REVIEW

Niger J Paed 2015; 42 (3):169 –179

Eke CB

Ubesie AC

Ibe BC

Challenges of childhood obesity in a

developing economy: A review

DOI:http://dx.doi.org/10.4314/njp.v42i3.1

Accepted: 24th February 2015

Abstract: Background: Obesity

once considered a high income

country’s malady is now on the

rise in most developing countries

particularly in urban settings.

Most of these emerging econo-

mies have been reported to have

different shades of under – nutri-

tion coexisting side by side with

over-nutrition. It is pertinent

therefore that we determine the

factors driving the increase in

obesity rates in developing coun-

tries as they generally lack the

infrastructure to adequately han-

dle the associated complications.

Objectives: This communication

is aimed at reviewing the burden

and risk factors for obesity in chil-

dren in developing countries,

double burden of malnutrition,

challenges including medical as

well as economic costs and sus-

tainable preventive programmes

of obesity in our environment

with the hope of sensitizing both

the health community and policy

makers of this emerging epi-

demic.

tive models in developing econo-

mies.

(

)

Eke CB

Results: Several relevant studies

were identified. The health as well

as economic costs of obesity is

diverse. Obesity is the major risk

factor for a variety of non – com-

municable diseases including car-

diovascular diseases, type 2 diabe-

tes and malignancies in later life.

Also obese children have higher

risk of orthopaedic problems and

psychological disturbances like

low -self esteem and bullying. This

can also lead to poor social adjust-

ments among our teeming youths

who are the bedrock of our future

economy. Most of these diseases

cause premature deaths in addition

to long term morbidities.

Many of these obesity associated

complications impose substantial

burden on the health care system

in developing countries with weak

health systems, and if allowed

unmitigated the implications are

that the cost of its care may over-

whelm not only the health budget

but also affect the provisions of

basic social amenities.

Ubesie AC, Ibe BC

Department of Paediatrics,

College of Medicine

University of Nigeria/University of

Nigeria Teaching Hospital

Enugu

Email: chriseke2006@yahoo.com;

christopher.eke@unn.edu.ng

Methods: We searched relevant

literature on the subject published

only in English language or trans-

lated into English language manu-

ally and electronically. The Index

Medicus, AJOL, Medline, PUB-

MED, and HINARI were specifi-

cally searched for the period be-

tween 1980 and 2014 and re-

viewed. The following key words

were applied in the search: Obe-

sity in childhood, its burden and

associated risk factors, complica-

tions of obesity in childhood, dou-

ble burden of malnutrition in de-

veloping countries, assessment of

obesity, childhood challenges of

obesity including its direct and

indirect costs in developing coun-

tries as well as practical preven-

Conclusions: Preventive pro-

grammes have been shown to

reduce the burden of obesity in

developed countries. Dearth of

data on burden of obesity and its

associated complications in chil-

dren and adolescents still a chal-

lenge in most developing econo-

mies. Efforts should be made to

prevent childhood obesity using

multi- pronged approach at popu-

lation level through targeted edu-

cation, sustainable interventions

related to healthy nutritional prac-

tices as well as physical activity

promotion.

Key words: Challenges; Obesity;

Children; Developing Economies

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11

Introduction

Musa et al studied 3240 children aged 9-16 years and

reported obesity prevalence of 1.8% and overweight

9.7% respectively. The obesity pandemic has spared no

age groups even among children with haemoglobinopa-

thy previously thought to be underweight due to their

chronic anaeamic state, obesity rate of 2.5% among chil-

dren aged 2-15 years has been reported in Lagos, South-

The World Health Organization (WHO) defined obesity

as a condition of abnormal or excessive fat accumu₁ lation

in adipose tissue resulting in impairment of health .

Obesity has been known to man since the middle ages;

during the Renaissance of Europe and the Ancient East

Asian Civilization when it was regarded as a mark of

affluence and wealth and was relatively common among

12

South Nigeria .

2

the elites . However the famous Hippocrates of Cos

Predisposing Factors

noted the danger that it portended and wrote that

“

ger of others” .

corpulence is not only a disease in itself but the harbin-

Obesity reflects a complex condition which is influ-

enced by a wide range of genetic, metabolic, cultural,

environmental, socioeconomic, and behavioral factors. It

is the convergence of these forces, biological and tech-

nological that has produced the current obesity epi-

3

Burden

13

14

Obesity earlier considered a problem of high income

countries is now on the rise in most low and middle in-

come countries particularly in urban settings . The world

including developing countries is facing a global epi-

demic of not only childhood but adulthood obesity .

demic , we see today. Scott and colleagues designed a

causality continuum model for obesity in sub -Saharan

Africa – the theoretical framework reviewed incorpo-

rates distal, intermediate and distal forces as pivotal to

the increase in overweight and obesity rates in sub- Sa-

hara Africa. These forces, while presented singly, inter-

act in several ways, with distal forces such as globaliza-

tion directly impacting on forces at other levels such as

occupation and diet. The distal forces incorporated in-

clude globalization and urbanization, with reduced

physical activity, cultural perceptions of weight, built

environment and socioeconomic class at the intermedi-

4

5

Overall more than 10% of the world’s population is

obese .

