Obesity

Definition

A chronic condition characterised by excess adipose tissue, causally

related to serious medical illness

Obesity Diagnostic Tools

• Percentile on Growth Charts

• Body Mass Index (BMI)

• Triceps Skin fold Thickness (TST)

• Waist-hip ratio

Diagnosis of Obesity

• Weight for height >120%

• Age specific growth charts

• Skin fold thickness: >85%centile for sex and age

• Waist : >40” in males & 35” in females

• WHR : >0.8 women & 0.9 in males

Percentage Wt. for Ht.

= ------------------------------------- X 100

Weight for Height

Actual Weight

Expected weight for actual height

< 90 % : PEM> 90 % : Normal> 120-130 : Obesity

Body Mass Index or BMIin Adolescents

Weight in kilograms is divided by the square of the height in meters

• Normal : 19 to 24.9 kg/m2

• Overweight : 25 - 26.9• Obese : 27 to 29.9• Severe Obesity : Over 30 (Over the 95th Percentile)

• Morbid Obesity : Over 40

Skin fold thickness

Skin thickness is an index of body fatSFT Taken at

Triceps (most common site) Subscapular Suprailiac Abdomen Upper thigh

Lange’sHarpenden’sSkin fold calipersSkin fold calipers

Adolescent Growth Chart

Measure of Height Weight and BMI in single graph

Types of Obesity

• Simple obesity

• Pathologic obesity– Dysmorphic syndromes– Endocrine– CNS – Drugs– Leptin deficiency

Prevalence: The National Health and Nutrition Examination

Surveys

• 75% relative increase in obesity in adolescents is noted since 1970

• 25% of American adolescents are identified as being obese

• 50% increase in morbid obesity (a BMI of 30 or more) over the past decade

• Indian studies 7-21 % prevalence

Factors Contributing to the Obesity Epidemic

• Increase – in intake of regular soda drinks– In intake of fast foods – in portion size of fast foods– highcarb snacks

• Decrease – in physical activity

• Increase – in physical inactivity (TV, video, computer time)

Why is it important?

• WHO has declared obesity as a “global epidemic”

• Childhood & adolescent obesity is a risk factor for adult obesity “Tracking”

• Life style diseases like NIDDM,Coronary artery disease Hypertension, dyslipidemia, cancers are linked with obesity

• Psychosocial problems

Obesity: Complications

• Psychological– Disturbed body image– Poor self-image/self-esteem– Poor family relations: scapegoat and source

of embarrassment– Poor peer relations and social isolation– Exclusion from activities, especially dating– Acting out and depression

Obesity: Complications

• Medical– Coronary artery disease– Cerebrovascular disease– Gallstones– Orthopedic problems– Sleep apnoea– Increased cancer risks (colon, rectum, prostate)– Diabetes mellitus

Overweight Screening Procedure

Screening includes evaluation for:– Family history– Blood pressure– Total Cholesterol ( 200 mg/dl)– Large change in BMI ( 2 points in previous

year)– Concern about weight– Smoking history

Family History

• Positive Family History includes history of:– Cardiovascular Disease– Parental hypercholesterolemia– Hypertension– Diabetes – Parental Obesity

Physical Exam

• Eyes– Peripheral view– Fundi

• Skin– Acanthosis

nigricans– Purple stria– Texture– Hirsutism, acne

• Endocrine\- Hypopituitarism- Hypercortisolism- Hyperinsulinemia- Hyperandrogenism in

females

Lab Work-Up

• T4, TSH

• Free testosterone (in females)

• Fasting insulin and glucose

• Lipid profile

• 24 hour urine for free cortisol

• DHEA-S

• Sleep studies

• Chest x-ray; EKG

Management Strategies of Obesity

Prevent weight gain

Promote weight maintenance

Manage co morbidities

Promote weight loss

Rule out treatable medical causes

Underlying Medical Conditions

• Hypothyroidism– Initiate treatment with

levothyroxin

• Cushing’s syndrome– Identify source of excess

cortisol– Surgically remove source of

excess ACTH or cortisol

Treatment Content

Diet / Nutrition Plan Physical Activity Controlling the environment Self-monitoring Goal setting and contacting Parenting skills Managing high-risk situations Maintenance and relapse

prevention

General Management Principles

Can start with weight stabilization Eventually a 10% weight reduction Can decrease by 500 calories/day

with low fat/high fiber diet Set realistic goals 2% decrease in 2500 calories: 5 lb

to drop in one year (use skim milk)

Physical Activity

Providing and choice of activities appears to be superior to providing a specific exercise prescription

Recent research suggests that reducing sedentary behaviors may be more effective than promoting physical activity in promoting weight loss

Exercise Exercise also plays

very vital role in the management of obesity.

