**5.3 Childhood diabetes**

The rise in prevalence of childhood obesity has mirrored the rise in prevalence of type 2 diabetes among children. For a long time, only type I diabetes was associated with childhood. The myth was shattered in 1979, when type 2 diabetes was described in children of Pima Indians. Type 2 diabetes accounts for 80% of childhood diabetes in Japan. The prevalence of type 2 diabetes in Japanese children rose from 0.2 to 7.3 per 100,000 children between 1976 and 1995 [62]. Ehtisham et al. observed that prevalence of type 2 diabetes in white UK children was significantly

less than that in South-Asian children (0.10/100,000 vs. 1.42/100,000, p < 0.001). According to them, the relative risk for type 2 diabetes in an Asian child compared to a white child in UK was 13.7-fold. Family history of diabetes, prevalence of obesity in the family, female preponderance and pubertal onset were some of the other significant associations that they noted apart from the ethnic clustering [63]. Ripamonti et al. found the prevalence of impaired glucose tolerance (IGT) to be 11% among the 398 obese Italian children studied [64]. Wabitsch et al. studied 520 obese children in Germany, and noted the prevalence of IGT and type 2 DM to be 2.1 and 1.5%, respectively [65]. Vijayalakshmi Bhatia observed that type 2 DM accounted for 10% of diabetes detected in children between the ages of 10–18 [66]. A higher BMI, and increased truncal and abdominal fat were important determinants of hyperglycaemia and insulin resistance [67, 68]. The GDB Collaborators Group found diabetes to be the second commonest cause of BMI-related deaths and DALY. It accounted for 9.5% of all deaths at a BMI of ≥30 kg/m<sup>2</sup> and 4.5% occurred at a BMI of <30 kg/m2 [5].

## **5.4 Dyslipidaemia**

Nearly 17% of obese adolescent American youth have abnormal non-HDLcholesterol. Class III obesity is associated with high total cholesterol (19%), low HDL-cholesterol (≤19%) and high triglycerides (29%) [69]. The commonly observed pattern of dyslipidaemia in obesity is one with increased triglycerides (TG), decreased HDL-cholesterol (HDL-C) and high normal or mildly raised LDL-cholesterol (LDL-C). The NHANES data indicate that in the US 42.9% of children with BMI >95th percentile have this pattern of dyslipidaemia [70]. Obesity is consistently associated with low HDL-cholesterol values [71]. In obese children and adolescents, there is a positive correlation between BMI and levels of VLDL and LDL-cholesterols [72]. The Princeton follow-up study conducted family lipid surveys between 1973 and 1978. Of all the children surveyed, 808 agreed to be a part of a CVD survey when contacted in 1998 and 19 live subjects reported CVD events. These events occurred at a mean age of 37.1+ 4.9 years. BMI and TG levels in childhood correlated significantly with occurrence of CVD events (p = 0.012 and 0.0001, respectively) [73].

### **5.5 Hypertension**

Childhood obesity is associated with future development of hypertension. In fact, elevated BMI even in infancy is associated with high BP later [74, 75]. Risk of hypertension is two-fold with obesity and four-fold with severe obesity [76]. The prevalence of hypertension in children in the US varies from 3 to 5%, but it rises to about 25% in children with obesity [77]. Yadav et al. found the prevalence of pre-hypertension and hypertension to be 1.14 and 2.57%, respectively, among school children in the age group of 10–16 years in Kanpur, North India. Among overweight children 6.25% were pre-hypertensive and 12.5% were hypertensive and among obese children, the figures were 14.28% and 42.5%, respectively. The association in both cases was statistically significant [19]. Vedavathy and Sangamesh studied prevalence of hypertension in school children between the ages of 11–19 in Bangalore. Pre-hypertension and stage I hypertension were found in 3.6% of the students. The prevalence was significantly higher in children with BMI >23 kg/m<sup>2</sup> . Family history of hypertension and obesity were significantly associated with pre-hypertension and stage I hypertension in the children (p < 0.001) [78]. An epidemiological survey of school children in Delhi found the prevalence of hypertension (systolic, diastolic or both) to be 11.9% in boys and 11.4% in girls.