1

The World Health Organization (WHO) is alarmed and

has warned that childhood obesity is one of t_sh_t e most

serious global public health challenges of the 21

century. Generally, obese children and adolescents are at

increased risk of developing various health problems

mainly non- communicable diseases like type 2 diabetes,

cardiovascular diseases in addition to psychological dis-

1

4

ate levels .

Caloric intake, physical inactivity and genetics lie at the

distant level and reflect the health behaviors most di-

rectly related to overweight and obesity while the envi-

ronment modifies how the genes are expressed, placing

genetics inside the causality continuum that produces

6

turbances .

In 2012, more than 40 million children under the age of

five were reported to be overweight/obese globally. Of

these more than 30 million (>75%) live in de₁veloping

countries and 10 million in developed countries .

14

overweight and obesity in humans .

The rate of overweight and obesity among preschool

African children has doubled over the past two decades,

from 4 to 8.5% between1990 to 2010 and is expected to

Genetic Linkage

Genes have been known to influence an uncontrollable

urge to eat; with likelihood of physical inactivity; an

increased capacity₅t_,o₁₆ store fat; and a minimal ability to

7

hit 12.7% by the year 2020 . Asia, excluding Japan has

also reported a dramatic increase in the rate of obesity

over the same period as in sub – Saharan Africa.

Though most countries are still combating poverty and

hunger, globalization has made societies wealthier, and

wealth and weight are linearly related. Similar increase

in prevalence has been observed in the Latin America

1

expend dietaryfat . Following epidemiological sur-

veys childhood obesity has been shown to be genetically

1

6

linked to metabolic syndrome . Over the last decade

large scale genome-wide association studies (GWAI)

have identified some of the genetic variants associated

with obesity in chi₁l₆dren of European and Hispanic an-

cestry respectively.

In general, genes interact with environmental factors to

produce overweight and obesity in at risk individuals.

This relates to the fact that exposure to under nutrition in

early life, or in utero, may increase the risk of obesity

development in late₁r₇ life owing to epigenetic changes in

metabolic function.

This “thrifty gene” hypothesis or fetal programming

postulates that due to dietary scarcity during human evo-

lution people are prone to survive during such periods

and when such individuals find themselves in environ-

ment with abundance of foods they will subsequently

acquire excess fats with the tendency to become obese

8

and the Caribbean . In the United States, over the last 3

decades childhood obesity has tripled and by 2008

8

nearly 7% of children were obese .

In Nigeria there are limited data on prevalence of over-

weight and obesity because of lack of representative

data from composite geopolitical regions. So far the

available studies on overweight and obesity in Nigerian

children have used different diagnostic criteria but high-

lighted the high prevalence of body weight disorders.

9

Opara and colleagues (2010) reported an obesity preva-

lence of 11.3% among primary school children in Uyo,

1

0

South South Nigeria while Yusuf and co - workers

found obesity and overweight prevalence of 0.84%

and 1.98% respectively among adolescents in Kano me-

tropolis, North West, Nigeria. In a more representative

study in Benue State, North Central Nigeria, Denladi

1

7

with its attendant complications. Hence, many parts of

1

71

the developing world may be vulnerable to increases in

obesity, given the high prevalence of under nutrition

among the poor, coupled with the rapid introduction of

caloric-dense, more affordable “westernized” diets and

living in₁₇_,₁a₈ mechanized world with little or no physical

up to 6folds) while in formula –fed infants evidence of

obesity was observed as a 0.4 unit increase in body

mass index (BMI) z- score at age 3 years. In contrast,

infants that were breastfed up to 4 months the timing for

the introduction of the₂s₇_,o₂₈lid food was not associated

activity

.

with evidence of obesity

.

Early Life Risk Factors

c. Sleep duration: The well known association between

growth hormone and sleep led to the hypothesis that

sleep patterns may be associated with the saltatory

growth spurts . In children it has been shown that an

inverse association occurs between sleep duration and

obesity. The longer the sleep duration in hours p₃a₀rticu-

larly nocturnal sleep the higher the risk of obesity.

a. Maternal obesity: The peri- conception period is a

critical period of opportunity when exposure of the fetus

could predict risk of obesity in later life for the off-

29

1

9

spring . Maternal obesity is one of the strongest and

most reliable predictors of obesity of children in later

life.

