CHILDHOOD ONSET OF ADULT METABOLIC DISEASES

Panna Choudhury

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Panna Choudhury.

Consultant Pediatrician, Maulana Azad Medical College & Lok Nayak Hospital, New Delhi- 110 002..

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There is an emerging epidemic of noncommunicable diseases like obesity, hyperlipidemia, heart disease, diabetes, stroke and cancers. Till recently these diseases were believed to be problem of affluent countries but are now being realized to be affecting developing countries. Many of these illnesses are the result of changes in diet and life-styles that characterize the 'nutrition transition' which accompanies economic development and the increasing urbanization.

It is estimated that by 2025, India will have more people with diabetes (57 million) than any other country(1) and that prevalence of coronary heart disease has increased by a factor of six to eight(2). Indians as an ethnic group are also more prone to abdominal obesity which is a major concern. Increase in visceral fat leads to a state of insulin resistance (impairment of insulin action) which in turn leads to a deadly Metabolic Syndrome (also known as Syndrome X, a combination of glucose intolerance, hyperinsulinemia, central obesity, hypertension and dyslipidemia)(3).

In this regard one area that needs attention is a common perception that- "Metabolic disease is only a problem of urban rich who can easily pay for their treatment". Undoubtedly the epidemic is currently more common in the urban rich. However, obesity and metabolic diseases affect the urban poor as well as the rich of Asia. That 20 to 60% of households in this region have both undernourished child and overweight adults is indicative of the need to address these issues also as problems of poverty and not exclusively of wealth (4). In a recent study from low socioeconomic stratum residing in urban slums of New Delhi, cardiovascular risks like hypertension and hypertriglyceridemia were noted in a significant number of cases even at BMI and waist circumference (WC) values considered "normal." The data suggested that definitions of "normal" ranges of BMI and WC need to be revised for Asian Indians (5).

Pediatricians have a very important role to play in the control of these epidemics with the accumulating evidence that most of these diseases have their origin in childhood, and particularly linked to obesity . Historically, a fat child meant a healthy child, and the concept of "bigger is better" was widely accepted by pediatricians and caretakers. In recent years, however, this perception has drastically changed as it is learnt that obesity in childhood causes a wide range of serious complications and increases the risk of premature illness and death later in life (6,7). In view of its rapid development in genetically stable populations, there is general agreement among experts that the environment, rather than biology, is driving this epidemic (8). Fundamental changes in the social environment and family life-styles will be needed to combat this emerging public-health crisis.

Childhood Overnutrition
The recent increases in child overweight and obesity are largely attributed to social and environmental forces which are not under the individual control of children and which, in turn, influence eating and physical activity behaviors (9). Children are exposed to obesogenic environments and the school is one of the many environments in which children may be exposed to 'obesogens' (10). Important social changes have affected family eating patterns and the consumption of fast foods, pre-prepared meals, and soft drinks. Likewise, the amount of physical activity that children engage in has been reduced by an increase use of cars, an increase in the amount of time spent watching television (with multiple TV channels around the clock) and playing sedentary games, and a decrease in the opportunities for physical activity on the way to school, at school, or during leisure time.

According to WHO (2000) 20% of children in U.K., U.S.A. and Australia are currently overweight (11). Similarly, a recent global analysis showed a rising trend in childhood overweight in 16 out of 38 developing countries with more than one national survey(12). In India also an 'urban, rural divide' scenario has emerged related to nutrition. In children, the difference between the rich and the poor is fairly evident in recently conducted urban studies. Ramachandran, et al. studied children from six schools in Chennai, two each from high, middle and lower income groups(13). The prevalence of overweight (including obese) adolescents ranged from 22% in better off schools to 4.5% in lower income group schools. In a Delhi school with tuition fees more than Rs. 2,500 per month, the prevalence of overweight was 31%, of which 7.5% were frankly obese(14). In Pune the figures for overweight children are 24% in a well off school and 6% in a 'corporation' school. Another area of concern for the epidemiologist has been rapid weight gain. Longitudinal data indicate that sustained and accelerated childhood weight and BMI gain (crossing into higher categories) is associated with adult morbidity including diabetes, hypertension and coronary artery disease. Interestingly many children and adolescents with insulin resistance are not overweight by International standards though getting bulkier relative to themselves (15). It signifies that an individual child need to be monitored with regular weight and or serial BMI measurements. Realizing that Indians are at risk of metabolic diseases at lower level of weight, the International Obesity Task Force (IOTF) has proposed the standards for adult obesity in Asia and India as BMI >23 as overweight and BMI >25 as obesity (16).