The more exercise one takes, greater is the daily energy expenditure and more rapidly the obesity reduces.

Energy expenditure in different activities

At rest    1Kcal /min Walking, gardening    5 Kcal/ min Cycling, swimming    7 Kcal /min Squash, jogging, hill climbing  10 Kcal/ min

Benefits of exercise

• Obese people with a heavier body to move, spend more energy for same amount of work.

• It is valuable as a diversion from sitting indoors and being tempted to eat.

• Exercise reduces appetite.

• After exercise the resting B.M.R. may increase for some hours.

Controlling the Environment

Help reduce cues (e.g., taking TV out of bedroom)

Limit access to high calorie foods Encourage family activities (e.g.,

family walks)

Parenting Skills

Parents often need practice in general parenting skills to implement many of the behavioral methods including: Being consistent Being observant so they can reward behavior

change Effectively using rewards Modeling desired behavior Limit setting (saying “no” when necessary)

Parental Problems

Child’s Attitude

What was wrong? Why were these kids such picky eaters?

Management Options

Behavioural interventions

Mealtime suggestions

Tactics for ToddlersTactics for Toddlers

To tempt little To tempt little taste buds taste buds

& & minimize minimize mealtime mealtime

hassles.hassles.

1. Offer a nibble tray

Toddlers like to graze their way through Toddlers like to graze their way through a variety of foods, so why not offer them a a variety of foods, so why not offer them a

customized smorgasbord? customized smorgasbord?

Use an ice-cube tray, a muffin tin, or a compartmentalized dish, and put bite-size portions of colorful and nutritious foods in each section.

Call these finger foods playful names that a two-year-old can appreciate

2. Spread it

Toddlers like spreading, or more

accurately, smearing.

Show them how to use a table knife to spread cheese, peanut butter, and fruit concentrate

onto crackers, toast, or rice cakes.

What and how much they are willing to eat may vary daily.

Don't be surprised if

"The only thing consistent about children’s feeding is "The only thing consistent about children’s feeding is inconsistency."inconsistency."

•your child eats a heaping plateful of food one day and practically nothing the next,

•adores spinach on Tuesday and refuses it on Thursday

• wants to feed herself at one meal and be totally catered to at another.

3. Count on inconsistency

Toddlers are into

toppings.

4. Top itPutting nutritious, familiar

favorites on top of new and less-desirable foods is a way

to broaden the finicky toddler's menu

Make a smoothie – together. Milk and fruit – along with supplements such as juice, egg powder, wheat germ, yogurt, honey, and peanut butter – can be the basis of very healthy meals.

5. Drink it..

If your youngster would rather drink than eat, don't despair

So what if they are consumed through a straw?

One note of caution: Avoid any drinks with raw eggs or you'll risk salmonella poisoning.

How much a child will eat often depends on how you cut it.

6. Cut it up

Cut sandwiches, pancakes, waffles, etc. into various shapes using cookie cutters.

7. Package it

Our kids enjoy the unexpected and fanciful when it comes to serving dishes – anything from plastic measuring cups to

ice-cream cones.

"Doctor, he won't eat his vegetables"

8. Become a veggie vendor

So if you aren't the proud parent of a veggie lover, try the following tricks

•Plant a garden with your child.

•Slip grated or diced vegetables into favorite foods

•Use vegetables as finger foods and dip them in a favorite sauce or dip.

•Concoct creative camouflages.

•Cut the vegetables into interesting shapes (Make veggie art).

9. Share it

If your child is going through a picky-

eater stage, invite over a friend who is

the same age or slightly older whom you know “likes to

eat.”

Your child will catch on. Group feeding lets the other kids set the example.

10. Respect tiny tummies

This less-is-more meal plan is not only more successful with picky eaters, it also has the added benefit of stabilizing blood-sugar levels, which in turn minimizes mood swings.

