Obesity in Adolescents Indian scenario Dr Swati Bhave

Obesity in Adolescents – Indian scenario Dr Swati Bhave Convener Adolescent Interest group of IPA ( International Pediatric association ) Chairperson IAP Indian academy of Pediatrics ) ADOL chapter Research & Training wing Member WHO SEARO Regional Adolescent Technical Advisory Committee

Obesity & Life style diseases ……Importance for adol age § Adolescent physicians and pediatricians have an important role in the prevention and control of the ‘epidemic. ’ of Life style disorders § As they begin in childhood (or even earlier, in fetal life), and Manifest due to interactions & accumulation of various risk factors, throughout the life cycle. WHO/NMH/NPH/ Life course perspectives on coronary heart disease, stroke, and diabetes. WHO, Geneva, 0. 1. 4: 2001. Fall CHD. The fetal and early origins of adult disease. Review. Indian Pediatr 2003; 40: 480 -502

Obesity in developing countries § Rapid epidemiological transitions : nutritional & socio-economic. § A complex picture : simultaneous under nutrition & overweight in all parts of India § Indian mothers : chronically malnourished (stunted) § Indian babies : small LBW > 25% of all ‘normal births’. § In this background, we are now witnessing problems of plenty such as obesity with its attendant risks. Barker DJP. Mothers, babies and health in later life. Edinburgh: Churchill Livingstone, 1998. Yajnik CS. The insulin resistance epidemic in India: Fetal origins, Later lifestyle, or both ? Nutr Rev 2001; 59: 1 -9.

Obesity in Urban Slums Most cases malnutrition but obesity also on rise Poor knowledge of healthy food habits Whatever little they earn is spent on junk food and soft drinks due to the impact of advertisements that are rampant on TV which is also seen avidly in the slums Popkin BM. Food Nutr Bull 2001; 22(S 4): 3 -4

Prevalance of obesity in India Prevalence ranges from 6 to 8% and occasionally higher but clubbed to mean overweight and obesity collectively. On a more positive note, tendency for overweight is more School children in Chennai § > 22% HSE group § 15% from MSE groups. § only 4. 5% from LSE group urban well-off children : highest risk. Ramachandran A, Snehalatha C, Vinitha R, Thayyil M, Sathish Kumar CK, Sheeba L, et al. Prevalence of overweight in urban Indian adolescent school children. Diabetes Res Clin Pract 2002; 57: 185 -190. Urban Delhi, >25% of adult males and 47% of adult females were found to be overweight or obese. KS, Prabhakaran D, Shah P, Shah D. Differences in body mass index and waist: hip ratios in north Indian rural and urban population. Obes Rev 2002; 3: 197 - 202.

Affluent Adolescent School children Delhi 31% overweight; 7. 5% obese. 2 Urban India Elite classes Urban slums Fattening Pune 24% overweight. 3 Chennai 22% overweight. 1 1. 2. 3. Indian Pediatr 2002; 39: 449 -452. Indian Pediatr 2004; 41: 559 -575. Diabetes Res Clin Pract 2002; 57: 185190. Rural India Poverty and Undernutrition

Factors responsible Changes in Life Style (Urbanisation) • Unhealthy eating patterns • Wrong choices of food, increased portions • Increased oil consumption • Snacks, colas, rewards…… Sedentary pursuits • Long school hours, tuitions, Reduced physical activity vehicles, reduced play areas Other factors High glycemic index of foods Genetic / Constitutional predisposition ‘Early life origins’ -programmed to accumulate fat Silent genes unmasked? Thrifty genotype Gestational diabetes – intergenerational effects 7 TV, telephones Bhave S, Bavdekar A, Otiv M. IAP National Task Force for Childhood , Prevention of Adult Diseases: Childhood Obesity. Indian Pediatr 2004; 41: 559 - 75. Khadilkar VV, Khadilkar AV. Prevalence of obesity in affluent schoolboys in Pune. Indian Pediatr 2004; 41: 857 -858