Infants born to overweight mothers are more likely to be

born large for gestational age and are at increased

chances for the development of obesity and its related

complications including type 2 diabetes mellitus in later

life. Babies born to mothers with impaired glucose toler-

ance during pregnancy are more likely to be macrocos-

mic and have higher body fat at birth and subsequently

be at increased risk for becoming overweight with its

attendant health consequences.

d. Early child care (Day care) attendance: The grow-

ing use of early child substitute care especially pre-

nursery/nursery schools has raised awareness among

health officials of the special role that child care settings

play in determining children’s eating and activity behav-

iour . Most of the privately owned schools approved by

government agencies do not have facilities including

play grounds for variety of physical activities for the

children.

31

Hence there is need for optimal maternal nutrition be-

fore conception and application of adequate weight loss

interventions in overweight and obese women during the

periconcep₅t_,₂io₀nal period in order to obtain favourable

Risk factors in early childhood through pre-school

Beyond the first year of life, a couple of risk factors

have been observed to be linked with obesity in later life

including:

1

outcomes . The application of dietary restrictions in

obese mothers during the peri-conceptional period may

suppress the programming of obesity.

a. Television Viewing: Among the school – aged chil-

dren, observational and experimental research have

shown that television viewing is positively associated

with risk of overweig₂ht. Among preschool aged chil-

b. Maternal Smoking: It is known that maternal smok-

ing during pregnancy results in low birth weight babies.

However for reasons that are not clearly understood off-

springs of women who smoke may be more predisposed

to be obese in later life compared to their counterparts

who their mothers₂₁did not smoke and this appears to be

dose – dependent.

3

dren, Denninson et al found that the number of hours a

child spends watching television (TV) is associated with

increased risk of obesity. During periods of commercial

TV viewing children are exposed to a lot of stations

showing cartoons with commercial advertisements on

variety of branded high calorie, nutrient –poor foods and

drinks as well as fast food restaurants. Children who

watched cartoonswith commercials are more likely to

prefer the products advertised than children who

watched the same cartoon but were not exposed to com-

Infancy Risk Factors

In the first year of life the primary determinants of obe-

sity in later life include rapid weight gain and the type

and duration of infant feeding.

33

mercials . These findings suggest that food advertise-

ment can affect children’s food preferences and could

contribute to greater intake of high calorie dense, nutri-

ent poor foods thus fueling the obesity pandemic.

a. Breastfeeding: Recentmeta-analyses showed that

babies who are breast fed are associated with a 13 -22%

reduced odds for overweight or obesity in childhood and

in later life and there is an associated dose dependent

response effect based on the duration of the breastfeed-

b. Sleep: Short sleep duration persists as a potential risk

factor for obesity in children. However the actual

mechanism is uncertain. In order for short sleep duration

to produce weight gain, short sleep duration could either

increase energy intake and/or reduce energy expendi-

ture. Reduced sleep has been shown to decrease plasma

leptin levels, increase plasma ghrelin and cortisol levels,

alter glucose homeostasis, and activate the orexin sys-

22, 23, 24

ing in the infant

.

b. Early Introduction of Solids: Studies have shown

that introduction of solids too early may predispose a

child to chronic diseases such as islet cell auto immunity

34

(

and obesity

the preclinical condition that causes type 1 diabetes)

.

tem, all of which impact the regulation of appetite .

Lack of sleep may result in weight gain and obesity by

increasing the time available for eating and by mak₅ ing

25,26

Recent studies show that among infants that were not

breastfed the introduction of solid foods before age

3

the maintenance of a healthy lifestyle more difficult .

4

months results in increased obesity by age 3 years (by

c. High Consumption of Sugar Sweetened Beverages:

1

72

The consumption of sugar sweetened beverages particu-

larly carbonated soft drinks (which contain simple sug-

ars either as sucrose or high fructose corn syrup as

source of fructose) has be₃₆e_,n₃₇linked with the epidemic of

disease of the elite class with better income and educa-

tional attainment. Similar experience has b₅ een reported

4

in other emerging economies like Nigeria and Bangla-

46

desh while a study in Brazil did not report any associa-

47

overweight and obesity

. Children start drinking

tion between obesity and SES .

sugar-sweetened beverages at a remarkably young age

and such consumption increases even to young adult-

hood. High fructose corn syrup (HFCS) is found in all

foods containing caloric sweeteners including majority

of the soft drinks, fruit drinks, canned fruits, dairy des-

serts and flavored yogurts, most baked goods, many

c. Urbanization: Currently rural - urban migration

could be due to a complex of “push” factors including

industrialization, insecurity about food security in rural

areas, search for refuge/safe haven from conflicts in-

cluding insurgency as in many countries in Sub- Sahara

Africa like Nigeria, Somalia, Kenya to mention among

others and environmental degradation, in addition to

pursuit for ‘better –life’ like opportunities for₁₄e_,₄m₈ ploy-

ment, social amenities and better quality of life.

36

cereals, and jellies .

The consumption of fructose -sweetened beverages in-

creases adiposity more than the consumption of either

38

sucrose or other artificially sweetened beverages . This

is partly due to a shift of substrate use to lipogenesis.

