Childhood obesity: a serious public health challenge.

Introduction

Childhood obesity has reached epidemic proportions and is today one of the most serious public health challenges of the 21st century. The problem is global; even though, more recently the childhood obesity rates appear to be plateauing in high-income countries, albeit at unacceptably high levels, they continue to soar in low- and middle-income countries. A study led by Imperial College, London and WHO, which analysed weight and height measurements from nearly 130 million people, including 31.5 million children aged 5-19 years of age, was published in ‘The Lancet’, a prestigious medical journal, on the eve of the World Obesity Day on 11th Oct 2017. According to the study, the areas of the world with some of the largest increase in the number of obese children and adolescents were East Asia and the Middle East and North Africa.

The rise in childhood obesity rates has recently accelerated, especially in Asia. According to the study, the world will have more obese children and adolescents than underweight by 2022. Unfortunately, in spite of the rapid rise in child and adolescent obesity rates globally, few countries are taking action against this damaging health issue. To focus world attention on this burning issue, World Obesity federation chose the theme ‘Childhood Obesity’ for the World Obesity day 2017, celebrated on 11th Oct each year.

How do you define childhood obesity?

In my post ‘What is obesity – is it merely about BMI? I had defined obesity as “a condition of abnormal or excessive body fat accumulation, to the extent that health may be impaired.” In my post ‘Body Mass Index – is it the best measure of obesity? I had highlighted that Body Mass Index (BMI) is the most widely used measure of identifying obesity. In the post, I had also discussed the interpretation of BMI in children and adolescents, including criteria for defining obesity in children and adolescents based on gender-specific BMI-for-age percentile charts.

WHO has defined overweight and obesity in children and adolescents based on the WHO Child Growth Standards. For children, age needs to be considered.

Children under 5 years of age

Overweight and obesity are defined as follows for children under 5 years of age:

Overweight – weight-for-height greater than 2 standard deviations above WHO Child Growth Standards median.

Obesity – weight-for-height greater than 3 standard deviations above the WHO Child Growth Standards median.

Children and adolescents aged between 5-19 years

Overweight and obesity are defined as follows for children aged between 5-19 years.

Overweight – BMI-for-age greater than 1 standard deviation above the WHO Growth reference median.

Obesity – BMI-for-age greater than 2 standard deviations above the WHO Growth Reference median.

There are three different systems by which a child or group of children can be compared to the reference population: Z-scores (standard deviation scores), percentiles, and per cent of median. Detailed discussion on the subject is beyond the scope of this post. Interested readers may access the weight-for-height charts and BMI-for-age charts (both z-scores and percentiles) for both boys and girls, age category wise, on the WHO site, link for which is given above.

Prevalence of childhood obesity

As per the study led by Imperial College of London and WHO, referred to above, in a span of just 40 years, the number of school-age children and adolescents (5-19 years of age) with obesity has risen more than 10-fold from 11 million in 1975 to 124 million in 2016. Many children who are not yet obese are overweight and on the pathway to obesity. An estimated 216 million children were classified as overweight but not obese in 2016. Traditionally the focus has been on children over 3 years of age but there is now evidence of a worrying prevalence of overweight and obesity in the under 5 age group with increases in the prevalence of both high birth weight babies and obesity in 1-5 year olds.

The number of overweight or obese infants and young children (aged 0 to 5 years) increased from 32 million globally in 1990 to 41 million in 2016. If current trends continue, the number of overweight or obese infants and young children globally will increase to 70 million by 2025. The vast majority of overweight or obese children live in developing countries, where the rate of increase has been more than 30% higher than that of developed countries. Almost half of all overweight children under 5 lived in Asia and one quarter lived in Africa.

Causes of childhood obesity

As in adults, childhood obesity is a complex, multifactorial (having or stemming from a number of different causes or influences) condition, affected by both genetic and non-genetic factors.

1. Genetic factors

The role of genetic factors in the causation of obesity is well established. However, one’s genetic makeup per-se does not necessarily cause obesity; instead due to the impact of susceptibility genes, the threshold for development of obesity is lowered. Obesity seems to be the result of a complex interplay between the ‘environment’ and the body’s predisposition to obesity based on genetics and epigenetic programming.