Indian scenario § Midst of a rapidly escalating epidemic T 2 DM and CHD § Prevalence T 2 DM increased in urban Indian adults from < 3% in 1975 to > 12% in the year 2000 § By the year 2025 it is predicted that India will have a rise of 59% of diabetics in the population. . . Which is the highest number of diabetic patients in the world. Ramachandran A, Snehalatha C, Kapur A, Vijay V, Mohan V, Das AK, et al. High prevalence of diabetes and impaired glucose tolerance in India: National urban diabetes survey. Diabetologia, 2001; 9: 1094 -1111. NY Times Sep 13 2006 NR Kelinfield Modern ways open India’s door to diabetes

Type 2 DM India -1 § 10% of newly diagnosed DM are in age group of 10 – 18 years § Most were asymptomatic: picked up on screening for obesity or strong family history. Venkatnarayan KM. Type 2 Diabetes in Children: A problem lurking for India ? Indian Pediatr (editorial) 2001; 38: 701 -704. § High incidence of gestational diabetes in young mothers, with intergenerational effects. § High (14%) prevalence of impaired glucose tolerance suggests a large pool of potential diabetics. Bhatia V. IAP National task for childhood prevention of adult diseases: Insulin resistance Type 2 Diabetes Mellitus in Childhood. Indian Pediatr 2002: 41: 443 -457.

Cut off values of BMI for overweight Agency State of overweight WHO Tendency for overweight > 25 kg/m 2 IOTF > 23 kg/m 2 > 25 kg/m 2 NCHS > 30 kg/m 2 > 85 thcentile > 95 th centile (90 th centile recently) (97 th centile recently)

Cutoff Values for BMI For Obesity in Indian Studies 95 th centile Girls 95 th centile Boys Author Range Year Vedavati 22 -27 kg/m 2 1998 Agarwal 23 -27 kg/ m 2 1988 -1994 Cole 24 -29 kg/m 2 1963 -1993 Khadilkar 24 -27 kg/m 2 2004 Agarwal 22 -27 kg/m 2 1988 -1994 Cole 23 -28 kg/m 2 1963 -1993 § BMI values show wide variations between regions, and the period of the studies. § Pune study, age 10 -13 years, BMI of boys have been even higher than the international values. § Delhi Agarwal’s chart for the 85 th and 95 th centile show lower BMI values than the WHO values §Local BMI values are collected on smaller samples and comparison between them and with international norms are not feasible.

Some thoughts on BMI …. . 1 § Cut of BMI > 25 kg/m 2 in adults - tendency for overweight- based on the concept of what is considered ideal for an adult of stable stature. § Similarly, IOTF values have been projected from an optimum BMI of 25 kg/m 2 at age 18 years. These valuable sets of values unfortunately, may not be applicable during the adolescent growth spurt. Till such time, we have our nationally representative values for BMI appropriate for age and sex; we are using the Task Force’s policy of IOTF values.

Some thoughts on BMI … 2 BMI per se or 95 th centile by itself may not be definitive indices of overweight. Waist measurement and waist/hip (W/H) ratios may not be applicable for adolescents due to their physiologically changing body shape §Whether this will translate into a yardstick for optimum health in adolescents needs to be seen by long term studies on the comorbidities and the ultimate BMI of these adolescents in the Indian context. § TSFT also needs consideration § Increased BMI / normal TSFT, likely to be overweight and not over-fat, § As skin fat thickness doubles normally between sexual maturity rating of breast stage 2 -5 in girls.

EHPA Chart § Elizabeth health path for adults and adolescents is a novel and easy chart, which is ideal for screening adolescents for risk of overweight. Elizabeth KE. A novel growth assessment chart for adolescents. Indian Pediatrics 2001; 38: 1061 -1064

Barker’s Hypothesis FOAD 1986 § Fetal origins of adult-onset diseases (FOAD) § Under nutrition and unfavorable intrauterine environment at critical periods in early life can cause permanent changes (in both structure and function) in developing systems of the fetus (i. e. programming). § May manifest as disease over a period of time due to `dysadaptation’ with changed environmental circumstances Barker DJP. Mothers, babies and health in later life. Edinburgh: Churchill Livingstone, 1998.

