EFFECTIVENESS OF

PHYSICAL THERAPY ON
PEDIATRIC OBESITY TO
IMPROVE PHYSICAL
FITNESS

Text

INDEX
S.No: TOPIC PAGE
NUMBER
1 INTRODUCTION 3-6
2 CAUSES 7-14
3 SIGNS AND 15-18
SYMPTOMS
4 PATHOPHYSIOLOGY 19-25
5 DIAGNOSIS 26-34
6 COMPLICATIONS 35-38
7 REVIEW OF 39-41
LITERATURE
8 MANAGEMENT 42-49
9 AIMS ​ 0-51
5
10 PHYSIOTHERAPY 52-67
MANAGEMENT
11 ASSESSMENT 68-70
12 RESULT 71-72
13 CONCLUSION 73-75

14 BIBILOGRAPHY 76-77
15 CASE STUDIES

INTRODUCTION

​Obesityis a condition where excess body fat

negatively affects a child’s health or wellbeing. As
methods to determine body fat directly are difficult,
the diagnosis of obesity is often based on BMI (body
mass index). Due to the raising prevalence of obesity
in children and its many adverse effects, it is being
recognized as a serious public health concern. The
mechanism include in weight regulation and the
development of obesity in children are varied and
includes genetic, environmental and developmental
factors. Children are thus defined as being overweight
or obese if they have a BMI above the cutoff for the
given age and sex. Accurate height and weight
measurements are an integral parts of general physical
examination.
Obesity has major health and
socioeconomic impacts, especially in children and
adolescents. These populations are at greater risk of
developing many other systemic diseases. Obesity in
children and adolescents should be considered a
severe pathologic state, and maximal efforts should be
made to improve prevention of therapy for obesity in
children and adolescents. To generate fat mass loss in
children and adolescents with obesity, an increase in
caloric expenditure and a reduction in calorie intake
are important physical activity related to recreation
and transportation should be increased. Sedentary
activities should be reduced, and regular structured
exercise should be achieved.
It is often implicitly assumed that
increased physical activity is feasible and medically
safe in children and adolescents with obesity. Given
the increased likelihood development of
comorbidities in children and adolescent’s obesity and
their potential role as exercise – limiting factor, a
correct interruption of someone’s physical capacity
and associated physical limitations as needed.
Therefore, children and adolescent who have obesity
and who intend to increase their level of physical
activity should be evaluated and monitored by
physical therapists, because of their knowledge of
pathology, pharmacology and exercise physiology.
 Systemic involvement of physical
therapists in the treatment of obesity in children and
adolescents can result in a more comprehensive
evaluation and improved care and treatment of
obesity at the community level, especially in children
and adolescents with increased health care needs. In
addition, multidisciplinary interventions are important
for addressing the specific needs of the patient and
maximizing treatment effectiveness. Unfortunately,
the expertise of physical therapists is currently under
recognized and underused in the prevention and
treatment of obesity in children and adolescents.
Most physical therapists are active in
private and home care settings. Therefore, it is
essential to provide guidelines on how to execute a
pre participation screening to execute and increase the
medical safety and effectiveness of exercise
interventions, given the limited infrastructure and
assessment tools that are available to physical
therapists should be provided in private and hone care
settings.
In addition, there is a large body of
evidence addressing the beneficial effect of regular
physical activity (related to healthy nutritional habits
and behaviors and adequate sleep) for the prevention
of pediatric over weight and obesity. By focusing on
the physical activity levels of children and youth, not
only do intend to increase daily energy expenditure,
but also aim to maintain and improve physical fitness
that is functional capabilities (motor skill,
musculoskeletal, metabolic and cardiovascular
structures and functions etc).
The aim of clinical recommendation is to
provide physical therapists in first line settings with a
systematic effective, and feasible approach for
prescribing clinically effective and medically safe
exercises interventions for children and adolescents
with obesity.
In this experimental study, children are
considered to be 6 to 12 years of age, and adolescents
are considered to be 12 to 18 years of age.

