**2. Obesity**

The obesity epidemic in children is a well-known fact in recent decades and still a growing issue in some countries that needs to be tackled accordingly. Adipose tissue, an active endocrine organ, is closely involved in production of atherogenic adipokines, oxidative stress and chronic inflammation, that altogether promote atherosclerosis. Therefore, the presence of obesity alone is a risk factor for CVD [7]. Mostly, it is due to sedentary lifestyle, inappropriate food habits and genetic susceptibility, and rarely a consequence of endocrine (e.g. hypothyroidism, Cushing syndrome, hypothalamic obesity, persistent hyperinsulinism, etc), syndromic (Alström, Bardet-Biedl, Prader Willi, Beckwith-Wiedemann, Carpenter, Cohen, Albright hereditary osteodystrophy, etc.) or monogenic causes (defects in genes encoding melanocortin 4 receptor (MC4R), leptin (LEP), leptin receptor (LEPR), pro-opiomelanocortin (POMC), etc.) [8].

Obesity and overweight diagnosis are based on anthropometric measurements and body mass index (BMI) calculation. Due to the growth and development there is no single cut-off point to define obesity in children, but is dependent on age and sex. Several curves that give BMI distribution as a function of age and sex have been established [8]. Body fat can also be estimated with dual energy X-ray absorptiometry, bioelectrical impedance, computed tomography and magnetic resonance imaging of abdomen, measurement of skinfold thickness at multiple sites, air displacement plethysmography and stable isotope dilution techniques, which apply to newer methods and future perspectives in obesity assessment [9]. Waist circumference is another anthropometric measurement that correlates well with obesity and is useful in determination of central obesity, correlating even more strongly with several obesity complications, such as insulin resistance, dyslipidemia and non-alcoholic fatty liver disease [10].

Complications of obesity in children and adolescents are numerous and are in part responsible for further cardiovascular damage. They can be categorized by organ systems: cardiovascular (hypertension, left ventricular hypertrophy, atherosclerosis), metabolic (insulin resistance, dyslipidemia, metabolic syndrome, type 2 diabetes), pulmonary (asthma, obstructive sleep apnea), gastrointestinal (nonalcoholic fatty liver disease, gastroesophageal reflux), skeletal (tibia vara, slipped capital-femoral epiphysis), psychological, other (polycystic ovary syndrome, pseudotumor cerebri) [11].

Lifestyle changes are the cornerstone of obesity management and are partly age dependent. Young infants up to two years of age with high body weight should have age appropriate amounts of formula, preferably should be breastfed, and should not be given sweetened beverages, fast food and desserts, should not have any screen of any kind, should have at least 12 hours of sleep a day, and should be allowed to be as active as possible. A toddler, aged from two to four, should have a balanced diet, should not be offered sugar sweetened beverages and fast food, size of the portion should be age appropriate and they should have a routine sleep pattern. Screen time should be kept to a minimum. It is important to stress that parents are role models for children and should model the eating behavior they want their child to have. A good meal hygiene with family based meals is recommended. Children, aged 5–9, should have a balanced diet with the exclusion of sweetened beverages and fast food, they should start to be involved in organized sports along with active play. At least sixty minutes of moderate physical activity is recommended. Screen time should be limited to academic requirements. With further growth and puberty, management evolves. Mostly, recommendations are similar, however, in adolescents skipping meals with overindulgence at the

*Cardiovascular Risk Factors in Children DOI: http://dx.doi.org/10.5772/intechopen.99729*

next meal or eating mostly in afternoon or evening can become an inappropriate habit leading to excess calories intake. Regular exercise routine of sixty to ninety minutes per day is recommended. With modern technologies, which in this age group are unavoidable, progress can be tracked and comparison can sometimes be encouraged between peers [12].

As parents are strong role models for children, especially younger, a family oriented approach with lifestyle changes for the whole family is recommended [12].

Pharmacological treatment of obesity in children is discouraged, however, a few studies with metformin and orlistat showed some success with weight loss, but small or none for cardio-metabolic complications [13].
