EFFECTIVENESS OF SELECTED SCHOOL BASED
INTERVENTION ON LEVEL OF BMI AMONG OVERWEIGHT / OBESE CHILDREN IN SELECTED SCHOOLS AT ERODE
THESIS
Submitted to
THE TAMILNADUDR. M.G.R MEDICAL UNIVERSITY, CHENNAI
for the award of the degree of
DOCTOR OF PHILOSOPHY IN
NURSING
By
MRS. M. KAVIMANI, M.Sc. (NURSING) APOLLO COLLEGE OF NURSING
CHENNAI-600 095
JANUARY 2018
EFFECTIVENESS OF SELECTED SCHOOL BASED
INTERVENTION ON LEVEL OF BMI AMONG OVERWEIGHT / OBESE CHILDREN IN SELECTED SCHOOLS AT ERODE.
THESIS Submitted to
THE TAMILNADUDR. M.G.R MEDICAL UNIVERSITY, CHENNAI
for the award of the degree of
DOCTOR OF PHILOSOPHY IN
NURSING
By
MRS. M. KAVIMANI, M.Sc. (NURSING)
Under the Guidance of
DR.JANANI SANKAR., DNB, Ph.D.
Senior Consultant in Pediatrics
Kanchi Kamakotti CHILDS Trust Hospital
Nungambakkam, Chennai-600034
EFFECTIVENESS OF SELECTED SCHOOL BASED
INTERVENTION ON LEVEL OF BMI AMONG OVERWEIGHT / OBESE CHILDREN IN SELECTED SCHOOLS AT ERODE.
THESIS Submitted to
THE TAMILNADUDR. M.G.R MEDICAL UNIVERSITY, CHENNAI
for the award of the degree of
DOCTOR OF PHILOSOPHY IN
NURSING
By
MRS. M. KAVIMANI, M.Sc. (NURSING)
GUIDED BY
DR.JANANI SANKAR., DNB, Ph.D. DR.A.HELEN M PREDITA., Ph.D(N) Senior Consultant in Pediatrics Principal,
KanchiKamakotti CHILDS Trust Hospital Apollo College of Nursing Nungambakkam, Chennai-600034 Madurai
DECLARATION
I hereby declare that the present study on “CONTRIBUTING FACTORS OF OVERWEIGHT / OBESITY AND TO EVALUATE THE EFFECTIVENESS OF SELECTED SCHOOL BASED INTERVENTION ON LEVEL OF BMI AMONG OVERWEIGHT / OBESE CHILDREN” is the outcome of original research work undertaken and carried out by me under the guidance of DR.JANANI SANKAR., DNB, Ph.D., Senior Consultant in Pediatrics, Kanchi Kamakotti CHILDS Trust Hospital, Nungambakkam, Chennai-34.I also declare that the material of this has not found in any way, the basis for the award of any degree in this university or any other universities. I further declare that to the best of my knowledge the thesis does not contain any part of any work which has been submitted for the award of any degree either in this university or in any other university/Deemed University without proper citation.
Date:M.KAVIMANI
Place: Research Scholar
ACKNOWLEDGEMENT
First and foremost I would like to praise and thank the omnipresent God Almighty for his blessings and giving me the strength, knowledge, ability and opportunity to undertake this research study so as to persevere and complete it satisfactorily.
I express my deepest sense of gratitude to Dr.LathaVenkatesan., B.Sc(N)., M.Sc(N)., M.Phil(N)., M.B.A., Ph.D(N)., Principal Apollo College of Nursing for grooming me with warm encouragement, critical comments, timely guidance and correction of thesis. Her innovative guidance helped me throughout the research writing. I could not have imagined having a better mentor for my Ph.D study.
I express my profound gratitude and since thanks to my inspiring guide Dr.JananiSankar., MD., Ph.D, Senior Consultant in Pediatrics, Kanchi Kamakotti CHILDS Trust Hospital, Chennai, for the scholarly guidance and advice, valuable suggestions and supervision.
I thank my co-guide Dr.A.HelenM. Predita, M.Sc(N)., Ph.D(N). Principal Apollo College of Nursing, Madurai for the effective time and effort in checking the manual script and providing the valuable suggestion.
I would like to express my deepest sense of gratitude to my Management Sri. Naveen Mandradiar., M.S(US)., Secretary, Shivparvathi Mandradiar Educational Trust, Smt. Mano Mandradiar, Correspondent, Shivparvathi Mandradiar Educational Trust and Smt. Pallavi Mandradiar, Trustee, Shivparvathi Mandradiar Educational Trust for providing the best opportunity for my higher education and the encouragement given to take up the study.
My sincere grateful thanks to Mr.Balasubramanian Manager, Shivparvathi Mandradiar Educational Trust for his support, encouragement and motivation throughout the study.
My gratitude goes to Dr.Lizy Sonia Vice Principal Apollo college of Nursing, Chennai, for her support and motivation.
I place my special thanks to Dr.Vijayalakshmi, HOD –Mental Health Nursing, Apollo College of Nursing, Chennai, for her valuable corrections and spending her precious time to correct the manuscript to make it complete one.
I express my heartfelt thanks to the subject experts to the subject experts who have validated my research tool and with their suggestions and recommendations.
I have great pleasure in acknowledging my gratitude to my fellow research scholars and friends Prof. Nesa Sathya satchi and Prof. Jega Juliet for being there at time of need to motivate, support, encourage and propel on the course of the thesis.
My sincere thanks to Dr.Kumerasen and Mr.Dhanapal Biostatistician for their help in the course of analysis and data interpretation.
I would like to place on record my sincere thanks to Dr.L.M.Ramakrishnan Correspondent Bharathi Vidhya Bhavan schools for granting permission to conduct the study in The BVB and Bharathi Vidhya Bhavan Matriculation and Higher Secondary School, Erode, TamilNadu.
I thank all the study participants and their parents for their participation and their kind cooperation throughout the study.
I thank Mr.Kannan, Office superintendent, Apollo College of Nursing for his timely remainders in every stage of the study which helped me to finish the study in time.
I thank the librarians Mr.Sivakumar and Mr.Gopinath, Apollo College of Nursing, Chennai . for their co-operations and help during period of study.
My heartfelt thanks to my beloved husband Mr. S. Adhavan for his extreme support and for sharing my family responsibilities in a greater extend .I adore my loving kids A.Karthikeyan and A.Karthika for their love, caring, adjustments and accepting my long absence at home during my course of study.
