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CHAPTER – I

INTRODUCTION
1. Childhood obesity is a global issue that has prevailed in Pakistan as well.
According to the World Health Organisation (WHO), in the year 2005, at least 20 million
children globally, under the age of 5 years, were considered overweight. Moreover,
obesity is considered to be the most common chronic childhood disease. It affects over
30% of American children. According to the Obesity Action Coalition 1. Childhood obesity
is an under-recognized issue which makes it even more challenging. Globally, more
people are obese than being underweight. Adolescents and children are the most
affected amongst other age groups when it comes to obesity. Estimates of 10% of
school-going children around the world are recorded to be overweight, and a quarter of
those are obese.
2. World Health Organization (WHO) has provided a range of Body Mass Index
(BMI) to identify obesity and overweight. Limits of greater than 25 are considered as
overweight, whereas more significant than 30 indicate obesity. Contrary to the
internationally used range, the BMI range for Asia-Pacific countries refers to overweight
with a limit greater than 23, and a limit more significant than 25 falls under obesity. The
psychological and psychosocial well-being of a child is significantly affected due to
obesity, and the child is at a higher risk towards adult obesity. It has adverse effects on
the child's physical health as well. Obesity can result in non-communicable diseases
(NCDs) such as diabetes, cardiovascular diseases (CVDs), and even cancer. It can be
the root cause of many preventable life-threatening diseases 2.
3. Childhood obesity, the issue has been prevailing around 5 to 20%, in various
settings, since 2005. Pakistan being a developing country, has been facing a lot of
challenges since it came into being. It has been struggling to establish a system that
works in harmony and covers all the socio-political, economic, health, and cultural
aspects. The problem of obesity in adults has received some attention in Pakistan,
whereas countering childhood obesity has a long way to go 3.
Background of Study

4. Obesity is different than Overweight, and obesity are defined as abnormal or

excessive fat accumulation that presents a risk to health. The key to childhood-obesity
management agrees on a definition of obesity. Obesity occurs when there is the
discrepancy between energy input and output. The original steady-state vanishes and a

1
Adab, preventing childhood obesity is im, phase II feasibility study focusing on South Asians:
BEACHeS." BMJ Open 4, no. 4 (2014): e004579
2
Anwar, Adeel, Faisal Anwar, Habib Ullah Joiya, Azhar Ijaz, Haroon Rashid, Atif Javaid, and Moazam
Mehmood. "Prevalence of obesity among the school-going children of Lahore and associated factors." Journal of
Ayub Medical College Abbottabad 22, no. 4 (2010): 27-32
3
, Bhardwaj, Swati, Anoop Misra, Lokesh Khurana, Seema Gulati, Priya Shah, and Naval K. Vikram.
"Childhood obesity in Asian Indians: a burgeoning cause of insulin resistance, diabetes, and sub-clinical
inflammation." Asia Pacific journal of clinical nutrition 17 (2008)

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new one appears at a higher level. The consequence is increased body-fat storage 4.
The European Childhood Obesity Group (ECOG) observed that researchers were
worried about a lack of definition of childhood obesity. BMI was renamed as body-mass
index from the Quetelet Index 46 years ago. However, there seems to be a general
acceptance of the concept of relative BMI. In year 2001 it was established that BMI
does not offer the ‘best’ definition, although it may be regarded as the most ‘useful’ and
‘practical’ one for clinical, epidemiological and population-research purposes 5.
5. The question if BMI alone was a suitable indicator to decide about interventions
for childhood obesity, concluding that setting a BMI-reduction cut-off might be
misleading, other competing outcomes should be considered. Gave a definition of
childhood obesity based on pooled-international data. They connected childhood
obesity to adult-obesity-cut off point of BMI 6. Classification of BMI-for-age is ranged
from ‘normal’, ‘intermediate’ to ‘high’. On behalf of ECOG, Rolland Cachera gave 4
ranges for main cut-offs of BMI distribution status from the age of 5 years: ‘thin’,
‘normal’, ‘overweight’ (not obese) and ‘obese’ 7.

6. There has not been a serious effort to develop growth standards for the Pakistani
children. American and European growth standards are found to be inadequate for
Pakistani children. Therefore, approximation methods need to be devised to use them
locally. The concept of obesity is not new for adolescents/ adults but has imprecise
connection to children. Modern nations like US are presently focusing on this issue but
it holds uniqueness in itself amongst developing or underdeveloped countries 8.
Presently, National Survey of Children’s Health show those 4.8 million kids’ ages 10 to
17 have obesity and this number is continuing to rise 9. Children have fewer weight
related health and medical problems than adults. However, overweight children are at
high risk of becoming overweight adolescents and adults, placing them at risk of
developing chronic diseases such as heart disease and diabetes later in life. They are
also more prone to develop stress, sadness, and low self-esteem 10.

4
Dennis, Barbara, Kalimuddin Aziz, Lilin She, A. M. Faruqui, C. E. Davis, Teri A. Manolio, Gregory L. Burke, and
Su Aziz. "High rates of obesity and cardiovascular disease risk factors in lower middle-class community in Pakistan:
the Metroville Health Study." J Pak Med Assoc 56, no. 6 (2006): 267-72
5
dos Santos, Hildemar, Wenes Pereira Reis, Mark Ghamsary, Adam Jackson, and Patti Herring. "Lifestyle and
Environmental Factors Associated with Predictors of Childhood Obesity." International Journal 7, no. 1 (2019):
313-324.
6
Booth, J. N., P. D. Tomporowski, J. M. E. Boyle, A. R. Ness, C. Joinson, S. D. Leary, and J. J. Reilly. "Obesity
impairs academic attainment in adolescence: findings from ALSPAC, a UK cohort." International Journal of
Obesity 38, no. 10 (2014): 1335-1342
7
Cole, Tim J., Mary C. Bellizzi, Katherine M. Flegal, and William H. Dietz. "Establishing a standard definition for
child overweight and obesity worldwide: international survey." BMJ 320, no. 7244 (2000): 1240
8
Flegal, Katherine M., Brian K. Kit, and Barry I. Graubard. "Overweight, obesity, and all-cause mortality—Reply."
JAMA 309, no. 16 (2013): 1681-1682
9
Flegal, Katherine M., Brian K. Kit, and Barry I. Graubard. "Overweight, obesity, and all-cause mortality—Reply."
JAMA 309, no. 16 (2013): 1681-1682
10
Ehtisham, S., T. G. Barrett, and N. J. Shaw. "Type 2 diabetes mellitus in UK children–an emerging problem."
Diabetic medicine 17, no. 12 (2000): 867-871
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Aim/Objective

