Overweight and Obesity in Childhood and Adolescence in Bangladesh and Its Consequences and Challenges.

Abstract not available
Bangladesh Journal of Medical Science Vol. 21 No. 04 October’22 Page : 667-675

strategies has implemented stringently, resulting in the country will have the 7 th highest diabetes prevalence rate worldwide 13,14 . Ominously, because of the increasing prevalence of childhood obesity, a growing percentage of new cases of diabetes occur among the younger population 15,16 . Childhood, adolescence, and adult obesity are equally prevalent in many European countries and around the globe [17][18][19][20] . Studies from India and Africa also indicate a similar ranged from less than 1-23% or more, and that of obesity ranged from less than 1-17.9% based on different reference standards, with higher percentage amongst urban children across different age groups and sexes. Still, the valid comparison was not feasible 26 . A study on urban children reported a 5-fold increase in these health problems in the past decades 27 . In addition, other studies documented 17.8% and 7.6% obesity in children of different age categories 28,29 , and one more study reported similar high cases 30 .
A descriptive cross-sectional survey on 150 primary school children of Dhaka city, Bangladesh, found a prevalence of overweight and obesity respectively, 28% and 16% among the total 75 students in public schools and 36% and 25.3% respectively among the total 75 students in private schools. This study also determined preference for fast food, lack of exercise, and sufficient consumption of fruits and vegetables as contributory factors 31 .
It is reiterated that body mass index (BMI)(kg/m 2 ) provides the most useful population-based measure of overweight and obesity 32,33 . For children under 5 years of age: overweight is weight-for-height >2 SD above, and obesity is weight-for-height > 3 SD above the WHO Child Growth Standards median. For children aged between 5-19 years(adolescents): overweight is the BMI for age> 1 SD above, and obesity is the BMI for age >2 SD above the WHO Growth Reference median 34 . Abdominal waist circumference is also an important marker of obesity 35 .
Obesity is etiologically related to varied biological, developmental, behavioral, genetic, and environmental factors [36][37][38] . Additionally, research demonstrates that the failure of proper communications between healthservice providers and patients may reinforce stigma and low self-esteem, reduce motivation for weight loss, and potentially cause avoidance of routine preventive care [39][40][41] . The role of epigenetics, gut microbiome, intrauterine, and intergenerational effects have emerged as contributing factors to the problem [42][43][44][45] . Other factors, including small for gestational age (SGA) status at birth, formula rather than breastfeeding in infancy, and early introduction of protein in an infant's dietary intake, have been reportedly associated with weight gain that can persist later in adulthood 36 . Family history of obesity in parents and grandparents, dyslipidemia, and coronary heart diseases (CH) are determinants of early-onset and severe obesity problems and markers of risk for precocious obesity 46 . Children and adolescents in low-and middle-income countries (LMICs) are more vulnerable to the illness, being exposed to high-fat, high-sugar, high-salt, energydense, and poor-micronutrient foods, which tend to be lower in cost but also lower in nutrient quality 47,48 . There is substantial evidence to associate soft drink consumption with weight gain. Soft drink intake is also related to an increased risk of diabetes mellitus, cardiovascular disease, and gout 37,49,50 . The obesity-related childhood behavior is not only shaped by parental behavior but also by 5 critical obesogenic environments: schools, television, the internet, retailers, and food advertising campaigns. The term "obesogenic environments" has been defined by Swinburn and colleagues as "the sum of the influences that the surroundings, opportunities or conditions of life have on promoting obesity" 37, 51-53 .
Childhood obesity is a marker of adulthood obesity, premature death, and disability. There is an increased probability of cardiovascular diseases, breathing difficulties, fractures, insulin resistance, impaired glucose tolerance, and psychological effects (low self-esteem, low confidence, impairment in cognitive functioning (memory, attention, visuospatial ability, response inhibition), movements/functions. Clinical obesity in adolescents is linked to menstrual irregularities, sleep disorders, and metabolic syndrome 21, 54-59 . It is further underpinned by serious terminal diseases such as cancers and type 2 diabetes mellitus, as reviewed in more than 1000 studies that reported the increased risk for at least 13 types of cancer [60][61][62] . These health disorders act as double edge sword, and increases financial overhead in both direct and indirect way on affected families. The direct cost is linked to healthcare expenditure from obesity and attributable diseases requiring attention and treatment (curative, rehabilitative, preventative care, ancillary services, and medical goods) 63 . The Direct Medical Cost = OAF × THE (OAF is obesity attributable fraction and THE is total therapeutic expenditure). There is a significant positive association between OAF and obesity prevalence 63 . Indirect costs represent the economic loss due to premature mortality and morbidity. They include the following components: financial loss from premature mortality, missed days of work (absenteeism), and reduced productivity while at work (presenteeism) [63][64][65] . Economic loss from premature mortality is calculated as the number of years of potential life lost by individuals (by age group and sex cohort) who died from obesity multiplied by the economic value of a life year 63 .
