should receive [9, 10]. The practical control and severe comorbidities exist. Poor weight control
way of avoiding consumption of high calorie containing with strong family history of type 2 diabetes mellitus and,
refined food is by avoiding stocking them at home. cardiovascular risk strengthen the case to start medication.
Therefore the cooperation of the entire family is needed Although several agents are available only sibutramine,
and by doing so it will help preventing obesity/overweight orlistat and metformin are commonly used [4].

Vol. 56, No. 2, June 2011 79

CME article (Series 9) – Nutrition

Bariatric Surgery 3. Lohman TG. The prevalence of obesity in children in the

United States. In: Advances in body composition assess-
Bariatric surgery is used in a highly selective manner ment. Human Kinetics, Champaign, IL. Monogram 1992;
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satisfactory behaviour modification programme with
4. August GP, Caprio S, Fennoy I, et al. Prevention and
pharmacological agents has failed. Commonly agreed treatment of paediatric obesity: an endocrine society clinical
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Prevention of obesity Davies PSW. BMI as a measure of obesity in Sri Lankan
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could already be obese or are highly vulnerable to develop Dietary Guidelines for Sri Lankans (2002) Colombo, Sri
obesity. Lanka.
Clinicians should play an advocacy role in drawing 10. Gidding SS, Dennison BA, Birch LL, et al. Dietary
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V P Wickremasinghe1
1
Department of Paediatrics, Faculty of Medicine, University of Colombo, Sri Lanka.
Correspondence: VPW, e-mail <pujithaw@yahoo.com>.

80 Ceylon Medical Journal