CAUSES
​

Causes

It is widely accepted that increase in

obesity results from an imbalance between energy
intake and expenditure, with an increasing in positive
energy balance being closely associated with lifestyle
adopted and the dietary intake preferences.
The risk factors for obesity include –
• Dietary intake
• Physical activity
• Sedentary behavior
The impact of these risk factors is moderated by
factors such as age, gender, parenting style.
Environment factors such as school policies,
demographics and parents work related demands
further influence eating and activities behavior.
 ​

Genetic factors-
Genetics are one of the biggest
factors examined as a cause of obesity. However,
genetic susceptibility often needs to be copied with
contributing environmental and behavioral factors.
Therefore, while genetics can play a role in the
development of obesity, it is not the cause of the
dramatic increase in childhood obesity.

Lifestyle issues-
To little activity and too many
calories from food and drinks or beverages are the
main contributions to childhood obesity.
Dietary factors have been studied
extensively for its possible contributions to the rising
rates of obesity. The dietary factors that have been
examined include fast food consumption, sugar
beverages, snack food and portion sizes.
Activity level-
One of the factors that is not most significantly
linked to obesity is a sedentary lifestyle. Each
additional how of television per day increased the
prevalence of obesity by 2%. The increased amount
of time spent in sedentary behavior has decreased
the amount of time spent in physical activity. The
number of hours children spent watching TV
correlates with their consumption of most advertised
goods. Therefore lack of physical activity has been
perceived as the major trending issue for the cause
of obesity in children and adolescents.

Environmental factors -
Opportunities to be physically active and safe
environments to be active in have decreased in the
recent years.
For example:
The majority of children in the past
walked or rode their bikes to school. But now, the
parents drove their children to school, since homes
were too far away from the school. Other reasons
parents gave for driving their children to school
include no safe walling route, fear of child predators
and out of convenience for the child. These lead to
fewer opportunities to be physically active.

Socio-cultural factors-
Socio-cultural factors also been found to influence
the development of obesity. Our society tends to use
food as a reward as a means to control others, and as
a part of socializing. These uses of food can
encourage the development of unhealthy relationship
with food, thereby increasing the risk of developing
obesity.

Family factors-
Family factors have been associated
with the increase of cases of obesity, the types of
food available in the house and the food preference
of the family member can influence the foods that
children eat.
In addition, family meal time can
influence the type of the food consumed and the
amount thereof. Lastly, family habits, whether they
are sedentary or physically active influence the
child.
Studies have shown that having an
overweight mother and living in a single parent
household are associated with overweight and
childhood activity.

Psychological factors-
A recent review concluded that
the majority of studies find a prospective
relationship between eating disturbances and
depression.
Depression and anxiety-
Depression may be both a
cause and consequence of obesity, however,
inaddition a clinical sample of obese adolescents, a
higher life-time prevalence of anxiety disorders was
reported compared to non-obese contends. Although
these is no significant relationship between increased
BMI and increased anxiety symptoms.
​

SIGNS AND
SYMPTOMS
​
Each child may experience
different symptoms but some of the most common
include –
Appearance-
• Stretch marks on hips and abdomen.
• Dark velvety skin (known as acanthosis
nigricans) and the neck and in other areas.
• Fatty deposition at tissue of breast area (an
especially troublesome issue for body)
• Additionally, they are likely to have an
accumulation of abdominal fat.
Systemic diseases include-
1. Pulmonary –
 - Shortness of breath when physically
active.
- Sleep apnea
- Breathlessness
- Chronic obstructive pulmonary disorder
2. Cardiothoracic –
- Coronary heart disease due to atherosclerosis
- Hypertension
3. Central nervous system –
- Depression
- Anxiety
- Stroke
4. Gastroenterological –
- Constipation, gastro esophageal reflex
- Liver – nonalcoholic fatty liver diseases and
endothelial dysfunction.
- Gallbladder – cholecystolithiasis
5. Reproductive –
- Early puberty and irregular menstrual cycles
in girls.
- Delayed puberty in boys.
- Genitals may appear disproportionally small
in males.

6. Musculo-skeletal –
- Flat foot
- Knock knees
- Dislocated hip
- Osteoarthritis
- Pain in knees and lower back
7. Metabolic disorders-
- High cholesterol (increase in LDL)
- Growth and nutrition tracking
- Increased basal metabolic rate (BMR)
- Deficiency of mineral iron which leads to
 anemia
8. Skin problems-
- Heat rash
- Acne
- Fungal infection
9. Endocrinal problems-
- Most commonly Type II diabetes (insulin
resistance)
10. Further symptoms include prone to eyesight
problems.
11. Infections due to decrease in the immune
response and lastly cancers such as prostate,
bowel, breast and uterine.

