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12 - Prevention
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- By Inge Lissau, National Institute of Public Health, Copenhagen., Walter Burniat, University Hospital for Children ‘Reine Fabiola’, Free University of Brussels., Elizabeth M.E. Poskitt, International Nutrition Group, London School of Hygiene and Tropical Medicine., Tim J. Cole, Department of Paediatric Epidemiology and Biostatistics, Institute of Child Health, London
- Edited by Walter Burniat, University of Brussels, Tim J. Cole, Institute of Child Health, University College London, Inge Lissau, National Institute of Public Health, Copenhagen, Elizabeth M. E. Poskitt, London School of Hygiene and Tropical Medicine
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- Book:
- Child and Adolescent Obesity
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- 02 November 2009
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- 29 August 2002, pp 243-269
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Summary
Prevention before management
It seems almost de rigueur to end medical and nutritional texts with a section on prevention of the problem under discussion. Yet is this intelligent planning? The editors had lengthy discussions on the most logical order for the chapters in this book. No current programme for the treatment of obesity is particularly successful. Thus, control of the epidemic of obesity sweeping many countries in the developed world, and indeed beginning to affect countries in the developing world, is likely to depend more on effective prevention than on ‘cure’ of obesity. For this reason, priority in the management of childhood obesity has been given to this chapter on prevention.
Why prevention?
There are many reasons for promoting obesity prevention in childhood:
the prevalence of obesity is rising in industrialized countries (Chapter 2);
childhood obesity is likely to lead to obesity in adult life (Chapter 2);
it limits physical activity (Chapter 5);
it is associated with psychosocial disadvantage (Chapter 6);
it is associated with a higher risk of adult conditions such as Type II diabetes mellitus and hypertension (Chapters 7, 8, 10 and 11);
it is difficult to treat successfully (Chapters 13–20).
Primary prevention
The focus for preventive health programmes operates at three levels (WHO, 1998):
primary prevention, aimed at reducing the number of new cases (incidence);
secondary prevention, aimed at reducing the numbers of established cases (prevalence);
tertiary prevention, aimed at reducing the degree of disability associated with the condition (treatment).
9 - Prader–Willi and other syndromes
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- By Giuseppe Chiumello, Clinica Paediatrica III, Universita degli Studi di Milano, Elizabeth M.E. Poskitt, International Nutrition Group, London School of Hygiene and Tropical Medicine
- Edited by Walter Burniat, University of Brussels, Tim J. Cole, Institute of Child Health, University College London, Inge Lissau, National Institute of Public Health, Copenhagen, Elizabeth M. E. Poskitt, London School of Hygiene and Tropical Medicine
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- Book:
- Child and Adolescent Obesity
- Published online:
- 02 November 2009
- Print publication:
- 29 August 2002, pp 171-188
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Summary
Introduction
Most children with obesity are basically normal healthy children with simple, primary or exogenous obesity. Some have psychological problems or orthopaedic complaints and simple obesity is also more common in children with mild nonspecific mental retardation. Over time, children with simple obesity also develop the health consequences of severe obesity, but their lack of problems in early childhood is often remarkable. By contrast, children with ‘pathological’, secondary or endogenous obesity have obesity in association with a wide variety of other problems. Obesity is rarely their presenting problem. True secondary obesity currently accounts for only a small proportion (<5%) of cases of obesity. However developments in understanding of the genetics of obesity may change this in the future as specific diagnoses become possible for increasing numbers of previously ‘simple’ obesity cases (Farooqi & O'Rahilly, 2000).
Secondary obesity occurs in association with two main types of condition: endocrine disorders and genetic/chromosomal abnormalities (Table 9.1). Clinical features which suggest that obesity may be part of a wider paediatric problem are listed in Table 9.2. Underlying conditions are of two general kinds: acquired endocrine conditions and syndromes which are usually congenital, although obesity may not be apparent in very early life.
Endocrine problems
Hypothyroidism
Typically hypothyroidism is associated with fat gain and in adult life this may be a major feature. In childhood, however, slowed linear growth is usually the feature which causes most concern. Obesity is rarely more than moderate.
13 - Home-based management
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- By Elizabeth M.E. Poskitt, International Nutrition Group, London School of Hygiene and Tropical Medicine
- Edited by Walter Burniat, University of Brussels, Tim J. Cole, Institute of Child Health, University College London, Inge Lissau, National Institute of Public Health, Copenhagen, Elizabeth M. E. Poskitt, London School of Hygiene and Tropical Medicine
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- Book:
- Child and Adolescent Obesity
- Published online:
- 02 November 2009
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- 29 August 2002, pp 270-281
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Summary
Introduction
The treatment of obesity has a depressing reputation. The reported levels of success are low at all ages (Serdula et al., 1993; Lake et al., 1997) with many obese children continuing life as obese adults. Yet, most of us know overweight or obese individuals, both adults and children, who slimmed successfully without formal ‘treatment’ and who have continued to maintain normal physique. Data suggest that, particularly amongst younger obese children without an obese parent, spontaneous slimming is a frequent occurrence (Whitaker et al., 1997). Thus there seems something anachronistic about the effect of treatment in obesity.
