Childhood Obesity: An emerging epidemic

Is deficiency of the growth the only worrisome problem in the childhood?

Every parent has got a similar refrain that my child is not eating well or growing well. But in the real time scenario, where we follow one or two child policy in most households, parents in their attempts to feed the child will agree to unreasonable demands of children and would give child anything to eat when the child does not eat the good home-made food. And that is leading to another problem - Obesity. Obesity is the root cause of majority of the lifestyle diseases like diabetes, cardio-vascular problems, hypertension and even stroke. And in the present scenario with our junk food friendly diets, obesity is gaining epidemic proportions.

Obesity in children and adolescents is a common phenomenon now-a-days. Childhood obesity can lead to a variety of diseases. Because of obesity,  type 2 diabetes (usually associated with older adults) accounts for 30% of newly diagnosed cases of diabetes in teenagers now. Also associated with obesity are sleep apnea (temporary interruptions of breathing during sleep), raised blood pressure, high cholesterol, bone and joint problems, and depression.

When to say that the child is obese?

Defining childhood overweight and obesity is difficult. Body mass index used to define obesity in adults varies with age and hence should be used only after correction for age. 

A BMI-for-age higher than that of 85% of children of similar age indicates overweight; a BMI-for-age higher than that of 95% indicates obesity. 

Childhood obesity is a serious matter. Having excess fat should not be dismissed as a condition the child will grow out of, something “in the genes,” or a merely cosmetic concern. Obese children become obese adults.

It is good to follow up with your endocrinologist to rule out any hormonal disturbance. Doctor would assess your child for overall health and may some test might be required to rule out incident diabetes or thyroid disorder.

What can I do to manage obesity in my child?

Lifestyle changes, in form of diet and physical activity, form the cornerstone of therapy for childhood obesity. Healthy eating habits would include:

1.     Controlling caloric intake through portion control

2.     Avoiding the consumption of calorie-dense, nutrient-poor foods (e.g., sweetened drinks (such as soda, juice and sports drinks ), most “fast food,” and high-calorie snacks such as chips and candy)

3.      Increasing dietary fiber, fruits, and vegetables

4.     Eating regular meals, particularly breakfast, and avoiding “grazing” after school.

What is the role of exercise in controlling obesity?

Energy intake (calories) is only half of the equation governing weight gain; the other half is energy output (physical activity). 

• Children should engage daily in 60 minutes of vigorous physical activity, and should not spend more than 1 to 2 hours daily watching television, playing video games, talking or texting on cell phones, or using the computer for fun.
• Family as a unit should be part of lifestyle change. For example, it is important for parent to be an example of these healthy lifestyles, avoid overly strict dieting, avoid use of food as a reward or punishment, and try to build children's self-esteem. 

A positive approach works best. Parents should encourage healthy eating and regular exercise without developing a fear of food. This is the first step in establishing the behaviours essential to long-term success.

Contributed by:

Dr Rajiv Singla

Consultant Endocrinology & Metabolism

MD,DM Endocrinology.

ADHD - Attention Deficit Hyperkinetic Disorder

ADHD is the most common behavioural disorder among children with approximately 5-8% of children being affected at any point of time in India.  A lot many times parents and teachers might come to their primary health giver with complaint of child not doing academically well or being inattentive. Would all of these children come under the category of ADHD. 



ADHD may either present with:


1.      Inattention.


2.      Hyperactivity-impulsivity. 
 

When should I suspect that my child has ADHD?


When the child has symptoms of either of the main presentations. Common symtoms are as given in the table.

Inattention means child

Hyperactivity-impulsivity means child

a)      Does not give attention to details, makes careless mistakes in schoolwork. b)      difficulty sustaining attention. c)      does not listen when spoken to directly d)     does not follow through on instructions and fails to finish schoolwork but not due to the oppositional behaviour or failure to understand instructions. e)      has difficulty organizing tasks and activities like arranging the bag. f)      avoids, dislikes, or is reluctant to engage in tasks needing mental effort like school work g)      Often loses things like toys, school assignments, pencils, books etc. h)     easily distracted and will leave the work if the doorbell or phone rings i)       forgetful

a)      Often fidgets with hands or feet or squirms in seat frequently. b)      leaves seat in classroom with out any definitve reason. c)      Often runs about or climbs excessively in situations in which it is inappropriate like in temples, social gatherings etc. (in adolescents it may be limited to subjective feeling of restlessness) d)     unable to play or engage in leisure activities quietly e)      often “on the go” or often acts as if “driven by a motor” f)      talks excessively & blurts out answers before the question has been completed g)      Often interrupts or intrude on others (e.g. butts into conversations or games   awaiting turn

ADHD – causation?