PATHOPHYSIOLOGY
​

Pathophysiology –
Chylomicrons do not last long in the
blood stream in only about 8 minutes because
enzymes called lipoproteins, lipases break the
fats into fatty acids.
Lipoprotein, lipases are found
in the walls of blood vessels in fat tissue, muscle
tissue, and heart muscle. The activity of
lipoprotein lipases are depends upon the levels
of insulin in the body. If insulin is high, the
lipases are highly active. If insulin is low, then
 the lipases are inactive. Fatty acids are then
absorbed from the blood into fat cells, muscle
cells, and bone cells. If these cells, under
stimulation by insulin, fatty acids are made into
fat molecules and stored as fat deposits.
It is also possible for fat cells to
take up glucose and amino acids which have
been absorbed into the blood stream after a
meal, and convert those into fat molecules. The
conversion of carbohydrates or protein into fat is
10 times less efficient than simply storing fat in
a fat cell, but the body can do it.
Regulation of body fat-metabolism and
thermogenesis:-
Adipose is regulated centrally by the
hypothalamus leptin (from adipose tissue) and
PPYY (from distal colon) inhibit appetite.
Ghrelin (from stomach) stimulates appetite.
Ghrelin levels are drastically reduced with
gastric bypass surgery. PPAR is generated by
adipose tissue to modulate CHO and lipid
metabolism. Activating mutations of PPAR can
cause obesity.

Thermogenesis has 3 components:-

• BMR energy
• Physical activity energy
• Thermic effect of food (energy required to
digest food, protein > 40 fat.
Obese people have the same
energy expenditure as non-obese people per
unit lean body mass. There is no metabolic
difference between obese and non-obese
people. However obese people have more
body mass. So their BMR is higher and
 calorie over consumption is necessary just to
sustain weight.

Adipose tissue as an endocrine organ:-

Free fatty acids cause insulin
resistance in muscle, and inhibit insulin release from
beta cells. Adipose tissue is deficient in obesity. It
sensitizes the cells to insulin and suppressants hepatic
glucose output. TNF ALPHA released by adipose
tissue stimulates lipolysis, releasing fatty acids. IL -6
stimulates release of C- reactive protein and
fibrinogen (pro-coagulant) plasminogen activation
released by adipose tissue in a pro-coagulant.

Evaluation of obese children:-

Only a small percentage of childhood
obesity is associated with a hormonal or genetic
defect, with the remainder being idiopathic in nature,
the most common of the endogenous causes of
childhood obesity and their associated are
hypercortisotism, acquired hypothalamic, praderwilli,
turners Cohen. An endogenous cause for obesity can
be either suspected or eliminated from the differential
diagnosis in virtually all children based on a careful
history and physical examination. Growth failure
characterize endogenous obesity. Children with an
associated genetic or hormonal syndromes are short
usually at or under the 5th percentile of height for age.
Conversely, children with idiopathic obesity are taller,
usually above the 50th compares the important
differences in the history and physical examination of
patients with endogenous and idiopathic obesity.
 Characteristics of idiopathic and endogenous
obesity-

Idiopathic obesity Endogenous obesity

1.>90 % of cases 1. <10% of cases
2. Tall stature (usually 2. Short stature (usually
>50th percentile) <5th percentile)
3. Family history of 3. Family history of
obesity common. obesity is uncommon.
4. Mental function 4. Often mentally
 normal. impaired.
5. Normal or advanced 5. Delayed bone age.
bone age.
6. Physical examination 6. Associated stigmata
otherwise normal. On physical
examination.

