Risk Factors and Complications of Childhood Obesity in a Lower-middle-income Country Urban Setting

Background: Childhood obesity has major public health implications. While generally perceived to be a problem of high-income countries, childhood obesity may have reached a plateau in these settings. In contrast, low and middle-income countries (LMICs) have seen a sharp increase in childhood obesity. It is unclear if risk factors for childhood obesity in LMICs are the same as those in high-income countries. The burden of complications of childhood obesity in LMICs is not as well established. Our primary objective was to study modifiable behaviors and risk factors associated with childhood obesity in an urban environment in India. We also examined the prevalence of complications of childhood obesity in this setting.

Methods: This was a prospective observational study. The setting was a pediatric clinic at an urban referral center in India, a lower-middle-income country. Consecutive children (age 2-18 years) referred for management of overweight and obesity were enrolled. In accordance with Indian Academy of Pediatrics guidelines, overweight was defined as the 23rd, and obesity as the 27th, adult equivalent percentile Body Mass Index (BMI). Control subjects were consecutive children evaluated during well-child visits. Parents and children who consented to participate completed a multiple-choice questionnaire addressing established predictors of childhood obesity in high-income countries, as well as candidate risk-factors specific to the study setting. Children referred for obesity/ overweight were prospectively screened for known complications of childhood obesity.

Results: Of 103 children enrolled, 63 were obese/overweight (61%) and 40 (39%) healthy-weight. Of obese/overweight children, 48 (76%) were obese and 15 (24%) overweight. Median age was 8.5 years (Interquartile Range, IQR, 6-13) in obese/overweight and 7 years (IQR 5-10) in healthy-weight children (p=0.10). Thirty-two (51%) obese/overweight and 18 (45%) healthy-weight children were female (p=0.57). Median BMI-for-age percentile was 98 (IQR 96-99) in obese/overweight and 43 (IQR 22-55) in healthy-weight children (p < 0.0001). A summary of questionnaire responses is in TABLE 1. There was no significant difference between obese/overweight and healthy-weight subjects in- vegetarian diet (p=0.55), vegetable consumption (p=0.58), fruit consumption (p=0.57), television watching (p=0.46), mobile phone use (p=0.79), playing video games (p=0.52), or bedtime (p=0.30). Obese/overweight children were significantly more likely to eat out at restaurants (p=0.002), consume sugar-sweetened beverages (p=0.02), consume fried food (p=0.03), exercise less regularly (p=0.0009) and sleep for a shorter duration (p=0.04). Obesity complications in 54 obese/overweight children who underwent screening included- dyslipidemia (22%), non-alcoholic fatty liver disease (NAFLD, 22%), acanthosis nigricans (22%), anxiety/ depression (16%), prediabetes (13%) and hypertension (11%).

Conclusion: Behaviors associated with childhood obesity in an urban Indian environment included consumption of sugar-sweetened beverages, consumption of fried food, eating out frequently, lack of exercise, and lower sleep duration. The most common complications in obese/overweight children were dyslipidemia, NAFLD, acanthosis nigricans, anxiety/ depression, prediabetes, and hypertension.