I am pleased to express my gratitude and heartfelt thanks to my beloved parents Mr.N.Murugesan, Mrs. K. Rajeswari for their moral support, prayers and blessings.
I sincerely thank to Ms.Saranya, Ms.Akhila, Mrs.Karthika office staffs and Mrs.Vanitha, Librarian, Shivparvathi Mandradiar Institute of Health Science, Palayakottai, Tirupur District, for their support and cooperation during the course of study.
My warm and sincere thanks to all my friends for their support, encouragement and prayers.
Finally, I thank each and every one who directly and indirectly involved in this research.
Date: M.KAVIMANI
Place:
INDEX
Chapter
No. Contents Page No
I INTRODUCTION 1-30
Background of the study 1-9
Significance Need for the study 10-20
Statement of the problem 21
Objectives 21
Operational Definitions 22
Null Hypotheses 24
Assumptions 24
Delimitations 25
Conceptual Framework 25-29
Projected Outcome 30
Summary 30
II Review of Literature 32-76
Literature Related to Prevalence of overweight / obesity among
school children 32-40
Literature Related to factors contributing to overweight/obesity
among School children 41-52
Literature related to school based intervention among overweight
/obese school children 53-60
Literature Related to awareness Program Regarding Overweight
and Obesity 61-63
Evidence Based Nursing Practice and Protocol 64-75
Summary 76
III Methodology 77-97
Research Approach 77
Research Design 77
Variables of the Study 78
Research Setting 81
Population 81
Sample 82
Sample Size Estimation 82
Sample Size 83
Sampling Criteria 84
Sampling Technique 84
Development and Description of Tools 85
Psychometric Assessment of the Tools 91
Ethical Consideration 92
Intervention Protocol 93
Pilot Study 94
Data Collection Procedure 95
Problem faced during the study 96
Plan for Data Analysis 97
Summary 97
IV Data Analysis And Interpretation 98-151
Presentation of Data Analysis 98-150
Summary 151
V DISCUSSION 152-175
VI SUMMARY , CONCLUSION, NURSING IMPLICATION 176-191
Summary of the study 176
Findings 180
Conclusion 189
Nursing Implication 189
Limitations 191
Recommendations 191
Summary 191
VII REFERENCE 192
Annexures
LIST OF TABLES
S.No Title Page No.
1 Characteristics of Included Papers in the Literature Review 69 2 Individual Evidence Summary of RCT’s based on effectiveness
of School Based Intervention among overweight/obese children
70
3 Plan for Data Analysis 97
4 Frequency and PercentageDistribution ofOverweight and Obesity Among School Children Pertaining to Gender and Age.
102 5 Comparison of BMI between Girls and Boys among
Overweight/Obese School children.
103 6 Frequency and Percentage Distribution of Demographic Variables
in Control and Study Group of Overweight/Obese School Children.
104
7 Frequency and Percentage Distribution of Parental Variables in Control and Study Group of Overweight/Obese School Children.
106 8 Frequency and Percentage Distribution of Clinical Variables in
Control and Study Group of Overweight/Obese School Children.
108 9 Linear Regression, Standard Error and ‘t’ value of Contributing
Factors of Overweight/ Obesity among Control Group of Overweight/obese School Children.
110
10 Linear Regression, Standard Error and ‘t’ value of Contributing Factors of Overweight /Obesity among study group School children.
111
11 Multivariate Linear Regression Between Demographic Variables and Physical Activity Factors Contributing to Overweight/Obesity in Control and Study Group of Overweight/Obese School Children.
112
12 Multivariate Linear Regression Between Demographic Variables and Sedentary Behaviors Contributing to Overweight/Obesity in Control and Study Group of Overweight/Obese School Children.
113
13 Multivariate Linear Regression Between Demographic Variables and Familial Factors Contributing to Overweight/Obesity in Control and Study Group of Overweight/Obese School Children.
114
14 Multivariate Linear Regression Between Demographic Variables and Environmental Factors Contributing to Overweight/Obesity in Control and Study Group of Overweight/Obese School Children.
115
15 Multivariate Linear Regression Between Demographic Variables and Dietary Factors Contributing to Overweight/Obesity in Control and Study Group of Overweight /Obese School Children.
116
16 Multivariate Linear Regression Between Demographic Variables and Eating Habits Contributing to Overweight/Obesity in Control and Study Group of Overweight/Obese School Children.
117
17 Multivariate Linear Regression Between Demographic Variables and Psychological Factors Contributing to Overweight/Obesity in Control and Study Group of Overweight/Obese School Children.
118
18 Multivariate Linear Regression Between Parental Variables and Physical Activity Factors Contributing to Overweight/Obesity in Control and Study Group of Overweight / Obese School Children.
119
19 Multivariate Linear regression Between Parental Variables and Sedentary Behaviour Contributing to Overweight/Obesity in Control and Study Group of Overweight / Obese School Children.
120
20 Multivariate Linear Regression Between Parental Variables and Familial Factors Contributing to Overweight/Obesity in Control and Study Group of Overweight / Obese School Children.
121
21 Multivariate Linear Regression Between Parental Variables and Environmental Factors Contributing to Overweight/Obesity in Control and Study Group of Overweight / Obese School Children
122
22 Multivariate Linear Regression Between Parental Variables and Dietary Factors Contributing to Overweight/Obesity in Control and Study Group of Overweight / Obese School Children
123
23 Multivariate Linear Regression Between Parental Variables and EatingHabits Contributing to Overweight/Obesity in Control and Study Group of Overweight / Obese School Children.
124
24 Multivariate Linear Regression Between Parental Variables and Psychological Factors Contributing to Overweight/Obesity in Control and Study Group of Overweight / Obese School Children.
125
25 Multivariate Linear Regression Between Clinical Variables and Physical Activity Factors Contributing to Overweight/Obesity in Control and Study Group of Overweight/Obese School Children.
126
26 Multivariate Linear Regression Between Clinical Variables and Sedentary Factors Contributing to Overweight/Obesity in Control and Study Group of Overweight/Obese School Children.
127
27 Multivariate Linear Regression Between Clinical Variables and Familial Factors Contributing to Overweight/Obesity in Control and Study Group of Overweight/Obese School Children
128
28 Multivariate Linear Regression Between Clinical Variables and Environmental Factors Contributing to Overweight/Obesity in Control and Study Group of Overweight/Obese School Children.