​ DIAGNOSIS
​

Diagnosis –
• In children, up to 24 months, the diagnosis of
overweighed and obesity is based on the weight to
length ratio, using the world health organization
(WHO).
• After the age of 2 years it is based on the body
mass index (BMI) and exceeds up to 5 years.
• The recommendation of using the WHO standard
is based on the need to propose a reference system
which, although is not an ideal model to assess
adiposity in single children or groups, it has a
greater sensitivity in identifying children and
adolescents with overweight and obesity, in a
period of particular seriousness of the pediatric
obesity.
 Diagnostic criteria to classify overweight and
obesity

Age 0-2 years 2-5 years 5-18

years
Index Weight to BMI BMI
length ratio
Reference WHO WHO WHO
>85th At risk of At risk of Overweight
percentile overweight overweight
>97th Overweight Overweight Overweight
percentile
>99th Obesity Obesity Obesity
percentile

The cutoff to define severe obesity is represented

by BMI >99th percentile:-
However, as for overweight and obesity classification,
the WHO terminology for severe obesity diffuse
between younger (0-5 years) and older
children/adolescents (5-18years). Obesity in the
former group and severe obesity in the taller group.

Body composition:-
Body composition is the proportion of fat and fat free
mass in your body. A healthy body composition is one
that include a lower percentage of body fat and a
higher percentage of fat free mass, which includes
muscles, bones and organs.
Body is composed of two types of mass –
1. Body fat
2. Fat free mass
Body fat: It can be found in muscle tissue, under the
skin (subcutaneous fat), or around organs (visceral
fat).
Fat free mass: This includes bone, water, muscles,
organs, and tissues. It may also be called lean tissue.
Estimates of adiposity:-
1. Body mass index- calculated by weight
(kgs)/height (mt.sq)
A BMI of 25 to 29.5 is considered overweight
and 30 or higher considered as obese.
2. Weight for height ratio-
PONDERAL INDEX –
Height (cms)/weight (kg)

Fat distribution:
• Waist-hip ratio - >1 are obese men and >0.85 are
obese women.
• Waist circumference
• Waist to height ratio
Anthropometrics:
Skin fold thickness- Most fat is deposited beneath
the skin. This test measure fat just beneath the skin
but cannot measure fat accumulated inside the
abdomen.
Description of skinfold measurement-
• Estimation of body fat by skinfold thickness -
Triceps
-Biceps
-Chest
• Measurements can range from 3 to 9 different
standard anatomical sites around the body –
- Mid axilla
- Subscapular
- Abdomen
- Suprailium
 - Thigh
- Calf
The sum of measurements should be less than 40mm
for males and 50mm in females.
• Mid arm muscle circumference
• Water displacement test
Fat floats – The rest of the body tissue sink
determining how well the float provides an estimated
ratio of fat to body mass.
Other diagnostic procedure includes:
• Hydro densitometry
• Isotope dilution
• Dual energy x-ray absorptiometry
• Total body potassium
• Quantitative magnetic resonances
Electrical measurements-
A couple of tests calculated percentage
of body fay by measuring the difference between the
electrical characteristics of fat and other tissues in the
body.
Analysis-
Primary forms of hypertension are mainly
associated with obesity and more frequent in children
>6years.
Hypertension – SBP and/or DBP >/= 90th but <95th
percentile by gender, age and height.
SBP- systolic bp
DMP- diastolic bp
The diagnosis of pre diabetes that is high fasting
blood glucose and impaired glucose tolerance (IGT)
or over type 2 diabetes (T2D) is based on fasting
plasma glucose or oral glucose tolerance test (OGTT).
The use of hemoglobin glycosylated AIC (Hb AIC) is
still controversial in pediatric age.
Since evidences provides from national studies
suggest that pre diabetes is already present in about
5% obese children <10 years.

Pre diabetes impaired fasting glucose- plasma glucose

(after 8h of fasting) between 100(5.6mmol/l) and
125mg/dl (6.9mmol/l)

Impaired glucose tolerance: plasma glucose after 2h

of the OGTT between 140 and 199mg/dl (78mmol/l)
Hb AIC between 5.7-6.4% (39-47mmol/mol)

Cholesterol:
The measurement of cholesterol, HDL-
cholesterol and triglyceride is recommended in all
children and adolescents with obesity since the age of
6.