7. Aim of this thesis is to identify the undermined issue of child obesity, related
problems/ diseases, response and involvement of the community. It has been
determined that obesity is the most prevalent nutritional disorder among children and
adolescents and is neglected by large in developing countries like Pakistan, posing
serious consequences in upbringing of quality youth for the country.
Research Questions

8. In this research, the researcher has endeavoured to answer the following key
question pertaining to the identified problem areas:

(a) Master Question. What factors influence the childhood obesity in a

developing state despite their fragile socio-economic development and low BMI
index?
(b) Sub Question.
(i) What are the socio-economic determinants and trends related to
child hood obesity?
(ii) How life style can play its role in controlling the situation?
Hypothesis

9. During the course of research following has been hypothesized:

(a) It is most like that the socio-economic determinants and trends are
contributing in the growing issue of childhood obesity in Pakistan.
(b) Lifestyle can play a major role in controlling the widespread problem of
childhood obesity, despite low-income in Pakistan.
Research Methodology
10. The topic of the widespread issue of childhood obesity is countered in this
research. To conduct this research, a mixed-method approach has been used.
Accordingly, the mixed-method approach is one of the most effective ways to hold valid
research. By amalgamating both secondary and primary data, the study analysed all
dependant and independent variables to reach conclusive result 11.
Sample Size
11. The primary data used in this study was collected through a close-ended
questionnaire filled by 120 respondents. 45% of the respondents were females,
whereas 55% of the respondents identified themselves as male. The average age of the
respondents in the study was 34. The questionnaire was filled out by doctors, medical

11
Morse, Janice M. Mixed method design: Principles and procedures. Vol. 4. Routledge, 2016.

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health professionals and child specialists – allowing the research to collect relevant data
to find reliable results12.
Outline of the study
12. Details of chapters are as follows:
(a) Chapter 1: The introductory section includes information on the nature,
scope and the aim of the study.
(b) Chapter 2: The second chapter outlines the methodology used to
conduct this study. From data collection or research philosophy, this chapter
includes factors, details about data collection and analysis methods.
(c) Chapter 3: In the third chapter, problems w.r.t Pakistan are discussed,
reviewed and analysed.
(d) Chapter 4: Finally, recommendations are made cogently in light of the
results to resolve the issues highlighted in the study. Furthermore,
recommendations are made for further studies on the same subject.

Literature Review

13. Childhood obesity is most likely to affect the adulthood of the children suffering
from it; thus, this issue needs to be countered beforehand 13. To ensure this issue is not
entirely ignored, several researchers have studied this issue extensively, and various
researches have made its way in the public eye in the past few years. The objectives of
the thesis describe the findings of authentic and well-researched articles and theories
based on epidemic childhood obesity 14. Many researchers have studied the areas of
physical activities, heredity, patterns and quality of food of a sample of children
including obese, undernutrition, overweight and healthy weight children in the recent
decades to come to a more authentic conclusion of the causes behind childhood
obesity15.

14. Fundamentally, obesity refers to a high intake of calories as compared to the

efforts done to burn those to stay on the good side. There are multiple factors which
influence eating habits and physical activities. According to a research conducted by the
International Journal of Advanced Nutritional and Health Science, there is an
association between physical activity, fast food consumption and children’s body mass
index percentiles16. Children who are more inclined towards the consumption of fast
12
IBID 11 conclusively

13
Russonello, Belden. Stewart. Americans’ attitudes toward walking and creating better walking communities."
(2003).
14
Ehtisham, S., T. G. Barrett, and N. J. Shaw. "Type 2 diabetes mellitus in UK children–an emerging problem."
Diabetic medicine 17, no. 12 (2000): 867-871
15
Flegal, Katherine M., Brian K. Kit, and Barry I. Graubard. "Overweight, obesity, and all-cause mortality—Reply."
JAMA, 309, no. 16 (2013): 1681-1682
16
Warraich, Haider Javed, Faisal Javed, Mohammed Faraz-ul-Haq, Fariha Batool Khawaja, and Sarah Saleem.
Prevalence of obesity in school-going children of Karachi. Plos One 4, no. 3 (2009)
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food are more likely to be obese than those who prefer home-made or healthy and
organic food. According to the results of this study, contrary to those who ate fast-food
once or fewer times per week, the percentage of obesity in children who consume fast
food twice or thrice in a week is 11.39 and those who have it 4 to 6 times a week is
24.97%. In the same study, the physical activity of this sample is also a recorder.
Children who engaged in physical exercises 1 to 3 days are 69%, whereas those who
participated in these activities 4 to 6 days are 78% healthier and have a considerable
margin of lower odds of obesity17.

15. According to the demographics published in a report on childhood obesity by

Dame Sally Davies, obesity recorded in last year is much higher than that of thirty years
back. In a class of thirty students, on an average, six are recorded to be obese,
whereas four are said to be overweight. The lives of children living in deprived areas are
affected disproportionately by obesity 18.
Eating habits play a significant role in shaping or distorting a child's BMI. Whether its
excessive consumption of fast food or unintentional intermittent fasting, it has a severe
effect and can propagate obesity amongst children 19. To get a better understanding of
this factor, the author studied the results of research conducted by the International
Journal of Behavioural Nutrition and Physical Activity on childhood obesity. The findings
were associated with Dietary Behaviours, Physical Activities and Sedentary Lifestyle of
a sample of children with varying habits in these categories 20.

