Recent advances in the treatment and prevention
of childhood obesity
by Dr Robert M Suskind
As caring physicians, we recognize the impact of obesity,
both medically and psychologically, on the child and the adult he or she will become.
There are several things I hope will occur as a result of this discussion. First,
that it will help physicians and other health care professionals both recognize
and treat more effectively the problem of obesity in patients. I also hope it will
also stimulate more ideas for research and for developing even better tools to eradicate
obesity in children. Obesity is a global problem that demands unified effort. Think
of me not simply as an expert here to share his experience and expertise, but rather
someone who wants you to join me in the effort to eliminate this problem.
1. What is the prevalence of childhood obesity globally?
in Asia? Why is the incidence of childhood obesity on the rise in developing countries
such as India and China?
An accurate overview of the global prevalence of obesity in younger age groups is
difficult because the classification of obesity in children and adolescents varies
from study to study. Nevertheless, whatever method is used to classify childhood
obesity, studies have generally reported that the prevalence of obesity is high
and that those rates are increasing. In Chennai, India, for example, a recent study
of children, ages 13-18, showed a prevalence of 17.8 % among boys and 15.8 % among
girls. At one time, these numbers would have been unheard of. Logic leads us to
speculate that it is the result of a change in eating habits, including higher intakes
of calories, sugar and fat, combined with a lessening in activity.
Why is it increasing in places that, at one time, had to deal exclusively with the
devastating effect of undernutrition? Probably for exactly the same reasons it is
occurring everywhere: more easily available food and less necessary physical activity.
Where once children walked, or bicycled, now very often they ride. Where once they
ran out of the house after school to jump rope or play ball, now they sit in front
of televisions or computers. And where once, meals were regulated, and often, because
of finances, limited, now heavily fatted, heavily sugared, snacks and fast foods
are the bridge between each family meal.
I'd like to add that, while we are sure the problem of obesity is global, it's also
important to understand why this is of such great concern. If it were simply a question
of esthetics, that is, how the child looks, obesity would be relegated to a much
lower level of concern. But it is not simply the question of esthetics that is the
problem. Obesity is, ultimately, an insidiously devastating disease, a devastation
that is almost guaranteed to occur in the future adult.
2. Is it true that contrary to popular belief, obese children
are generally at a higher risk of becoming obese adults?
Absolutely. Up to 70% of obese children ages 10-13 become obese adults. Restated,
that's almost three quarters of obese children growing up to battle the same problem.
In fact, an even greater problem, because the adult is now not only dealing with
being "fat," but with the terrible ramifications of this disease, including heart
disease, vascular and respiratory problems and, there is indication, some cancers.
An interview of morbidly obese adults, during the International Congress of Obesity
in Montreal, revealed that 100 % of the morbidly obese adults interviewed had been
chubby/obese children in whom there had been no effective intervention during childhood.
3. Childhood obesity occurs as a result of the complex
interaction between Nature (genes) and Nurture (environment). What are these factors?
Both genetic and environmental factors are known to influence the prevalence of
childhood obesity. If a child has one obese parent, there is a 40% chance of that
child's being obese. Children with two obese parents have an 80% chance of being
obese.
Genetically, it is known that genes control such mechanisms as metabolic rate and
the production of hormonal factors, which may influence intake and, therefore, weight.
Environmental factors involved in obesity include infant feeding practices, the
availability of calorie-dense food and the encouragement of activity levels during
childhood.
While a definitive determination of what is the most culpable determinant of obesity
is yet to be established, it is known that early sugar excesses lead to a magnified
insulin response with its resultant impact on adipocyte cell number and size. Subsequently,
exposure to fast foods, calorically dense foods and excess sugar associated with
a sedentary lifestyle dominated by excessive amounts of TV and computer time have
a significant impact on the prevalence of childhood obesity. A likely scenario is
that genetic factors which influence the potential for obesity are exacerbated in
face of contemporary reliance on calorie-dense fast foods, less segmented eating
regimes, a tendency toward "grazing," and "recreation" now defined by television
viewing and computer playing.
4. What are the factors that can be modified to prevent
and treat childhood obesity?
While the dream of the obese child, or adult, is a "magic bullet," the truth is
that prevention and treatment of childhood obesity is accomplished only by modification
of diet, exercise and behavior. So simple to say it but so much harder to put into
practice. In truth, even small changes in caloric intake, combined with an increase
in physical activity, will have a marked impact on obesity in the child. But the
most important factor is consistency and continuity. It's somewhat easy to lose
a pound or even ten, what's hard is keeping it off. And that's what puts behavior
modification on a par with diet and exercise as a determinant of success in treating
childhood obesity.