Category Acceptance High

Total cholesterol
>/= 200
(mg/dl) <170
LDL-cholesterol
<110 >/=130
(mg/dl)
Non HDL- <120 >/=145
cholesterol(mg/dl)

Triglycerides (mg/dl)

Age Acceptable High

0-9 years <75 >/=100
10-19 years <90 >/=130
Acceptable Low
HDL-
cholesterol(mg/dl) <40
>45
 ​ COMPLICATIONS

Complications:-
1. Acute:
• Type II diabetes
• Hypertension
• Hyperlipiclemia
• Precocious puberty
• Ovarian hyperandrogenism
• Gynecomastica
 • Cholecystitis
• Pancreatitis
• Pseudo tumor cerebri
• Fatty liver
• Renal disease (focal glomerulosclerosis)
2. Orthopedic disorders-
• Slipped capital femoral epiphysis
• Tibia vara
• Blocent disease
3. Liver and gall bladder dysfunction-
• Elevated transaminases
• Cholecystitis
4. Physical and psychological-
• Depression
• Eating disorders
• Social isolation
• Sleep disorders
5. Cardiovascular and endocrine-
• Hyper insulanism and insulin
• Hyper cholesterolemia
• Hyper triglyceridemia
• Low levels of high density lipoprotein
• Hypertension
• Polycystic ovary syndrome
• Coronary artery disease
• Left ventricular hypertrophy
6. Cancer- colorectal carcinoma
7. Long term-
• Ischemic heart disease
• Short life span
• Stroke
• Sudden death
 REVIEW OF LITERATURE​
Attributable risks for childhood overweight:evidence
for limited effectiveness of prevention.
-Plachta-Danielzik S,Kheden B,Landsberg
Establishing a standard definition for child over
weight and obesity world wide .
-Cole TJ,Bellizzi MC,Flegal KM,Dietz WH
Children and adolescence: Pathophysiology,
Consequences ,prevention and treatment.
-Danniels SR,Arnett DK, Eckel RH
Challenges of accurately measuring and using BMI
and other indicators of obesity in children.
-Himes JH
Validity of the BMI as an indicator of the risk and
presence of overweight in adolscense.
-Malina RM, Katzmarzyk PT
The effects of high protein ,low fat ,ketogenic diet on
adolscense with morbid obesity : Body composition
,blood chemistries,sleep abnormalities.
-Willi SM,Oexmann MJ, Wright NM,
Collop NA
Childhood overweight and relationship between
parent behaviours ,parenting style, and family
functioning.
-Rhee K
Expert committe recomandation on the assessment ,
prevention ,and treatment of child and adolescent
overweight and obesity.
 -Barlow SE
Efficacy of exercise for treating overweight in
children and adolsencents : a systemic review .
-Atlantis E, Barnes EH, Singh MA
Effects of decreasing sedentary behavior and
increasing activity on weight change in obese
children.
-Epstein LH, Valoski AM ,Vara LS

MANAGEMENT

Management:
• Changes in the diet and lifestyle leading to a
negative calorie balance is recommended to
gradually reduce the BMI.
• The main objective is permanent change in the
child’s eating habits and lifestyle, rather than
attaining rapid weight loss through low calorie
diets. It is indispensable involving the whole
family and setting realistic goals.
• Children ages 6-11 years who are obese might be
 encouraged to modify their eating habits for
gradual weight loss of no more than 1 pound (or
about 0.5kg) a month.
• Older children and adolescents who are obese or
severely obese might be encouraged to modify
their eating habits to aim for weight loss of up to 2
pounds (or about 1 kg) a week.
• The methods for maintaining child current weight
or losing weight are the same
- Healthy diet
- Type and amount of food
- Increase physical activity
Conservative treatment-
Component Comment
1.Reasonable weight Initially, 5 to 10lb, or a
loss goal rate of 1 to 4lb per
month.
2.Dietary management Provide dietary
prescription specifying
total number of calories
per day and
recommended
percentage of calories
from fat, protein and
carbohydrates.
3.Physical activity Begin according to
child’s fitness level
with ultimate goal of 20
to 30 min per day (in
addition to any school
activity).
4.Behavior Self-monitoring
modification nutritional education,
stimulation control,
 modification of eating
habits, physical activity,
attitude change,
reinforcement and
reward.
5.Family involvement Review family activity
and television viewing
patterns, involve
parents in nutrition
counselling.