In an obesogenic environment (an environment that promotes high energy intake and sedentary behaviour. This includes the foods that are available, affordable, accessible and promoted; physical activity opportunities; and the social norms in relation to food and physical activity) – sedentary and stressful with ready access to abundant (it’s all around – in the neighbourhood, school and workplace), tasty, low-cost, high-calorie convenient foods – the genetically susceptible, obesity-prone individuals gain excessive body fat.

Contrary to the common belief that it’s a single defective gene which predisposes to obesity, nearly, 100 genes have been identified that are related to obesity. These genes influence a vast array of energy regulation mechanisms throughout the body, including appetite and satiety. Though, rarely single gene defects have been found to cause obesity.

2. Environmental factors

Every aspect of the environment in which children are conceived, born and raised can contribute to their risk of becoming overweight or obese. The risk of obesity can be passed from one generation to the next and maternal (relating to a mother, especially during pregnancy or shortly after childbirth) health can influence fetal development and the risk of a child becoming obese.

During pregnancy, gestational diabetes (a condition in which a woman without diabetes develops high blood sugar levels during pregnancy) may result in increased birth weight and risk of obesity in the child later in life. Infants born with low birth weight (WHO defines low birth weight as weight at birth less than 2500 g [5.5 lb]) are predisposed to various complications, including increased risk of developing obesity and diabetes later in life. Apart from premature birth, which is the commonest cause of low birth weight, a number of risk factors in mother, including poor nutrition and insufficient antenatal care, may contribute to low birth weight. In brief, the care that women receive before, during and after pregnancy has profound implications for the later health and development of their children.

However, the fundamental causes behind the rising levels of obesity are a shift in dietary and physical activity patterns. Children’s choices, diet and physical activity habits are influenced by their surroundings and rapid social and economic development has changed the environment many children are growing up in.

(a) Food environment

Accompanying the economic development, there was a sea change in the type of food we consume. To begin with, developed nations saw an explosion in fast food outlets and a reduction in those selling fresh produce. However, in the last few decades, globalisation has integrated the various populations spread all across the globe. Though globalisation has had many beneficial effects including on health and medical care, one negative health-related effect of globalisation is a trend known as “nutrition transition”. As a result, populations in low- and middle-income countries are now consuming diets high in total energy, fat, salt and sugar.

While these foods have become more abundant, being readily available to us in our neighbourhood, schools and places of work, and portion sizes have increased, at the same time these foods have become less expensive. Lack of information about sound approaches to nutrition and poor availability and affordability of healthy foods contribute to the problem. Unfortunately, the aggressive marketing of energy-dense foods and beverages to children and families further exacerbate it.

Cultural Norms

In some societies, longstanding cultural norms (such as the widespread belief that a fat baby is a healthy baby), may encourage families to over-feed their children. In certain societies deeply marked by food scarcity, a perverse reverse psychology could be at work; cultural orientation here is to shower food on one’s children as the principal means of showing affection on the part of those who can afford it. This stark reality is strikingly evident in India, which has the highest prevalence of underweight children and adolescents in the world. According to the study led by Imperial College, London and WHO referred to above, India had the highest prevalence of moderate and severely underweight children throughout from 1975 to 2016. 97 million of the world’s moderately or severely underweight children and adolescents lived in India in 2016. Paradoxically, according to a study by WHO, the child obesity rate in India among children and adolescents in the 5-19 years age group is a staggering 22%. This surpasses even the US where child obesity estimates run between 17.5% and 20.5%.

(b) Physical activity environment

The increasingly urbanized and digitalized world offers fewer opportunities for physical activity through healthy play. Unplanned urban sprawl has encroached on open spaces, limiting the availability of parks, ground and stadia. The dramatic rise in the automobiles as a means of transport not only discourages active means of transport such as cycling or walking but has rendered these activities unsafe.

Mechanisation and computerization of human labour over the last few decades has made most jobs sedentary. Not only the occupations have become more sedentary, but even leisure time pursuits have also been taken over by television screens and computer games, making lifestyles more sluggish. Total screen time (amount of time spent using a device such as a smartphone, computer, television, or video game console) has a direct relationship with the development of obesity.

