Sina Aziz ( Sarwar Zuberi Liver Centre, Medical Unit 5, Civil Hospital Karachi, Dow University of Health Sciences, Karachi. )
March 2009, Volume 59, Issue 3
Editorial
Obesity is defined by the age and sex specific charts for BMI released by the Center for Disease Control (CDC)1 The CDC defines normal weight for height as a BMI greater than 5% but less than 85%. A BMI between 85-95% is called at risk for overweight and a BMI greater than 95% is usually specific for increased body fat and is called overweight. These terms overweight and obesity are used interchangeably in the paediatric population though obesity can also be referred to as a level of overweight that has accompanying adverse physical or psychological issues1,2
The International Obesity Task Force (IOTF) terms obesity as the millennium disease and emphasizes on the international impact of this condition.3 The IOTF definition for obesity is not designed for clinical use; also it is not linked to a definition of extreme overweight. A z score to express BMI as a continuous measure for children of different ages cannot be driven from it and children less than 2 years of age are not included. A consensus definition on cutoff points to define overweight and obesity has not been reached.4adolescent girls from Egypt, Kuwait and Lebanon were compared. .10In Thailand the prevalence of overweight and obesity in 11 to 13 year olds was 18.4%.11 Studies from Iran, Qatar, Sri Lanka, India, Malaysia, and Saudi Arabia all show increased trend of obesity and overweight.12-17
Data from Pakistan is scarce. Recent study on affluent school children showed percentage of obese and overweight children to be 6% and 19% respectively.18 Other data has shown that under nutrition and obesity co-exist.19,20 Comparison of National Health Survey of Pakistan (NHSP) in urban areas21 and Karachi survey20 showed the prevalence of overweight and obesity as 3.0% vs 5.7% (p<.001) respectively. Two studies done in different areas of Karachi by Aziz et al and Jaffar et al have suggested comparable prevalence of obesity (6% and 5.7%).18-20
Genetic predisposition is important in the etiology of obesity. Data suggests lack of physical activity, urbanization/modernization and, globalization of food markets as causes of overweight/obesity in adults and children.5,8 Intake of energy dense food, change in diet from complex carbohydrates to foods with high proportion of saturated fats and sugars is responsible for the epidemic of obesity. Nutritional transition in Asians with a change of diet based on staple grains, starchy roots, legumes, fruits, vegetables and small amount of meat to processed, refined food, more red meat, added sugar, fat and preservatives is an important causative factor for obesity.14
The transformed diet along with a decline in physical activity leading to a sedentary life with long hours of television viewing and computer games is an important factor for obesity.4,18-20 Childhood obesity is affiliated with a higher disability in adulthood and sometimes premature death.
Definite steps have to be taken to curb this dangerous epidemic of obesity. Mild to moderate obesity can be treated by behaviour modification, increase in physical activity, and a decrease in sedentary activities. A multidisciplinary approach has to be adopted, based on family involvement with community and care facilities. Severe obesity in children and adolescents is serious and may require hospitalization, non conservatory dietary modification, drug therapy (Metformin in obese adolescents with hyperinsulinaemia and a family history of diabetes) and bariatric surgery (BMI > 40 kg/m2 with skeletal
BMI (kg/m2), a formula for calculating obesity in adults cannot be applied to children as it may not correspond to the degree of fatness.5 CT, MRI, DEXA, total body conductivity, air displacement plethysmography, other methods for estimation of obesity are not used routinely, for economic reasons. Triceps skin fold, waist-hip ratio, bioelectric impedance analysis, all require special training and expertise.6,7
Currently more than one billion over weight adults and 300 million of these are clinically obese. Obesity levels range from below 5% in China, Japan and certain African nations, to over 75% in urban Samoa. In certain Chinese cities, prevalence rates are almost 20%.8 It is estimated that 17.6 million children less than five years of age are overweight worldwide.5 Since 1980 in USA number of overweight children and adolescents has doubled and trebled. Prevalence of obese children 6 to 11 years has more than doubled since the 1960s. Obesity prevalence in youths aged 12-17 years has increased from 5% to 13% in boys and 5% to 9% in girls between 1966-70 and 1988-91 in USA.8
In Australia, intake of sweetened beverages has been associated with overweight and obesity in schoolchildren.9 In Eastern Mediterranean Region, overweight and obesity was highest in Kuwait and lowest in Lebanon whenmaturity and obesity associated co-morbids).4
World Health Assembly of 2004, WHO global strategy on diet, physical activity and health8 describes actions needed to support, adoption of healthy diet and regular physical activity. The objectives of this forum include health promotion, and chronic disease prevention, especially for poor and disadvantaged populations.