Both sugars i.e. HFCS and sucrose are not interchange-

able. But it is important to note that HFCS also contains

glucose. Fructose, may lead to greater weight gain and

insulin resistance by elevating plasma triacylglycerols

and subsequently decreasing the production of insulin

and leptin in peripheral tissues – not suppressing ghrelin

thereby decreasing signaling to the central nervous sys-

tem from insulin and leptin – and possibly ghrelin. How-

ever the glucose (sugar) composition of fructose is simi-

lar to that of sucrose. Whether HFCS is more detrimen-

tal to weight gain than other types of sugars is not fully

In addition several “push” factors operating in many

rural settings, as changes in trade and food production

due to globalization and the desire to leave subsistence

48

farming, make rural life less desirable. Urbanization

could offer economic and social advantages to some but

many migrants languish in urban centres, resulting in

rising income in- equalities in some sub- Sahara African

settings. In the centre of all these are our children who

are either moving with their parents/caregivers or are

born in the course.

Urban relocation by rural dwellers could predispose

them to abrupt changes in diet and physical activity lev-

els for reasons related partly to globalization. While in

rural areas, many people grow and consume traditional

staple foods that are low in fat and calories but high in

fibres and carbohydrates and micronutrients those living

in urban areas can afford and buy variety of high energy

dense drinks and “junk” foods with the likelihood of

being obesogenic in nature.

39,40

elucidated and may require further studies

.

General Risk Factors

a. Culture: Several reasons have been proposed for the

differences in the burden of obesity among groups in-

cluding genetics, physiology, culture, socioeconomic

status, environment and interactions among these vari-

41

ables . Obesity however is viewed differently across

cultures, and perceiving it as a disease is more of a

d. Globalization: This is a process characterized by the

growing inter-dependence of all particularly in the areas

of the integration of economies, culture, technology and

governance.

‘Western’ phenomenon.

In most cultures obesity has been historically been asso-

42

ciated with wealth, health and happiness. The cultural

norms may serve to catalyze the increases in overweight

and obesity and act as a significant barrier to success of

any intervention program. Culture may play a role in

shaping parental perception of their children’s health

status e.g. In some cultures like the Hispanics in South

America, Igbo ethnic nationality in Nigeria mothers may

view thinness as a reflection of poor health and undernu-

trition. Thus, they may encourage their children to eat

more and accumulate more fat.

Several emerging/developing countries have benefitted

tremendously from richer economies particularly in the

area of food security and nutrition via increased employ-

ment opportunities, productivity and better quality of

1

4

life .

Free trade and commerce have led several countries in

developing countries to the current nutrition transition

where they shift away from their usual traditional pro-

duction and consumption of local staple foods rich in

whole grain, fruits and vegetables to importation of

processed obesogenic western staples that are ‘nutrient

poor’ energy dense, high fat, and above all low cost par-

b. Socioeconomic status (SES): There is a positive re-

lationship between SES and obesity in developing coun-

tries as obesity is more of the problem of the wealthy in

such environments. In addition a positive association

between higher SES and obesity appears to be an in-

verse relationship as one moved from countries with

lower human development index (HDI) to countries of

49

ticularly among those resident in urban areas .

e. Sedentary lifestyles/Reduced Physical activity:

Levels of physical inactivity are rising globally with its

implications for the prevention of non –communicable

diseases including obesity and its related metabolic syn-

43

higher HDI .

44

50

Wang et al reported that there may be a bidirectional

causal link between SES and obesity, because obesity

may adversely affect one’s opportunity for education,

occupation, and marriage.

drome in later life . This is primarily due to increasing

14

use of mechanization . Among children there appears to

be general decline in physical activity owing to less trek-

king and down-playing of physical education in our edu-

cational systems. Many private schools are being

In many sub – Saharan African settings obesity is a

1

73

licensed without playgrounds. In some cities notable

recreational/amusement parks are now been given-up for

The challenge for developing economies is how best to

confront the ‘double burden’ of malnutrition: under-

nutrition; and overweight and obesity, and how to en-

sure optimal childhood nutrition in a fast changing soci-

ety. No action will lead to escalation with the short and

long term health consequences.

‘exotic’ housing estates and shopping malls for the rich.

Also insecurity particularly in urban settings in the guise

of kidnappings, armed robbery, rape and the big one –

insurgency/sectarianism have all made the teeming

population of our children to be locked indoors after

school hours by apprehensive parents who are afraid of

the unknown. Thus limiting the time and liberty they

have for adequate and variable physical exercise needed

to burn off some stored energy. The resultant effect is

that urban children will be confined to their homes and

given the opportunities to get glued to screens in the

form of television, computer games and consumption of

energy dense foods/drinks making the vicious cycle of

obesity to continue

Secondary Causes of Obesity

Some of the following have also been implicated in

childhood obesity in both developed and developing

countries. They include:

1. Endocrinopathies: Cushing syndrome, hyper-

insulinism, hypothyrodism, growth hormone deficiency.