Developmental origins of adult disease: hypothesis Placental transfer Maternal malnutrition Fetal genome FETAL UNDERNUTRITION (Nutrient demand exceeds supply) Altered body composition Down regulation of growth Muscle mass Fat mass HYPERLIPIDAEMIA HYPERTENSION Early maturation Cortisol Brain sparing Impaired development (Liver, Pancreas, Blood vessels) CENTRAL OBESITY INSULIN RESISTANCE Type 2 Diabetes and CHD Fall CHD. The fetal and early origins of adult disease. Review. Indian Pediatr 2003; 40: 480 -502

Characteristics of obesity in India § Frank obesity not as high as in the West But body composition & metabolism of Indians (asians in general) make them especially prone to ‘adiposity’ (fat content in the body) and its consequences. § South Asians have at least 3 to 5% higher body fat for the same BMI as compared to Caucasians. § The fat is typically located ‘centrally’ (i. e. waist, trunk) and around visceral organs metabolically more dangerous than peripheral fat.

Additional features associated with Metabolic Syndrome Insulin resistance (fasting insulin, HOMA IR) • Dyslipidemia (in addition to above, increased small dense LDL) • Hypercoagulability of blood (increased plasminogen activator inhibitor) • Vascular dysregulation (beyond elevated blood pressure) • Endothelial dysfunction – microalbuminuria • Pro-inflammatory state – raised high sensitive C-reactive protein, TNC-alpha and IL 6 • Polycystic ovarian disease (PCOS) • Acanthosis nigricans Adapted from * International Diabetes Federation. The IDF consensus worldwide definition of the metabolic syndrome. Brussels: IDF, 2005 http: //www. idf. org/webdata/docs/IDF-Metasyndrome, definition. pdf (May 2005)3

Acanthosis Nigricans Indian studies § This simple diagnostic marker in a clinical examination in office practice was seen in 20% of obese adolescents, § who also had high insulin and C-peptide levels with normal Hb. A 1 c level Subramaniam V, Jayashree R, Rafi M. Prevalence Overweight and obesity in Chennai 1981& 1998. Indian Pediatrics 2003; 40: 332 -336.

Constituents of the Metabolic Syndrome (Syndrome X, Insulin Resistance Syndrome) Central Obesity: waist circumference > 90 cms for males and > 80 cms for females) As per the new 2005 International Diabetes Federation definition 3, the criteria for the diagnosis of the metabolic syndrome are: central obesity + any two of the following four factors* • Raised serum triglycerides > 150 mg /dl • Reduced serum HDL cholesterol < 45 mg / dl • Raised blood pressure (BP systolic > 130, and diastolic > 85 mm Hg) • Raised fasting blood sugar level ( > 100 mg/dl)

Hypertension and other CVS Risk factors (Hyperlipidemia, hypercoagulability) § Indian cohort studies : high risk factors for CVS diseases are associated with both fetal origins and later life styles. § High incidence of mortality & morbidity due to MI and stroke in young adults implies : start insidiously in childhood / adolescence and are obviously asymptomatic for long periods. § Other ‘life style’ risk factors developed during childhood / adolescence (food habits, alcohol, physical activity, drugs) also track through into adult life. Reddy KS. Cardiovascular diseases in developing countries: dimensions, determinants dynamics and directions for public health action. Pub Hlth Nut 2002; 5: 231 -237.

Indian scenario- CHD § Central obesity adversely influences (SBP) i. e. peak response minus mean pre-stressor level, and greater (DBP) reactivity to postural change § Increase is seen in left ventricular mass in obese children and adol related to central obesity and elevated insulin levels. § Predicted CHD will soon over-take infectious diseases as the leading cause of premature death in adults. § 20 -25% of obese adolescents : hypertension, dyslipidemia & PCOS Gupta AK, Ahmad I. Childhood obesity and hypertension. Indian Pediatr 1990; 27: 333 -337

Studies of FOAD in India § Affluent countries, emphasized the importance of birth weight and other measures of poor fetal growth in the genesis of FOAD disorders. § The role of genes especially ‘thrifty genotype’ had also been suggested. § In recent years cohort studies from india however, have highlighted the importance of subsequent over nutrition in the development of this disorder. § (beginning in Pune in 1990, followed by cohorts in Mysore, Delhi and Vellore) Yajnik CS, Fall CHD, Koyaji KJ, Hirve SS, Rao S, Barker DJP, et al. Neonatal anthropometry: the thin-fat Indian baby. The Pune Maternal Nutrition Study. Int J Obes 2003; 27: 173 -180.

