Prospective clinical study of the skin markers in childhood obesity-an emerging pandemic

Introduction: Obesity poses an alarming threat to the children in recent days due to poor lifestyle and improper dietary habits. These children are at higher risk of developing Coronary artery diseases, Hypertension, Diabetes mellitus in their early thirties and emerge as an important public health problem. Childhood obesity manifests with a wide array of dermatological changes. In this study we analyzed the dermatological manifestations in the obese and overweight children in the age range of 5-14 years. Methods: All the children taken into the study were either obese or overweight as per WHO criteria of BMI according to the height and weight. Triceps skin fold thickness and waist circumference of these children were also taken for confirmation of obesity. Skin manifestations in these children were diagnosed by the dermatologists and plotted in graph. Results: Total 76 children were taken into the study out of which Acanthosis nigricans is the most common manifestation in the age group of 10-14 years and infections are most common in the age group of 5-9 years. Conclusion: The skin manifestations are the markers of chronic obesity in childhood having negative impact on the quality of life and imparting low self esteem among the peer group.


Introduction
Obesity and overweight issues in childhood is nothing less than an emerging pandemic globally and the trend is increasing phenomenally in developing countries. In India a sizeable fraction of children are recorded being overweight and obese, and the reason behind this current scenario is attributable to the changing lifestyle preferences and cultural environment on a background of predominant familial predisposition. There is a significant association of physical and psychological impairment with this condition, such as social rejection and teasing by their peer groups ending in low self esteem [1,2].
The WHO center for disease control and prevention defined obesity as above 95% percentile of body mass Index (BMI) for age and sex and overweight as between 85 th to 95 th percentile of BMI for age and sex. [3,4,5]. As the BMI does not distinguish between fat and muscle mass it is not a very sensitive measure of the percentage of body fat. More accurate methods to measure the percentage of body fat includes underwater weighing (densitometry), Multi-frequency bioelectrical impedance analysis (BIA), and magnetic resonance imaging (MRI) [6]. Clinically assessment of obesity can be done by waist circumference and skin fold thickness apart from BMI. The cutaneous changes are highly prevalent in obese individuals and the skin manifestation includes acne, acanthosis nigricans, striaedistensae, sebborhoea, keratosis pilaris, plantar hyperkeratosis, stasis dermatitis etc [7,8].
There is also increased incidence of skin infections like folliculitis, erysipelas, impetigo, fungal infections and mixed infections like Intertrigo. Conditions like Psoriasis, atopic dermatitis and hidradenitis suppurativa have a complex interaction with obesity and exhibit a worsened course.
Our study is a prospective cross sectional study to determine the prevalence of skin manifestations in overweight and obese patients of the pediatric age group.

Material and Methods
A prospective cross sectional study was conducted in the department of pediatrics in collaboration with the department of dermatology in a tertiary care teaching hospital.
Duration of study was 1 year from January 2015 to December 2015. Patients enrolled in the study were otherwise healthy non diabetic children between 5-14 Years fulfilling the CDC criteria of obesity and overweight.
Exclusion criteria: All the children with BMI less than 85 percentile for the appropriate age and sex were excluded from the study.
Children with BMI more than 85 percentile for the appropriate age and sex having abnormal endocrinological or congenital abnormalities were also excluded from the study.
Detailed medical and family history and medication records were taken. The clinical evaluation included Anthropometric measurements of weight and height, BMI, Waist circumference and skin fold thickness. Patients who were diagnosed as overweight and obese were subjected to dermatological examination. Children with skin manifestation were enrolled in our study and referred to the dermatology OPD for detailed examination, evaluation and management.
The detailed dermatological examination was done involving the skin, mucosa, muco-cutaneous junction, scalp and hair, nails and palms and soles. All the data were recorded and statistically analyzed.
Anthropometric Measurement 1. Height measurement  Height of the child was measured using a measuring scale attached to the wall.  The child was made to stand with heels together in standing position, with shoes removed and buttocks, shoulder & occiput touching the wall.  Accurate reading to the nearest centimeter was taken 2. Weight Measurement  Weight of the child was taken in a digital weighing machine with range of 100gms in a standing condition with light clothes and shoes removed.