16. The accumulative result which involves the percentile of children skipping breakfast,
consuming fast food, and having a sedentary lifestyle had a more excellent ratio of
being overweight or obese. The breakdown of these factors are; 8% of those who
skipped breakfast daily, 48% of those who consumed fast food once or more than once
a week and 49% of those who have a sedentary lifestyle for more than an hour a day.
Contrary to these, the 53% children who participated in physical activities more than
twice a week were less likely to be overweight and obese 21.

17. The media and advertising industry play a vital role in shaping the preferences of
children when it comes to food. Children usually opt for the most desirable and fancy
looking foods. As enticing as these foods look, they are one of the significant role-
players in promoting obesity. From billboards to advertisements on television and social
media, the fast food and processed food chains have taken over, and the dietary habits
of children are changing22.
17
IBID 2
18
Davies, Sally, Oliver Mytton, and Emma Pawson. Time to solve childhood obesity: an independent report by the
Chief Medical Officer, 2019 Professor Dame Sally Davies." (2019)
19
Gortmaker, Steven L., Aviva Must, James M. Perrin, Arthur M. Sobol, and William H. Dietz. "Social and
economic consequences of overweight in adolescence and young adulthood." New England journal of medicine 329,
no. 14 (1993): 1008-1012
20
IBID 11
21
Gupta, Nidhi, Kashish Goel, Priyali Shah, and Anoop Misra. "Childhood obesity in developing countries:
epidemiology, determinants, and prevention." Endocrine Reviews 33, no. 1 (2012): 48-70
22
Hayes, Mark, Helen Baxter, J. Müller‐Nordhorn, J. K. Hohls, and R. Muckelbauer accordingly. "The longitudinal
association between weight change and health‐related quality of life in adults and children: a systematic review."
Obesity Reviews, 18, no. 12 (2017): 1398-1411
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18. The quantity of such processed food is substantial but what's more important is the
frequency of its consumption. It's more instrumental in children's weight gain. The
quality of calories consumed by children in the form of fast food is lowered by fast food
which results in poor health and an increased number of overweight and obese
children23.

23
IBID 18
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CHAPTER – II

FACTORS AFFECTING OBESITY

Influence of Physical and Social Environments

1. The trend of overweight and obese children is slowly creeping in every society
and region. It is not just a medical issue anymore, preferably a social and environmental
one. The ratio of obese children has exceeded more than expected in the previous
years. Scientific researches provide enough reasons to the cause of obesity being
genes and inheritance. Still, the social and environmental factors are playing a more
prominent role in shaping children's perspectives and influencing their choices of food
and entertainment. Gone are the days when children ate a healthy snack with optimum
nutrition and played for at least a couple of hours in the playground. Now their food is
processed, and their stadium is their phones and television sets 24.

2. The family bonding and the type of family a child is born in has significant
influences on his life. From cultural upbringing to eating habits and activities, everything
depends on how well the family is shaped and what set of principles are followed in a
family. The family norms vary from country to country. It is never the same. The
stratification is based on the socio-economic status 25. This stratification narrows down to
two different types of areas where a child is brought up; rural and urban. The socio-
economic status of urban families is higher than of those who live in the rural areas
generally. The second most crucial thing in this stratification is the level of education the
family has. The uneducated or less educated people living in urban areas are less
privileged as compared to those who don't have education but have immense power in
the rural areas.

3. The environmental factors involved in the propagation of obesity include the

society where a child is born, live, work, play, learn and evolve. This also caters in a lot
of health, activities and quality of life-related aspects. Cheap and unhealthy food options
are now readily available for everyone, and it's almost impossible to stop children from
consuming those. Shops and takeaways are enough to entice adults as well as children
with their impeccable presentations and large portions. Companies even use cartoon’s
and toy gifts to attract children’s attention towards fast food 26.
Technology Promoting Obesity

4. The excessive use of technology amongst children and teens plays a significant
role in promoting obesity. There are two ways it affects a child; the fast-food he sees on

24
Herngren, Bengt, Margaretha Stenmarker, Ludek Vavruch, and Gunnar Hagglund. "Slipped capital femoral
epiphysis: a population-based study." BMC Musculoskeletal Disorders 18, no. 1 (2017): 304
25 Kang, Na Ri, and Young Sook Kwack. "An Update on Mental Health Problems and Cognitive Behavioral Therapy in Pediatric Obesity." Pediatric Gastroenterology, Hepatology & Nutrition 23, no.

1 (2020): 15-25
26 IBID 15

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TV or digital platforms in the form of advertisements and other structures and the lack of
physical activity resulting in sedentary lifestyle in front of TV sets or on their phones and
laptops. The request of children for different kinds of processed and unhealthy food
items from excessive television viewing or usage of social media. These fast-food
chains are cheaper to acquire than that of healthy and organic food, yet the way they
present it is enough to gain the interest of children, even adults. Despite being cheaper,
due to the broad consumer market it serves.

5. A quarter of Pakistan’s population can be considered overweight due to the

excessive use of this low-quality fast food. Other than the recognised food-chains, there
are a lot of different outlets where the processed or fast food range is much cheaper,
and the quality is even below unhealthy. According to the Medicine Fact Sheet, 2004,
the advertisements based on junk foods and soft drink alone cost more than one billion
US dollars annually to advertisers. The primary medium of posting these
advertisements is television as the most accessible form of media to children of all age
groups is television27. Thus, these chains have a larger audience and revenue they
generate is enormous, despite the three billion US dollars these companies spend
annually on the packaging and design of their product to attract children. The
advertisements do not have a direct impact on the children's obesity, but it plays a vital
role in making these children desire for unhealthy food, which in return promotes
obesity28.

6. The other factor which directly promotes obesity due to excessive usage of
technology is the lack of participation in physical activities. Kids who spend more time
on various screens are less likely to spend their leisure time in playgrounds, resulting in
an increased risk of overweight and obesity. Children who spend time outside school
glued to their screens are more likely to end up as prey to obesity than those who spend
their leisure time in other activities.

