Cardio-metabolic risk stratification and life style interventions for risk reduction among overweight and obese school children

Author(s): Shardul Kamale, Ipseeta Ray Mohanty*, Vijay Kamale, Nimain Mohanty and Sabita Dash Mishra Background and Objectives: Childhood obesity strongly correlates with risk of developing type 2 diabetes and cardiovascular disease in the future. Screening of school children for diabetes and cardiovascular disease risk will be effective in identifying children at risk of developing cardio metabolic diseases and successfully enrolling them in a lifestyle modification ... Abstract View Full Article View DOI: 10.17352/ojpch.000027

Citation: Kamale  and a study conducted in South India has shown that 68% of children have at least one elevated risk factor [3]. Clustering of these risk factors will result in enormous personal, societal, and economic costs for many decades. Strategies to address this problem are needed immediately, as prevention of cardiometabolic disorder is far preferable to treatment [4].
Presence of cardiovascular risk factors in youth is known to be associated with the extent of arterial wall damage and intima-media thickness [5]. Given that many cardio-metabolic risk factors track through adolescence and into adulthood, it is vital that these risks be assessed as children progress through puberty and into early adulthood [6,7]. Thus, assessment and modulation of CVD risk factors during childhood is essential.
Further, there is a need for effective interventions that target reduction of cardio-metabolic risk factor levels beginning at an early age.
Hypertension and Obesity in Youth (AHOY) recently emphasized that besides clinical set up, schools were important stakeholders in population-based health promotion and risk-reduction efforts [8]. The primary objective of the study was to assess the cardiometabolic risk among school children using standardized non-invasive tools. Our central hypothesis is that screening and recruitment will be effective in identifying children at high risk for cardio metabolic diseases and successfully enrolling them in a lifestyle modifi cation program. To accomplish this objective, validated non-invasive tools to assess cardiovascular risk (the Healthy Heart Score) [4] and diabetes risk (Indian Diabetes Risk score) [1], score were used in present study to stratify the cardio metabolic risk among the children. The impact of life style intervention on the knowledge regarding preventive strategies for cardio metabolic risk reduction (Diet and Physical Activity, Weight control) was also delineated.

Materials and Methods
Approval from the Institutional Ethics Committee was obtained before initiating the study (N-EC/2019/04/49). • Children and whose parents agreed to sign the informed consent form.

Exclusion criteria
• More than 18 years

Case Record Form (CRF)
A CRF was prepared to record the following information of the school children

Lifestyle
• Physical activity: refers to the previous 7-days and required children to recall, activities that they participated in over the previous week [11].

• Dietary habits:
The children were required to recall previous 7-days dietary habits.

Cardiovascular fi tness:
The test begins with children running 20-m laps at 8.5kmph. Running speed increases by 0.5kmph after each 1-min stage. Children continue running until they can no longer maintain the pace. The test has been shown to be a valid and reliable measure of cardiovascular fi tness in children [12].
5. Blood pressure: A systolic and diastolic blood pressure was recorded using sphygmomanometer.
8. Study procedure: School children between the age of 10 to 18 years were screened to identify the overweight and obese children who were enrolled for the study after taking written informed consent from their parents. Assent was also taken from the children.
Subsequently the parameters mentioned on the CRF were fi lled up. The Healthy Heart Score and diabetes risk score for assessment of cardio-metabolic risk was used to stratify the overweight and obese children into risk categories (low, moderate, high). The children's baseline knowledge on preventive Strategies for cardio metabolic risk modifi cation were scored. Subsequently, the children were counseled on preventive strategies for cardio-metabolic Risk Reduction and thereafter re-administered the same questionnaire to assess the impact of educational intervention.

Data analysis and statistical methods
SPSS software was used to summarize the children's survey responses. Mean + SD was used to summarize the study results.
Student t test was used to compare the pre and post counselling scores of the school children. P <0.05 was considered as statistically signifi cant.

Disposition summary of type II diabetic patients
Three hundred and fi ve (305) school children were screened for Cardio-metabolic risk stratifi cation and overweight as well as obese children were selected for life style interventions for risk reduction (Figure 1).

Categorization of students as per BMI into overweight and obese
After calculating the BMI which is a considered a reliable tool for determining obesity, 10.16% (i.e 31) children were found to be overweight and 3.93% (i.e 12) were obese out of the total 305 children. Rest of the children was under the normal BMI category ( Table 1).