In Pakistan majority of mothers still breast feed the babies which is considered to be protective against obesity, though the exact mechanism is unclear. Hence exclusive breast-feeding should be encouraged for a longer duration as this is inversely associated with risk of overweight.
Other recommendations include, counseling children and parents on a healthy diet in school and through the media. Government policy should encourage physical activity as part of the school and madressah syllabus.Reference
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2. Milliken K. Childhood obesity. The APGNN Clinical Handbook of Pediatric Gastroenterology. The Association of Pediatric Gastroenterology and Nutrition Nurses 2008, pp 171-81.
3. International obesity task force. http://www.iotf.org/millennium.asp. Accessed Oct 10, 2008.
4. Obesity working group: Quak SH, Furnes R, Lavine J, Baur LA. Obesity in children and adolescent. JPGN. 2008; 47:254-59.
5. World Health organization. http://www.who.int/nutrition/topics/obesity/en/ Accessed September 21, 2008.
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8. World Health organization. Global strategy on diet, physical activity and health 2003.
9. Sanigorski AM, Bell AC, Swinburn BA Association of key foods and beverages with obesity in Australian schoolchildren. Public Health Nutr 2007; 10:152-7.
10. Jackson RT, Rashed M, Al-Hamad N, Hwalla N, Al-Somaie M Comparison of BMI-for-age in adolescent girls in 3 countries of the Eastern Mediterranean Region. East Mediterr Health J. 2007; 13:430-40.
11. Pawloski LR, Ruchiwit M, Pakapong Y. A cross-sectional examination of growth indicators from Thai adolescent girls: evidence of obesity among Thai youth? Ann Hum Biol. 2008; 35:378-85.
12. Ayatollahi SM, Mostajabi F, Prevalence of obesity among school children in Iran. Obes Rev. 2007; 8: 289-91.
13. Prevalence of obesity, overweight, and underweight in Qatari adolescents. Food Nutr Bull 2006. 27:39-45.
14. Wickramasinghe VP, Lamabadusuriya SP, Attapattu N, Sathyadas G, Kuruparanantha S, Karunarathne P. Nutritional status of school children in an urban area of Srilanka. Ceylon Med J 2004; 49:114-18.
15. Sharma A, Sharma K, Mathur KP Growth pattern and prevalence of obesity in affluent schoolchildren of Dehli Public Health Nutr 2007; 10: 485-91.
16. Sumarni MG, Muhammad Amir K, Ibrahim MS, Mohd Rodi I, Izzuna Mudla MG, Nurziyana I. Obesity among schoolchildren in Kuala Selangor: A crosssectional studyTrop Biomed. 2006; 23:148-54.
17. Al-Saeed WY, Al-Dawood KM, Bukhari IA, Bahnassy A. Prevalence and socioeconomic risk factors of obesity among urban female students in Al-Khobar city, Eastern Saudi Arabia, 2003. Obes Rev. 2007; 8:93-9.
18. Aziz S, Noorulain W, Zaidi UR, Hossain K, Siddiqui IS. Prevalence of overweight and obesity among children and adolescents of affluent schools in Karachi JPMA 2009; 1: 36-39.
19. Aziz S, Puri DA, Hossain KZ, Hussain F, Naqvi SA, Rizvi SA. Anthropometric indices of middle socio-economic class school children in Karachi compared with NCHS standards — a pilot study. J Pak Med Assoc. 2006; 56:264-7.
20. Jafar TH, Qadri Z, Islam M, Hatcher J, Bhutta ZA, Chaturvedi N. Rise in childhood obesity with persistently high rates of undernutrition among urban school-aged Indo-Asian children. Arch Dis Child. 2008; 93:373-8. Epub 2007 Oct 17.
21. Mallick MD National Health survey of Pakistan (NHSP) Pakistan J Med Research 1992; 31:289-90.
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