Genes and Cognitive Learning

7. In shaping a child, nature and nurture, both are important. When it comes to obesity,
a child's family, especially parents, can pose significant effects in propagating obesity.
There are two ways how obesity is transferred in a child due to his or her parents;
genetic and cognitive. When inherited to the offspring through genes, obesity cannot be
stopped from prevailing unless the obese parents do specific remedies to get healthy
before bearing a child. In twin studies, it is stated after extensive research that
heritability estimates almost around 0.7 of the entire BMI of a person. There are other
comparable levels of measurements of adiposity; waist circumference, skinfold
thickness, and complete regional distribution of fat in the body 29. This clearly shows that
around 70% of adiposity in individuals is determined by genes and inheritance. Thus,

27 Kato, Noriko, Hidemi Takimoto, and Noriko Sudo. "The cubic functions for spline smoothed L, S and M values for BMI reference data of Japanese children." Clinical Pediatric

Endocrinology 20, no. 2 (2011): 47-49

28 IBID 13

29
Kovač, Marjeta, Gregor Jurak, and Bojan Leskošek. "The prevalence of excess weight and obesity in Slovenian
children and adolescents from 1991 to 2011." Anthropological Notebooks 18, no. 1 (2012)
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people at high genetic risk are also those susceptible to unhealthy environment and
living patterns30.

8. The development of obesity due to cognitive behaviour can be addressed with more
ease than that of genetic but as easy as it seems, it is the most challenging topic to be
worked with. The children who at first imitate and later adapt the eating patterns and
lifestyle of their parents need to be provided with the right path, which leads them to a
healthy future and self. The parents, who eat junk and unhealthy food more than that of
organic and healthy and have a sedentary lifestyle most of the time after work, are less
likely to encourage their children to participate in physical activities and eat healthily.
Even if they do after a certain period, their children are too trained to act like their
parents to change their habits31.

9. The education and schooling of parents pose a significant impact on the upbringing
of their children. Obesity is a negative factor that comes in their children's childhood; the
educational background affects their children's food consumption as well. For instance,
the parents who belong to a professional environment and have knowledge about
healthy lifestyle are more likely to provide their children with healthy low-fat milk, as
compared to those who have as much as a college degree. The food selection, health
consciousness and knowledge about a healthy lifestyle are influenced by the higher
level of parental education32.

30
IBID 20
31
Kuriyan, Rebecca, Swarnarekha Bhat, Tinku Thomas, Mario Vaz, and Anura V. Kurpad. "Television viewing and
sleep are associated with overweight among urban and semi-urban South Indian children." Nutrition Journal 6, no. 1
(2007): 25
32
Lindsay, Ana C., Katarina M. Sussner, Juhee Kim, and Steven Gortmaker. "The role of parents in preventing
childhood obesity." The Future of children (2006): 169-186
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CHAPTER – III

CHILDHOOD OBESITY IN PAKISTAN

Socio-Economic Determinants and Trends

1. A researcher proposed a conceptual framework at the individual level, at the
family level, at the community level and at the policy-making level, to understand the
environment as well as the socio-cultural factors, which influence the occurrence of
obesity in youngsters. The child was portrayed at the centre of a socio-ecological model
with culture and society at the outermost periphery, followed by government/industry,
community, school and peers as well as family and home 33. Other scholars as well
investigated relationship of pubertal height gain and peak body-mass index in childhood
discussed the mother's experiences of masculinity in the context of childhood obesity in
Mexico. In 2018, scholars investigated earlier BMI rebound and lower pre-BMI rebound
as obesity risk among Japanese preschool children. In 2014 have investigated
childhood-obesity trends in England and concluded that the prevalence of overweight
and obesity might have stabilized between 2004 and 2013 34.

2. The socioeconomic status is a significant player in the prevalence of obesity.

Obesity seems to be more frequent and a growing health issue in the developed
countries as compared to underdeveloped and developing countries. The activities and
patterns of behaviour of an entire family has a significant influence on the food eaten,
the physical actions and health care preferences which are correlated to the rising
trends of obesity. But in Pakistan, it has more to do with the socioeconomic status of a
family35. Children belonging to families with higher economic status tend to be obese as
compared to those whose families belong to a lower socioeconomic status where
undernutrition is rising. In urban areas, the privileged families are more inclined towards
consuming high-quality meat and processed a portion of food which increases the risk
of obesity amongst children. Other causes of obesity recorded in Pakistan include
maternal diabetes and obesity, genetic and environmental factors and the relationship
of children with their parents36.

33
Liszewski, Natalia, Urte Scholz, Theda Radtke, Karolina Horodyska, Michal Liszewski, and Aleksandra
Luszczynska. "Association between Children's Physical Activity and Parental Practices Enhancing Children's
Physical Activity: The Moderating Effects of Children's BMI z-Score." Frontiers in Psychology 8 (2018): 2359
34
Lundorff, Marie, Helle Holmgren, Robert Zachariae, Ingeborg Farver-Vestergaard, and Maja O’Connor.
"Prevalence of prolonged grief disorder in adult bereavement: A systematic review and meta-analysis." Journal of
Affective Disorders 212 (2017): 138-149
35
Lundorff, Marie, Helle Holmgren, Robert Zachariae, Ingeborg Farver-Vestergaard, and Maja O’Connor.
"Prevalence of prolonged grief disorder in adult bereavement: A systematic review and meta-analysis." Journal of
Affective Disorders 212 (2017): 138-149
36
Mushtaq, Muhammad Umair, Sibgha Gull, Hussain Muhammad Abdullah, Ubeera Shahid, Mushtaq Ahmad Shad,
and Javed Akram. "Prevalence and socioeconomic correlates of overweight and obesity among Pakistani primary
school children." 11, no. 1 (2011): 724
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3. The costs parents bear when their child ends up as a victim of obesity is much
higher, both physical and psychological than the cost they spend on buying them fast
foods. The cost to society and health care and the extra amount paid to get their kids
enrolled in a physical or extra-curricular activity session could've been saved if parents
had paid more attention to their child's activities earlier 37.

4. There seems to be a strange symmetry between the socioeconomic status and

weight gain or loss in various countries. In developing countries, the ratio between
weight and socioeconomic status is directly proportional, which means that children
studying in private schools and having a privileged lifestyle are more prone to obesity
than those who belong to a lower socioeconomic status. Contrary to this, in developed
countries, there is recorded to be an inverse relationship between weight and
socioeconomic status; the privileged the family, the healthier it eats. There are pieces of
evidence that the poor living in urban areas can be a victim of obesity due to their
unhygienic and unhealthy lifestyle and food consumption.