Distribution of diabetes risk among obese and overweight children
Post categorization, depending on their age, waist circumference, physical activity and family history, the children were stratifi ed into low, moderate and high diabetes risk categories. Only 1% of school children were found to be under low diabetes risk, 61.3% under moderate risk and 35.5% under high diabetes risk out of the 31 children categorized to be obese and overweight.
Among the 31 children with high BMI, were divided into two categories-obese and overweight. 22 fell under overweight category and 9 under obese category. Only 1 child in the overweight category fell under low diabetes risk. Maximum number of overweight children fell under moderate risk of diabetes (68.2%). Distribution of obese children into moderate and high risk is almost equal with 44.4% and 55.5% respectively ( Figure 2).

Distribution of Cardiovascular Disease (CVD) risk among obese and overweight children
Based on their BMI, systolic blood pressure, diastolic blood pressure, cardiac fi tness and physical activity, the children were categorized into low, moderate and high CVD risk categories (scores <5 in low category, 6-10 under moderate category and >11 under high risk category) The highest score noted among school children was found to be 18.    (Figure 3).

Clinical profi le and life style pattern among obese and overweight children
Among the overweight children 72.7 % had waist circumference (>+2 SD) compared to age matched controls whereas 100 % children had waist circumference (>+2 SD) in the obese group. Systolic and diastolic blood pressure (>+2 SD) was encountered among 4.5 % the overweight children compared to 11.1 % in the obese group. Thus, central obesity and hypertension are important determinants of increased cardio-metabolic risk and therefore need to be addressed to reduce the burden of diabetes and cardiovascular disease related morbidity and mortality.
Looking at the lifestyle pattern among obese and overweight children abstinence of intake of fruits & vegetable Intake /day (400-500 g) was noted in 9.1% children who were overweight.
Abstinence of Salt restriction (<5 g/day) was noted among 72.7 % belonging to overweight category as compared to 44.4% obese children. Not practicing saturated fat restriction (<30 % of total calories) was encountered in 13.6 % overweight children as compared to 55.6 % children who were obese.
Physical activity less than 30 min was encountered in 9.1% school children who were overweight compared to 33.3 % obese children. This shows that the children were lacking in baseline knowledge regarding lifestyle habits and needed guidance.

Discussion
Childhood obesity is on the rise in India especially in the urban areas. Prevalence of obesity among school children in India varies between 5.74% to 8.82% [13,14]. Studies have reported that 21.4% boys and 18.5% girls are either obese or overweight in South India [12,15]. In the present study out of the 305 children who were screened 10.16% were overweight and 3.93% were obese. Studies have reported that in children above 5 yr, the prevalence of obesity varied between 2 to 8 per cent [10]. Overweight rates were around two times higher and seem to be more in northern and eastern India than in southern India. One study from Srinagar reported a high prevalence rate of 25 per cent, probably due to the smaller numbers studied and being from affl uent families [16]. The least prevalence of obesity was reported from Nagaland (2.3%) and the maximum from New Delhi (29%) [14][15][16].

Cardio-metabolic risk among obese and overweight children
Childhood obesity strongly correlates with insulin resistance and type-2 diabetes. Moreover, severe obesity occurs in a majority of diabetic youth, and the emergence of prediabetes and type-2 diabetes in children closely correlated in time with the childhood obesity epidemic. A direct pathological association of obesity with cardiovascular disease may be mediated by increased preload and vascular damage. When combined with ectopic fat accumulation in the myocardium, increased ventricular stiffness leads to vascular dysfunction, hypertension and left ventricular hypertrophy. Independently, obesity-associated insulin and leptin resistance also promote infl ammation and endothelial dysfunction which increases arterial stiffness, susceptibility to plaque formation and accelerated atherosclerosis [17,18]. The myriad of cardio metabolic complications associated with diabetes will make the disease a public health problem in the future.
In the present study the cardio metabolic risk among school children who were overweight and obese was assessed using validated scales. Diabetes prediction tool like the Indian Diabetes Risk score, a simple user friendly tool modeled by

Structured educational Intervention for cardiometabolic risk reduction
Overweight and obese children were administered structured counseling for CVD and Diabetes risk reduction.
Also, the impact of structured counseling on the knowledge regarding cardiometabolic risk reduction was assessed.