Dole out small portions at first

and refill the plate when your

child asks for more.

11. Make it accessible

Reserve a low shelf in the refrigerator for a variety of your toddler's favorite (nutritious) foods and drinks.

This tactic also enables children to eat when they are hungry, an important step in acquiring a healthy attitude about food.

Give your child shelf space.

12. Use sit-still strategies

One reason why toddlers don't like to sit still at the family table is that their feet dangle. Try sitting on a stool while eating.

Children are likely to sit and eat longer at a child-size table and chair where their feet touch the ground.

13. Turn meals upside downThe distinctions between The distinctions between

breakfast, lunch, and dinner breakfast, lunch, and dinner have little meaning to a have little meaning to a child. child.

If your youngster insists on If your youngster insists on eating chapathi in the eating chapathi in the morning or fruit and cereal morning or fruit and cereal in the evening, go with it – in the evening, go with it – better than her not eating at better than her not eating at all. all.

This is not to say that you should become a short-order

cook, filling lots of special requests,

but why not let your toddler set the menu sometimes?

14. Let them cook

Let your child help prepare the food.

Use cookie cutters to create edible designs out of foods.

Give your assistant such jobs as tearing and washing lettuce, scrubbing potatoes, or stirring batter.

15. Make every calorie countOffer your child foods that pack lots of nutrition into

small doses.

Nutrient-dense foods that most children are willing to eat include:

•Pasta,Brown rice and other grains, Potatoes,Cheese, Poultry, Eggs, Squash, Fish, Sweet potatoes, Kidney beans,Yogurt, etc.

Behaviour Modification - Adolescents

Aimed at changing behaviour

useful while treating obesity

Flash Card Technique

• Increases motivation• involves writing

reasons for wanting to lose weight

• I will look better• I will feel better• I will be be healthier• I will fit into my

favourite pair of jeans

Food DiaryTime Food Or Liquid

consumed Place Circumstances

7.50 pm

1 pack of chips 1 piece of cake 1 cola

bedroom watching TV

• Identifies triggers• Useful in understanding eating patterns• Logs exact amount of food or liquid consumed

Setting diets & goals

• Identifying and sticking to – a specific diet– food to be consumed– Place– time

• Setting reasonable goals like – losing one or two pounds

a week likely to be achieved

Food Pyramid

Cereals Pulses

GLV Fruits

Non-Veg FoodMilk

Sweets, oily & fatty food

Ways of controlling urges

• Removal of tempting foods• Use of distractors like engaging in

another activity• Using positive self-statements like

I can do this, I must control myself, I will be fine, The urge will pass

Use of Reinforcement

• Positive reinforcement : Rewarding oneself as goals are met

e.g. going for a film with a friend

• Negative reinforcement : escape unpleasant stimulus to increase desired behaviour > missing a favourite TV programme if overeaten

Obesity Treatment Strategies NOT recommended

Surgery Drug Treatment

(including herbal treatments)

Quick Weight Loss Diets

Pharmacotherapy

Shown to be effective in the treatment of obesity in some adults

Their use in most youth is limited at this time Teens should be

at least 16 years of age with morbid obesity

Failure of Obesity Treatment

• Lack of family involvement and support

• lack of flexibility• Lack of emphasis on increasing

physical activity• Lack of a maintenance phase

Diets may produce weight loss but do not cure obesity; weight regain is

common.

Eat less; eat 2/3 or ½ the calories you have been eating

Target is to eat about 1200-2000 kcal/d, depending on the age of the child

Try to cut out empty calorie foods – fats, soft drinks, and fast foods.

Amounts of low calorie foods can be increased – fruits and vegetables

Avoid other activities while eating (except conversation)

• Meal or food should not be provided as reward.

• Make small portions of food appear as large (small plate, food cut up in small pieces)

Leave eating place as soon as you have eaten

Slow down the rate at which you eat

Chew each mouth full for long.

Reduce inactivity

Take steps to minimize hunger, loneliness, depression, boredom, anger and fatigue which lead to overeating,

Think positively

WHAT can we do to prevent obesity ?

Right from childhood into adolescence into adulthood we must encourage •Exercise, •Physical activity •Physical Fitness •Life style modification •Nutritional intervention

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• C.S.N.VittalC.S.N.Vittal