129
29 Multivariate Linear Regression Between Clinical Variables and Dietary Factors Contributing to Overweight/Obesity in Control and Study Group of Overweight/Obese School Children.
130
30 Multivariate Linear Regression Between Clinical Variables and Eating Habits Contributing to Overweight/Obesity in Control and Study Group of Overweight/Obese School Children.
131
31 Multivariate Linear Regression Between Clinical Variables and Psychological Factors Contributing to Overweight/Obesity in Control and Study Group of Overweight/Obese School Children.
132
32 Comparison of pretest and Post test BMI between Control and Study Group of Overweight/Obese School Children.
133 33 Comparison of Post test BMI between Control and Study Group of
Overweight/Obese School Children.
134 34 Comparison of Pretest and Post test Parental Knowledge Score
Between Control and Study Group Parents of Overweight/Obese School Children.
135
35 Comparison of Post test Parental Knowledge Score Between Control and Study Group Parents of Overweight/Obese School Children.
136
36 Comparison of Lifestyle Practices of Children Between Control and Study Group of Overweight/Obese School Children.
137 37 Comparison of Post test Lifestyle Practices of Children Between
Control and Study Group of Overweight/Obese School Children.
138 38 Comparison of Pretest and Post test Diet Diary Between Control
and Study Group of Overweight/Obese School Children.
139 39 Comparison of Post test Diet Diary Between Study Group and
Control group of Overweight/Obese School Children.
140
40 Comparison of BMI Between Pretest, on 8th week and Post test using ANOVA in Control Group of Overweight/Obese School Children.
141
41 Comparison of BMI Scores Between Pretest, at 8th week and Post test using ANOVA in Study Group of Overweight/Obese School Children.
142
42 Correlation Between Post test Parental Knowledge Score and Lifestyle Practices of Children in Control and Study Group of Overweight/Obese School Children.
143
43 Association Between the Demographic Variables and the Post test Level of BMI in Control Group of Overweight/Obese School Children.
144
44 Association Between the Parental Variables and the Post test Level of BMI in Control Group of Overweight/Obese School Children.
145
45 Association Between the Clinical Variables and the Post test Level of BMI in Control Group of Overweight/Obese School Children.
146 46 Association Between the Demographic Variables and the Post test
Level of BMI in Study Group of Overweight/Obese School Children.
147
47 Association Between the Parental Variables and the Post test Level of BMI in Study Group of Overweight/Obese School Children.
148 48 Association Between the Clinical Variables and the Post test Level
of BMI in Study Group of Overweight/Obese School Children.
149 49 Level of Acceptability Regarding School Based Intervention in
Study Group of Overweight /Obese School Children.
150
LIST OF FIGURES
S.No Title Page
No.
1. Conceptual Framework Based on the Pender’s Health Promotion Model
31
2. PRISMA Flow Diagram 68
3. Schematic Representation of Research Design 80
4. Prevalence of Overweight and Obesity among School Children 99 5. Percentage Distribution of Overweight and Obesity among Boys 100 6. Percentage Distribution of Overweight and Obesity among Girls 100 7. Percentage Distribution of Overweight and Obese Pertaining to
Gender of the School Children.
101
LIST OF APPENDICES
S.No Title
A
Part Time Provisional Registration Certificate - Ph.D DegreeB
Confirmation of Provisional RegistrationC
Constitution of Doctoral Advisory Committee - CertificateD
Institutional Ethics Committee approval CertificateE
Plagiarism check Certificate, Plagiarism Analysis Report by Urkund,F
Screenshot of Plagiarism AnalysisG
Certificate for English EditingH
Letter granting permission to conduct the studyI
Grant of permission to use the Johns Hopkins Nursing Evidence Based Practice Models and Tools
J
List of experts who validated the toolK
Request for opinions and suggestions of experts for content validity, Content Validity Index and Content Validity Certificate
L
Tool in EnglishM
Tool in TamilN
Parental Awareness Programme –EnglishO
Parental Awareness Programme –TamilP
Intervention ProtocolQ
Thesis related PublicationsR
Ph.D Synopsis Submission Application FormS
Ph.D Thesis Submission Application FormT
PhotosU
Master coding SheetsABBREVIATIONS
1 BMI Body Mass Index
2 WHO World Health Organisation 3 CDC Center for Disease Control
4 IOTF International Obesity Task Force 5 NCD Non Communicable Diseases 6 NFHS National Family Health Survey
7 WHR Waist Hip Ratio
8 DEXA Dual Energy X-Ray Absorptiometry 9 CHD Coronary Heart Disease
10 US United States
11 UK United Kingdom
12 OECD Organisation for Economic Co-operation and Development
13 NIN National Institute of Nutrition
14 AP Andhra Pradesh
15 HPM Health Promotion Model 16 IAP Indian Academy of Pediatrics 17 SES Socio Economic Status
18 RDA Recommended Daily Allowances
19 TV TeleVision
20 NCHS National Center for Health Statistics 21 ORANGE
Obesity Reduction and Awareness and
screening of Non communicable diseases
through Group Education
22 TBF Total Body Fat
23 STP Structured Teaching Programme 24 TSFT Triceps SkinFold Thickness
25 PA Physical Activity
26 RCT Randomized Controlled Trial
27 MVPA Moderate Vigorous Physical Activity
28 PE Physical Education
29 TEE Total Energy Expenditure 30 BEE Basal Energy Expenditure 31 SLEE Sleep Energy Expenditure
32 PRISMA Preferred Reporting Items for Systematic Review and Meta-Analysis
33 PICO Population Intervention Comparison Outcome
34 CBSE Central Board of School Education 35 ANOVA Analysis of Variance
36 SPSS Statistical Package For Social Studies 37 SCC Sweet Chocolates Carbohydrate
Consumption
38 BM Behaviour Modification
39 FMS Fundamental Movement Skill
40 IEC Information Education Communication
ABSTRACT
Overweight and obesity are among the most prevalent nutritional problem in developed and developing nations. In developing countries such as India, especially in urban populations, childhood obesity is emerging as a major health problem. This study was attempted to identify the contributing factors of overweight/obesity and also to assess the effectiveness of school based intervention on the level of BMI among school children in selected Schools at Erode. The study objectives were,
1. To determine the prevalence of overweight /obesity among school children.
2. To identify the contributing factors of overweight /obesity in control and study group of school children.
3. To find out the association between the selected variables and the other contributing factors of overweight /obesity in control and study group of overweight/obese school children.
