Farhan (not his real name) was taken to a private hospital by his parents to seek treatment for an infection on his right leg.
For any healthy 12-year-old, medication and aftercare service would suffice to get them on their feet again.
However, Farhan was far from healthy. His weight at that time was more than 100 kilogrammes, and he was referred to a government hospital to treat the complications that had arisen due to his obesity.
Sadly, due to his weak heart, Farhan lost his fight and passed away at the tender age of 12.
According to the World Health Organisation (WHO), the prevalence of childhood obesity has increased at an alarming rate globally - in 2016, the number of overweight children under the age of five was estimated to be over 41 million.
A 2010 study published in the International Journal of Environmental Research and Public Health cited genetics as the common non-modifiable cause of obesity, with greater risk of obesity found in children of obese and overweight parents.
UM Specialist Centre (UMSC) paediatric endocrinology senior consultant Associate Prof Dr Muhammad Yazid Jalaludin said children with at least one overweight parent are bound to have a four- to five-fold greater chance of becoming obese adults.
“If one parent is overweight the chance of the child being obese is four to five times more, and worse still if both parents are overweight, the risk is 13 times more,” he said in a recent interview with Bernama.
He said that based on the 2011 National Health and Morbidity Survey (NHMS), Malaysia topped the list of Southeast Asian countries with the highest population of obese adults at 44.2 percent. In 2015, it shot up to 47.3 percent.
A closer look at the statistics revealed that among childbearing adults (aged 30-35), 34.2 percent were overweight and another 30.5 percent obese.
This in itself is a worrying trend, but what is more disturbing is that these same adults are either parents to growing children or parents-to-be, Dr Muhammad Yazid added.
Childhood obesity defined
The 2013 South East Asian Nutrition Survey cited that 21.6 percent of children aged between six months and 12 years fell under the overweight or obese category.
According to a study in Asia conducted by Prof Dr Poh Be Koon in 2013, Malaysia was among the top three countries with a high percentage (11.5 percent) of obese children (aged between six months and 12 years).
In the 2015 NHMS, 11.8 percent of children below 18 years of age were found to be obese.
“Based on the latest data, 1.65 million Malaysian schoolchildren are expected to be overweight or obese by 2025 if we don’t do anything,” said Muhammad Yazid.
Breaking up that enormous number, 88,000 of Malaysian children are expected to have impaired glucose tolerance, 28,000 may suffer from Type 2 diabetes, a whopping 191,000 may have high blood pressure, and 264,000 may suffer from first-stage fatty liver disease, he said.
Unlike adults, overweight is defined as at or above the 85th percentile and below the 95th percentile for children and teens of the same age and sex as plotted on the WHO body mass index (BMI) chart.
Meanwhile, obesity is defined as a BMI at or above the 95th percentile for children and teens of the same age and sex.
Muhammad Yazid said childhood obesity can also be determined by the measurement of the child’s waist circumference.
“Based on a study conducted by Prof Dr Poh in 2011 on Malaysian children, boys aged seven had a waist circumference at the 90th percentile, which is larger than the children of the same age and gender in the United Kingdom, Hong Kong, Turkey and Australia,” he said.
This study involved more than 18,000 children in Malaysia aged between six and 18 years.
“We used to say that the prevalence of obese children is higher among the Malays and Indians, but based on a recent MyBreakfast study, Chinese children are now leading the pack,” he said.
Muhammad Yazid also said in the United States, childhood obesity mainly involved children in the lower socio-economic groups as their parents cannot afford to buy nutritious, low-calorie foods.
However, in developing countries like Malaysia, childhood obesity is prevalent among both rich and poor families. In the case of the poor, the children tend to consume lower-priced, less nutritious, but high-calorie foods. Rich families, on the other hand, often make unwise decisions and buy the wrong kinds of food.
Judging from the current statistics and the co-morbidities, obesity among children is definitely a disease and not just a condition, stressed Muhammad Yazid.
Implications of childhood obesity
WHO notes that childhood obesity is associated with a higher chance of premature death and disability in adulthood. Overweight and obese children also run a higher risk of developing non-communicable diseases such as diabetes and cardiovascular diseases.
Muhammad Yazid said the rapid rise in obesity among Malaysian children is cause for concern because overweight children are at a higher risk of becoming obese adults.
They are also susceptible to developing serious health problems such as Type 2 diabetes, high blood pressure and liver disease, and also have cholesterol issues which will result in cardiovascular disease, hypertension and insulin resistance.