There have been various theories regarding the reason of ADHD, however none has been specified.  Genetics, dietary and environmental factors do play a significant role.

 


Why is recognizing ADHD important?


It is often the high activity level, high disruptive behaviour, inability to utilize intelligence properly; academic underachievement and difficulty getting along with peers which makes early recognition and mangement of ADHD imperative. ADHD has few co morbid disorders like oppositional defiant 
disorder; conduct disorder, depressive and anxiety disorders. These disorders if recognised early leads to early interventions which may lead to better management of child behaviour. 


What the long term implications?


The disorder follows different course over the long run. Infrequently but possibly, it may subside on its own. In a large number, the inattentive symptoms continue in later life. The patient, if left untreated have high chances of mood disorders, drug dependence and anti-social personality traits in adulthood.

 


What are the treatment options?


Treatment options are pharmacological and psychotherapy. The medicine treatment is often combined with parents training and patients’ concentration building exercises,though children may have difficulty in sustaining attention during the psychotherapy sessions. The results of treatment are promising in the long run with substantial remission rates.
 


Contributed by:

Dr Rajiv Mehta

Consultant Psychiatry

Sir Ganga Ram Hospital

MD, Psychiatry

Has my child got short height/ Stature? Physical aspect of child development…

Physical growth of a child is another issue where parents tend to spend a lot of time and energy worrying about its adequecy. Physical growth in children is result of concerted optimal functioning of hormonal, nutritional and psychosocial milieu. If a child is growing well physically in stature, it reassures us about endocrine/hormonal and nutritional wellbeing. It is important that parents maintain health records of their children regularly and recording of height and weight is an integral and essential part of this.

How do I know if my child is shorter than normal?

This can be answered by comparing your child’s height to the height of other children who are the same age and sex. This comparison is done with help of standard charts that are available with your doctor. It is advisable to use Indian growth charts for our children. If your child is much shorter than other children of the same age and sex, doctors call it “short stature.”

If my child is short, does it mean he or she has a medical problem?

Not essentially. Children who are short may be healthy and may not have any medical problem. Reasons for short stature in these children can be:

1. One or both of their parents are short. If a child’s parents are short, chances are good that he or she will be short, too.

2. They are growing more slowly than usual i.e. they have “growth delay.” These children are short because they have their growth spurt delayed than other children. But these children will grow to a normal height as adults.

Some children who are short do have a medical problem. Some of these include:

1. Very low body weight

2. Long-term diseases affecting the digestive system, heart, lungs, kidneys, or blood.

3.“Growth-hormone deficiency”.  Growth hormone is a hormone made in the pituitary gland in brain that helps children grow normally. Children with this condition have too little growth hormone in their body to have normal physical growth.

4. Other hormonal diseases like thyroid problem, pituitary abnormality etc.

5. Problems that babies are born with, for example  abnormal genes

Will my child need some investigations?

Perhaps. First step is to confirm whether your child is short. A physical exam followed by measurements of height, weight, arm and leg length is the next step to diagnosis. These will be followed by questions about family history, which will give clues to whether the short stature could be the result of an inherited condition.  If any of the above medical condition is suspected in your child then we might also do some blood tests to check for different conditions, including growth hormone deficiency and x-rays of 1 of your child’s hands and wrists – these X-rays to help tell how tall your child will grow.

Will my child need treatment?

Treatment of short stature depends on the underlying cause. For example, if the cause is a chronic disease such as diabetes or sickle cell anemia, these conditions should be treated first.

Is growth hormone treatment ever used for children without growth hormone 

deficiency?

Not usually. That’s because growth hormone treatment doesn’t always make these children grow. The treatment costs a lot of money and is not easy. Children usually need to take an injection every day for many years.

Is there anything I can do on my own to help my child?

Yes. You can make sure your child gets enough food and eats a healthy diet. If you need help changing your child’s diet, ask the doctor or nurse. Help your child feel good about him or herself. Try to point out your child’s strengths and not focus too much on his or her height.

Contributed by:

Dr Rajiv Singla

Consultant Endocrinology & Metabolism

MD, DM Endocrinology

 

Developmental Disorder: Cerebral Palsy a common cause.