4. To assess the pretest and post test BMI in control and study group of overweight /obese school children.
5. To evaluate the effectiveness of selected school based intervention on the level of BMI among overweight /obese school Children in study group.
6. To find out the correlation between the parental knowledge and the lifestyle practices of children in control and study group of overweight /obese school children.
7. To find out the association between the selected variables and the post test level of BMI in control and study group of overweight /obese school children.
Based on the study objectives null hypotheses were formulated .Conceptual framework of the study was based on the Pender’s Health Promotion Model and the review of literatures were done on following headings; prevalence of overweight and obesity among school children, factors contributing to overweight/obesity among school children, school based intervention among overweight/obese school children, awareness programme regarding overweight and obesity on school children. A Quasi experimental research design with control and study group- pretest and post test time series was used in this study. Major variables of the study were BMI, parental knowledge regarding overweight andobesity, lifestyle practices of children and diet pattern.
Study was conducted at two private schools namely Bharathi Vidhya Bhavan Matriculation and Higher Secondary School-control group, The Bharathi Vidhya Bhavan - Study group. Total enumerative sampling technique was used for screening of overweight and obesity among school children through Quetelet Index BMI status.
Then consecutive sampling method was used to recruit the samples for study and control group children. Schools were randomly selected for control and study group.
After screening, based on the sampling criteria children were included into the study.Resesarch tools were prepared by the researchers. Informed consent for both the groups was obtained and the study was approved by the Institutional Ethical Committee.
Structured Questionnaire was used to collect the data regarding contributing factors of overweight /obesity among school children. Followed by the pretest on parental knowledge, lifestyle practices of children and diet diary were sent to the parents to fill and return. Then study group children were involved for aerobic exercise programme 40 minutes for 3 days a week up to 16 weeks through structured video instruction under the supervision of Physical education teacher and also by the researcher. Parental awareness programme regarding overweight/obesity was given twice with the help of Power point presentation cum discussion. At the end of 16th week post test of parental knowledge, lifestyle practices of children and diet diary were done.BMI of school Children were measured at 8th week of intervention and at the end of 16th week of intervention.
A total of 2291 school children were screened for BMI. Participants from both sex were included in the study and boys were 1283 in numbers (56%) and girls were 1008 (44%). Among them majority 1952 (85.2%) had normal BMI (below 25), 219(9.6%) were overweight and 120 (5.2%) were obese .None of the children were under weight.
Among 1008 girls screened, 810 (80.4 %) had normal BMI, 129(12.8 %) were overweight and 69 (6.8) were obese and among the boys who were screened has shown that among 1283 boys, 1139 (88.9 %) had normal BMI, 90 (7.1%) were overweight and 51(4%) were obese. It can be observed that the prevalence of overweight and obesity were higher among girls in comparison with boys.
Distribution of Overweight were found to be high in the age group of 13 and 14 years among the girls (11.8%,13.6%), as well as boys (8.6%, 10.9%)
respectively. Similarly the prevalence of obesity also was found to be high in the age group of 13 years and 14 years among the girls (7.4%, 8.6%) and the boys (5%, 6.5%) respectively.
Majority of the children in control and study group were in the age of 14 years(44.4%, 39.7%) and girls (63.7%, 56.3%) ,were Hindus (83.9%, 73%), living in urban area (95.2%,88.1%), first born in the family (48.4%,54%), had one sibling (84.7%, 84.9%), belonged to nuclear family (75%,70.6%) and their parents were responsive not demanding (38.7%, 44.4%) in control and study group respectively. There was no significant difference (p>0.05) between the groups except with regard to gender where girls were more in both groups. .
Majority of the fathers of school children in both control and study group were undergraduates (59.7%, 54.8%), doing business/ self-employed (50%, 31%) mothers were graduates (71%, 61.9%) and were home makers (74.6%, 66.1%) and most of their family income was above Rs.40000 /-.
Majority of the school children in control and study group had no history of gestational diabetes (93.5%, 96%),conception was natural (92.7%, 97.6%),were full term (89.5%, 89.7%), had normal birth weight (92.7%, 85.7%), received both bottle and breast feeding (62.5%, 53.2%),their dietary preferences were non vegetarian (87.1%, 87.3%) respectively in control and study group. There was no significant association between the control group and study group of overweight/obese school children.
Among the control group of school children none of the contributing factors of obesity/overweight were significant and only the combined factors caused 3.5
%variance (R2=.035). Among the study group of school children, physical
activity factor (B=31.3%, t=3.094) at p<0.01 and dietary factors (B=22.1%, t=2.187) at p<0.05 were the significant contributing factors of overweight and obesity compared to other contributing factors. The combined factors caused 12.9% variance (R2=.129).
The control group pretest mean BMI was 29.083, SD= 3.335and the overall post test mean was 30.314, SD=3.248 .The mean difference was 1.231. The calculated ‘t’ value 18.309 was also significant at p<0.01. Whereas in study group pretest mean was 28.583, SD= 4.801and post test mean was 25.610, SD=1.865 .The mean difference was 2.973. The obtained ‘t’ value 37.639 was significant at p<0.01 in study group.
The control group pretest parental knowledge mean score was 11.333, SD=
2.739and post test mean score was 11.524, SD=2.658.The calculated ‘t’ value 2.955 was statistically significant at p<0.01 in control group. And the study group pretest parental knowledge mean score was 11.145, SD=0.868 and the overall post test mean score was 14.056, SD=2.053 .The mean difference was 2.911 and the calculated ‘t’ value 13.828 was significant p<0.01 in study group.
In the control group mean score of pretest lifestyle practices of children was 18.579, SD=6.092 and post test mean was 18.794, SD= 5.775. The mean difference was 0.215. The calculated ‘t’ value 2.9187 was statistically significant (p<0.01) in control group. The study group pretest mean score of lifestyle practices of children was 18.234, SD= 5.507 and the post test mean was 31.315, SD= 4.135. The mean difference was 13.081. The calculated ‘t’
value 25.488 was significant at p<0.01 in study group overweight/obese school children.