Physical activity declines from the age of school entry and low physical activity is rapidly becoming a norm. Unfortunately, due to the weight bias (negative social devaluation based on body size or body weight), being overweight or obese further reduces children’s opportunities to participate in group physical activities. They then become even less physically active, which makes them likely to become more overweight over time.

(c) Social environment

The changed occupational structures have not only changed the nature of the work but also the hours of work with longer working hours becoming the norm. On top of this, within the current economic environment, most households have become dual income households. Both these factors have left increasingly less time for parents to plan and prepare a meal at home, resulting in lack of structured eating (pre-planned meals at planned times) and increased consumption of convenient takeaway food. Also, in the busy work schedules, eating has become a recreation.

3. Behavioural factors

An obesogenic environment in itself cannot lead to obesity. Whatever the environmental influences on the obesity epidemic, they must be mediated by the population’s eating and physical activity behaviours (i.e. through energy intake and energy expenditure). In this context, our eating and physical activity behaviours are critically important, since it is these behaviours that form the interface between our biology and the environments to which we are exposed. Some important dietary and physical activity behaviours found to be associated with obesity are as follows:

Dietary behaviours

– Frequent consumption of fast foods (i.e. energy dense foods; high in fats and sugars).
– High consumption of beverages high in sugar.
– Consuming large portion sizes.
– Increased consumption of convenient take-away foods.
– Less intake of fruits and vegetables.

Physical activity behaviours

– Time spent watching TV.
– Time spent sitting (reading, computer use, academic work etc.).
– Use of automobiles vs active transportation (i.e. cycling and walking).
– Time spent playing sports at school or in the community.
– Leisure time activities/pursuits.
– Occupational activities.

4. Medical conditions

In rare cases, overweight can be caused by a medical condition such as a hormonal problem. A physical exam and some blood tests can rule out the possibility of a medical condition as the cause of obesity. Some common medical conditions associated with obesity are as under:

Endocrine diseases – Some common endocrine diseases which can lead to obesity are hypothyroidism and growth hormone deficiency or resistance.

Central nervous system pathology – Hypothalamus, is a small region of the brain located at the base of the brain. It plays a crucial role in many important body functions, including controlling satiety and hunger and regulating energy balance. Congenital or acquired hypothalamic abnormalities have been associated with obesity.

Health implications of childhood obesity

In my post, “Is obesity a disease or a risk factor for other conditions?” I had described that obesity is a chronic, relapsing, progressive disease process and is associated with a lot of ill-health. Obesity in adulthood is a major risk factor for the world’s leading causes of poor health and early death including cardiovascular diseases, diabetes, several common cancers and osteoarthritis. These health risks of obesity will be discussed in a subsequent post. So when considering overweight and obesity in children, one important issue is whether they grow out of their problem or are likely to stay obese into adulthood. Many parents think that “baby fat” will melt away as kids get older. However, without intervention, for children over 5 years of age, being overweight incurs at least a 40% risk of their overweight persisting into adult life. By the mid-teenage years, the risk is increased to 60-75%. Compared with children with a healthy weight, those with overweight or obesity are more likely to experience negative health consequences, including:

1. Poorer health in childhood

Obesity during childhood can have a harmful effect on the body in a variety of ways. Children with obesity are more likely to have –

(a) Increased risk for cardiovascular diseases

(i) High blood pressure and high cholesterol, which are risk factors for cardiovascular disease.

A research study based on ultrasound imaging of the neck (carotid) arteries in obese children (both girls and boys; average age 13) was presented at the American Heart Association Scientific Sessions, on 11th Nov 2008. Researchers used ultrasound to measure the thickness of the inner walls of the neck (carotid) arteries that supply blood to the brain. Increasing carotid artery intima-media thickness (measurement of the thickness of tunica intima and tunica media, the innermost two layers of the wall of an artery) indicates presence of atherosclerosis, the fatty buildup of plaque (accumulation of degenerative material in the inner layer of an artery, forming a swelling in the artery wall, which may intrude into the channel of the artery, narrowing it and restricting blood flow) within arteries (blood vessels that carry oxygen-rich blood in your body) feeding the heart muscle and the brain, which can lead to serious health problems, including heart attack, stroke or even death.