Nutrition intervention:
• A balanced and varied diet is recommended.
• The classic diet-therapy based on the prescription
of a low calorie diet is the medium/long term
sessions.
• The educational process starts from the assessment
of the child’s and family dietary habits by means
of the assessment of meal consumption, portions,
adequate of food intake, food preferences of
aversions, use of condiments, cooking methods
and food presentation.
Dietary advice:
1. Eating 5 meals a day (three meals and no more
than two snacks).
2. Have an adequate breakfast.
3. Avoid eating between meals.
4. Avoid high energy and low nutrient obesity
food (e.g.-sweetened or energizing drinks, fruit
juices, fast food, and high energy snack).
5. Increase intake of fruit, vegetables and fiber
rich cereals.
6. Limit portions.
Required portion of nutrients include:
 • Protein-sparing modified fast-600-800k.cal/day.
• Protein – 1.5-2kg ideal weight.
• Carbohydrates – 20-25 g/day.
• Multivitamins + minerals, water - >2000ml/day.

Medial intervention:
• Pharmacologically therapy can be applied after the
failure of the multidisciplinary lifestyle
intervention.
• When clinically significant weight loss cannot be
achieved through lifestyle based on interventions,
use of drugs is considered, especially in severe
obesity with cardio metabolic, hepatic or
respiratory disorders.
• Orlistat (tetra – hydro lipstinate) is the only drug
approved for the treatment of obesity in pediatric
age.
• It doesn’t affect the mineral balance, but attention
must be paid to prevent liposoluble vitamins
deficiency.

Surgical procedure:
 Bariatric surgery is the ultimate
solution in adolescents with severe obesity and
resistant to all other treatments, especially when
serious complications are present.
The indications for surgery in the adolescent are:
1. BMI>/=35kg/m2 with at least one severe
comorbidity, such as T20, moderate to severe
obstructive sleep apnea.
2. BMI >/=40kg/m2 with less serious comorbidities,
such as mild sleep apnea (apnea/hypopnea index
>5), hypertension, dyslipidemia, carbohydrate
intolerance.
For the multifactorial nature of obesity, variability in
its severity, and the health implications, treatment
should be conducted in multiple settings with
different levels of treatment.

Preventing obesity:

• Respect the child’s appetite- children do not need

to finish every bottle or meal.
• Avoid pre-prepared and sugared foods when
possible.
• Limit the amount of high-calorie food kept in the
home.
• Provide a healthy diet, with 30%of fewer calorie
derived from fat.
• Provide ample fiber in the child’s diet.
• Skim milk may safely replace whole milk at 2
years of ages.
 • Do not provide food for comfort or as a reward.
• Do not offer sweets in exchange for a finished
meal.
• Limit amount of television viewing.
• Encourage active play.
• Establish regular family activities such as walks,
ball games and other outdoor games.

AIMS

Aims:
• Maintaining an appropriate growth rate and
achieving a healthier weight to height ratio.
• Reducing weight excess (without necessarily
achieving the ideal weight), in particular the fat
mass, while preserving the lean mass.
• Maintaining or promoting good mental health
(self-esteem, correct attitude toward food and
body image, health related quality of life).
 • Treatment and improvement /resolution of
complications, if present, in the shortest time
possible.
• Achieving and maintaining a healthier weight-to-
height ratio and preventing relapses.
• Weight concern aims to address the physical and
psychological needs of overweight children and to
guide the development of more effective program
of prevention and treatment.
• Improving access to weight management
information and programs for different patient
groups.