Another important modification in determining success is that the family, itself,
modify its eating habits. An isolated child dieting in the midst of overeaters is
not as likely to be successful. Another modification is in the perception of the
physician. Often young children are told that they will "grow out of it." That's
rarely, if ever, the case. If a child is six or older, and above the 85% for BMI,
active therapeutic intervention involving diet, exercise and behavior modification
are critical.
In our study, which has been duplicated in centers throughout the US, we have effectively
used the combination of a high protein -low calorie diet, nutrition education, exercise
and behavior modification to help over three hundred children successfully lose
and maintain weight loss for up to 5 years after they started the group weight loss
program. We did this with young children, we included families, and we had bi-weekly
exercise programs. And we saw remarkable changes, often in children who had lost
hope that they would ever be of healthy weight.
5. One of the primary causes of childhood obesity is poor
nutrition. What are the dietary factors that positively influence weight gain and
obesity? What should mothers do to inculcate healthy eating habits in their infants
in terms of these dietary factors?
Excessive caloric intake, including excessive fat and sugar intake, during very
early childhood is clearly one of the primary causes of childhood obesity. Mothers
should be encouraged to breastfeed exclusively during the first 4-6 months of an
infant's life. This should be followed by the gradual introduction of cereals, fruits
and vegetables.
One should avoid the early introduction of sweetened formulas and fruit juices,
essentially "empty calories," which are not contributing to development but are
simply a continuous intake of liquid desert. Eating, it's important to recognize,
is not only a necessity, it's a habit. If we ate only what we needed to live well,
no one would be overweight. But we eat for many other reasons, comfort, socializing,
boredom.
Obese children or adults rarely eat because of hunger. Babies and children should
not be pressured to "clean" their plates, to finish what they are too filled to
finish. Feeling satiated should be a signal, that the time to eat is over. Mothers
should allow children to recognize this feeling as a time to push away from the
plate. Maternal love, past the breast-feeding stage of infancy, should come from
reading books to the child, playing games, just "being together," and not from plying
the child with non-essential food especially food that provide excess amounts of
sugar.
6. Fat has traditionally been singled out as the main
culprit of weight gain and obesity. Recently, some studies have shown a correlation
between sugar intake and obesity. Please elaborate about these studies and their
findings.
Fat has traditionally been singled out as the main culprit of weight gain and obesity.
Recently, however, studies have shown a correlation between sugar intake and obesity.
Ludwig et al. found a correlation between sugar-sweetened drinks and increasing
weight in 11 and 12-year-old children. Parents should be aware that early introduction
of sugar sweetened drink may start a lifetime habit so that when the child, and
later the adult, is thirsty, simple water is never even an option. A glass of water
has no calories. A glass of soft drinks over 100. It doesn't take much calculation
to see that quenching daily thirst with soft drinks is an easy road to obesity in
the child and, eventually, the adult.
7. What are the current WHO recommendation on sugar intake?
What does that mean in terms of the number of teaspoons of sugar in the diet of
children and adults?
The current WHO recommendation is that no more than 10% of an individual's caloric
intake should be sugar. If an individual's caloric intake is 2000 calories, this
translates into a requirement for sugar of 200 calories or 50 grams of sugar which
is equivalent to about 10 teaspoons of sugar/day or the equivalent of a can of soft
drink.
8. What, in your opinion, is the future of adult and childhood
obesity in India and other developing countries?
As the world's largest democracy and with a rapidly growing middle class society,
one can anticipate that if there is no active national or individual physician intervention
in India, the problem of obesity and its complications will only increase in size
and intensity. At present 10% of the population is overweight. This represents 100
million people, a number roughly equivalent to the number of overweight children
and adults in the US.
With further development, one can anticipate that without intervention, the % and
therefore the total number of obese individuals in the India will increase dramatically.
The morbidity associated with obesity, i.e., type 2 diabetes, hypertension, hyperlipidemia
and heart disease will only grow placing added strain on the medical resources of
India.
9. Can obesity be prevented? If so, what can and should
be done?
Obesity is definitely a disease that is preventable. It requires
active monitoring by the physician who routinely obtains weights and heights on
all of his patients. For children under 6 years of age whose BMI exceed the 85th
percentile an active counseling program should be undertaken where advice is given
to the parents regarding appropriate diet and activity. For children over six with
BMI's exceeding the 85th percentile, an active group intervention program should
be offered which combines a high protein-low calorie diet, exercise and behavior
modification. This program should be offered until a child's BMI is less than the
85th percentile for age.