Researchers found that obese children as young as 10 had the arteries of 45-year-olds and other heart abnormalities that generally raise their risk of heart disease. In other words, the children’s “vascular age” (vascular age provides you with a measure of the apparent age of your arteries when compared with healthy people. For e.g., if your real age [chronological age] is 45 and your vascular age is 55, this means that your blood vessels are more like those of a healthy 55 years old) was about 30 years older than their actual age.

According to the researchers, vascular age was advanced the furthest in the children with obesity and high triglyceride levels (children with triglycerides over 100 mg/dL were most likely to have an advanced vascular age), so the combination of obesity and high triglycerides should be a red flag to the doctor that a child is at high risk of heart disease. Other risk factors for increased artery intima-media thickness in children are high blood pressure, exposure to second-hand smoke and insulin resistance – which is frequently seen in obese children.

“There’s a saying that ‘you’re as old as your arteries,’ meaning that the state of your arteries is more important than your actual age in the evolution of heart disease and stroke,” said Geetha Raghuveer, M.D., M.P.H., associate professor of paediatrics at the University of Missouri Kansas City School of Medicine and cardiologist at Children’s Mercy Hospital, who led one of the studies. “We found that the state of arteries in these children is more typical of a 45-year-old man than of someone their own age.”

Perhaps the most convincing evidence for the association between obesity and the risk of early onset of cardiovascular diseases has been provided by the findings of atherosclerosis itself on autopsy studies of adolescents; the extent of atherosclerosis was strongly associated with the presence of obesity.

Research studies have also suggested that childhood obesity is associated with higher risk for coronary heart disease and premature death.

High blood pressure is a common obesity-related health problem and its prevalence in youth appears to be increasing along with the rising rates of obesity. Studies have suggested that high blood pressure in childhood tends to persist into adulthood. It independently increases the risk of cardiovascular diseases.

(ii) Metabolic Syndrome

In both children and adults, clustering of various risk factors (metabolic disorders) has been known to increase the chances for future cardiovascular diseases and type 2 diabetes more than any one factor presenting alone. The various metabolic disorders, which are known to increase the risk for CVDs and type 2 diabetes, include – abdominal obesity, high blood triglyceride levels, low HDL cholesterol (good cholesterol) levels, high blood pressure, and hyperglycemia (high blood sugar). In adults, metabolic syndrome has been defined as the presence of 3 or more of these metabolic disorders and is associated with increased risk of both cardiovascular diseases and type 2 diabetes. Metabolic syndrome in adults has been discussed in my posts “Waist size: measure your waist, measure your risk” and “Complications of Obesity: the mother of all diseases”.

However, in children and adolescents, metabolic syndrome remains a controversial topic for several reasons and is challenging to define in this population. In children and adolescents, more than 40 definitions of metabolic syndrome have been proposed and there is no clear consensus on which to use. In addition, metabolic syndrome is highly unstable throughout childhood. A child can meet the criteria at one point in time and not meet it at another point in time.

In view of the above, American Academy of Paediatrics (AAP) recommended that rather than focusing on defining metabolic syndrome in youth, focus should be on screening for various risk factors for cardiovascular diseases. Identifying children with multiple metabolic disorders allows health care providers to target focussed intervention towards children at highest risk for cardiometabolic diseases (cardiovascular diseases and diabetes).

(b) Increased risk of impaired glucose tolerance, insulin resistance, and type 2 diabetes.

With the increasing prevalence of obesity, the prevalence of type 2 diabetes in youth has also been increasing. As the risk of complications associated with obesity increases with age, early development of type 2 diabetes, in childhood, increases the chance of developing these complications early in life. In addition, the course of type 2 diabetes in some youth may be more aggressive than in older adults. The life expectancy in a 20-year-old youth with diabetes is shorter by an average 15.5 years, compared with a youth of similar age but without diabetes. This drastically reduced life expectancy can be explained by various health complications associated with diabetes. For e.g. renal (relating to the kidneys) failure associated with diabetic nephropathy (kidney damage that results from having diabetes) reportedly develops in at least 10% of young adults who were diagnosed with type 2 diabetes in childhood, and is a potentially lethal complication.