The national US rate of obesity among children between 2 to 19 years climbed from 19.3% in 2019 to 22.4% in 2020, with the annual direct cost of obesity management estimated at $14 billion during the pandemic 66 . The majority of industrialized, high-income-countries (HICs), predominantly west European countries, Canada, Australia, New Zealand, and Japan, have strategies to make available healthcare for the entire population regardless of socio-economic status (SES), employment status, or ability to pay principally based on governmentfinanced 67 . The World Health Organization (WHO) defines universal healthcare as "ensuring that all people have access to needed health services (including prevention, promotion, treatment, rehabilitation, and palliation) of sufficient quality to be effective while also ensuring that the use of these services does not expose the user the financial hardship" 68 . A universal healthcare approach does not exist in the USA 67, 69 .
The United Kingdom runs a state-supported universal healthcare strategy called the National Health Service (NHS) 70 . In Australia, healthcare is a mix of public and private services 71 . In certain countries of African continent had substantial improvement in primary health care (PHC) service. Thereby, PHC in these countries is affordable and reasonably good access to healthcare for most of the population. Nevertheless, such development is heavily dependent on international donor agencies 72 . In Bangladesh, there is a pluralistic health care system. The government health care expenditure has plunged from 6.2% to 4.3%, and the out-of-pocket payment (OPP) is 64.7% 73 .
Consumers know far less about the health and nutrition content of the foods than the suppliers. Environmental changes, effortless access to highcalorie fast foods, increased consumption of sugary beverages, and sedentary lifestyles are linked with rising obesity. The easy availability of high caloric fast foods, and super-sized food portions, are increasingly common choices due to their palatability and often being less expensive than fruits and vegetables 36 . We can ask ourselves how to address the childhood obesity problem; by focusing on choices that one makes in the obesogenic environment or limiting access to the favorite weightgaining food products available. Studies have shown the benefits of effective government legislation on access to harmful food products and taxes on sugarcontaining beverages 74,75 . Parents must be aware of childhood overweight and obesity as severe health concerns to seek proper health services 76,77 . Parents should be proactive, unlike the common acute and chronic ailments of childhood and adolescence (such as asthma, diarrhea, fever, allergy, infections, etc.;) to seek health services. Obesity and overweight are often blatantly ignored and delay early intervention, which inevitably increases the risk of significant health hazards 78 . In addition to behavioral and dietary recommendations, changes in the community-based interventions are crucial measures 79,80 .
The WHO introduced a voluntary target to stop the increase in obesity prevalence by 2025 81 . Unfortunately, the results show most countries have a less than 10% chance of meeting the 2025 target for halting the rise in obesity 82 . Country-level income inequality also influences obesity 83, 84 . The sociocultural landscape of LMICs and the epidemiological transition demands early prevention of childhood obesity and controlling the obesogenic environmental issues as a health economic approach 64,[85][86][87][88] .
In its national strategy under the nutrition section, Bangladesh has stated vital processes: micronutrient supplementation of diet, community-based awareness campaigns, advocacy on good nutritional practices and healthy food, access to sports and physical activity in workplace and community recreational areas (e.g., parks) 89 . Routine assessment of all children must be standard clinical practice from very early childhood, and long-term sustainable changes are ingrained in the active participation of families, schools, and communities. In the footsteps of developed countries such as the US and the UK, in our country, we need to develop support innovations for businesses to build healthier food industries, ensure the availability of healthy food choices in all public health settings, ensure more explicit food labeling, provide a suite of technology-based applications to make best options and establishment of local weight management services and doctors making referrals a needed.
Childhood overweight and obesity are preventable states of health that can be modified by addressing multiple factors that are the significant determinants of the conditions. Obesity has been declared an epidemic with urgent implications for affected countries, including western developed countries and countries in economic transition, quality of life, growth, and development of children with overweight and obesity problems, economic productivity, and premature loss of life. It is essential to take a holistic approach to manage this health problem. Children cannot make rational decisions about best practices in food habits. It is imperative to develop methods and strategies to motivate health-seeking behavior in the community so that parents and their children can actively participate in reducing the incidence and prevalence of obesity and obesity-related health disorders and their long-term irreversible consequences. Family physicians or pediatricians need to be proactive in identifying the overweight or obese child and then engaging the parents as partners in a management plan; hence, they should counsel parents to encourage and effectively alter their children's food habits through well-paced crucial family-based interventions. Bangladesh needs to develop and implement effective and pragmatic preventive health intervention programs with the long-term vision of reducing associated morbidity, mortality, and reducing financial overhead because of overweight/obesity related illness. Additionally, the country need to ensure effective surveillance and monitoring.

Financial Support and Sponsorship
This editorial was not funded.

Conflicts of Interest
The authors declare there are no conflicts of interest.