PHYSIOTHERAPY
MANAGEMENT

Physiotherapy management:
Exercise programs for obese children-Creating an
exercise program that burns calories builds muscles
and that kids enjoy which will help to reduce the
serious consequences of obesity for child.
Beginners exercise program:
Start slowly, with moderate intensity, non-impact
workouts. Take walks, ride a bike, swim, and skate or
do calisthenics such as -
- Pushups
- Sit ups
 - Crunches or walking stair
• Start doing pushups from a kneeling position to
make them easier.
• Crunches maybe easier because they do not
require a child with weak core muscles to go all
the way down.
• Walk and cycle up and down hills to raise and
lower the heart rate and use different muscles.
• Change strokes every few laps when swimming to
vary muscle use.
• Try to add strength, flexibility and endurance
exercises for each workout.
• For example, children can use dumbbells while
walking or using an exercise like
1. Intermediate workout-
- Raise the intensity level of workouts after the
child improves the cardio stamina and
muscular endurance.
- Pick up the pace of the walks or rides, trying
to finish more minutes of course.
2. Aerobic exercise-
- Exercises on treadmill, cycle ergometer, and
elliptical trainer.
- Water activities (swimming or water
aerobics)
- Child does not need to do full aerobic
workouts using these machines, just raise the
headache each week as the child improve his
condition.
- Creating a circuit training workout that
include a variety of exercise.
- Have the child spend 30 sec of jumping
jacks, 30 sec of jump rope, 30 sec of
crunches and 30 sec of stairs.
 - Take a two or three minute break, then start
another circuit, which might include
pushups, jogging in place, squats and lunges.
- Keep the circuit going for 30 minutes and
more.
3. Outdoor games-
- Play games such as basketball, tennis or
volleyball, even if need to adapt the
equipment to make it easier.
- Children are more likely to continue
exercises if it’s fun.
- Exercising with children sets a good example
for physical fitness.
Arm exercises-
- Biceps, triceps and forearm exercise improve
muscle strength and range of motion for the
arms.
- Exercises do not have to be difficult to be
effective, so choose arm exercises based on
a child’s fitness level.
- Children should always be supervised when
using exercise equipment a lifting weights.

1.Pushups-
- Pushups can be done on the toes or on the
 knee, but use a mat underneath the knees on
hard surfaces.
- Pushup target the arm and chest muscles.
- Vary hand positions to increase or decrease
the intensity of the pushups.
- To begin, kids should do one set of 10 to 15
repetitions.
- Increase sets as strength increase.

2.Medicine ball-
- A light weight medicine ball can be used for
various arm exercises. Toss the ball back
and forth to a partner for a total arm
workout. Lift the ball over the head, extend
the arms, and twist from side to side. Toss
the ball in air to strengthen arm and shoulder
muscles. Use a 1 pound or 2 pound
medicine ball. Start with one set of 10-15
repetitions per exercise.
3.Free weights-
- Use a small set of hand weights 1-3 pounds
to do biceps curls, lateral raises, front raises,
and upright rows or triceps kickbacks. Begin
with one set of 10-15 repetitions of each
exercise. Increase the number of sets or
weight as strengthen increase.

4. Resistance band-
- Resistance bands come in different colors,
 according to resistance level. The
appropriate color should be used when
exercising. Do lateral raises with a resistance
band by standing in the middle of the band
and grasping the ends of the band at waist
level. Raise the arms out to the side, then
slowly lower them. For biceps curls, stand
on the middle of the band, gasp the end of
the band, and bend the elbow to pull the
hands toward the shoulder. Keep the elbows
in at waist level. Start with one set of 10 to
15 repetitions of each exercises. Increase
sets as strength increase.

Lower body exercises-

- Squats and lunges are simple exercises that
offer a total leg workout for the child. Proper
form when squatting and lunging is essential
to avoid injuries do knees or back. Once the
child’s leg strength improves, add light hand
weight or a medicine ball to squats and
lunges. Have the child hold a medicine ball
with both hands and perform a wall sit.
 Challenge the child to sit begin with 10 sec
working toward holding the sit for one
minute. Simple exercises such as the calf
raises and leg lifts work leg muscles such as
the front and back of the calf and the inner
and outer thigh.
Cardiovascular exercises:
- Cardiovascular activities for at least 60
minutes a day is required. Start by jumping
rope for 10 sec and work up to one minute,
do several sets of jumping rope intervals.
Jumping rope offer both cardiovascular and
bone strengthening benefits. The child rests
as needed between each set. Jumping jacks
and jumping squats are also beneficial
cardiovascular exercise

Abdominal exercises-
- A proper technique should be taught while
performing an abdominal exercises. Use a
gym mat and have the child lie on the back
with knees bent, feet resting on the floor.
Using the abdominal muscles and not his
neck or arms, encourage him to lift his
shoulder off the ground and tighten his
upper and lower abdominal muscles. As the
child’s abdominal strength improves, add a
 medicine ball to basic crunches or oblique
exercises. Light hand weights or a medicine
ball maybe used when performing standing
oblique exercises, such as side bend

