*5.8.3 Psychosocial*

*Public Health in Developing Countries - Challenges and Opportunities*

lifestyle programmes which are difficult to sustain on their own.

Adipocytes secrete hormones which have paracrine and exocrine actions. The common abnormalities noted include increased production of steroid hormones, decreased progesterone secretion in females and decreased testosterone secretion in males. There is also a strong association between obesity and occurrence of polycystic ovarian syndrome. A study from Bombay looked at the prevalence of PCOS among 600 girls in the age group of 15–19 years from under privileged backgrounds. The prevalence of PCOS by Rotterdam criteria was 22.5%. PCOS was more common in obese than non-obese girls (p = 0.002) [101]. In comparison to Caucasians, Asian girls develop PCOS at an earlier age, are more symptomatic and have more fasting hyperinsulinemia and lower

The most serious orthopaedic disability associated with childhood obesity is slipped capital epiphysis of the femur. Blount disease is another disorder that has

Non-alcoholic disease is a component of metabolic syndrome. It is being increasingly recognised since abdominal ultrasonography has become a common diagnostic tool. The overall prevalence of NAFLD in children is about 10%, which includes a prevalence of 17% in teenagers and 40–70% in obese children. Steatosis *per se* is benign and self-limiting but it can progress to non-alcoholic steatohepatitis (NASH) in 3–5% of patients [93]. In the US, about 12–24% of the children are obese and 10–25% of these have elevated serum transaminases. That means that 1–4% of children, in the US, are obese and have deranged transaminases and are at risk for NAFLD [94]. A more accurate estimation comes from an autopsy study done in San Diego. Steatosis was found in 9.6% of children between 2 and 19 years of age and in 38% of obese children autopsied between 1993 and 2003 [95]. Prevalence of NAFLD in obese children in China is estimated to be between 20 and 77% [96]. The latest theory on pathogenesis of NAFLD is a 'multi-hit' one where there is an interplay of numerous factors like hepatic fat accumulation, insulin resistance, oxidative stress due to genetic and epigenetic factors, unfavourable lifestyles, gut microbiota, gut-liver axis dysfunction, and trace element deficiency and fluctuations [97, 98]. The best predictors for NASH in obese individuals with no evidence of other liver disease are elevations of AST or ALT to >200 IU/L, or any elevation of AST (>46 IU/L) and ALT (>35 IU/L) for greater than 6 months. These criteria identified 100% cases of NASH in a small study [99]. If detected early, hepatic steatosis is reversible. Weight loss is the most effective treatment. A 10% reduction in weight can normalise AST, ALT values and decrease ultrasound evidence of fatty liver on 30 months follow-up [100]. Compliance to weight loss and lifestyle changes is poor, especially in children. A number of medical and surgical therapies are emerging. Medical approaches include micronutrient supplementation (Vit E, Vit D, PUFAs, choline), probiotics, anti-obesity medication, metformin, cysteamine, antioxidants, obeticholic acid, growth hormone, lipid-lowering agents and hormones like adiponectin, resistin and TNF alpha. Surgical approach is mainly bariatric surgery [93]. These therapeutic measures could serve as boosters for the weight loss and

**5.7 Non-alcoholic fatty liver disease (NAFLD)**

**230**

**5.8 Other disorders**

insulin sensitivity [102].

*5.8.2 Orthopaedic*

*5.8.1 Endocrine*

Obesity is described as 'one of the most stigmatising and least socially acceptable conditions of childhood'. [103]. Not surprisingly, low self-esteem and poor body image adversely impacting scholastic performance are common in obese children. They are bullied and excluded from group activities, especially sports and games, because they are slower and less agile. They get marginalised and withdraw from society. This makes them more sedentary and also predisposes them to eating disorders which further worsen their obesity [104].