Waist Circumference
 The midpoint of the lower rib and the upper most part of the iliac crest was marked on both sides of the trunk, both these points were joined by a measuring tape and the waist circumference was recorded.
4. Tricep skin fold thickness was recorded using a caliper on the non-dominant upper arm.

Results
76 children within the age range of 5-14 years were taken into the study those fulfilling the criteria of CDC of either overweight or obese. (According to BMI).
There were 40 (52%) boys and 36 (47.47%) girls. 22 children were obese according to their BMI as per their age and sex and rest 54 were overweight. Children in the age group of 5-9 years were 53 and those in the age group of 10-14 were 23. (Table1).  Skin manifestations were examined clinically by the dermatologists and their prevalence was documented. (Table2). It was found that the most common manifestation was acanthosis nigricans (AN) followed by superficial infections. Among all skin manifestations AN (Fig-1)was found in around 30% cases followed by infections like Folliculitis, Furunculosis (Fig-2), Tinea Corporis. Around 20% pts had Striae distensae and 10% had Acne vulgaris (Fig 3, 4). We also found 2 cases of hirsutism in the age group of 10-14 years. Overall within the age group of 5-9 years Superficial skin infections were the commonest and those in the age group of 10-14 years AN was the commonest dermatological manifestations. (Table-3).

Discussion
Childhood obesity is an important predictor of increased morbidity and health issues in adulthood. The rising incidence of this health problem is slowly gripping the developing countries and becoming an important public health issue putting immense adverse physical, psychological and social impact in the society.
Obesity is commonly associated with many dermatological manifestations. In our study we encountered a wide spectrum of skin diseases in obese and overweight children. The effect of obesity on skin includes alteration in the barrier functions, increased sebaceous and sweat gland activities, decreased lymphatic flow, increased cutaneous vascular supply, alteration in collagen structures and wound healing [7,8]. These changes are responsible for increased risk of skin infections, lymphedema and venous insufficiency.
In our study, the incidences of bacterial and fungal infections are more in relation to excessive skin folds leading to occlusion and maceration. Folliculitis, a superficial bacterial infection of the hair follicle commonly infected by staphylococcus aureus has the highest prevalence among the infections in our study specially in the age group of 5-9 yrs, irrespective of the gender. Intertrigo and Dermatophytic fungal infection also accounts to a significant proportion among all the infections. These findings are comparable to the study conducted by Al-Saeed WY et al [9].
Insulin Resistance and androgen excess has a significant risk of developing Acne, Acanthosis nigricans, Hirsutism, Sebborhoea, Alopecia etc. The stretching of the skin leads to striaedistensae and excessive body weight contributes to plantar Hyperkeratosis. [8,9,10]. Acanthosis nigricans (AN) was the most prevalent manifestation among all reported children, mostly with 10-14 year girls. AN was the most common disease with the average BMI value 24.4 for 10-14 year boys as well as, BMI value of 25.1 of 10-14 year girls. Striae distensae (SD) was most prevalent among 10-14 year girls.
In a comparative study conducted by Boza et al [8] they found statistically significant relationship between the skin manifestations and obesity as compared with the control groups. The presence of striae, AN and bacterial infections were also found to have a co-relation with degree of obesity. In their study skin manifestations of acrochordons and lymphedema were found which is not documented in our study.

Conclusion
This study reflects the high incidence of skin diseases in obese and overweight children. Measures should be taken for adequate health education and counseling. The parents should be aware of the importance of healthy lifestyle and right nutritional choices to reduce the burden of childhood obesity in the society. Early identification and management of these skin conditions can significantly improve the quality of life among these children.
Funding: Nil, Conflict of interest: Nil Permission from IRB: Yes