5. According to a research conducted in New Delhi, India, obesity amongst children

from private schools was recorded to be 29%, as compared to those of government-
funded schools which was 11.3%, less than half. There can be multiple reasons behind
this observation38. The children studying in private schools are usually privileged
enough to afford fast food and get a fixed amount of pocket money that they can spend
on processed food apart from their occasional dine-outs with family. In addition to that,
most of these children have domestic help which makes them inactive. As compared to
them, those belonging to the lower class, attending government-funded schools are
more inclined towards home-made food which is cheaper and healthier 39.

6. Children who belong to the urban areas with a high socioeconomic status are
more likely to be exposed to obesity and overweight than those who belong to a lower
socioeconomic status or live in rural areas. The prevalence of overweight was recorded
to be 35.5%, whereas obesity was found 18% in the urban children belonging to high
socioeconomic status40. This ratio decreased to 22% for overweight and 10% for obesity
when the middle SES was considered. It further narrowed down to overweight being 8%
and obesity 2% when the demographics of lower SES urban children was studied.
Moreover, when rural children were considered, only 3% were overweight, and 0.6% of
children were obese. These statistics reveal that socioeconomic status has a direct
impact on the prevalence of overweight and obesity amongst children.

37
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38
Okoniewski, William, Kim D. Lu, and Erick Forno. "Weight loss for children and adults with obesity and asthma.
A systematic review of randomized BMC Public Health controlled trials." Annals of the American Thoracic Society
16, no. 5 (2019): 613-625
39
Okoniewski, William, Kim D. Lu, and Erick Forno. "Weight loss for children and adults with obesity and asthma.
A systematic review of randomized BMC Public Health controlled trials." Annals of the American Thoracic Society
16, no. 5 (2019): 613-625
40
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Reference of BMI Categories

7. According to the results of research conducted in a government-funded school with

students from different socioeconomic backgrounds, there is a reference of BMI
categories against the socio-economic status of a person. Amongst 284 students, the
number of those belonging lower socioeconomic status was 160, whereas, 124 students
belonged to a comparatively higher socioeconomic status. The number of underweight
students was 147 (51.8%), 93 of them belonging to lower SES and 54 from higher SES.
97 (34.1%) students were recorded to be normal/ healthy, among which 52 of them
were from lower SES and 45 from higher SES. There were 23 (8.0%) students in the
overweight zone, with ten such students belonging to lower SES and 13 from higher
SES. At last, the number of obese students was 17 (6.0%) with five from lower SES and
12 from higher SES41.

8. These statistics show that those who belong to a higher socioeconomic status are
more prone towards overweight and obesity as compared to those who belong to a
lower socioeconomic status. According to the scoring system of this research team,
there were 80% of those kids who consumed fast food, regardless of their
socioeconomic status. The basic reason which could be concluded was the high level of
meat consumption. 65% of obese children ate meat every day as compared to 33% of
healthy kids42.
Physical Inactivity

9. With the prevalence of video games and television sets and all the time spent
outside school being glued to these screens contributes a huge chuck in the ever-
growing issue of childhood obesity. This major shift in the activity patterns of kids has
helped a lot in the growth of obesity amongst children specifically. The dawn of indoor
entertainment has entirely taken over children's interest making them more attracted
towards screen than anything else 43. Television viewing, usage of social media and
video games have made the lifestyle of kid’s pretty sedentary lifestyle. [ CITATION Pop01 \l
1033 ] Research conducted amongst 596 urban Indian children ranging from 6 to 16
years in age, suggests that there was an adjusted off of 19.6% of obesity amongst
children who viewed television more than 90 minutes per day, as compared to the
children who saw it not more than 45 minutes per day. [ CITATION Kur07 \l 1033 ] Moreover,
a child's regular energy intake is done while they're exposed to the screens and have no
activity afterwards, this elevates uniquely on weekends.

10. The generation demands access with ease. Since this mentality has taken over
the minds of the young population around the world as well as the lack of attention from
parents, there seems to be an apparent change in the activities of children. They are not

41
Saldaña-Tejeda, Abril, and Peter Wade. "Obesity, race and the indigenous origins of health risks among Mexican
mestizos." Ethnic and Racial Studies 41, no. 15 (2018): 2731-2749
42
Saxena, Sonia, Gareth Ambler, Tim J. Cole, and Azeem Majeed. "Ethnic group differences in overweight and
obese children and young people in England: cross-sectional survey." Archives of Disease in Childhood 89, no. 1
(2004): 30-36
43
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as active physically within the school or outside school as they used to be 44. From riding
a bicycle from an early age, they have switched to electric bikes and cars. From playing
football in the playground, they prefer playing it on their PlayStation in the comfort of
their lounge. They are no longer running and playing around in the parks and grounds.
They are usually sitting in a corner with their phone in their hand. This has contributed
to the sudden growth of childhood obesity like never before 45.

11. According to research conducting on the prevalence of childhood obesity in

Lahore, the results clearly stated that the children who had little to no participation at all
in any physical activity, in school or outside school premises were found to be more
inclined towards overweight and obesity as compared to those who had active
participation is physical games apart from studies. Out of 11.9% obese and 21.8%
overweight children, 48.6% obese children responded as being inactive and not
participating in any physical activity or field sport at all. When it comes to attending the
gym, 71.4% obese children did not participate in the gym as compared to the 46.8%
normal/healthy kids46.

12. The engagement in physical activities like cycling, swimming, playing football or
basketball, or simply playing traditional games was considered immensely important
earlier. This alone ensured the smaller number of cases of childhood obesity and
overweight children. This is heavily neglected now with the busy lifestyle of parents and
the easy getaway provided by technology 47. Accessibility to location, timings and cost
for organising a healthy play environment is necessary for children. The feasibility of
sports goods to carry out desired activities is also a big problem in terms of both
economic as well as cultural aspects. For instance, the desire of a kid associated with
getting an expensive sports kit comes off as an economic burden, and girls wanting to
get into swimming with the proper swim gear moves outside the set cultural
boundaries48.