**229**

1.30–1.78, p = 0.001) [91].

skin-fold thickness [92].

*Obesity in School Children in India*

failure in childhood [77].

**5.6 Cardiovascular disease**

*DOI: http://dx.doi.org/10.5772/intechopen.89602*

There was a positive correlation between hypertension and BMI [79]. In another study from North India, Gupta et al. surveyed 3851 children between the ages of 5 and 15 and found that 292 were obese. The prevalence of hypertension was 0.34% among the obese children and 0.16% among the non-obese children [80]. In another study from Ludhiana, where 5000 children in the age group of 5–17 years were studied, the prevalence of hypertension in obese children was 3.5% and among normal ones 0.23% [81]. Hypertension in obese children results from an interplay of numerous factors which include, increased intravascular volume, increased cardiac output, increased sympathetic tone, increased steroid production, increased sodium intake and increased sodium retention and hyperinsulinemia. Among adolescents, hormonal changes and biological maturation are additional contributory factors [82, 83]. By the time hypertension is diagnosed in childhood, 20–40% have left ventricular hypertrophy. This correlates with high carotid intimal-media thickness (cIMT), which is a known predictor of heart-

In relation to high BMI, cardiovascular disease (CVD) was the leading cause for death and disability-adjusted life-years (DALY). It accounted for 2.7 million deaths and 66.3 million DALY. Among the obese, 41% of deaths and 34% of DALY were due to CVD [5]. Current adolescent overweight prevalence is estimated to increase future adult obesity by 5–15% by 2035, and this will result in an additional 100,000 CVD cases [84]. Cardiovascular disease associated with obesity is usually secondary to hypertension (already discussed above) and atherosclerosis. Atherogenesis is mainly due to sub-intimal deposition of LDLcholesterol particles. The combined atherogenicity of childhood obesity is an ideal scenario for this to occur. High circulating levels of small LDL-cholesterol particles and decreased clearance of the same by LDL receptors increases risk of their entrapment in the sub endothelial matrix. Further, low levels of HDLcholesterol limit reversal of cholesterol transport. An objective measure of the damaging potential of atherogenicity of combined dyslipidaemia in childhood is the carotid intimal-media thickness (cIMT). The Young Finns study followed up children from childhood for 21 years. Children with combined dyslipidaemia had significant cIMT compared to normo-lipidaemic controls even after adjusting for other factors [85]. The Childhood Cardiovascular Cohort (i3C) was a 23.4 years follow-up of 2893 children aged 12–18 years across three continents. i3C data showed a strong correlation between childhood obesity, hypertension and dyslipidaemia with high cIMT in adulthood. Obesity increased the risk for high cIMT 3.7 (2.0–7.0)-fold and hypertension by 1.9 (1.3–2.9)-fold [86]. Another study showed that 90% of children with high cIMT also had left ventricular hypertrophy [87]. Obesity has been associated with a 50% increase in heart-failure incidence among young adults (18–34 years) from 1987 to 2006 in the US [88]. The frequency of stroke and renal failure are also higher in young adults with history of childhood obesity [89, 90]. In a recent study published in JAMA, positive associations were observed between consumption of artificially sweetened soft drinks and death due to circulatory diseases (>2 drinks/day vs. <1 glass per month; HR 1.52; 95%CI

Sub-clinical vascular inflammation may also be a contributory factor to development of CVD. In Indian adolescents, raised C-reactive protein (CRP) levels are seen in 13% of all subjects, 22% of overweight and 25% of obese ones. CRP levels have a strong association with percentage body fat, WHR, waist circumference and triceps

#### *Obesity in School Children in India DOI: http://dx.doi.org/10.5772/intechopen.89602*

*Public Health in Developing Countries - Challenges and Opportunities*

DALY. It accounted for 9.5% of all deaths at a BMI of ≥30 kg/m<sup>2</sup>

[5].

at a BMI of <30 kg/m2

0.0001, respectively) [73].