2. Rare Genetic syndromes (Syndromic Obesity):

Prader Willi Syndrome, Turner Syndrome, Beckwith

Wiedmann, Lawrence – Moon Biedl, Melano cortin – 4-

receptor gene mutation . Leptin or Leptin Receptor gene

mutation., Alstrom syndrome ,Carpenter syndrome etc.

3. Psychological dis_.₅o₄r_,₅d₅e_,₅r₆s: Binge eating disorder and

night eating disorder

The World Health Assembly in 2004 recommended that

each member state should develop national physical

activity plans and policies to increase physical activity

51

levels in their population .

f. Drug use: Several herbal medications have been re-

ported to be in use in some settings in Africa like in

Western Sahara (also known as Sahrawi) where they

practice traditional fattening involving periods of ritual

overfeeding and use of appetite enhancers and tradi-

tional medication (suppositories composed of a mix of

dates, seeds, and medicinal plants that₂are believed to

Possible Pathophysiologic Mechanisms

Further to the previously listed causes of obesity several

hormones, genetics, neurotransmitters and receptors in

the hypothalamus and its adjourning structures have

been shown to contrib₅u₇te in the regulation of appetite as

well as body weight. Some of agents have effect on

long-term control of energy intake (e.g. leptin, neu-

ropeptide) while others have a short-term impact on en-

5

increase peripheral fat accumulation), in addition to

prolonged use of some certain orthodox medications

including insulin, antipsychotics, selective serotonin

reuptake inhibitors, tricyclic antidepressants, anticonvul-

sants/mood stabilizers and prednisone that that have

been implicated in weight gain/change in body composi-

tion.

58

ergy intake (e.g. Ghrelin, insulin, and cholecystokinin).

Assessment of Obesity in Children

Accurate assessment of obesity in children is a critical as

well as challenging aspect of present day paediatric

practice globally. The measurement of body composi-

tion provides more detailed information about nutri-

tional status than the measurement of stature and weight

alone. Recent technological development has led to the

availability of several instruments for assessing body

composition including densitometry, dual energy ab-

sorptiometry (DEXA), tracer dilution techniques neutron

activation, ultrasound, magnetic resonance imaging,

computerized tomography scan and bio- electric imped-

ance analysis. Most of these techniques are complex,

expensive and not practicable for routine clinical use

and hence are restricted mainly to research.

The Double Burden of Malnutrition in Developing

Economies

The obesity epidemic is particularly disturbing in devel-

oping countries where nutrition transition in addition to

continuing infectious diseases, poverty and ignorance

propel the dual burden of under-nutrition and obesity

within the same households. The synergetic links among

infectious diseases, under-nutrition and overweight/

obesity are manifest across the lifespan.

Double burden malnutrition exists in developing coun-

tries with varying degrees of public health importance

owing to the uneven socio – economic development

within the segments of the society. Middle and low in-

come countries continue to face the challenges of infec-

tious diseases and under- nutrition in the face of a rapid

rise in non- communicable diseases including obesity

and overweight. Obesity co-existing with varying de-

grees of under nutrition has be₅e₃ n reported even in the

fast emerging nations like India

Anthropometric measurements are most commonly used

in clinical settings and epidemiological studies as indi-

rect methods of estimating fat mass. Weight and BMI

are generally applied. The BMI is standard and reliable

indicator of overweight and obesity. It is also the pre-

ferred measure for evaluating obesity among children

and adolescents 2 – 19 years of age. It expresses the

weight for height relationship as a ratio i.e. weight (in

In Nigeria, under-nutrition accounts for >50% of under

five mortality_n_drate (142 per 1000 live births) directly or

in-directly (2 largest world contributor). At the same

time there is rising rates of overweight/obesity within

the same communit₉i_,e₁s₁ with different shades of under –

nutrition in Nigeria.

59

kilograms)/height in meters .

Its strengths include the following: It is easily obtained,

correlates str₆o₀ngly and weakly with body fat and height

respectively. Above all the BMI correctly identifies the

fattest individuals with acceptable accuracy at the upper

1

74

end of the distribution (e.g. ≥ 85^t^h or ≥ 95^t^h percentile for

age and gend_t_her). Using BMI, obesity is defined as BMI

that is ≥ 95 percentile using either the United States

Centers for Disease Control and Prevention (CDC) or

the World Health Organization growth charts.

studies on the burden of obesity in our setting answers to

these very important operational research questions may

become obvious over time.

However, what is certain is that most developing coun-

tries particularly in Africa have weak health systems that

are unable to cope with the double burden of infectious

diseases and chronic diseases. In most Africa settings

there no national chronic disease policy to deal with this

burden of chronic diseases adequately, many have just

got a national health policy. Most of the countries in

developing countries have been shown to have high

rates of disabilities and death rates due to chronic dis-

eases such as diabetes, hypertension and stroke mainly

in the last two decades straining the health systems and

these have been attributed to changing behavioural prac-

tices (e.g. sedentary lifestyles and diets high in saturated

fats, salt and sugar).