13. The increased usage of technology contributing to obesity does not only refer to
the exposure of screen. There are other elements involved, as well. For instance, one
such advancement is the automobile and its excessive usage. Gone are the days when
children rode to schools on their bicycles or walked, if near. The miles driven by the
vehicle per person have increased exponentially, and so has obesity 49. As per the
44
Sherin, Akhtar. "Obesity: how to prevent Pakistani people from getting heavier?." Khyber Medical University
Journal 5, no. 2 (2013): 59-60
45
Simmonds, M., A. Llewellyn, C. G. Owen, and N. Woolacott. "Predicting adult obesity from childhood obesity: a
systematic review and meta‐analysis." Obesity Reviews 17, no. 2 (2016): 95-107
46
IBID 19
47
Skinner, Ashley Cockrell, Sophie N. Ravanbakht, Joseph A. Skelton, Eliana M. Perrin, and Sarah C. Armstrong.
"Prevalence of obesity and severe obesity in US children, 1999–2016." Pediatrics, 141, no. 3 (2018): e20173459

48
Tanzil, Sana, and Tanzil Jamali. "Obesity, an emerging epidemic in Pakistan-a review of evidence." J Ayub Md
Coll Abbottabad 28, no. 3 (2016): 597.
49
Van Jaarsveld, Cornelia HM, and Martin C. Gulliford. "Childhood obesity trends from primary care electronic
health records in England between 1994 and 2013: a population-based cohort study." Archives of disease in
childhood 100, no. 3 (2015): 214-219
13
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national representative survey, conducted in the year 2002 states that the percentage of
students driven to school was 53%, other than that, 38% went to school by school bus.
In contrast, the percentage of children walking to school has come down to 17% only.
The children riding to school in their bikes is almost non-existent with only 5%. The
increase of vehicle had resulted in lowering the number of children walking or riding
their bikes to school which is a significant cause of childhood obesity paired with lack of
attention towards participating in field sports and other physical activities. The kids of
this era are living a life where these luxuries are making their health condition worse
than before50.

14. Walking, cycling, swimming and other sorts of outdoor play are very important for
the kids in such a situation where overweight and obesity are one of the biggest threats
to children’s health and further stems other, more severe health issues. The streets and
towns have grown noisy unpleasantly by the absence of kids playing around and
increment of motorised vehicle 51. Parents are too busy to participate in children's
playtime, and they think that letting them wander on their own is not the safest option,
so they succumb to handing over technology to them at a very early age. Moreover, the
new planning system, architecture of public places and road building has made it very
difficult for the ones who prefer walking or cycling over taking a cab or driving
themselves. Improving these basic things can also contribute to improving the health
and environment quality. The lesser is the distance every person travel per year, and
the national health expenditure will go through a more substantial burden. As a result 52.

15. Through various studies, it has come to light that the higher level of child
participation in physical activities corresponds to a better educational background of
their parents. Not just that, but the involvement of parents and their involvement in their
child’s physical activities have shown a significant increment in the frequency with which
they engage in these activities 53. The parental support and encouragement result in
better productivity not just in studies, but also in field sports and other extra-curricular
activities which can keep them healthy and away from overweight or obesity. In
research conducted by the International Journal of Paediatrics, it was stated that girls of
the same age as boys in childhood are less active than their male counterparts. Thus,
special attention is needed to be paid to their activities and growth.
Risks of Obesity

16. Increased BMI results in overweight and obesity. Obesity in itself is not a
situation so deathly, but is the root cause of a lot of situations which may eventually lead
50
Wardle, Jane, Susan Carnell, Claire MA Haworth, and Robert Plomin. "Evidence for a strong genetic influence on
childhood adiposity despite the force of the obesogenic environment." The American journal of clinical nutrition 87,
no. 2 (2008): 398-404
51
Wickramasinghe, V. P., G. J. Cleghorn, K. A. Edmiston, A. J. Murphy, R. A. Abbott, and P. S. W. Davies.
"Validity of BMI as a measure of obesity in Australian white Caucasian and Australian Sri Lankan children."
Annals of human biology 32, no. 1 (2005): 60-71
52
of Wickramasinghe, V. P., G. J. Cleghorn, K. A. Edmiston, A. J. Murphy, R. A. Abbott, and P. S. W. Davies.
"Validity of BMI as a measure of obesity in Australian white Caucasian and Australian Sri Lankan children."
Annals of human biology 32, no. 1 (2005): 60-71
53
IBID 30
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to severe medical conditions, some curable and some incurable threatening the victim’s
life. The medical consequences of obesity include the metabolic syndrome, T2DM,
insulin resistance, Subclinical inflammation, PCOS, NAFLD, Hypertension, High
cholesterol, Gallstones, Dyslipidaemia, Obstructive sleep apnoea syndrome, Early
puberty or menarche, Eating disorders, Skin infections, Pseudotumor cerebri,
Orthopaedic disorders, Asthma and other respiratory diseases. One of the most
prevalent defects of childhood obesity is that it can easily lead to adulthood obesity as
well. Children with overweight or obesity are more likely to be exposed to some
diseases (Appendix - I)

17. Various researches have proven that obesity is a significant cause of the
prevalence of cardiovascular morbidity and a lot of other non-communicable diseases
which can end up causing the victim's premature death. This is considered a severe
health concern for everyone and needs urgent attention because it can be prevented,
diagnosed and treated beforehand 54. The pathogenesis of obesity involves a lot of
factors like hormonal, metabolic, genetic predisposition, nutritional, eating patterns,
ethnicity and a sedentary lifestyle. Apart from all these factors, the primary factor
contributing to obesity to a great extent is the caloric imbalance caused by the
excessive consumption of energy and lack of physical activities to burn this calorie
intake55. Obesity and overweight are not just the root cause of cardiovascular factors but
also contributes to a variety of musculoskeletal problems. They suffer from constant
muscle and lower back pain, with an increased risk to undergo go some sort of fractures
as well as damage to the cartilages present in their weight-bearing joints due to their
dense body mass56. If this gets even more severe than certain orthopaedic conditions
may also prevail, such as, osteochondritis dissecans bowing of the legs which are
called Blount's disease, and slipped under upper femoral epiphysis (SUFE) which may
later cause osteoarthritis and there is a need for surgery then in life 57.