**5.5 Hypertension**

**5.4 Dyslipidaemia**

less than that in South-Asian children (0.10/100,000 vs. 1.42/100,000, p < 0.001). According to them, the relative risk for type 2 diabetes in an Asian child compared to a white child in UK was 13.7-fold. Family history of diabetes, prevalence of obesity in the family, female preponderance and pubertal onset were some of the other significant associations that they noted apart from the ethnic clustering [63]. Ripamonti et al. found the prevalence of impaired glucose tolerance (IGT) to be 11% among the 398 obese Italian children studied [64]. Wabitsch et al. studied 520 obese children in Germany, and noted the prevalence of IGT and type 2 DM to be 2.1 and 1.5%, respectively [65]. Vijayalakshmi Bhatia observed that type 2 DM accounted for 10% of diabetes detected in children between the ages of 10–18 [66]. A higher BMI, and increased truncal and abdominal fat were important determinants of hyperglycaemia and insulin resistance [67, 68]. The GDB Collaborators Group found diabetes to be the second commonest cause of BMI-related deaths and

Nearly 17% of obese adolescent American youth have abnormal non-HDLcholesterol. Class III obesity is associated with high total cholesterol (19%), low HDL-cholesterol (≤19%) and high triglycerides (29%) [69]. The commonly observed pattern of dyslipidaemia in obesity is one with increased triglycerides (TG), decreased HDL-cholesterol (HDL-C) and high normal or mildly raised LDL-cholesterol (LDL-C). The NHANES data indicate that in the US 42.9% of children with BMI >95th percentile have this pattern of dyslipidaemia [70]. Obesity is consistently associated with low HDL-cholesterol values [71]. In obese children and adolescents, there is a positive correlation between BMI and levels of VLDL and LDL-cholesterols [72]. The Princeton follow-up study conducted family lipid surveys between 1973 and 1978. Of all the children surveyed, 808 agreed to be a part of a CVD survey when contacted in 1998 and 19 live subjects reported CVD events. These events occurred at a mean age of 37.1+ 4.9 years. BMI and TG levels in childhood correlated significantly with occurrence of CVD events (p = 0.012 and

Childhood obesity is associated with future development of hypertension. In fact, elevated BMI even in infancy is associated with high BP later [74, 75]. Risk of hypertension is two-fold with obesity and four-fold with severe obesity [76]. The prevalence of hypertension in children in the US varies from 3 to 5%, but it rises to about 25% in children with obesity [77]. Yadav et al. found the prevalence of pre-hypertension and hypertension to be 1.14 and 2.57%, respectively, among school children in the age group of 10–16 years in Kanpur, North India. Among overweight children 6.25% were pre-hypertensive and 12.5% were hypertensive and among obese children, the figures were 14.28% and 42.5%, respectively. The association in both cases was statistically significant [19]. Vedavathy and Sangamesh studied prevalence of hypertension in school children between the ages of 11–19 in Bangalore. Pre-hypertension and stage I hypertension were found in 3.6% of the students. The prevalence was significantly higher in children with BMI

. Family history of hypertension and obesity were significantly associ-

ated with pre-hypertension and stage I hypertension in the children (p < 0.001) [78]. An epidemiological survey of school children in Delhi found the prevalence of hypertension (systolic, diastolic or both) to be 11.9% in boys and 11.4% in girls.

and 4.5% occurred

**228**

>23 kg/m<sup>2</sup>

There was a positive correlation between hypertension and BMI [79]. In another study from North India, Gupta et al. surveyed 3851 children between the ages of 5 and 15 and found that 292 were obese. The prevalence of hypertension was 0.34% among the obese children and 0.16% among the non-obese children [80]. In another study from Ludhiana, where 5000 children in the age group of 5–17 years were studied, the prevalence of hypertension in obese children was 3.5% and among normal ones 0.23% [81]. Hypertension in obese children results from an interplay of numerous factors which include, increased intravascular volume, increased cardiac output, increased sympathetic tone, increased steroid production, increased sodium intake and increased sodium retention and hyperinsulinemia. Among adolescents, hormonal changes and biological maturation are additional contributory factors [82, 83]. By the time hypertension is diagnosed in childhood, 20–40% have left ventricular hypertrophy. This correlates with high carotid intimal-media thickness (cIMT), which is a known predictor of heartfailure in childhood [77].