A normal child will follow a more or less typical pattern of development both mentally and physically. A common refrain that might be heard amongst parents is my child is not catching up, that might  be in terms of mental development, academically, physically. It might be a benign concern coming from a parent who expects children to win all the possible ways in this big race called life. But when should we suspect that there is actually wrong with my child. We commonly use milestones that should be reached for particular age groups. Skills such as taking a first step, smiling for the first time, and waving “bye-bye” are called developmental milestones. Children reach milestones in how they play, learn, speak, behave, and move (for example, crawling and walking). A brief overview of the common milestones that are monitored is given below. A pediatrician or a neurologist should examine any child who is lagging behind in these milestones.

 

                 image courtesy : www.cdc.gov 

When do we know that is not keeping up and when does the parents should meet their healthcare provider. There are few red flags that indicate child is not developing well:

1.      If child is lagging on milestone chart
2.      If is unable to attend to task given
3.      If child is hyperactive
4.      If child has any seizure
5.      Has difficulty in sensory perception, progressive decreased vision and decreased hearing.

If there is any of the above symptoms, we should suspect Developmental disorder in the child and take medical help as soon as possible.  

What cause developmental disorders? Most of developmental disorders are caused by a mix of factors genetics; parental health and behaviors (such as smoking and drinking) during pregnancy; complications during birth; infections the mother might have during pregnancy or the baby might have very early in life; and exposure of the mother or child to high levels of environmental toxins, such as lead. For some developmental disabilities, such as fetal alcohol syndrome, which is caused by drinking alcohol during pregnancy, we know the cause. But for most, we don’t.
  

Can my child be affected? 

Developmental disabilities occur among all racial, ethnic, and socioeconomic groups. 

What are the common Developmental disorders? 

Common developmental disorders include:
1. Cerebral Palsy
2. Autism and austic spectrum disorder
3. ADHD
4. Hearing Loss
5. Vision Loss
6. Miscellaneous – including specific genetic syndromes.
  

What is cerebral palsy (CP)? 

Cerebral palsy is a group of disorders that affect a person’s ability to move and keep their balance and posture which may occur because of brain injury or abnormal brain development. The cause of the palsy may begin before or as is more common during and immediately post birth. Cerebral palsy causes different types of disabilities in each child. A child may simply be a little clumsy or awkward, or unable to walk at all. 

How does CP present ? 

Presenatation of CP vary greatly because there are many different types and levels of disability. The main sign that your child might have cerebral palsy is a delay reaching the motor or movement milestones. CP might be suspected if child do not attain the below mentioned milestoenes at the ages mentioned aside them.A child at: 

2 months cannot control head or has stiff legs that cross or “scissor”.
6 months continues to have a hard time controlling head when picked up or reach with only one hand while keeping the other in a fist.
10 months crawls by pushing off with one hand and leg while dragging the opposite hand and leg and not sit by himself or herself.
12 months not crawl and not be able to stand with support.
24 months not be able to walk or to push a toy with wheels. 

Are there any other symptoms that the child with CP have? 

Apart from motor symptoms, child might have associated seizures, speech problems, ,  clumsiness in doing work, eating problems, skeletal problems, sensory impairments, intellectual disability, learning disabilities, urinary incontinence, fecal incontinence, and/or behavioural disorders. Pain because of stiffness in the muscles is another disabling complaint in these children. 

What causes CP? 

CP is caused by damage to the motor centers of the developing brain which may occur during pregnancy, during childbirth, or after birth up to about age three. Upto 2% of all cerebral palsy cases are believed to be due to a genetic cause. 

In a case of suspected cerebral palsy, Please seek the help of a specialist such as a developmental pediatrician or child neurologist, who might after evaluating the child might guide on the path to its management.  

Contributed by:
Dr Sweta Singla
MD, DM Neurology 

Consultant Neurology & Sleep Disorder.

Development of child: the basic factors involved.

Right from the moment a human life is conceived, the process of development starts and it does not stop till we die. The development is a constant process that brings about a change in a being every moment, mostly in the positive direction but many a times it might cause regressive changes also.

The process of development constitutes both mental and physical development including growth of all the somatic organs of the body. 

As a life is conceived, initially cell division from the fertilized ovum increases the number of cells, so there is enough number of cells to complete growth of all organs.  Alongside the increase in number of cells, each cell is also gradually allotted a specific function. Initially the cells are segregated broadly and are marked to become a specific organ in the body and accordingly they take their specific place in the architecture of the human body. Later on the cells targeted for a particular organs further differentiate and form various types of cells that are necessary to a form an organ. One of the foremost organs to take shape in a developing embryo and later on the fetus is the brain, aptly emphasizing its importance in the body considering it is the control panel of the development in rest of the body. The cells destined to become brain cells or the neurons are allotted their specific function as soon as 13^th day of the embryonic life. The brain then grows to accommodate around 86 (+/- 8) billions of cells at the time birth with trillions of networks between these cells. 

