Clinical and Metabolic Profile of Obese Children at a Tertiary Care Hospital

Objectives: Our study aimed to find out the physical features and biochemical complications of obese children presenting to our hospital. Materials and Methods: This cross-sectional study was conducted in the outpatient department (OPD) of POF hospital Wah Cantt from January 2019 to June 2020. Non-probability convenient sampling was used to include obese children less than 14 years of age. The child was labeled obese as per W.H.O. criteria. History and complete physical examination were done according to the pre-designed proforma of all the participants. Blood samples were sent for analysis after taking consent. Results: A total of 100 obese children were included in the study out of which 62 % were females and 38% were males. The majority were under 10 years of age (70%). Arthralgia (55%) was the most common complaint and Acanthosis Nigricans (31%) was the most common physical finding. Vitamin D deficiency was present in 60% of the cases. Iron deficiency was found more in females (64.5 %) (p-value 0.01) and in children of both sex under 10 years of age (62.8 %) (p-value 0.02). Conclusion: Obesity can lead to various health complications. Early detection and prevention of these complications can decrease the associated morbidities and mortalities in adulthood.


Introduction
Obesity in children has become a major health problem due to the increase in its prevalence globally. According to recent World Health Organization (WHO) figures, 40 million children under 5 years of age and over 340 million children in the age range of 5 -19 years are either overweight or obese. 1 For classification of obesity and overweight WHO recommends using Body mass Index (BMI) charts. 2 Previously cases were reported only from high-income countries but recently they have been reported from low and middle-income countries also. 3 In various countries because of socio-economic inequalities, there is the simultaneous presence of undernutrition and obesity resulting in a financial burden on society. 4 The prevalence of childhood obesity varies in Pakistan from 4.78% to 12%. 5,6 Although it involves both sexes and children from every background but boys 7 and children from high socioeconomic statuses are affected more due to their dietary behavior and lifestyle. 8 Obesity is a preventable disease with serious shortterm and long-term health effects. The most important consequence of childhood obesity is its persistence into adulthood along with its side effects. 9 It almost affects every structure of a child in a very adverse way. It is also considered as an independent risk factor for various diseases like cardiovascular disease, type 2 diabetes, obstructive sleep apnea, orthopedic complications, and psychiatric disease. Early onset of these diseases results in early morbidity and mortality. 10 Although various local studies have been conducted to find out the prevalence of obesity in our country there is a dearth of local literature on complications of childhood obesity. Thus our study aimed to find out the physical features and biochemical complications of obese children presenting to our hospital.

Materials and Methods
This descriptive cross-sectional study was carried out in the OPD of POF hospital from 1 st January 2019 to 3o th June 2020 after approval of the ethical committee of the institute. Children with endocrine disorders, dysmorphic features, chronic illnesses, and those on drugs resulting in obesity were excluded from the study. By using the WHO sample size calculator, a sample size of N = 100 was calculated by taking population prevalence of 6 % 11 and error of precision 1%. Data was collected through non-probability consecutive sampling. The weight and height of all the children between 2-14 years of age coming to the OPD were taken and plotted on respective WHO charts for age and sex. Weight of each child was taken in minimal clothing to the nearest kg using a standardized weight scale and height was calculated in standing position without shoes to the nearest cm using a wall-mounted stadiometer. BMI was calculated as weight in kilogram (Kg) divided by square of the height in meter. History and physical examination were done according to the pre-design proforma of those patients who fulfilled the criteria and noted. Blood samples were taken for Blood CP, renal function tests, and vitamin D level. Serum iron levels were done in those cases that had low MCV (70-86 fl), MCH (23-31 pg), and MCHC (30-36 g %).
Fasting samples were done for fasting blood sugar, serum cholesterol, and serum Triglycerides. Urine R/E was done to check proteinuria. Operational Definition: Obese:  Children between 5-14 years: BMI for age > +2 SD above the WHO Growth Reference median 2  Children below 5 years of age: Weight-forheight greater than 3 SD above the WHO Child Growth Standards median 12 Overweight:  Children between 5-14 years: BMI for age > +1 SD above the WHO Growth Reference median 2  Children below 5 years of age: Weight-forheight greater than 2 SD above the WHO Child Growth Standards median 12 Vitamin D Insufficiency: 25-

Results
Out of 100 children included in the study, the majority were females (62%) and under 10 years of age (70%).
The mean age of the study group was 9.4 years with a minimum age of 3 years and maximum age of 13 years with STD ± 1.6. Hemoglobin values ranged between 10 to 14.7 ± 0.97 mg/dl (mean 12.4). The majority had a history of arthralgia and Acanthosis Nigricans was the most common physical finding. The most common abnormal laboratory result was Vitamin D deficiency (Table 1). Only 39% of the children had a family history of obesity. Multivariate analysis showed a high prevalence of high FBS, anemia, and iron deficiency in females as shown in Table 2. Anemia was labeled as per WHO criteria 13 and the underlying cause was an iron deficiency in all the cases. Anemia was present in a significant number of children above 10 years of age (20%) (p-value 0.02) whereas iron deficiency without anemia was seen more in children below 10 years of age (62.8%) (p-value 0.02).

Discussion
The current lifestyle of the children has led to an upsurge of obesity cases in children which may lead to complications in adulthood. Our study found increased cases of obesity in females which is in disparity to a study done in Islamabad 7 while the increased incidence was also seen in children less than 10 years of age which was also documented by Ahmed et al 6 . Both of these findings could be attributable to decrease access to physical activities as a consequence of little access to outdoor activities because of social factors which is a risk factor in various studies. 11,14 The most common physical finding of our study was Acanthosis Nigricans followed by hypertension which was also observed by Khuhro et al in their study. 15 Acanthosis Nigricans has been the most common skin manifestation in obese children and has been linked to insulin resistance and high risk to type 2 diabetes mellitus (T2DM). 16 23 Our study also showed cases of dyslipidemia in a number of children as observed by a Vietnam study 24 but we did not look for the presence of metabolic syndrome which was shown in an Indian study 25 . Zabeen et al in their study witnessed a high prevalence of diabetes in obese children with a predominance of females 26 which was also seen in our study.
Our study has few limitations as this was a crosssectional study where only obese children were considered and overweight children were excluded. We did not evaluate for any risk factors like dietary habits and lifestyle leading to obesity nor did screening for metabolic syndrome.

Conclusion
Our study has revealed various clinical and metabolic abnormalities in obese children. Due to the increase in the prevalence of obesity, it is recommended for health professionals to screen these children for various abnormalities to prevent long-term complications.