Managing obesity positively in children, adolescents and adults is an important step in improving individual and community health. Overweight and obesity are conditions characterized by abnormal excessive fat accumulation in body, which may impair health. Serious physical illnesses such as heart disease, hypertension, diabetes, sleep apnea, fatty liver, osteoarthritis and many others, besides psychosocial disorders such as depression, anxiety, eating disorders and social isolation/ discrimination are associated with obesity.
Heredity (genetics), as well as some medical disorders and medications, play some role in causing Overweight-Obesity. But majority of such cases are related to lifestyle factors such as unhealthy nutrition, lack of physical activity, excess screen exposure and lack of sleep; and environmental factors such as food inequity and certain questionable food industry practices. How to manage obesity encompasses all these areas.
Obesity Management Plan:
Management of childhood obesity (and adolescent obesity, and adult obesity) has following steps.
- Confirming the diagnosis
- Checking for the underlying causes, associated health disorders and metabolic disturbances
- Achieving healthy weight control through Lifestyle and behavior modification, Medications and Surgery
Confirming the diagnosis
Overweight and obesity are diagnosed clinically through BMI (Body Mass Index) charts.
Body Mass Index (BMI) is a simple weight for height index, which is calculated by the formula of
BMI = Weight in kilograms / Square of (Height in meters)
BMI is expressed as kg/m2 units.
- In adults, BMI over 85 is considered Overweight and over 90 is Obesity.
- In children, BMI for Age charts are used, which are different for males and females. On these charts, a reading over 85th percentile is Overweight and over 95th percentile is Obesity.
Checking for the underlying causes, associated disorders, and metabolic disturbances
The doctor will check if heredity, medical disorders, or medications are causing the obesity, or if some lifestyle or environmental factors are responsible.
He will also assess if there are any associated physical or psychosocial disorders.
He may order some laboratory tests such as Blood glucose measurement to check for prediabetes or diabetes; Blood lipid (fat) profile to check for cholesterol and triglyceride levels, and sometimes even check some hormone levels such as thyroid hormones, corticosteroids, or sex hormones.
According to this assessment, the obesity management will be tailored for the individual.
Healthy Weight Control:
Healthy weight control strategies include Lifestyle Modification, Behavior Modification, Medications and Surgery.
Obesity Lifestyle Modification and Behavior Interventions
Healthy dietary practices:
1. Start Early.
- Practice Breastfeeding (if possible Exclusive for 4-6 months and then, at least for a year.)
- Avoid or limit bottle-feeding.
- Avoid or limit marketed baby-foods.
- Start weaning by introducing fresh, natural, home-cooked foods.
- Set a good parental role model in terms of diet, exercise, sleep and screen time.
2. Make healthy food choices.
Say Yes to (Use liberally):
- Whole fruits
- Variety of colored vegetables
- Whole grains (Whole wheat, Brown rice, Quinoa)
- Healthy protein sources such as lentils, beans, nuts, fish, and poultry
- Low fat milk and milk products
- Plant oils
3. Avoid or limit unhealthy food choices.
Say No to or Use minimum:
These foods are common sources of excess calories, salt, sugar, or fats. Many of them are low on good nutrients.
- Sugary drinks (sodas, energy drinks, sports drinks)
- Fruit juices
- Refined grains (White rice/wheat/pasta)
- Red Meats (Mutton, Beef, Pork, Lamb)
- Processed Meats (Sausages, Burgers, Salami)
- Packaged snacks (Cakes, Cookies, Candies, Chips etc.)
- Fast Foods
- Butter, ghee, lard
4. Choose healthy cooking practices.
- Use fresh foods (fruits, vegetables, meats) instead of frozen.
- Lean meat cuts instead of fatty ones.
- Boiling, Baking, Grilling, Roasting, Broiling or Shallow frying instead of deep frying.
5. Avoid Overeating.
- Keep portion sizes small.
- Give more food only if desired.
- Don’t force-feed.
- No pressure to finish the food on the plate.
- Don’t use food as a reward or punishment.
- Eat at home. (Restaurant food portions are large and usually not as nutritious.)
- Eat slowly and without distractions, allowing the brain to send signal that the body has had enough food.
- Eat mindfully. Give thought to hunger, choice and quantity of food.
Regular Physical Activity
Staying physically active keeps the metabolism healthy and controls weight.
The recommended activity levels for healthy adult lifestyle are 150 minutes of moderate or 75 minutes of vigorous activity in 1 week. For controlling weight, at least 1 hour of moderate to vigorous activity is recommended. The recommended levels can be achieved through combining multiple short bursts (min. 10 minutes long).
In children, minimum 1 hour of moderate to vigorous physical activity is advised every day, where the total time can be achieved through multiple short bursts of activities that are minimum 10 minutes long. In addition, muscle strengthening and bone strengthening activities are advised at least thrice a week.
Read Keeping Children Active.
Inadequate sleep can disturb the overall health and change appetite controlling hormone levels to cause obesity. National Sleep Foundation in US recommends:
1-3 years old: 12 to 14 hours a night
3-5 years old: 11 to 13 hours a night
5-12 years old: 10 to 11 hours a night
Adolescents: 8.5 to 9.25 hours a night
Adults: 7-8 hours a night
Limited Screen Time
TV, computers, tablets, mobile phones and gadgets exposure has increased the sedentary screen time in sofas or beds, also serving as the time for unnecessary and unhealthy snacking. This screen time also interferes with healthy sleep patterns.