The control group pretest mean Energy, Protein and Fat were 2666.2 (SD = 365.2) , 45.74 (SD = 6.75) and 50.95 (SD = 6.69) respectively and the post test mean were 2689.0 (SD= 359.8),46.19(SD=5.88) and 51.49(SD = 6.54) respectively .The calculated ‘t’ value -0.722 (Energy),-0.941 (protein), - 0.91(Fat) were not significant (p>0.05) in control group . The study group pretest mean of Energy, Protein and Fat were 2649.9 (SD= 357.9), 46.05 (SD=5.69) and 50.88 (SD=6.67) respectively and the post test mean were 2428.9 (SD=295.7), 47.61 (SD=6.55) and 47.88 (SD=4.17) respectively. The obtained ‘t’ value 15.706 (Energy), 4.389 (protein), were significant at p<0.01 in study group and the calculated ‘t’ value 0.818 of fat was not significant p>0.05.
Among Post test BMI of control group was 31.4 and SD=3.248 and the overall post test mean of study group was 25.610, SD= 1.865, Mean difference between the groups was 4.704. The calculated ‘t’ value 14.126 was statistically significant at p<0.001.
With reference to control group, the post test mean parental knowledge score was 11.524, SD=2.658 and whereas in study group the mean post test parental knowledge score was 14.056, SD=2.053. Mean difference between the groups was - 2.532 and the obtained ‘t’ value 8.497 was significant at p<0.001.
Regarding control group, overall obtained post test mean score of lifestyle practices of children was 18.794, SD=5.775 and in study group the overall mean score of lifestyle practices of children was 31.315, SD= 4.135. The mean
difference between the groups was -12.521 and the calculated ‘t’value 19.843 was significant at p<0.001.
Post test diet dairy between control and study group of overweight/obese school children. In the control group, the post test mean of energy, protein, fat were 2689.0 (SD= 359.8), 46.19(SD=5.88) and 51.49 (SD=6.54) respectively and in study group, the post test mean of energy, protein, fat were 2428.9 (SD= 295.7), 47.61 (SD=6.55) and 47.88 (SD=.17) respectively. The calculated ‘t’values were 6.289, 1.818 and 5.239 in respect to energy, protein and fat were significant at p<0.001.
Comparison of BMI on pretest, at 8th week and post test among overweight/obese school children in study group. The overall mean of pretest, at 8th week and post test were 28.583 (SD=2.191), 27.258 (SD=2.077) and 25.1.865 (SD=1.865) respectively. The obtained F value 65.579 was significant at p<0.15.
Regarding parental knowledge and lifestyle practices of children in both control and study group and found to be significant (p<0.01). It reveals that there was a high positive correlation (r=0.795) between parental knowledge score and lifestyle practices of children in study group overweight/obese school children where as in control group the obtained ‘r’ value 0.258 shows that there was mild positive correlation between the parental knowledge and the lifestyle practices of children in control group.
Regarding level of satisfaction, 87.90 % of children were highly satisfied with the school based intervention on level of BMI among study group overweight and obese school children.
The study results revealed that there was a significant reduction on the level of BMI. Hence it was inferred that the school based interventions; aerobics exercises and parental awareness program were effective in reducing the level of BMI. School based program is cost effective, fun as group activity among children peer involvement and motivation, the family involvement helps to monitor them at home.
And also the school samples become captive population, so that implementing the weight reduction strategies at schools become much easier compare to other settings.
1
CHAPTER I
INTRODUCTION
Background of the Study
Every human being wishes to have healthy children who would grow to be healthy adults and enjoy a long life. A healthy childhood is the foundation for the healthy adult life1. Habits formed in childhood have a long term impact on health and wellbeing. It is the responsibility of the parents, family community and society to cultivate healthy habits towards optimal health2. It is clear that in many countries this aim may be unachievable for number of years because many specific adult health problems have their origins in childhood. One such health problem is “Childhood Obesity1”. All mothers want to have chubby babies. So, increasing prevalence of obesity has become a most common and serious nutritional disorder in children. Many mothers believe that childhood fat is puppy fat, which children will lose as they grow up3. But children who are obese before age five seem to have greater risk of adult obesity4.
India faced two major nutritional problems during 1950’s.One was the threat of famine and the resultant acute starvation and the other was chronic energy deficiency5. The country adopted a multi-sectoral, multi-pronged strategy to combat these problems and improve the nutritional status of the population6. This was followed by green revolution and industrialization. In 1992, Government of India adopted open market policies, which brought in rapid industrialization throughout the country. Review of the situation in 2000/2001 prior to
2
formulation of the Tenth Five-Year Plan (Planning Commission, 2002) showed that although under nutrition and micronutrient deficiencies continue to be major public health problems, over nutrition and obesity are also emerging as a major health problem in many states5.
Childhood obesity has become a worldwide phenomenon cutting across regional and economic barriers7 and affecting all socio-economic groups, irrespective of age, sex or ethnicity8. It has emerged as an epidemic not only in the developed countries but also in the developing countries that are in rapid epidemiological transition, and India is no exception (Yadav S 2001)9.
In the past few years, obesity has become one of the most frequent nutritional disorders in the world, resembling a pandemic and being considered the 21st century disease threatening the viability of basic health care delivery8. The prevalence of child obesity is increasing rapidly worldwide. Childhood obesity has tripled more in the past 30 years. At present, there is an increased tendency with an epidemic character of obesity and overweight frequency, which came to affect, on a world scale, approximately 20-25% of children and 45-50% of the teenagers9. Previously considered to be bane of western affluent countries, now it has assumed epidemic proportions in India and China also1.Developing countries like India are facing the peculiar situation of having to deal with both ends of the spectrum of nutritional disorders. On one hand, mal (under)nutrition is an epidemic which has been in vogue for ages10.
The fetal period and the first months of lifestyle were shown to be critical period for later development of the child. Nutrition during these early stages of
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growth which included the effects of breastfeeding and weaning was shown to be important as a predisposition for lower and enhanced deposition of fat leading to obesity11. The export of western way of lifestyle along with unsuitable diets and low physical activity regimes appear to be a significant risk with regard to desirable development of population in many countries. Fast food, soft drinks with lot of sugar were found to be significant12. In Europe, Asia and Pacific countries where sedentary lifestyle was reordered on the increase, effective intervention on the proposed concept of diet and physical activity within the family, School and community environment in early age was found to be necessary13.
Adolescent is the period of crucial growth. During this phase physical changes including growth, the onset of menarche for the girls and increase in fat and muscle mass take place and the total nutrient needs are higher14. Urbanisation has the remarkable impact on socio economic status, life style and also globalisation of food markets in the major force thought to underline the epidemic. In addition to this, cultural factors such as dietary practices and attitude towards food are changing which ultimately contribute to the prevalence of incidence of obesity. People who are obese or severely overweight are at risk in many ways15.