Indian cohort studies –pune -1 § Deleterious effects of accelerated weight gain in childhood i. e. ‘crossing of centiles’ especially in LBW babies. § Indices of insulin resistance and CV risk factors were found to be highest in those that were born `small’ but were big by 8 years even though they were not obese in absolute terms. § accelerated growth in childhood is associated with early puberty and greater risk of obesity. Bavdekar A, Yajnik CS, Caroline HD, Bapat S, Pandit A, Deshpande V. , et al. Insulin resistance syndrome in 8 -year-old Indian children – Small at birth, big at 8 years, or both ? Diabetes 1999; 48: 2422 – 2429.

FOAD now DOHa. D – Developmental Origins of Health & disease Hypothesis for D O H a D § Multiphasic Nutritional Insult § Genes + early Under nutrition + subsequent Over nutrition § Fetal origins or later lifestyles or both ` Yajnik CS. The insulin resistance epidemic in India: Fetal origins, Later lifestyle, or both ? Nutr Rev 2001; 59: 1 -9

Indian cohort studies –pune -2 Maternal Nutritional Studies have shown convincingly that this high risk body composition is present even at birth, i. e. lower birth weight, lower muscle mass but relatively high fat mass and hyper insulinemia (`thin fat’ phenotype) § It is possible that such fat offers survival benefits to newborns but also endangers predisposition to insulin resistance from birth itself. Yajnik CS, Fall CHD, Koyaji KJ, Hirve SS, Rao S, Barker DJP, et al. Neonatal anthropometry: the thin-fat Indian baby. The Pune Maternal Nutrition Study. Int J Obes 2003; 27: 173 -180.

“ Thin-fat “ baby § Newborns, even relatively small at birth (BW < 2. 9 kg) reported to have greater subscapular skin fold thickness, which is shown to correlate well with truncal obesity § Also been shown that this adiposity tracks to 4 years of age Agarwal KN, Saxena A, Bansal AK, Agarwal DK Physical growth assessment in adolescence Indian Pediatr 2001; 38: Krishnaveni GV, Hill JC, Veena SR, Fall CHD. Truncal obesity is present at birth and in early childhood in south Indian children. Indian Pediatr 2005; 42: 527 -538

Indian cohort studies-delhi § An increase of BMI of 1 SD from 2 to 12 years of age, § increased the odds ratio for disease (IGT / DM) by 1. 36. in young adults § It is now evident that our traditional understanding of concepts of `catch up growth’ in childhood, and ‘healthy’ weight gain during adolescence may need redefining. Bhargava SK, Sachdev HPS, Fall CHD, Osmond C, Lakshmy R, Barker DJP, et al. Relation of serial changes in childhood body-mass index to impaired glucose tolerance in young adulthood New Eng J Med 2004; 350: 865 -875.

MONITORING AND COUNSELLING THE ADOL § Most FOAD related disorders can be prevented or effectively managed if picked up early in life. § Main focus of preventive programmes should be directed towards prevention of obesity throughout childhood and adolescence. § Public health campaign directed towards life style changes in the family / society as a whole. § Benefits of healthy eating, increased physical activity & reduction in sedentary activities have to be inculcated from early age. § School based programmes most likely to be successful but health authorities and media have an important role to play to spread awareness. Greydanus DE, Bhave Swati. Obesity and adolescents. Time for increased activity. Indian Pediatr 2004; 41: No 6

Life style diseases prevention programs Chairperson Swati Bhave Five year program advocacy and awareness § Standard set of slides and Training modules for Pediatricians § school teachers & parents § community § Pre and post assessment of the intervention strategies § Colloboration with USA universities

KEY MESSAGES § India : alarming epidemic of T 2 DM, CHD & other LSD associated with the IRS (metabolic syndrome X). Ethnically, Indians have lower muscle mass and higher body fat (especially central obesity). § The fetal origins hypothesis proposes : dysadaptation between fetal growth restriction (LBW ) & subsequent over nutrition (obesity). § The FOAD epidemic is potentially preventable with life style changes in childhood and adolescence. § Targeted effectively through school / college campaigns to focus on healthy eating, increased physical activity and reduction in sedentary habits.