Insulin resistance and Type 2 Diabetes Mellitus (DM) in Children

The proportion of childhood DM attributable to type 2 DM is increasing worldwide(17). In USA there is a tenfold increase in the proportion of young diabetes between eighties and nineties(18).Increase in type 2 DM parallels an increase in obesity. Obese have about 40% lower glucose utilization rate. A clinic based study from Connecticut, USA, on 55 unselected obese children and 112 obese adolescents referred to an obesity clinic revealed silent DM in 4% of adolescents and IGT in 25% of children and 21% of adolescents(19).Data on type 2 DM in Indian children and adolescents has started appearing. Ramachandran et al(20) reported on 18 children (5 boys and 13 girls) with type 2 DM diagnosed below the age of 15 years at their clinic. Family history of DM was present in all.The youngest age at diagnosis was 9 years. These children were asymptomatic and picked up on screening which was performed due to strong family history of DM and / or because of obesity. Report from a North Indian Clinic showed that type 2 DM accounted for all diabetes cases with onset of DM below 18 years of age (21).

Why Pediatricians need to be concerned?
It is a bit ironic that a problem of "plenty" namely childhood obesity has arisen while we are still fighting undernutrition and infectious diseases. Adverse health consequences of positive nutrition transition in children are undermined as these are seemingly "remote" and therefore "relatively invisible". This has resulted in a false sense of complacency leading to inaction in this age group (22).
The treatment of obesity ultimately involves eating less and being more physically active. As simple as this may sound, long-term weight loss has proven difficult to achieve and, overall, there has been a lack of success of treating obesity once it has become established (9,23). The psychological immaturity of children and their greater susceptibility to peer pressure compared to adults present additional difficulties to the successful treatment of childhood obesity. Because of this, there seems to be consensus that prevention is the most realistic and cost effective approach for dealing with the problem of childhood obesity (24). Thus, although interventions to improve individual lifestyles are needed, especially for children already overweight or obese, remedial actions taken from a broader public health and policy perspective will be necessary to have a significant impact on the problem. As primary care physicians of the children, it is actually the pediatricians who will now have to perform a crucial role by looking after children and adolescents more meaningfully. To create awareness among pediatricians of their role in the prevention of these metabolic conditions, and to provide clear guidelines for actions to be taken by them, the Indian Academy of Pediatrics published its recommendations in a series of articles (25-27). The pediatric community now will have to take a lead role to orient their routine clinical practice in the prevention and early recognition of childhood overweight and obesity. This should be done by dietary history, family history of metabolic diseases, assessment and anticipatory guidance about weight and physical activity. These are briefly outlined below:

Early recognition of excessive weight gain relative to linear growth
This should be done by yearly growth assessment by routine collection of weight and height measurements (recumbent length up to 2 years of age and standing height for older children) to enable monitoring weight-for-height and BMI. Interpretation of weight-for-height and BMI indices based on prescriptive reference data. The NCHS/ CDC charts can be used for this purpose (28). These charts can be downloaded from website. Early intervention after an increase in weight-for-height or BMI percentiles has been observed. International definition for overweight and obesity have been provided by WHO (29). However, it is important for pediatricians to recognize the fact that crossing into higher centiles remains early warning sign.
Dietary modifications
Emphasis should be on nutrition rather than 'dieting'. It is important to maintain healthy components of traditional diets (i.e., micronutrient rich food such as fruits, vegetables and whole grain cereals). Recommended dietary allowances for children are given in Table I (31). and guard against heavily marketed energy dense fatty and salty foods (e.g., pre-packaged snacks, ice-creams and chocolates) and the sugary cold drinks. The strategy should be to recognise and eliminate risk features of high calorie intake such as frequent snacking (samosas, potato chips, chiwdas), eating out frequently (burgers, dosas), celebrating with food (cake, chocolates) and drinks (colas, beers) (Table II). Habits attained early have more chance of remaining throughout life.
A simple Indianized message based on recommendations of AHA (30) could be-"think of a day's food composition as a 'Thali' wherein 50% (half) is full of vegetables, salads and fruits. A quarter (25%) should be made up of cereals such as rice and/or chapattis and the remaining quarter should be protein based (dal/milk/egg/animal protein)"(Fig 1.)
Increase physical activity level
The WHO recommends at least 30 minutes of cumulative moderate exercise (equivalent to walking briskly) for all ages; plus for children, an additional 20 minutes of vigorous exercise (equivalent to running), three times a week. In general, moderate to vigorous activities for a period of at least one hour a day may be a more practical recommendation for all school going children. Perhaps even more important is decreasing sedentary behavior like viewing television (should be restricted to no more than 2 hours a day), computers, telephone conversations. Energy expenditure related to various physical activities are shown in Table III.