Current evidence indicates that obesity is a multi-factorial condition influenced by many variables, including genetic, demographic and lifestyle factors.
Genetic and demographic variables such as family history of obesity, age, ethnicity and sex cannot be modified16. However, obesity associated lifestyle factors are often modifiable. In fact, previous research had shown that childhood obesity is associated with many lifestyle factors, including sedentary behaviors, physical inactivity and unhealthy dietary choices. However, not all the studies showed the associations
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between childhood obesity and some lifestyle factors, such as the consumption of soda beverages or computer use. Information on lifestyle factors associated with obesity in adolescents indicated that unhealthy dietary choices and inactivity were generally correlated with BMI in children and adolescents17.
The fundamental cause of obesity and overweight is an imbalance between calories consumed and calories spent. Globally, there has been an increased intake of energy-dense foods that are high in fat and an increase in physical inactivity due to the increasingly sedentary nature of many forms of work, changing modes of transportation, and increasing urbanization.
Changes in dietary and physical activity patterns are often the result of environmental and societal changes associated with development of overweight and obesity among children and also lack of supportive policies in sectors such as health, agriculture, transport, urban planning, environment, food processing, distribution, marketing, and education18.
Children are also particularly vulnerable to marketing and the price of foods and drink. There is clear evidence that the marketing of unhealthy foods and drinks to children is related to childhood obesity. The low price and widespread availability of energy-dense, nutrient-poor foods is also an important factor19.
Exclusive breastfeeding from birth to 6 months of age is an important way to help prevent infants from becoming overweight or obese20. A study by the cognitive neuroscience society (2017) says that continuous sleep deprivation makes the brain more sensitive to food smells. People with such sleeping patterns are more likely to eat unhealthy snacks21.
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According to Dr.Choubey, in 60 per cent cases, unhealthy food habits are the main factor of obesity and cases in the age group of 11-18 years have increased by 15- 20 per cent in recent years22.
Recent research done by Prof. Dolton in UK has found that 35-40% of children all over the world inherit obesity from their parent 23.In the recent decades, family practices have significantly changed, and several of these practices greatly contribute to childhood obesity with a decreasing number of mothers who breast-feed, more infants become obese children as they grow up and are reared on infant formula.
Fewer children go outside and engage in active play as techno gadgets, such as the television and video games, mute children indoors. Rather than walking or biking to a bus-stop or directly to school, more school-age children are driven to school by their parents, reducing physical activity. As family sizes decrease, the children's pester power, their ability to force adults to do what they want, increases. This ability enables them to have easier access to calorie-packed foods, such as candy and soda drinks. The social context around family meal-time plays a role in rates of childhood obesity24.
Dramatic and rapid societal changes during the last few decades have contributed significantly to childhood obesity. There are evidence stating that individual’s eating and physical activity behaviors are heavily influenced by surrounding social and physical environmental contexts both for adults and children.
Urbanization related intake behaviors that have been shown to promote obesity include frequent consumption of meals at fast-food outlets, consumption of oversized portions at home and at restaurants25, 26.
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Many countries in South-East Asia including India are going through an economic and nutrition transition27. The nutrition transition is associated with a change in dietary habits, decreasing physical activity and rising in prevalence of obesity. Overweight and obesity are major risk factors for a number of chronic diseases, including diabetes, cardiovascular diseases and cancer. Obesity in children and adolescents is gradually becoming a major public health problem in many developing countries, including India. ‘One-half of obese school children become obese adults. Whether or not obesity persists into adulthood, obesity in childhood appears to increase the risk of subsequent morbidity. Significance of estimating prevalence of childhood obesity thus cannot be overemphasised28.
Many low- and middle-income countries are now facing a "double burden" of disease. While these countries continue to deal with the problems of infectious diseases and under nutrition, they are also experiencing a rapid upsurge in non- communicable disease risk factors such as obesity and overweight, particularly in urban settings. It is not uncommon to find undernutrition and obesity co-existing within the same country, the same community and the same household29.
Children in low and middle-income countries are more vulnerable to inadequate pre-natal, infant, and young child nutrition. At the same time, these children are exposed to high-fat, high-sugar, high-salt, energy-dense, and micronutrient-poor foods, which tend to be lower in cost but also, lower in nutrient quality. These dietary patterns, in conjunction with lower levels of physical activity, result in sharp increases in childhood obesity while undernutrition issues remain unsolved30.
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The technological revolution of the 20th century has left in its wake an
“obesogenic environment “that serves to expose the biological vulnerability of human beings31.A country where 270 million people live below the “poverty line “; obesity seems to be a distant issue, meant for the kids of first world. But India is under siege of junk food, sedentary lifestyle and alcohol are leading us to silent self-destruction32.
Technology has a large factor on the children's activeness. Many children fail to exercise because they are spending time doing immobile activities such as computer usage, playing video games or watching television33.Advertisement of unhealthy foods correlates with childhood obesity rate34.
Over the last few decades, children around the world have become taller and also in some countries significantly heavier.Height and weight have been increasing since the 18th century, as income, education and living conditions gradually improved over time. While weight gains were largely beneficial to the health and longevity of our ancestors, an alarming number of people have now crossed the line beyond which further gains are dangerous. Severely obese people die 8-10 years sooner than those of normal weight, similar to smokers, with every 15 extra kilograms increasing risk of early death by approximately 30%. Obesity is estimated to be responsible for 1% to 3% of total health expenditure in most countries (5% to 10% in the United States) and costs will rise rapidly in coming years as obesity-related diseases set in35.
Body Mass Index (BMI) or Quetelet Index is a statistical measure of the weight of a person scaled according to height. It was invented between 1830 and 1850 by the Belgian polymath AdolpheQuetelet during the course of developing "social physics". It is weight adjusted for height squared (weight in
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kg/ height in m2), a useful index to assess overweight and is fairly reliable surrogate for adiposity. Based on large scale population data, WHO has defined overweight/obesity. As a measure, BMI became popular during the early 1980s as obesity started to become a discernible issue in prosperous western society.
However, the limitation of BMI is that it cannot differentiate muscle mass to body fat and cannot locate the site of fat e.g., people with ‘central obesity’
may have normal BMIs36,37,38.
Other markers of obesity are; skin fold thickness, waist circumference, waist hip ratio (WHR), bioelectrical impedance analysis, dual energy X-ray absorptiometry (DEXA), air displacement plethysmograpgy method33. All these markers have their individual advantages but none are really standardized as yet. Waist circumference/ waist hip ratio has an additional advantage for central obesity39. It has been documented that increase WHR is associated with type 2 diabetes, CHD and other metabolic problems40.