- No screen time below 2 years.
- Maximum 2 hours of recreational non-educational screen time (the lesser the better!) at other ages.
- No screen time during meals and close to sleep.
- No TV, gadgets, or internet in bedrooms.
Obesity Behaviour Modification
Since the habits about food, physical activity, sleep and screen time need to be modified to establish a healthy lifestyle, and since this is a lifelong process, Behaviour Modification becomes an important part of obesity management.
Educating about obesity, its causes and management; motivating to make positive lifestyle changes, and to maintain them; setting and meeting goals; managing stress; controlling cravings and managing temporary setbacks are parts of this behavior modification process.
Medical, family and community support are essential in achieving these goals.
Medications for obesity
Studies suggest that anti-obesity medicines, used in tandem with lifestyle and behaviour modification, work better than the modification strategies alone in morbid or severe obesity.
As anti-obesity medicines, FDA has approved Orlistat for children over 12 years age, and Phentermine over 16 years age. Orlistat inhibits intestinal lipase enzyme and reduces fat absorption. Phentermine suppresses appetite by releasing catecholamines in hypothalamus.
Anti-diabetic medicines Metformin (which improves insulin sensitivity with increased peripheral tissue glucose uptake and utilization) and Liraglutide (which improves insulin release through GLP1-receptor activation and cAMP increase) and medicines such as Topiramate, Bupropion, Naltrexone and Zonisamide (all of which suppress appetite through modification of neurotransmitters in brain) are some medications, which are currently being tried for obesity treatment. They have not yet been officially approved by FDA for treating obesity in children.
Weight-loss surgery or Metabolic Bariatric Surgery (MBS) has become an important treatment in severe obesity and moderate obesity with co-morbidities. While its practice in adults is now quite common, its use in children below adolescent age is still not accepted by experts.
Bariatric surgical procedures are approved for adolescents with severe obesity and moderate obesity with co-morbidities such as diabetes, hypertension, heart disease, sleep apnea or osteoarthritis. Bariatric surgery’s safety and efficacy in sustainable weight loss and morbidity reduction has been shown in many studies.
These operations can be performed as keyhole (laparoscopic) surgeries, where through small cuts a tube with video camera is inserted to allow the surgeon to visualize the insides of the abdomen. Sometimes when this method is not suitable, the surgeon will do an open surgery where he cuts to open the abdomen for the operation.
Following are the common types of bariatric surgery.
An adjustable silicone ring or band is placed around upper part of stomach to create a small pouch to reduce the food holding capacity and slow down the food passage. The tightness of the band can be adjusted through an inflatable device, which is placed under the skin of the chest and connected by a tube to the band. It is a reversible procedure unlike other surgeries. It is offered to patients over 18 years of age.
Gastric Bypass Surgery
In Gastric Bypass surgery, the surgeon using surgical staples creates a small pouch from upper stomach, and then connects the small intestine to that pouch, thus only a small amount of ingested food can be held in, and absorbed from the stomach pouch, bypassing the rest of the stomach.
In Sleeve Gastrectomy, almost 80% of stomach is removed, leaving only a small vertical sleeve. This reduces the ingested food amount, which can be held and absorbed from stomach.
Bilo-Pancreatic Division with Duodenal Switch is a more complex surgery in different steps such as creating a gastric sleeve, rerouting intestinal food passage, and changing the way bile and pancreatic juices break down the food.
It leads to more weight loss compared to other bariatric surgeries, but it is also associated with more complications during and after the surgery. Usually, this procedure is not offered to adolescents.
Endoscopic Bariatric Procedures
Endoscopic procedures have provided less invasive, less painful, less time-consuming, and less complicated options in bariatrics (the study of obesity, its complications and management).
Gastric Balloon is a procedure where an inflatable balloon is placed for up to 6 months duration to reduce stomach capacity.
POSE (Primary Obesity Surgery Endolumenal) or Enolumena is a new technique where using endoscopic instruments folds are created inside stomach to reduce its capacity.
Patient selection criteria for bariatric surgery or endoscopic procedures:
Bariatric surgical or endoscopic procedures are not to be offered to every patient as an easy way out for obesity management. They are offered to carefully selected patients who satisfy certain criteria.
- An unsuccessful trial of medically guided weight loss program (Lifestyle and Behaviour Modification, Medications) for 4-6 consecutive months
- BMI > 40; BMI>35 with significant co-morbidities like Type 2 Diabetes, heart disease, dyslipidemia, sleep apnea or osteoarthritis
- Patient commitment for regular physical and psychological monitoring, and for follow-up nutrition and exercise program
- Willingness to avoid pregnancy for at least 2 years post-bariatric surgery
Managing Obesity Positively: Summary
- Managing obesity positively at all ages is a global challenge now.
- Obesity is a complex metabolic disease with multiple physical and psychosocial consequences.
- It needs a lifelong multi-pronged management.
- Confirming diagnosis; assessing causes, effects, and associated disorders, and achieving healthy weight control through lifestyle and behavioral modification, anti-obesity medications and bariatric surgery are the different steps of the management.