Other measures
Children overweight and with family history of metabolic diseases need to be checked with blood pressure and lipid profile from the age 3 years and screening of blood glucose after age 10 years. School based programs to enhance physical activity are already in place in many developed countries and should be encouraged. Campaign against substance abuse like smoking, non smoking tobacco use, alcoholism need intensification. Advocacy at all levels notably teachers, government functionaries, professionals, media, academic bodies, food regulatory authorities and so on are urgently needed to stall the ensuing epidemic of metabolic syndrome.

TABLE I: Recommended dietary allowances. Macronutrients and Minerals

Age	Weight (Kg)	Net energy Kcal/day	Protein gm/d	Fat gm/d	Calcium mg/d	Iron mg/d

0-6 mo	5.4	108/kg	2.05/kg	-	-	-
6-12 mo	8.6	98/kg	1.65/kg	-	-	-
1-3 yrs	12.2	1240	22	25	400	12
4-6 yrs	19.0	1690	30	25	400	18
7-9 yrs	26.9	1950	41	25	400	26
10-12yrs(b)	35.4	2190	54	22	600	34
10-12yrs(g)	35.4	1970	57	22	600	19
13-15 yrs(b)	47.8	2450	70	22	600	41
13-15 yrs(g)	46.7	2060	65	22	600	28
16-18 yrs(b)	57.1	2640	78	22	500	50
16-18 yrs(g)	49.9	2060	63	22	500	30

b = boys, g = girls

TABLE II: Fast foods, desserts, nuts having high fat content

Item	Portion	Calories	Fat (g)	% of fat
Potato chips (Lay's)	30 g	150	10.0	60
French fries (Regular-McDonald's)	1 serving	220	11.4	47
Potato pakora	1 plate	354	12.9	32
Bread pakora	1 Plate	376	14.2	34
Samosa(potato filling)	2 Nos	221	10.2	40
Pop corn buttered	30 g	41	2.0	44
Cheese toast	2 Nos.	171	9.0	47
Cheese pizza	1	340	13.0	34
Cheeseburger (McDonald)	1 serving	315	15.0	45
Scrambled eggs/Omlette	2 eggs	190	14.0	66
Seekh Kabab	4 Nos.	252	14.1	50
Chocolate Bar, plain (Nestle)	30 g	149	7.9	48
Chocolate Bar, walnuts (Cadbury)	30 g	153	8.9	52
*Cakes (homemade)*
Carrot cake	30 g	101	11.9	53
Chocolate with icing	30 g	87	3.2	33
*Ice Cream*
Chocolate	½ cup	155	7.2	42
Strawberry	½ cup	116	5.0	39
Vanilla 10% fat	½ cup	134	7.2	48
Bon Bon	1 piece	179	12.9	65
*Nuts*
Almonds	30 g	165	15.0	81
Coconut, raw	30 g	35	3.4	87
Peanuts, roasted	30 g	160	14.0	78
Cashews	7	98	7.9	73

TABLE III: Energy* Expenditure of Various Physical Activities

*Activity*	Calories Used per hour
Cleaning /mopping	210
Walking, 4 km/hr	300
Running
12 (Km/hr)	750
10 (Km/Hr)	655
8(Km/Hr)	522
6(Km/Hr)	353
Gardening	300
Watching TV	86
Cycling 15 (Km/Hr)	360
Shuttle	358
Table Tennis	348
Tennis	392
Volley Ball	180
Dancing	372
Fishing	222
Shopping	204
Typing	108
Sleeping	57
Standing	132
Sitting	86

Compliance with Ethical Standards

Funding None

Conflict of Interest None

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