Health hazards of overweight and obesity epidemiological studies have shown a progressive increase in the incidence of hypertension, diabetes mellitus, and coronary heart disease, sleep apnea syndrome, and certain cancers in obese persons 41. Epidemiological and metabolic studies conducted over the last 15 years have confirmed the notion that a high proportion of abdominal fat (central obesity) is a major risk factor for coronary heart disease, type 2 diabetes mellitus, and related mortality . Epidemiological studies have mainly used ratio of waist-to-hip circumference (waist:hip ratio) to estimate the proportion of abdominal adipose tissue. Visceral obesity isassociated with insulin resistance, hyperinsulinaemia and glucose intolerance42. Apart from this these
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persons are associated with dyslipoprotenemias and other metabolic derangements.
Non metabolic Hazards associated with obesity are osteoarthritis and gout, reflux esophagitis, sleep apnea syndrome, cholelithiasis, cancer of the endometrium, ovaries, breast, biliary tract in females and prostate, colon and rectum in males, Poor post- surgical risk, Abdominal hernia, Depression and anxiety with psychological disability, acanthosisnigricans, fungal infection over skins folds (intertrigo), Poor-body-image and attendant psychological maladjustment43.
According to a study carried out in 79 countries, WHO estimated that there are 250 million obese people in the world, among which approximately 22 million are children aged less than 5 years. The latest data from the National Centre for Health Statistics showed that in US among youth, 18 percent of children aged 6-11 years and 21 percent of teens aged 12–19 years are considered obese. These rates of obesity have substantial implications for Americans’ health. Being obese increases the risk of many diseases and health conditions44.
The treatment of overweight and obesity in children and adolescents requires a multidisciplinary, multi-phase approach, which includes dietary management, physical activity enhancement, and restriction of sedentary behavior, pharmacotherapy and bariatric surgery45. A holistic approach to tackle the childhood obesity epidemic needs a collection of activities including influencing policy makers and legislation, mobilizing communities, restructuring organizational practices, establishing coalitions and networks, empowering providers, imparting community education as well as enriching and reinforcing individual awareness and skills. The
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implications of this global phenomenon on future generations will be serious unless appropriate action is taken46.
The prevention of obesity is a public health issue which imposes a careful monitoring of the children with a tendency in gaining weight. Obesity is the most frequent nutritional disorder of the child in the developed countries, representing one of the major public health problems in numerous regions of the world. There is an urgent need of increasing awareness about and sensitizing the policy makers, healthcare personnel and the community at large to the huge burden of dual malnutrition i.e. under nutrition and over nutrition that we are facing47.
Schools play a large role in preventing childhood obesity by providing a safe and supporting environment with policies and practices that support healthy behaviours48. At home, parents can help prevent their children from becoming overweight by changing the way the family that eats and exercises together. The best way children learn is by example, so parents need to lead by being living example with healthy lifestyle49. The challenge ahead is to identify “obesogenic environments”
and influence them so that healthier choices are more available, easier to access, and widely promoted to a large proportion of the community50.
SIGNIFICANCE AND NEED FOR THE STUDY:
Obesity is one of the most serious public health problem and challenges of the 21st century. The problem is global and steadily sweeping the developing nations.
Obesity implies excess fat and not merely excess weight. Body weight is determined by an interaction between genetic, environmental, psychological factors acting
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through the physiological mediators of energy intake and expenditure. Management of childhood obesity is challenging with major impetus on life style measures51.
Recent WHO global estimates states that the worldwide prevalence of obesity nearly tripled between 1975 and 2016.In 2016, an estimated 41 million children under the age of 5 years were overweight or obese. Overweight and obesity that was once considered a high-income country problem are now on the rise in low and middle- incomecountries, particularly in urban settings. The prevalence of overweight and obesity among children and adolescents aged 5-19 has risen dramatically from just 4% in 1975 to just over 18% in 2016. The rise has occurred similarly among both boys and girls. In 2016 18% of girls and 19% of boys were overweight52.
When it was below 1% of children and adolescents aged 5-19 were obese in 1975, more than 124 million children and adolescents (6% of girls and 8% of boys) were obese in 2016.Overweight and obesity are linked to more deaths worldwide than underweight53.
Childhood obesity rates appear to be plateauing in high-income countries, but at very high levels54. The areas of the world with some of the largest increase in the number of obese children and adolescents were East Asia and the Middle East and North Africa. The rise in childhood obesity rates has recently accelerated, especially in Asia. Worldwide Non Communicable Disease represents 43% of the burden of disease and is expected to be responsible for 60% of the disease burden and 75% of all deaths by 2020 because of emerging Non Communicable Disease epidemic in developing countries55.
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Childhood obesity is emerging as a major health problem in developing countries such as India, especially in urban populations56, 57. The World Health Organization (WHO) has declared overweight as one of the top ten health risks in the world and one of the top five in developed nations58. The magnitude of overweight ranges from 9% to 27.5% and the obesity ranges from 1% to 12.9% among Indian children59. Existing WHO standards and data from 79 developing countries including a number of industrialized countries suggest that about 22 million children 5 years old are overweight world-wide60. Once considered a problem of affluence, obesity is fast growing in many developing countries also61. Even in countries like India, which are typically known for high prevalence of under nutrition, a significant proportion of overweight and obese children now coexist with those who are under nourished62.
Obesity in India has reached epidemic proportions in the 21st century. India is following a trend of other developing countries that are steadily becoming more obese. Unhealthy, processed food has become much more accessible following India’s continued integration in global food markets63.
The prevalence has increased at an alarming rate. According to WHO it is estimated that 300 million obese people worldwide and the data from 79 developing countries and a number of industrialized countries suggest that about 22 million children under five are overweight64. There is also evidence that this problem is increasing in the USA, the percentage of overweight children aged 5-14 years has doubled in the last 20 years from 15 % to 32%65.Globally in 2020 the number of overweight, under the age of five is estimated to be over 42 million, close to 35 million of these are living in developing nations. Overweight and obesity are largely preventable .Prevention of childhood obesity therefore needs high priority.
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Concurrently, a growing prevalence of obesity and its related chronic diseases is being observed in these countries. Increasing obesity is already a major concern in developed countries for pre-school children as well as school children66.