18. Cardiovascular problems in obese children are apparent from an early age. From
blood pressure too low HDL cholesterol, children suffering from obesity experience it all.
Risk of raised blood pressure in obese children is 5.8 times greater in obese and 2.4
times in overweight children as compared to normal healthy children 58. Besides, high
LDL cholesterol level is increased by 3.1 times in obese children and 2.4 times for
overweight children, whereas low LDL cholesterol level is increased by 2.5 times in
obesity and 1.9 times in overweight 59. The insulin resistance causes raised fasting
plasma glucose by 29.1 times in obese and 9.6 times in overweight. Obesity also
causes severe damage to the arteries of people of all ages. The thickening of carotid

54
Lobstein, Tim, Louise Baur, and Ricardo Uauy. "Obesity in children and young people: a crisis in public health."
Obesity Reviews 5 (2004): 4-85
55
Ong, Ken K. "What triggers puberty?." (2017): 209-210
56
Robert, Jason Scott. Embryology, epigenesis and evolution: Taking development seriously. Cambridge University
Press, 2004
57
Morse, Janice M. Mixed method design: Principles and procedures. Vol. 4. Routledge, 2016
58
Manasse, Henri Richard. Medication safety: a guide for health care facilities. Ashp, 2005
59
IBID 52
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intima is one of the causes of obesity and this risk increases by 1.7 times in obesity and
1.5 times in overweight60.

19. One of the reasons for the common threat of obesity amongst all age groups,
especially children, is the dietary habits established in Pakistan. A country where the
concept of a healthy diet has little to no meaning; the menu becomes energy-dense. So
is the case with Pakistan. The energy-dense food consumed all over in Pakistan except
for those families who are health and nutrition-conscious but also drink this kind of food
in their 'cheat-days' is full of saturated fats 61. The food is preparation involves excessive
proportions of trans-fatty, saturated fats, and a high amount of sugar contributing in an
increased caloric intake to a great extent. The use of ghee, sweets in every occasion,
and intake of excessive amount of fat-rich meat more often than not, is the common
dietary patterns observed by the people in Pakistan 62. In addition to this, the intake of
processed and fast food is very common amongst the new generation, topped with
sugary treats and fizzy drinks which make the situation much worse than it already
seems63.

20. Asthma is one of the most common diseases of obesity. When studied closely,
there was a bi-directional relationship found between asthma and obesity 64. It was then
found that although obesity has a causal role in asthma; it can also exacerbate the
condition in a lot of children. Researches and studies confirm that approximately 1.1
million children suffering from asthma, out of which several thousand and as many as
120,000 are found to have the causal relationship between asthma and obesity or
overweight65.

21. Another major health risk caused by obesity couples with metabolic syndrome is
the diabetes mellitus type 2. Globally, it is reported that there is a rapid increase in the
prevalence of diabetes type 2 since a very early age. From Middle East and several
Asian countries including Thailand, the reports of this disease have increased. The first
ever condition of diabetes mellitus type 2 in children was reported in Asia in 2000 and
later in England in 200266.

60
Han, Joan C., Debbie A. Lawlor, and Sue YS Kimm. "Childhood obesity." The Lancet 375, no. 9727 (2010):
1737-1748
61
Wabitsch, Martin. "Overweight and obesity in European children: definition and diagnostic procedures, risk
factors and consequences for later health outcome." European journal of paediatrics 159, no. 1 (2000): S8-S13
62
Kraak, Vivica I., Jennifer Appleton Gootman, and J. Michael McGinnis, eds. Food marketing to children and
youth: threat or opportunity?. National Academies Press, 2006
63
James et al. (1997), Population-Based Prevention of Obesity, AHA Scientific Statement
64
Hurley, Kristen M., Matthew B. Cross, and Sheryl O. Hughes. "A systematic review of responsive feeding and
child obesity in high-income countries." The Journal of nutrition 141, no. 3 (2011): 495-501
65
O'Dea, Jennifer A. "Prevention of child obesity:‘First, do no harm’." Health education research 20, no. 2 (2005):
259-265
66
Dewey, Kathryn G. "Is breastfeeding protective against child obesity?." Journal of Human Lactation 19, no. 1
(2003): 9-18
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Impact on Adulthood

22. Children who suffer from obesity are more likely to end up being obese even
when they are adults. This leads to a chain of diseases including some cancers,
musculoskeletal disorders and a range of cardio-metabolic diseases in adult life. Adult
obesity is also associated with a wide range of health issues. Childhood obesity poses a
range of health risks in adult’s physical and mental health 67. (Appendix - II)

23. Clinicians around the world are still concerned about the impact of childhood
obesity in adults since the studies done on the adults who were obese in childhood had
a very different lifestyle in childhood than children of this era. The impact of high levels
of adiposity and excessive weight will be much worse as these obese children steps into
adulthood68.
Psychological Impact on Children

24. The children suffering from obesity or overweight go through a tough time in their
social life. They always try to appear as if it doesn’t matter but they have a hard time to
fit in without feeling inferior 69. They begin to develop a low self-esteem, and as a result a
lot of psychological issues arise. They succumb to social isolation and stress about their
body image so much so that they end up in a whirlwind of emotional vulnerabilities like
depression, anxiety and emotional fallouts. These negativities hamper the overall
growth, development and learning of a child 70.

25. Another contribution towards this issue is the stigma and discrimination towards
obese or overweight children. For instance, during the selections for sports, obese
children are more likely to be ignored completely, resulting in a low self-esteem. They
are prone to being bullied than other children of their age. This can impact their attitude
towards seeking help to get out of obesity 71.