In the first two years of life post birth, the network that are emphasized stay in the brain but those that are not used are pruned. Meanwhile child grows and experiences the gamut of stimuli form the environment and according to the stimuli perceived, it consolidates its neurological networks and so its’ function, its emotional structure, its hobbies and its personality.

Though the genetics and DNA provides the blueprint of how the human being should be, but it is the environment that by creating the stimuli, modulates how the gene would be expressed or whether that gene would be expressed or not. During the whole of prenatal period, birth and also a significant part of the first few years of the childhood, the development occurs majorly in response to the environment. How was the environment in the womb including nutrition, exposure to the chemical milieu inside the womb, even the mood and stress level of the mother when the child is developing inside her creates an environment to which the developing fetus responds and lodges a nourish or protect kind of response which further guides the gene expression, which in turns decides how well the child’d body and responses would develop. Later on during the birth, whether there was any stress to child in the form of the birth injury or any metabolic insult like kernicterus or severe jaundice determines development. Postnatally, child’s environment is majorly formed by the mother and other family members who take care of the child. And what kind of the stimuli child gets will determine his/her future perceptions, beliefs and responses and reflexes.   

Child development - the key for the better future

“A child is the seed that we sow to create the future; the future that remains unseen”

A child is like a new beginning, with limitless possibilities that may emerge out of him. While raising a child, a lot many questions come to our mind. What should I do to provide my child the best possible environment so that she/he grows to achieve the best of his potential? What food should I give him? What kind of mental stimulus should I expose her to? Is her physical growth adequate? Why is my child not the best amongst all? Is there any thing else that I should do? This and many more doubts come to our mind as a parent when we are doing this tremendous job of raising a child.

Though, endless discussions can take place on such topics, what we shall try here, is to give you in a nutshell, the normal development on the brain and physical aspects of the body of a child and when should we suspect any discrepancy in the same.

We may start the discussion with normal brain development during the early childhood. Followed by common conditions that may hamper the development of the brain. The most common of these is cerebral palsy. Also mental health is important and so comes the discussion on autism spectrum disorders and ADHD. Lastly we will discuss the physical aspects of the growth and the growth disorders.

PREGNANCY DILEMMA : How much to eat and what to eat…

Pregnancy is one of the most crucial time in a woman’s life. Giving birth to a baby needs special preparations and it is vital that mother takes care of her nutrition and health as that has a direct bearing on the child’s development. Simple things like planning your meals may help in the foetus development while giving you energy throughout the day.

What is the calorie requirement during pregnancy and lactation?

The calorie requirement for a pregnant woman ranges between 2200 calorie to 2900 calorie ( depending on height, weight and activity undertaken). The first three months of pregnancy doesn't require extra calories. During 4-6 months of pregnancy additional 340 calorie a day should be added. In the last 3 months another 120 calories ( 340 + 120 cals) should be added. It is highly recommended that these additional calories come from cereals, fruits and vegetables and proteins.

Does Pregnant lady need other nutrients? If yes, what are those nutrients?

Yes, apart from the calories, there is increase in daily requirement of various nutrients. The most common deficiencies that need to taken care of are of folic acid, calcium and omega -3 fatty acids. 

Folic Acid: Folic acid reduces the risk of birth defects that affect the spinal cord. Pregnant women need 600 micrograms of folic acid a day. Sources include fortified foods like cereals, pastas and breads, supplements and natural food sources of folate. 

Iron: Maternal iron deficiency is the most common nutritional deficiency during pregnancy. Pregnant women need at least 27 milligrams of iron a day. High-iron foods include spinach, kale, leafy greens, beans, fortified cereals, red meat, chicken and fish. For vegetarians and women who do not eat a lot of meat, increase iron absorption by combining plant-based sources of iron with vitamin C-rich foods. For example, try spinach salad with mandarin oranges or cereal with strawberries.

Calcium: During pregnancy, calcium is needed for the healthy development of a baby’s teeth, bones, heart, nerves and muscles. When a pregnant woman does not consume enough calcium, it is taken from her bones for the baby. It is important to consume 1,000 milligrams of calcium a day before, during and after pregnancy. That means at least three daily servings of calcium-rich foods such as low-fat or fat-free milk, yogurt or cheese or calcium-fortified cereals and juices.