According to Professor Majid of Imperial College, London School of Public Health, obesity rates in children and adolescents have soared globally and continue to do so in low- and middle-income countries for the past few decades53.
The study published recently in the Journal of Lancet analyzed weight and height in nearly 130 million people, including 31.5 million children aged 5-19 years of age. The number of obese children and adolescents rose from 11 million in 1975 to 124 million in 2016 which was tenfold increase in the prevalence and additional 216 million children were overweight. After China, India ranks second in highest number of obese children in the world53.
Dr.Sachdav, part of the WHO’s guideline development group stated that in 2016, one half of children with overweight or obese lived in Asia and one quarter lived in Africa. Paradoxically, overweight and obesity are found in populations where under nutrition is common and also recommended that early prevention is the need of the hour to avoid an entire generation from falling prey to heart alignments, hypertension and diabetic complications67.
According to a study published in the pediatric obesity, it reveals that by 2025 India will have over 17 million overweight children68.
The International Obesity Task Force (IOTF); World Health Organization (WHO) estimated the prevalence of overweight (including obesity) among children
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aged 5-17 years is 10%. In India, still around 46 per cent of all children below the age of three are too small for their age, 47 per cent are underweight and at least 16 per cent are wasted. Many of these children are severely malnourished¹. On the other hand, over nutrition evident as overweight and obesity has been recently on the rise and is present in 20.6% of boys and 18.3% of girls69.
Globally there are more people who are obese than underweight this occurs in every region except parts of sub-Saharan Africa and Asia. The obesity epidemic in the U.S., which affects about 10.4% of children between 2 years and 5 years of age and more than 23 million children and teens in total. According to the Robert Wood Johnson Foundation, it is estimated to cost the nation $117 billion per year in direct medical expenses and indirect costs, like lost productivity, that total is for one nation for one year. Taking into account the lifetime cost for each obese child, the global effect of the obesity epidemic is staggering70.
The United States and some countries in the Caribbean, such as Puerto Rico, as well as the Middle East, including Kuwait and Qatar, came next with levels of obesity above 20% for the same age group, according to the new data, visualized by the NCD Risk Factor Collaboration53.
Most countries within the Pacific Islands, including the Cook Islands and Nauru, had the highest rates globally, with more than 30% of their youth ages 5 to 19 estimated to be obese. A whopping 44 present of boys and 38% of girls in the Mediterranean nation are overweight or obese, making Greek kids the fattest in the world71.
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The number of overweight or obese infants and young children (aged 0 to 5 years) increased from 32 million globally in 1990 to 41 million in 2016. In WHO African Region alone, the number of overweight or obese children increased from 4 to 9 million over the same period. Nearly half of the children under 5 who were overweight or obese in 2016 lived in Asia. Over 340 million children and adolescents aged 5-19 were overweight or obese in 201672.
In the largest study of its kind, more than 1,000 researchers collaborated to analyse weight and height data for almost 130 million people, including more than 31 million people 5 to 19 years old, to identify obesity trends from 1975 to 2016.And found that they have plateaued in higher-income countries,. “Rates of child and adolescent obesity are accelerating in East, South and Southeast Asia, and continue to increase in other low and middle-income regions," noted by James Bentham, a statistician at the University of Kent. It is not an excuse for complacency as more than one in five young people in the U, S. and one in 10 in the UK is obese," he said53.
OECD projections show a steady increase in obesity rates until at least 2030.Obesity levels are expected to be particularly high in the United States, Mexico and England, where 47%, 39% and 35% of the population respectively are projected to be obese in 2030. On the contrary, the increase is expected to be weaker in Italy and Korea, with obesity rates projected to be 13% and 9% in 2030, respectively. The level of obesity in France is projected to nearly match that of Spain, at 21% in 2030.
Obesity rates are projected to increase at a faster pace in Korea and Switzerland where rates have been historically low73.
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Indian studies shown that there is 50% of the increase in prevalence of childhood obesity in two years with the highest incidence in boys. A study done with school children in urban Chennai found the number of overweight boys to be 17.8%
and girls 15.8% .In affluent cities of India, the prevalence of obesity reaches the levels of industrialized countries, with values increasing with socioeconomic class74.
Various studies over the last decades in India have shown that there was an increase in prevalence of overweight and obesity. The prevalence of overweight was estimated to be 12.64 % (95% CI 8.48-16.80%) and that of obesity to be 3.39% (95%
CI 2.58-4.21%) 74.
As per statistics provided by the National Family Health Survey-3, undivided Andhra Pradesh was among the top five states in obesity, with 17.6% males and 22.7% females falling in the obese category. The four other states that topped the obesity charts include Punjab, Kerala, Goa and Tamil Nadu. Also, a state-wide survey conducted by scientists of National Institute of Nutrition (NIN) in undivided AP around four years ago found that at least 15% of school students coming from higher socio-economic backgrounds in urban areas suffer from obesity4, 75.
In India, we have just started reporting the high prevalence of obesity in children. Obviously there, no much intervention studies have been carried out as yet.
But a number of studies have been carried out and reported from the western countries. Some reports from developing countries have started to emerge. By and large recent studies in children (as against adult studies) have shown some positive short term and long term results with programs that target the whole life style of children76.
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The vast majority of overweight or obese children live in developing countries, where the rate of increase has been more than 30% higher than that of developed countries. If current trends continue the number of overweight or obese infants and young children globally will increase to 70 million by 202577.
According to Anjanaa pediatric endocrinologist, identification of obese children is a big challenge, because parent’s feel the necessary to see the doctor only when their children develop complications. Obesity in childhood is associated with a wide range of serious health complications and an increased risk of premature onset of illnesses, including diabetes and heart disease78. Without intervention, obese infants and young children will likely continue to be obese during childhood, adolescence and adulthood. While there have been major public health interventions to promote improved diet and patterns of physical activity in adults, while the interventional contributions of antenatal and young children are very few. Child interventions in reducing the risk of obesity in later life have not been significantly reviewed79.
Childhood obesity can profoundly affect children's physical health, social, and emotional well-being, and self-esteem80.It is also associated with poor academic performanceand a lower quality of life experienced by the child. Childhood obesity is associated with a higher chance of premature death and disability in adulthood.
Overweight and obese children are more likely to stay obese into adulthood and to develop Non Communicable Diseases (NCDs) like diabetes and cardiovascular diseases at a younger age. For most NCDs resulting from obesity, the risks depend partly on the age of onset and on the duration of obesity. Obese children and