However for children ≥ 2years of age the weight for

recumbent length percentile from the year 2000 CDC or

WHO growth charts should be regarded as appropriate

for evaluating weight relative to linear length. But gen-

erally the term obesity is avoided in these_t_hage group

rather weight for length percentiles ≥ 95 identifies

61

these as overweight.

The WHO standard growth charts are generally pre-

ferred in infants aged 0 – 24months due to the fact that

they establish growth of the breastfed infant as the norm

for growth, provides better description of physiological

growth in infancy and the standards are based on a high

62

quality designed explicitly for growth charts .

For screening purposes especially field work the Interna-

tional Obesity Task Force (IOTF) charts could be ap-

plied. It is not meant for routine clinical use. It is impor-

tant to note that as a quick screening tool the IOTF chart

has got comparable sensitivities and specificities as the

regular BMI charts.

Experts have recommended a three – prong approach to

dealing with the burden:

(a). Epidemiological surveillance;

(b). Primary prevention (preventing disease in healthy

populations); and

(c). Secondary prevention (preventing complications and

65

improving quality of life in affected communities) .

These efforts should be made to control and begin to

reverse the rising trend of childhood obesity. These

medical complications include:

For research purposes the age specific z- scores or stan-

dard deviation (SD) scores are generally used for ex-

treme values of anthropometric measures. A BMI online

calculator is available: http;//www.kidsnutrition.org/

59

bodycomp/bmiz2.html. The WHO – Anthro - and an-

thro –Plus internet calculator are also in use online.

Other useful anthropometric tools in the assessment of

overweight and obesity in children is skin fold thickness

and waist circumference measurements.

Other general components of nutritional assessment in

the evaluation of obesity include the medical history,

dietary and physical activity assessment.

The challenge for most countries in sub- Saharan Africa

is the lack of adequate local clinical tools and represen-

tative data to assess the burden of obesity in our envi-

ronment. Most of the tools we have for practice are ei-

ther from the Centers for Disease Control, United States

or the WHO charts which may have some variations

with regards to our local population and may either

under – or over-estimate the risk of childhood obesity in

our setting.

(a). Endocrine/Reproduction System: Insulin resis-

tance (type II diabetes mellitus, metabolic syndrome),

menstrual disorders, polycystic ovarian syndrome etc;

(b). Digestive system: Non-alcoholic fatty liver diseases

(NASH), cholelithiasis, gastro-esophageal reflux disease

(GERD).

(c). Respiratory system: Obstructive sleep apnoea

(OBSA), obesity hypoventilation syndrome, asthma. It

is important to note that asthma severity, however, does

not seem to be altered by obesity, leaving open the pos-

sibility that weight – related but not non-asthmatic air-

flow limitations are being misdiagnosed as asthma in

some obese children.

(d). Central nervous system: Idiopathic intracranial

hypertension.

(e). Psychosocial: Distorted peer relationships, poor self

esteem, anxiety, depression.

(

f). Musculoskeletal system: slipped capital femoral

Challenges of Obesity in a Developing Economy

epiphysis, tibia vara (Blount’s disease), spinal complica-

tions and acute fractures.

Obesity is a public health and policy proble₃_,m₆₄ because of

(g). Integumentary system: Furanculosis intertrigo

(h). Urology/Renals: Sub- nephritic proteinuria, glome-

rulomegaly, microalbuminuria – chronic kidney disease.

Focal segmental glomerulosclerosis is the ultimate find-

ing in morbid obesity.

6

its prevalence, costs and health effects. The health

implications of obesity are multi - systemic and legion.

However most of them may not be prevalent in the

paediatric age groups but if childhood obesity is not

adequately controlled, these children will eventually

become obese adults and ultimately develop chronic

complications with their attendant costs.

It is not certain whether there are differences in- terms

of the frequencies of these medical complications be-

tween obese children in developing economies and those

living in developed countries. Hopefully with the up-

coming of quality systematic reviews and meta- analytic

(i). Nutritional Def₅i₄c_,₅i₅e_,₆n₆c_,₆i₇es: lower levels of vitamin D

and iron deficiency.

(j). Malignancies: The association between obesity and

cancer remains uncertain compared to that for diabetes

and cardiovascular disease. This may partly be due to

the fact that cancer is not a single disease but a collec-

tion of individual diseases. In 2007 the World Cancer

Research Fund and the American Institute for Cancer

1

75

Research expert panel reported that there was adequate

evidence supporting a link between obesity and cancers

of the esophagus, pancreas, colon and rectum, breast,

endometrium, and kidney, and a probable association

between obesity and gallbladder cancer. Though these

are all diseases arising in obese adults, efforts should be

made to control/ pr₈event childhood obesity from spilling

stigmatization by peers and the belief that obese children

are generally lazy all could impact on the overall aca-

demic performance of obese children.