Insulin resistance syndrome is a constellation of risk factors for the development of Type 2 diabetes mellitus and cardiovascular disease.
“I have been running a paediatric obesity clinic since 2006, and I have witnessed children as young as 12 inflicted with Type 2 diabetes,” the doctor said.
He cited a case of a seven-year-old obese child who was initially admitted for dengue.
Due to his weight, the child was brought to the obesity clinic where he was scheduled to see a dietitian, sports medicine specialist and sleep specialist.
The child defaulted his follow-up after a few clinic visits.
Six years after the initial visit, he came back to the clinic with Type 2 diabetes.
According to Dr Muhammad Yazid, more than five years ago, eight out of 10 children were diagnosed with Type 1 diabetes, and the remaining Type 2. But over the last five years, five out of 10 children have Type 2 diabetes.
“This is because they are super obese... we have a seven-year-old child who weighs 70 kg and a 12-year-old who weighs 100 kg.
"Most of the cases at our clinic did not come willingly, but due to other reasons such as asthma or dengue, hence the not-so-good outcome (in reducing their weight).
"We also have kids who lost a good amount of weight and this happened mainly due to the initiative of their parents,” he added.
Apart from a host of serious diseases, obesity is also one of the main causes of obstructive sleep apnea (OSA) and hypoventilation syndrome in children.
In a study on childhood obesity and OSA that was published in the Journal of Nutrition and Metabolism in 2012, it was found that OSA occurred in up to 60 percent of obese children.
The study also noted that OSA is characterised by snoring and recurrent partial or complete obstruction of the upper airway.
“In obese children, the airway becomes narrower because of the increased fat around the neck and this results in repeated cessation of breathing during sleep due to airway obstruction. This is termed OSA," explained UMSC paediatric respiratory and sleep medicine specialist Dr Eg Kah Peng
She said hypoventilation can occur when one has too much fat around the abdomen and the chest.
"Their breathing becomes restricted by the fat, which in turn results in shallow breathing during sleep," she said.
Eg said sleep-disordered breathing may cause children to have too little oxygen and too much carbon dioxide in their blood during sleep, which consequently would affect their health and quality of life.
Children who suffer from this sleep problem, often snore loudly during sleep, and they find it difficult to wake up in the morning. They also complain of headaches and tend to feel drowsy during the day.
“If the sleep problem is severe, they can fall asleep even while sitting down."
According to Eg, the long-term lack of oxygen in the blood can also result in heart failure and early deterioration of memory.
There are medications and medical devices to treat and alleviate the symptoms of OSA and hypoventilation.
“But the most important step is getting back to the root of the problem. That means patients need to lose weight or else they will have to rely on these medications and devices forever,” she said.
Sharing the case of an obese boy who passed away suddenly in his sleep, Eg said he was diagnosed as having severe OSA and was advised to undergo treatment. However, his parents were not keen and defaulted on the follow-up.
Educating the parents
UMSC clinical dietitian and head of Dietetic Services Rozanna M Rosly said parents should play an active role in checking childhood obesity.
They should be made aware of the importance of following a balanced diet in accordance with their children’s age and gender, and make sure that the food they eat contain the essential nutrients to promote optimal growth. They should also make their children participate in physical activities regularly.
“Parents tend to say that their children are ‘active’ and my question will always be, 'How often and how long and what kind of exercises do your children do?'."
Being active is just half of the story because parents should also focus on their intake of total calories, fat, protein and other essential nutrients each day, Rozanna said.
The children should also be educated on food intake portions and requirements for main meals and snacks and should be told that they may not need any extra calories or additional portions.
Rozanna recommended that parents use the age-appropriate sectional plates to educate children on food portions for main meals, and measuring cups for snacks and beverages.
This role-modelling and education always begin at home, specifically at the dining table.
“Parents should try to eat with their children and not separately or have separate meals. If you want your child to eat fresh vegetables or fruits, parents must show by role-modelling that they love their fresh vegetables or fruits too,” she said.
Parents should also educate their children on the harmful effects of consuming processed foods or frozen hotdogs, sausages and nuggets as their nutritional benefits are not the same as that of real meat.
"Entice them with the colours of real foods, such as papayas, oranges, apples, carrots and tomatoes and enlighten them about the nutritional and health benefits of these foods,” Rozana added.
For more information or tips on diet and recipe ideas for children, parents can refer to the Malaysian Dietitians Association and Nutrition Society of Malaysia websites: https://www.dietitians.org.my/, http://www.mynutribaby.org.my/ and http://www.nutriweb.org.my/.