(c) Obesity and cancer

While obesity in adulthood has been linked with certain types of cancer (discussed in my post “Complications of Obesity”, referred to above), much less is known about the impact of childhood obesity on future development of cancer. Girls with obesity tend to have early onset of puberty. Hormonal changes takes place in a women with the onset of puberty. Early development of puberty has been shown to be associated with an increase in hormonally influenced cancers in adulthood, including breast cancer. Moreover, obesity in a prepubescent (relating to or in the period preceding puberty) girl is associated with an increased risk for breast cancer after menopause, even after controlling for the adult women’s current BMI.

Obesity related Polycystic ovary syndrome (PCOS) leads to anovulation (state when ovaries do not release an oocyte (an immature female egg cell, which develops into ovum or egg cell), which may also increase the risk for endometrial (related to the inner layer of the uterus [womb]) hyperplasia (abnormal thickening of the lining of the uterus due to an increase in the number of endometrial glands) and endometrial cancer in adulthood. In addition to increasing the risk for developing certain cancers, high BMI has been associated with poor oncological outcomes (survival rates). In adults some studies also suggest that lowering BMI can significantly improve the survival rate in some types of cancer. PCOS has been discussed in details in my post “Complications of obesity” referred to above.

Thus entering adulthood at an already obese BMI may increase the rates of some types of cancer and worsen survival rates once a cancer is contracted.

(d) Gastrointestinal complications

(i) Nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease is characterised by increased accumulation of fat, especially triglycerides, in the liver cells. It is normal for the liver to contain some fat and by itself, this does not cause any symptoms. However, in some patients, the excess fat can cause inflammation called steatohepatitis (steato ~ fat + hepar ~ Latin word for liver + itis ~ a suffix used in pathological terms that denote inflammation of an organ). Steatohepatitis can lead to cirrhosis (chronic liver damage from a variety of causes leading to fibrosis, scarring and hardening.  As liver cells give way to tough scar tissue, the organ loses its ability to function properly. Severe damage can lead to liver failure and possibly death.

Obesity significantly increases the risk for NAFLD. NAFLD also affects the obese children in large numbers; the estimated prevalence of NAFLD in obese youth is 53% compared to 2.6% in normal weight paediatric patients. In children NAFLD presents differently than in adults, with higher rates of fibrosis and cirrhosis than in adults. In comparison with children without NAFLD, children with NAFLD have a 13.6-fold higher chance of mortality (the state of being subject to death) or need for liver transplant.

Thus NAFLD provides another example in which childhood obesity is associated with poor adult outcomes. Currently, no therapies other than weight loss show clear benefit for growth.

(ii) Other GI complications of obesity include gallstones, and gastro-oesophageal reflux (i.e. heartburn, which is a painful burning feeling in your chest or throat. It happens when stomach acid backs up into your oesophagus, the tube that carries food from your mouth to your stomach).

(e) Breathing problems such as asthma and obstructive sleep apnoea (OSA).

These have been discussed in details in my post “Complications of Obesity” referred to above.

(f) Joint problems and musculoskeletal discomfort.

These have been discussed in details in my post “Complications of Obesity” referred to above.

(g) Poor quality of life

Weight bias, due to its effects on physical and psychological health, affects the quality of life (QOL). A landmark study titled ‘Health-Related Quality of Life of Severely Obese Children and Adolescents’ was published in the ‘Journal of the American Medical Association’ in Apr 2003. The study examined the health-related QOL of obese children and adolescents compared with children and adolescents who are healthy or those diagnosed as having cancer. The study found that severely obese children and adolescents have lower health-related QOL than children and adolescents who are healthy and similar QOL as those diagnosed as having cancer. 