Indirect costs

Are “resources forgone as a result of a health condition,”

and they include:

6

over to adulthood .

(

k). Social Stigmatization: This is of major concern in

older children and adolescents. Obesity can lead to so-

cial stigmatization and disadvantages in employment

and marriage and association with poor personal hy-

giene. Some adolescents have been reported to have

inflicted serious injuries to themselves and in some ex-

treme cases committed suicide as a result of being bul-

Value of lost work: strictly involve days missed from

work meaning its costs to both employees (in lost

emoluments) and employers (in work not done or com-

pleted). Obese employees miss more days from work

due to short-term absences, long-term disability, work-

ing at less than full capacity (termed presenteeism) com-

pared to their counterparts. However, these may indi-

rectly apply to children when they are sick and probably

hospitalized and their parents/caregivers may apply for

excuse duty to take care of them.

69

lied for one reason or the other .

Direct and Indirect Costs of Obesity

The health and social consequences of obesity have over

Other aspects of indirect costs of obesity like life insur-

ance premiums and lower wages may not directly app₇l₀y

to children since by law they are not licensed to work.

Prevention has been shown to be cost effective com-

pared to treatment, both in terms of economic and indi-

vidual costs. Hence health care providers and policy

makers should educate the public adequately on the im-

portance of obesity and its prevention, and develop

effective policies and programmes to prevent obesity.

-

shadowed the economic cost to society and to the indi-

vidual. The costs implications of obesity on health and

well-being are beginning to raise global as well as politi-

cal awareness that individuals, communities, nations,

and international organizations like World Health Or-

ganization must take urgent measures to stem its rising

tide. These challenges include both direct medical as

well as indirect costs.

Direct costs

Prevention of obesity in children

Pregnancy

Costs arising from outpatient and inpatient health care

services (including surgery), laboratory and radiological

tests, physiotherapy, drug therapy, etc. Managing obe-

sity and its related conditions cost billions of dollars

each year. One United States estimate, projected that

In a cross sectional study of 232 preschoolers in Brazil,

mother's obesity [OR = 3.12 (95% CI, 1.41-6.91), P =

0.01], weight gain of more than 0.85kg/month in the

first four months of life [OR = 2.16(95% CI 1.01-4.64),

P = 0.04] and lower per capita income [OR = 0.32 (95%

CI 0.13-0.79), p = 0.01] remained significant predictors

of obesity after multivariate adjustments. It is therefore

imperative that obesity prevention in children should

start during conception. There is need to normalize body

mass index of potential mothers before pregnancy. Dur-

ing pregnancy, adequate maternal nutrition including

micronutrient supplementations need to be ensured.

Pregnant mothers should avoid smoking and other pre-

ventable risk factor for small for gestational (SGA) ad-

dressed. Studies have linked low birth weight babies

with risk of obesity later in life as a result of biological

programming. Moderate exercise as tolerated should be

maintained. In gestational DM, provide meticulous

glucose control.

$

190 billion was spent on obesity-related health care

expenses in 2005—double previous estimates. For de-

veloping countries without health insurance policies for

majority of the population including children. Caregiv-

ers when they present with their children usually ‘pay

out of pocket’. Also in most cases there are no available

national data on₆₈_,e₇c₀onomic costs of obesity complica-

tions treatments.

Health related quality of life: Studies of the effect of

obesity on specific health outcomes such as diabetes or

depression provide just a tip of the ice- berg on the spec-

trum of impact of obesity on health and well-being. Ac-

cording to the World Health Organization, health is not

just the absence of disease or infirmity but a state of

holistic well being. Hence this health-related quality of

life (HRQoL) integrates the effect of obesity physical,

psychological, and social functioning and obesity has

been reported to impact on them either directly or indi-

rectly.

71

Post-partum

Breastfeeding is associated with reduced incidence of

obesity in childhood and later in life. In a systematic

review of nine studies with more than 69,000 partici-

School absenteeism: Owing to prolonged period of ill –

health in some obese children arising from complica-

tions of obesity like slipped capital femoral epiphysis

some school days could be lost with its attendant impact

on academic performance.

22

pants, Arenz et al showed that breastfeeding signifi-

cantly reduced the risk of childhood obesity [AOR 0.78,

95% CI (0.71, 0.85)]. The authors also reported a dose-

dependent effect of breast-feeding duration on the preva-

Poor academic performance: Days lost due to ill-

health/hospitalization, poor self esteem arising from

22

lence of obesity in four studies . Sadly the reported

1

76

average exclusive breastfeeding rate in infants < 6

months of age in Nigeria is 16.4% (95%CI: 12.6%-

close to schools.

2

1.1%) and even lower (7.1%) in their 5th month.

2

Strategies that promote, protect and support breast-

Community

7

feeding are therefore, critical in reducing the obesity

incidence around the world.

The cultural perceptions and norms that views excessive

weight gain in children as a sign of adequate nutrition

should be discouraged.