Omega 3 fatty acids: Increase blood flow to reproductive organs and may help regulate reproductive hormones. Consumption is also known to help prevent premature delivery and low birth weight.The best dietary source of omega-3 fatty acids is oily fish. Other omega-3 fatty acids not found in fish can be found in foods such as flaxseeds, walnuts, pumpkin seeds, and enriched eggs.

Through these simple guidelines a pregnant woman may enrich her diet for a happy and energetic pregnancy term.

Contributed by: 

Vineet Tiwari

Freelance Health columnist.

Keep looking this space for more nutrition related information and some interesting dietary guidelines and tips that would be given by Ms Shafina Segon, who is diet consultant and manages her Diet Consultancy services that goes by the name of Nourish.

Vertigo: An Enigma demystified

The term vertigo has been derived from the latin word ‘ vertere’ that means ‘to turn’. 

Simply put it is a sensation that might be described as a pre-syncope, light-headedness, disequilibrium to describe that feeling of floating in our environment and losing our sense of direction.

According to a recent report by a French study, 1-year prevalence for vertigo was 48.3%, for unsteadiness 39.1%, and for dizziness 35.6%.

The vestibular system comprises of the labyrinthine part of the inner ear and its connections in the brain stem and cerebellum, which are the balance regions of the brain. 

Equilibrium Pathway:

Vertigo is caused by the abnormal functioning of the vestibular system that is responsible for managing our balance, motion perception and response of eye movements to different positions. 

Broadly, vertigo may be classified as peripheral and central in etiology.

• Peripheral vertigo means that it is originating at the ear end of the vestibular system;
• Central vertigo means that the causation lies some where in the brain.

Common causes of the peripheral vertigo are:

Benign paroxysmal positional vertigo (BPPV), thought to be caused by a displacement of otolith particles, calcium deposits in the inner ear, is the most common type of peripheral vertigo in the clinical practice, twice as common in women than men, usually affects older people and most often arises without a known cause (idiopathic). While most cases are spontaneous, BPPV vertigo can also follow head injury, reduced blood flow in a certain area of the brain (vertebrobasilar ischemia), labyrinthitis: inflammation of the inner ear labyrinth and vestibular nerve (the nerve responsible for encoding the body's motion and position, ear surgery, prolonged bed rest.

Other common peripheral causes of vertigo are : 

• Vestibular neuronitis - this is thought to be due to inflammation of the vestibular nerve. 
• Ménière's disease: caused by inflammation, usually infective & thought to be caused by high pressure of a fluid in a compartment of the inner ear .

Central vertigo is a term that collects together the central nervous system causes - involving a disturbance to one of the following two areas: The parts of the brain (brainstem and cerebellum) that deal with interaction between the senses of vision and balance, or sensory messages to and from the thalamus part of the brain.

Most common of the central vertigo is Vertiginous Migraine that would be associated with the headache.

Other rare but important causes are:

▪                 stroke and transient ischemic attack

▪                 cerebellar brain tumor

▪                 acoustic neuroma (a non-cancerous growth on the acoustic nerve in the brain) and

▪                 multiple sclerosis

Let's make one thing very clear, that cervical spondylosis is not a cause of the vertigo as most of us try implying cervical spondylosis as the cause of our unexplained vertigo  though emotional upheavals may sometimes cause pre syncope type of states that may be confused with vertigo and may be misinterpreted leading to unnecessary investigation.

As described above, most of the cause of vertigo are benign and there is nothing to worry about. But we all should know the red flag signs so that we know when to call the doctor for evaluation.

Please consult a Neurologist if there is: 

• worsening vertigo or disequilibrium, 
• imbalance or in-coordination of the movement, 
• associated non relieving headache, 
• recurrent vomiting, 
• loss of consciousness associated with vertigo, 
• double or blurred vision, 
• speech difficulty, 
• limb weakness, 
• atypical “non-peripheral” vertigo, such as vertical movement;  

Peripheral vertigo should be best evaluated by an ENT expert. So, ENT opinion is warranted if vertigo is:

• short duration, 
• episodic, 
• postural vertigo 
• associated with hearing loss and /or tinnitus

Medications are prescribed according to the etiology of the vertigo. Apart from the medicine your doctor might tell you a few exercises that might improve your vestibular system function and hence the vertigo.

Contributed by :
Dr Sweta Singla
MD, DM Neurology