The obese children and adolescents reported significant impairment not only in total scale score, but also in all domains – physical, psychosocial, emotional, social and school functioning – in comparison with healthy children and adolescents. Children and adolescents diagnosed as having cancer and who were receiving chemotherapy were previously found to have the lowest QOL scores when compared with healthy children and adolescents and children and adolescents with juvenile rheumatoid arthritis, type I diabetes mellitus, and congenital heart disease.

Children and adolescents diagnosed as having cancer experience severe adverse effects due to treatment and consequently often have difficulties keeping up with their peers and maintaining normal activities. Young cancer patients also experience teasing and withdrawal from peers at school. Although obese children and adolescents may also experience physical limitations and teasing from peers, they are often not exposed to intense medical interventions (and subsequent adverse effects) that are common in pediatric cancer. Thus the similar health-related QOL of obese sample was an unexpected and important finding of this study.

2. Poorer health in adulthood

As stated above, overweight and obese children are more likely to stay obese into adulthood and to develop lifestyle diseases (chronic or noncommunicable diseases[NCDs]) like diabetes and cardiovascular diseases at a younger age, which in turn are associated with a higher chance of premature death and disability in adulthood.

For most lifestyle diseases resulting from obesity, the risks depend partly on the age of onset and on the duration of obesity. As a result, due to the onset of these diseases at a younger age, in obese children, their obesity and disease risk factors in adulthood are likely to be more severe. The most significant health consequences of childhood overweight and obesity, that often do not become apparent until adulthood, include the following. These have been discussed in details in my post “Complications of Obesity” referred to above.

• Cardiovascular diseases (mainly heart disease and stroke).
• Diabetes
• Musculoskeletal disorders (injuries or pain in the human musculoskeletal system, including the joints, ligaments, muscles, nerves, tendons, and structures that support limbs, neck and back).
• Certain types of cancers (endometrial, breast and colon).

As per WHO data, at least 2.6 million people each year die as a result of being overweight or obese. As is evident from the above discussion, obese children and adolescents suffer from both short-term (i.e. during childhood) and long-term (i.e. during adulthood) health consequences.

3. Weight bias

Individuals with obesity often face persistent social stigmatisation, prejudice and discrimination. This unfair treatment or prejudice because of body weight is referred to as “weight bias” and negatively affects not only psychological well-being but physical health as well. In fact, the mental health effects of obesity can be as damaging as the physical effects. Being an important issue with wide-ranging consequences, this topic will be discussed in details in a subsequent post.
Weight bias exists in many life domains – social relationships, education, employment, healthcare and mass media. Some of the major consequences of weight bias include – lower self-esteem and lower self-reported quality of life, stigma, higher likelihood of being bullied (body weight is the most common reason why youth are bullied [in comparison with sexual orientation, race or ethnicity, religion, academic ability, family income, physical disability etc.]), poor school attendance levels and poorer school achievements, poorer employment prospects as an adult, and a lower paid job, and lower rates of marriage.

Prevention of childhood obesity

Overweight and obesity, as well as their related diseases, are largely preventable. Prevention of childhood obesity, therefore, needs high priority.

Health is an investment

According to WHO data, an economic analysis in 2014 estimated that globally, obesity was costing US $2.0 trillion annually. There are significant benefits from investing in children’s health. Acting on childhood obesity can have major benefits for the healthcare services and wider economies of all countries. Investing in children’s health will help meet the global health targets and substantially reduce the predicted health and economic costs of obesity.

As highlighted above, untreated obesity is responsible for a significant proportion of lifestyle diseases including heart disease, diabetes, liver disease and many types of cancer. Unfortunately, long-term weight management of obesity remains a very difficult task and is associated with a high risk of failure and weight regain. This illustrates the critical importance of obesity prevention efforts for normal and overweight individuals – invest in prevention to reduce the need for treatment. Investing in the prevention, management, and treatment of obesity is a cost-effective action for governments and health services. To underline the significance of early intervention and prevention, World Obesity Federation chose the theme “Treat obesity now and avoid the consequences later” for the World Obesity day 2017.

No single intervention can halt the advance of the epidemic of obesity. To challenge childhood obesity successfully requires countering the obesogenic environment and addressing vital elements in the life course through coordinated, multisectoral action that is held to account.

