When I was a medical student (so long back that it was actually in the last century), two of the cases placed before us as spotters (look and diagnose, dont touch or question) in an examination were children with kwashiorkor (lethargic and disproportionately swollen with fluid) and marasmus (wizened, wasted and looking like a wise elder). Both were common conditions, the result of malnutrition.
Such diseases are rare today. In fact, now doctors have to spot diagnose children at the opposite end of the spectrum. About 20 per cent of children (some less than a year old) and teenagers in India can be defined as overweight, obese or morbidly obese. Their weights exceed that expected for their heights by 20 per cent, 50 per cent, and even 80-100 per cent. The BMI (body mass index, calculated as weight divided by height in meter squared) which should be 23 is often well above 30. Many of these children maintain their obese status into adult life.
In addition to having a paunch, big hips, knock knees and a double chin, such children have a peculiar velvety black discolouration of the skin — called acanthosis nigricans — on the nape of the neck. No amount of scrubbing will remove it, nor talcum powder conceal it. It is a marker for obesity that is likely to progress in diabetes.
This unhealthy state of over nutrition starts in infancy. Babies are breast fed for less than a year and weaned early. They are often force fed high energy, ready-to-eat carbohydrate substitutes instead of healthy, home cooked weaning foods. Older children gorge on unhealthy packaged snacks that often serve as a substitute for meals.
The children also have limited outdoor activity. Schools do not encourage physical training or games, as academics takes precedence over sports. In the evenings, tuition, homework and television usurp their time. Many parents do not have the time, inclination or space to take the children out.
Energy intake soon overtakes energy expenditure. In children, the waistline expands and fat is deposited in the abdominal regions. A paunch develops and pushes up the stomach and other abdominal contents against the diaphragm (a muscle that separates the abdomen from the chest). The chest is unable to expand fully and breathing becomes shallow, noisy and inefficient. Infections are frequent.
The excess fat is also deposited in muscles and liver tissue. The fat makes the body resistant to the actions of its own insulin. Even young children develop relative insulin resistance. Glucose intolerance and hypertriglyceridemia begin to develop in them. Fat gets deposited in the blood vessels. And this can cause the blood pressure to rise and result in premature coronary artery disease.
Adolescent obesity causes hormonal imbalances. In obese girls, androgens are present in excess. They develop unsightly facial hair and menstrual irregularities. This may result in PCOS (polycystic ovarian syndrome). In men, estrogen levels rise and gynacomastia develops. Eventually, these obese adolescents become subfertile adults. Pregnancy occurs only after expensive and frustrating treatment.
Obese children are also prone to numerous orthopedic problems. They may develop bowlegs. The ends of the growing bones may slip causing deformities. All this results in the early onset of arthritis.
Moreover, children are psychologically affected by their obesity. They are often the brunt of jokes. They are often excluded from sports and cultural events.
Quite often, the overweight children appear to have a familial obesity. This correlation is likely to be due to the environment with excessive food intake, limited exercise and almost compulsive television viewing. In these children, the obesity is not genetic but a result of the upbringing.
Boys (not girls) who are obese in childhood and adolescence are at risk for sudden death from coronary artery disease (CAD) as adults. They are also at increased risk for gout and colorectal cancer. This risk remains constant even if they manage to lose weight as adults. Girls who are obese become women at high risk for arthritis.
Television viewing should be restricted to a minimum. If the parents watch television for many hours every day, children too get hooked on to it. It is better to enroll them in coaching classes for activities like cricket, swimming, tennis, football or basketball. The Sports Authority of India conducts camps during summer vacations. Children who attend these camps should be encouraged to maintain the momentum even after school re-opens. Daily running or jogging for 20-40 minutes will help them keep up their stamina and maintain weight till the next round of coaching starts.
As parents and elders, we have to keep our children fit and not fat.
Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at firstname.lastname@example.org