26. There is also reported to be a bi-directional relationship between obesity and

psychological health. Often when obese children are stressed or depressed, they isolate
themselves. In addition to that, they get into the pattern of binge eating. This further
contributes in their energy consumption and their lack of physical activity worsens the

67
Garasky, Steven, Susan D. Stewart, Craig Gundersen, Brenda J. Lohman, and Joey C. Eisenmann. "Family
stressors and child obesity." Social science research 38, no. 4 (2009): 755-766
68
Jackson‐Leach, R. A. C. H. E. L., and Tim Lobstein. "Estimated burden of paediatric obesity and co‐morbidities in
Europe. Part 1. The increase in the prevalence of child obesity in Europe is itself increasing." International Journal
of Pediatric Obesity 1, no. 1 (2006): 26-32
69
Ho, Mandy, Sarah P. Garnett, Louise Baur, Tracy Burrows, Laura Stewart, Melinda Neve, and Clare Collins.
"Effectiveness of lifestyle interventions in child obesity: systematic review with meta-analysis." Pediatrics 130, no.
6 (2012): e1647-e1671

70
Oken, Emily. "Maternal and child obesity: the causal link." Obstetrics and Gynaecology Clinics 36, no. 2 (2009):
361-377.
71
Fogelholm, Mikael, Outi Nuutinen, Matti Pasanen, E. Myöhänen, and T. Säätelä. "Parent–child relationship of
physical activity patterns and obesity." International journal of obesity 23, no. 12 (1999): 1262-1268
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situations72. This inter-relationship can be termed syndemic. Such children are also
reported to be not so bright in their education as well. Due to the constant feeling of
being the odd-one-out and being mentally absent most of the time, they can be a victim
of poor health and lack of interest in studies which eventually results in declining grades
in school. In girls, obesity can make their puberty occur earlier than expected resulting
in a range of psychological disturbance and a shorter height. Early puberty in girls is
associated with a range of issues like lack of interest in education attainment, a poor
mental health and greater risk-taking behaviour 73.

72
Grow, H. Mollie Greves, Andrea J. Cook, David E. Arterburn, Brian E. Saelens, Adam Drewnowski, and Paula
Lozano. "Child obesity associated with social disadvantage of children’s neighborhoods." Social science &
medicine 71, no. 3 (2010): 584-591
73
Lobstein, Tim, Rachel Jackson-Leach, Marjory L. Moodie, Kevin D. Hall, Steven L. Gortmaker, Boyd A.
Swinburn, W. Philip T. James, Youfa Wang, and Klim McPherson. "Child and adolescent obesity: part of a bigger
picture." The Lancet 385, no. 9986 (2015): 2510-2520
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CHAPTER – IV

RECOMMENDATIONS AND CONCLUSION

1. With the prevailing issue of childhood obesity, there are lot of rectifications that
need to be considered. These rectifications are not just important for fighting childhood
obesity but are also essential to maintain a healthy and disease free lifestyle. Children
who are prone to a sedentary lifestyle must be motivated to go out and participate In
physical activities or field sports. There are various factors involved in childhood obesity,
ranging for unhealthy diet plan to an increase in the use of technology resulting in lack
of outdoor sports. It is about time we set our priorities straight and focus on a healthy
living rather than keeping it at bottom of our list of priorities.

2. The issue cannot be solved on broad level. One has to engage in individual
efforts along with collective efforts to effectively eradicate childhood obesity from
Pakistan. A healthy lifestyle is not posed by government or institutions; this is to be
adopted by individuals of one household. This will come with knowledge about this
prevailing issue and a lot of other issues which must be resolved.

3. Parents need to be given awareness and education regarding the rising problem
of childhood obesity in Pakistan. With a small fraction of educated population, one
cannot expect the entire population to know of this issue. This is where awareness
campaigns and public service messages come in handy. Education and awareness
about childhood obesity and the benefits of a healthy is essential to rectify this problem.

4. Shifting the children from indoor and video games along with excessive television
viewership towards playgrounds and outdoor activities is very important for their healthy
growth and development. Childhood obesity can only be defeated if adults along with
children adapt a healthy lifestyle.

5. Monitoring the intake of nutrition, participating in outdoor games, keeping a check

of your social environment, and limiting your video game and television viewership time
will help reduce the outbreak of obesity in Pakistan.

6. Obesity might not sound as the most threatening problem, but the health issues
stemming from it may be life threatening. A lot of health issues might develop due to this
one problem. Thus, keeping yourself and your family in a hygienic environment and
cutting down on your fat intake will help u maintain a healthy lifestyle and is essential to
combat the prevailing issue of childhood obesity in Pakistan.

Conclusion

7. With all the demographics and statistics from various studies, it is clear that
childhood obesity is indeed a prevailing issue in Pakistan. Children suffering from
obesity have a high risk of being obese even in adulthood as well. There are various
factors involved in this issue more than ever. Pakistan being a developing country faces

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more consequences of childhood obesity than other developed countries where this
issue is prevailing as well. The non-communicable diseases and poor quality of life are
more common due to rapid industrialization and urbanization and adding childhood
obesity to this worsens the situation ten folds.

8. The National Health Survey of Pakistan (NHS) reported that almost around 5% of
the young population of Pakistan is overweight while 1% is obese, the age group being
15-24 years. In Pakistan, obesity amongst kids and adolescents has emerged as a
result of poor environment and unhealthy lifestyle as per the diet and physical activities
of children. It is posing huge problems in the youth but is still not recognised as that big
a threat.

9. To counter this issue effectively a lot of work needs to be done. It is providing

awareness to children and parents regarding a healthy lifestyle. It is also providing
children with opportunities to explore their physical strengths through activities which
can boost their overall physical strength and growth. In this, the educational institutions
and government health organisations can play a vital role. Parents need to make sure
that their kids are taking healthy diet and cut down on adding saturated fats and reduce
the use of sugar in foods.

10. Moreover, there is a need to conduct screening for obesity and overweight along
with other general health issues faced by children and young adults, so that they are
aware of these shortcomings beforehand and can take required measures to overcome
these issues in the right time before it gets severe or in some cases untreatable.

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APPENDIX – I

Figure 1 – The Effects of Obesity on Children’s physical and

mental health.
APPENDIX - II

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Figure 2 – The Effects of Obesity on Adults’ Physical and Mental Health