Infancy

Government and regulatory agencies

Beyond the immediate post-partum period, economic

pressures on families put undue pressures on working

mothers and fathers. This has resulted in improper use of

breast milk substitutes and complementary feeds. The

higher protein content of infant formula causes rapid

weight increase in the first of year of life with attendant

obesity risk . It is therefore, imperative that nutrition

education on adequate, appropriate and safe complemen-

tary feeds be provided for mothers and potential moth-

ers. The nutrition education should include merits and

demerits of home-made versus commercial complemen-

tary feeds, need for micronutrients supplementation and

fortifications; and importance of age-specificity and

enough flexibility.

They need to provide financial incentives to industry to

develop more healthful products and to educate the con-

sumer on product content. Appropriate laws and regula-

tions that will influence advertising and distribution of

non-healthy foods need to be enacted. There should be

outright ban of advertising of fast foods directed at pre-

school children while restricting advertising to school-

aged children. Other measures include taxation and

pricing to promote or limit consumption of foods. Gov-

ernment can also assist in changing built environment

(building parks, walk ways) and in urban planning.

73

Health care setting

Family

It is important that weights and heights of children are

routinely monitored. The body mass index (BMI) Calcu-

lated and plotted 6 monthly or at least yearly. The health

care providers should discuss the benefits of increased

physical activity and decreased sedentary activity with

caregivers; as well as encourage them to promote

healthy eating habits at family levels.

The growing child should be exposed to a wide variety

of foods while limiting sweetened beverages to the bar-

est minimum. It is advised that families eat meals to-

gether in a fixed place and time. Meals especially break-

fast should not be skipped. Regular vegetables and fruits

should be served at meals. Portion control such as use of

small plates may be required for some children. Judi-

cious use of technologies to do work at homes is recom-

mended. Children should be allowed to wash their

clothes and dishes instead of using machines.

International collaboration

Like tobacco addiction, obesity does not observe na-

tional boundaries and is deeply connected to issues of

globalization. It will be necessary to engage policymak-

ers and regulators at the international level, asking ques-

tions related to governance as well as those related to

Physical activities

77

The WHO states that 60% of the world's population

does not obtain the level of physical activity recom-

mended for health benefits with rates varying from 17 to

public health infrastructure, inequality and inequity .

Treatment principles

74

1% in developing countries . It is postulated that

9

physical activity protects individual from development

obesity by increasing energy expenditure and resting

metabolic rate and leading to favourable fuel utiliza-

Therapies often combine diet, exercise, behavior modifi-

cation, medications, and rarely, surgery. Medical man-

agement of obesity in children include dietary (portion

control), increase physical activity, pharmacotherapy.

Evaluation of the overweight/obese child requires com-

passion. The dietary practices, family structure, and hab-

its need to be explored. Any underlying secondary cause

(genetic or hormonal) should be excluded. Most suc-

cessful approach requires substantial lifestyle changes

that include increased physical activity and altered eat-

ing habits. Initial goal should be weight maintenance

rather than reduction. Weight loss should be attempted

only in skeletally matured children or in those with seri-

ous complications at weight loss goal of 0.5 kg or less

per week. Once a 10% reduction in weight is achieved,

the weight should be maintained for 6 months before

further weight loss is attempted. Medications such as

Orlistat (an intestinal lipase inhibitor), has been effective

in adolescents older than 12 years of age. Octreotide has

75

tion . The American Academy of Pediatrics recom-

mends avoiding television and computers in children

76

younger than 2 years . Children 2–18 years of should

have less than 2 hours/day of “screen time” (television,

video games, computer), and televisions should be re-

moved from children's bedrooms.

Schools

In the school environment, minimum standards for

physical education, including 30–45 min of strenuous

exercise 2–3 times weekly should be mandated.

Balanced school meals need to be provided as part of

school health program. Discourage junk foods, sugary

beverages in the children’s lunch pack and encourage

addition of fruits. Fast-food joints should not be located

1

77

shown promise for weight control in children with hypo-

Conclusion

78

thalamic obesity . Dietary supplements are of question-

able efficacy. One of the goals of treatment will be to

evaluate for the presence of complications and manage

accordingly: Hypertension, DM, PCO syndrome.

Preventive programmes have been shown to reduce the

burden of obesity in developed countries. Dearth of data

on burden of obesity and its associated complications in

children and adolescents still a challenge in most devel-

oping economies. Efforts should be made to prevent

childhood obesity using multi- pronged approach at

population level through targeted education, sustainable

interventions related to healthy nutritional practices as

well as physical activity promotion.

Surgery is indicated if unsuccessful with prior organized

weight loss attempts or BMI of 40 or > with some obe-

sity related health problems or BMI≥35 with type 2

diabetes mellitus, obstr₉uctive sleep apnoea, OSA,

7

pseudo- tumor or NASH .

Conflict of interests: None

Funding: None

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