Key areas of action

1. Early nutrition

Obesity prevention requires action throughout the life course, starting before birth.

(a) Maternal nutrition

Mothers with a high body weight or who are poorly nourished before or during pregnancy and mothers who put on excess weight during pregnancy are more likely to have children that develop overweight or obesity. While undernutrition in women has been declining over the last two decades, maternal overweight and obesity have been increasing.

(b) Breastfeeding

Good nutrition in early life is crucial for lifelong health. The positive impact of breastfeeding on lowering the risk of death from infectious diseases in the first two years of life is now well established. A mounting body of evidence suggests that breastfeeding may also play a role in programming lifestyle diseases risk later in life including protection against overweight and obesity in childhood.

The precise mechanisms underlying the potential protective effect of breastfeeding on overweight and obesity are not known. One of the various mechanisms proposed suggests that exclusive breastfeeding precludes inappropriate complementary feeding practices such as the early introduction of complementary foods that could lead to unhealthy weight gain. Protein and total energy intake, as well as the amount of energy metabolised, are higher among formula-fed infants relative to breastfed, leading to increased body weight during the neonatal period and data suggests that both higher protein intake and weight gain early in life is positively associated with the development of obesity later in childhood.

WHO recommendation on breastfeeding

To achieve optimal growth, development and health, infants should be exclusively breastfed for the first six months of life. Thereafter, to meet their evolving nutritional requirements, infants should receive nutritionally adequate and safe complementary foods, while continuing to breastfeed for up to two years or beyond.

(c) Complementary feeding

Complementary feeding is an opportunity to ensure good nutrition at an early age, but, unfortunately, it can often be undermined by the inappropriate marketing of commercial products.

2. Promote intake of healthy foods

Choosing healthy foods for infants and young children is critical because food preferences are established in early life. Children need to be supported by food environments where the healthy choice is an easy and affordable choice and they need to be protected from exposure to the powerful marketing of foods and beverages. Feeding infants and young children energy-dense, high-fat, high-sugar, and high-salt foods is a key contributor to childhood obesity. Lack of information about sound approaches to nutrition and poor availability and affordability of healthy foods play an important role in the choice of foods.

3. Promote physical activity

Regular physical activity is proven to help prevent and treat lifestyle diseases such as heart disease, stroke, diabetes and breast and colon cancer. It also helps to prevent hypertension, overweight and obesity and can improve mental health, ability to learn, quality of life and well-being. In spite of these proven benefits, according to the WHO, physical activity levels in adolescents is poor, with some 81% of adolescents globally (78% boys, 84% girls) falling below minimum recommended levels. Similar low levels of activity are found in all WHO regions and in low- as well as middle- and high-income countries.

Children and youth should be encouraged to participate in a variety of physical activities that support the natural development and are enjoyable and safe. For children and young people, physical activity includes play, games, sports, transportation, recreation, physical education, or planned exercise in the context of family, school and community. The WHO’s ‘Global Recommendation on Physical Activity for Health’ recommends:

• Children and youth aged 5-17 should accumulate at least 60 minutes of moderate- to vigorous-intensity aerobic physical activity daily.
• Amounts of physical activity greater than 60 minutes provide additional health benefits.
• Most of the daily physical activity should be aerobic. Vigorous-intensity activities should be incorporated, including those that strengthen muscle and bone, at least 3 times per week.

4. Proper preconception and pregnancy care

• Diagnose and manage hyperglycemia and gestational hypertension.
• Monitor and manage appropriate gestational weight gain.
• Promote good nutrition, healthy diets and physical activity in antenatal care.

5. School-based interventions

Schools offer an important opportunity to address childhood obesity by improving children’s and adolescent’s nutrition through providing healthy food and drink options, promoting physical activity and providing physical education. Moreover, childhood experience can influence lifelong physical activity behaviours.

6. Family-based lifestyle interventions

It is important that the lifestyle of the whole family, and not only the child who has been identified as having a weight problem, is changed. For instance, don’t have the parents and siblings eating something different from the child who is affected – the whole family should eat similar food. Playing with friends and family can be extra fun. Parental involvement, especially in pre-adolescent children is important as parents play important role in food bought (i.e. food choices), cooking, sleep routines etc of children. Parents must act as role models and agents of change.