Goals of slimming
One of the reasons why the outlook for the treatment of obesity has such a poor reputation is a lack of definition of what is perceived as successful treatment. Ideally, the return to, and maintenance of, normal fatness would be the goal of all treatment. However, many children and adults are so obese before they embark on treatment that to return to normal fatness may be an impossible dream. Too often, clinicians are confronted by totally unrealistic expectations: the social and nutritional crisis created by an obese girl's appointment as bridesmaid in 8 weeks time, for example. Failure to achieve normal body weight in time is seen as total failure of the slimming process. Yet … Mission Impossible?
The goal of all weight-control programmes should be some reduction in excess fat even if this does not result in normal nutrition.
15 - Management through activity
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- By Jana Parizkova, Centre for the Management of Obesity, Prague, Claudio Maffeis, 2Department of Paediatrics, University Hospital, Verona., Elizabeth M.E. Poskitt, International Nutrition Group, London School of Hygiene and Tropical Medicine
- Edited by Walter Burniat, University of Brussels, Tim J. Cole, Institute of Child Health, University College London, Inge Lissau, National Institute of Public Health, Copenhagen, Elizabeth M. E. Poskitt, London School of Hygiene and Tropical Medicine
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- Book:
- Child and Adolescent Obesity
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- 02 November 2009
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- 29 August 2002, pp 307-326
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Summary
Introduction
Physical activity is usually included in treatment programmes for obesity and can be considered a cornerstone in management. Yet, what do we mean by physical activity? Too often physical activity is equated with formal exercise, since these two terms, physical activity and exercise, tend to be interchangeable although they refer to different constructs. For the purposes of this chapter and in conformity with the definitions used by others in this book, we have adopted the following definitions of physical activity, exercise and physical fitness (Caspersen et al., 1985):
Physical activity: any bodily movement produced by skeletal muscles which results in increased energy expenditure.
Exercise: a subcategory of physical activity which is repetitive, structured and purposive in the sense that improved maintenance of physical fitness is an objective.
Physical fitness: the ability to carry out daily tasks with vigour and alertness without undue fatigue and with ample energy to enjoy leisure-time pursuits and to meet unforeseen circumstances.
Physical activity programmes should be part of all multifaceted programmes for the treatment of childhood obesity. Skeletal muscle is the site of most fat oxidation in the body. Physical activity affects total fat oxidation and fat balance through promotion of more favourable body composition (loss of fat, especially of visceral fat; preservation of lean body mass). Moreover, increased fat oxidation rates help maintain glycogen stores, thus influencing the regulation of food intake and energy balance (Flatt, 1987a).
7 - Clinical features, adverse effects and outcome
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- By Karl F.M. Zwiauer, Department of Paediatrics, General Hospital, Saint Poelten., Margherita Caroli, Preventive Medicine, Francavilla Fontana (Brindisi)., Ewa Malecka-Tendera, Department of Pathophysiology, Silesian School of Medicine, Katowice., Elizabeth M.E. Poskitt, International Nutrition Group, London School of Hygiene and Tropical Medicine
- Edited by Walter Burniat, University of Brussels, Tim J. Cole, Institute of Child Health, University College London, Inge Lissau, National Institute of Public Health, Copenhagen, Elizabeth M. E. Poskitt, London School of Hygiene and Tropical Medicine
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- Book:
- Child and Adolescent Obesity
- Published online:
- 02 November 2009
- Print publication:
- 29 August 2002, pp 131-153
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Summary
Clinical findings and immediate adverse effects
Obesity is one of the few conditions often diagnosed as easily by the layperson – even from a distance – as by the clinician. However, distinguishing normal fatness from abnormal fatness can be extremely difficult. This has been discussed in earlier chapters. Once obesity has been diagnosed, it is important to recognize the small proportion of obese children who have specific syndromes or pathology underlying their obesity. The vast majority of obese children remain those whose obesity does not seem associated with any underlying medical cause: simple, exogenous or nonpathological obesity. It is important to distinguish the obese children with underlying clinical disease or syndrome, but children with simple obesity also have specific problems and clinical signs. Tables 7.1 and 7.2 list the particular points to elicit in the clinical history and in clinical examination of children with simple obesity. Assessment is not easy. Too often, the subjective assumption – not totally unjustified – is that any symptomatology in these children must be secondary to their overweight and can therefore be cured by weight reduction alone. Further, the examination of grossly obese children, even when they are happy to be examined thoroughly, which is not always the case, is clinically difficult. Signs have to be elicited through the mass of fat. Equipment such as sphygmomanometers are not designed for use with the grossly obese. Thus, important symptoms and signs can easily be missed or ignored.