by Randima Attygalle

‘All work and no play makes Jack a dull boy’ calls for rephrasing today into ‘Bad food and screen time make Jack an obese boy’. Childhood obesity is increasing rapidly in Sri Lanka and the present COVID-19 pandemic is a double whammy, with children being home-bound with no physical activity. The increased screen time spent on virtual learning adds fuel to the fire.

“Although we did see more obese and overweight children in high income settings in the past, today the incidence of obesity is rising among the urban middle class,” observes the Consultant Paediatrician and Professor of Paediatrics from General Sir John Kotelawala Defence University, Prof. Ishani Rodrigo. She cites a recent survey among 5-18 year olds in urban Sri Lanka which showed an obesity prevalence of 10.3% and overweight prevalence of 11.3%. Studies in the Colombo, Gampaha and Jaffna Districts reflect a higher prevalence of childhood obesity says Dr. Rodrigo. “We are yet to unearth island-wide data on the problem,” she adds.

In 2019, according to the WHO, an estimated 38.2 million children worldwide, under the age of five years were overweight or obese. Once considered a high-income country problem, excess weight and obesity are now on the rise in low- and middle-income countries, particularly in urban settings. In Africa, the number of overweight children under five has increased by nearly 24% percent since 2000. Almost half of the children under five who were overweight or obese in 2019 lived in Asia.

The etiology of obesity is multi-factorial and complex. Although at a basic level it is about more ‘calories in’ than ‘calories out’, there is a genetic contribution as well, says the paediatrician. “Although pathological obesity is attributed to medical conditions such as Cushings Syndrome and hypothyroidism what is more often seen is simple obesity. It is often the food and lifestyle which contribute to it.”

Increased intake of food high in simple carbohydrates, sugars and fats, convenience food such as pastries and kottu high in energy, fast food, sweetened beverages, flavoured milk, fizzy drinks, large portion sizes and frequent snacking are among the major triggers of obesity in children. Poor intake of vegetables and fruit in the diet, less outdoor play, increased screen time, less household chores for children and dependence on electrical appliances as opposed to doing tasks manually have made the situation worse.

Food advertising aimed at children, enabling availability of sugary beverages at affordable prices and lack of healthy food choices in school canteens/tuck shops (the choices largely being starchy and sugary food) have also accelerated this national health dilemma. “In the UK, the school meal policy was revised, adopting the healthy school lunches which were promoted by the famous master chef Jamie Oliver. The country also imposed a sugar tax on beverages depending on the amount of sugar they contain,” explains Prof. Rodrigo who calls for a similar shift in the local policy. “Although the Ministry of Health had issues dietary guidelines, they have not yet filtered to communities and there are no national level programmes to have a dialogue with parents, teachers and school authorities on this national health crisis.”

COVID pandemic has also led to an alarming increase in the weight of children across all age groups. “Children have lost most opportunities for physical activities including walking to school, playing with friends and organized sports. With virtual classrooms replacing real classrooms, children spend a considerable time before screens. Most of the entertaining is also afforded by screens. With very little to do at home, children eat often to relieve their boredom and mothers too tend to make more treats at home and feed their children which could go against them.”

Once obesity is established, managing of it becomes very challenging, warns Dr. Rodrigo who urges parents to encourage healthy eating and living. “Children usually eat the family diet, hence if the family diet is rich in starchy, fatty and sugary food and low in vegetables and fruit, they will automatically follow this.”

The long term repercussions of childhood obesity are multiple: adult obesity, the increased risk of cardiovascular disease, hypertension, heart disease, strokes and orthopaedic complications including joint pains and early osteoarthritis, increased levels of cholesterol, Type 2 diabetes and fatty liver are among these. The condition can also trigger skin problems such as thickening and discolouration of skin and stretch marks and also cause breathing problems including obstructive sleep apnea (stopping breathing during sleep), obstruction to airway and snoring. Childhood obesity also increases risk of fractures and certain cancers in adulthood including endometrial, breast, ovarian, prostate, liver, gallbladder, kidney, and colon cancers.

Addressing childhood obesity requires a multidisciplinary approach with collective inputs of paediatricians, nutritionists, physical training instructors, psychologists etc. “Motivation of the child and family or motivational counseling is the key in intervention which if often very intensive,” remarks the Professor. Following the initial assessment involving physical markers and other necessary medical tests, the psychological assessment involving the child and his/her family would follow. “Family history of obesity, family perception and understanding of the problem and motivation to achieve a healthy weight is important in this process,” she notes. Regular monitoring of children and motivational therapy sessions help keep children and their families on track, she says.

The ‘Nutri-Fit Programme’ at the University Hospital of the Kotelawala Defence University manages overweight and obese children. Conducted through the Paediatric Clinic of the hospital, the programme emphasizes on becoming healthier and more fit rather than losing weight. “Weight loss inevitably happens as a result of this approach,” explains the professor who goes on to note that this facility is extended to healthy cooking demonstrations for children, exercise and yoga sessions.

Obese children need to be empowered to overcome psychological trauma the condition entails, remarks the Consultant. Destigmatizing obesity, motivational counseling, removing the guilt stigma, making them partners in achieving the target, emphasizing health rather than obesity, identifying their strengths and encouraging them and early involvement of a clinical psychologist in addressing these issues are among the tools of empowerment. Severe cases of obesity may need certain medications.