7. Reduce sedentary behaviours

Don’t focus only on physical activity – focus on sedentary behaviours too. 5-6 hours of screen time is a common finding these days. Many national guidelines for screen time recommend less than 2 hours of screen time per day in children over the age of 5.

8. Monitor body weight/BMI

Regular growth monitoring at the primary health care facility or at school provides an opportunity to identify children at risk of becoming obese. The American Academy of Paediatrics recommends the use of BMI to screen for overweight and obesity in children beginning at 2 years old. BMI should be calculated at least annually and plotted on appropriate BMI-for-age percentile charts. Review of growth charts is of utmost importance as this would help with early detection of an increasing BMI trend (more than 3 to 4 units kg/m2) and starting to cross percentile lines, indicating a need for early intervention.

Conclusion

Childhood obesity undermines the physical, social, and psychological well-being of children and is a known risk factor for adult obesity and lifestyle diseases. Dr Fiona Bull, programme coordinator for surveillance and population-based prevention of noncommunicable diseases (NCDs) at WHO says: “These data highlight, remind and reinforce that overweight and obesity is a global health crisis today, and threatens to worsen in coming years unless we start taking drastic action.”

As the obesity epidemic in children continues to grow, there will be an unprecedented growth in health risks associated with obesity, including early onset of type 2 diabetes and its associated comorbidities, cardiovascular diseases, PCOS, NAFLD, OSA, orthopedic problems, psychiatric illnesses and increased rates of certain cancers, unless preventive measures are instituted at a war footing. Should the gloomier scenarios relating to obesity turn out to be true, type 2 diabetes related kidney damage, necessitating dialysis and kidney transplant and liver damage due to NAFLD necessitating liver transplant will increase and occur at younger ages and further aggravate the short-supply of healthy organs available for organ transplantation. The positive trends in recent decades in combating heart disease, partly the consequence of the decline in smoking, will be reversed. The sight of amputees will become much more familiar in the streets. There will be more blind people. Prof Paul Zimmet, Professor of Diabetes at Monash University, Australia, and Honorary President of the International Diabetes federation, rightly commented:

“This will be the first generation where children may die before their parents as a consequence of childhood obesity.”

Obesity is difficult to treat and previously obese people experience tremendous challenges to maintain a healthy body weight. No single intervention can halt the advance of an epidemic of obesity. Early intervention has the most potential for preventing obesity and other long-term health consequences in high-risk children. To challenge childhood obesity successfully, countering the obesogenic environment and addressing vital elements in the life course are of paramount importance. This requires a coordinated multisectoral approach. The governments have a responsibility to support their citizens in their pursuit of a healthy, long life by providing an ‘enabling environment’ that support individuals in making healthy choices. It’s not enough to say, “we have told them to take regular exercise, we have told them to eat healthy.” They should implement policies to address the environments that children are growing up in today, that increase the risk of obesity.

The food industry can play a significant role in reducing childhood obesity by reducing the fat, sugar, and salt content in the foods while ensuring that healthy and nutritious choices are available and affordable to all consumers. They also need to practice responsible marketing especially those aimed at children and teenagers.

Places such as childcare centres, schools, or communities can affect diet and activity through the food and drinks they offer and the opportunities for physical activity they provide.

Nearly all children need to be considered at risk for later adult obesity, and targeted early with preventive efforts. The first years of life are critical in establishing good nutrition and physical activity behaviours that reduce the risk of developing obesity. It is important to initiate lifestyle modifications early in life, beginning at age 1 or 2 years, when children transition to adult food habits, and continuing through the remaining lifespan. Early prevention of obesity in high-risk children holds promise and these efforts may contribute to the reduction of obesity and its consequences and will contribute to improvement in public health for the future generations. Adopting Holistic Health Approaches for wellness is the right approach. In the end, I would like to conclude with a statement by Lucila Godoy Alcayaga, better known by her pseudonym Gabriela Mistral, a Chilean poet-diplomat, educator and humanist and a Nobel laureate for literature (1945).