Circuit training exercises for children:

- Introducing kids to circuit training can be a
fun way to get children involved in physical
fitness and put them on the path to a lifelong
enjoyment of exercise.
- From simple games to more strenuous weight
lifting, circuit training exercises should be
adapted to the level of the children
performing the circuit.
- Circuit training exercises for younger
children can include jump rope, hop scotch,
throwing balls, jumping in the air, hula
hoop, relay races, jumping jacks and dashes.
- Create a circuit with simple calisthenics and
familiar bodyweight exercises like sit up,
pushups, pull up, and chin ups.
- Timed dashes are a good circuit exercises, as
 well as hop scotch, high-knee skipping,
giant steps down the length of a driveway
and forth running.
- To keep heart rates up, time each circuit so
that each child is working 30-60 sec, with no
more than a one minute break between each
leg of the circuit.
- Keep the circuit going for a minimum of 15
minutes.
- If the children have enough muscular
strength, add weighted exercises, use
weights that the children can perform for 6-8
repetitions before getting tired.
- Breaks between sets should be one minute or
less, with the entire circuit lasting about 30
minutes.
- Encourage exercise and active hobbies.
Include at least 60 minutes of physical
activity in the child’s day. It can be like one
long session or split it up into smaller
sessions throughout the day. Exercises can
include walking, swimming, cycling, and
dancing. And sports can be of soccer or
basketball, playing hide and seek.
1.Walking-
- Walking is an essential way to burn fat and
improve heart health. Other benefits include
improving cholesterol levels, lowering blood
pressure and reducing the risk of type 2
diabetes.
- Walking up hills require to push himself up
the incline with calf muscles while he brake
himself with quadriceps.
- Swinging or pumping the arms brings more
 muscle into workout.
2.Swimming:
- Swimming is another low impact activity that
does not require strenuous effort.
- Walking briskly in a pool is another way for
low skill swimmer, to add resistance
exercise to their fitness.
- If he can use his arms, he will create a total
body workout. Consider a life vest to help
him stay above water while swimming.

3.Cycling:
- Whether riding outdoors or indoor, on a
stationary bike, cycling is an excellent way
to burn calories and improve cardiovascular
health.
- Life walking, cycling emphasizes different
muscles going up and down hills. Changing
gears on a level terrain at home lets to
increase resistance to increase muscle work
or decrease effort to let the pedal move
faster, creating a splint type workout.
- Because of lack of shears on joints and
muscles, cycling lets exercise longer and
improve results.
 4.Dancing:
- Sweating to the oldies is no joke when it
comes to burning calories and improve
aerobic fitness.
- Whether taking a partner or get it alone,
break a sweat and use lower and upper body
muscles with the use of dumbbells.
- Zumba dance is the most effective way for
burning calories which have amount of
entertainment and improving physical
fitness.

ASSESSMENT
Assessment:
Subjective-
• Name:
• Age:
• Sex:
• Occupation:
• Address:
• History:
 - Presence of any symptoms:
- Past medical history:
- Current medications:
- Family history:
- Psychological history:
- History of substance abuse:
- Home, social environment:
• Assess for complicating features:
- Diabetes:
- Hypertension:
- Sleep apnea:
- Psychological problems:
Objective assessment:-
Examination:
• Measure height in meters
• Measure weight in kilograms
• Blood pressure
• Heart rate
• Respiratory rate
Measure body mass index (BMI):
BMI= weight/height (kg/m.sq)
Waist circumference:
Skinfold measurement:
Estimation of total body weight:
Estimation of total body fat:
Assess for long term risks of obesity:
- Type 2 diabetes
- Coronary heart disease
- Some cancers
Assess reasons for weight gain:
Consider referral to an appropriate specialist:
Management of obesity:
- By proper diet
- By exercise program
 RESULT

Our primary analytic sample included

particular aged 6-18 years. The average time spent in
moderate and vigorous physical activity was 55
minutes per day and the average time spent in total
sedentary behavior was 4-6 hours per day. It found the
more time spent in physical fitness was independently
associated with lower basal metabolic index (BMI)
and waist circumference (WC). The present results
and together support that increasing and improving
diet balance and physical fitness could help to prevent
childhood obesity, potentially by increasing energy
expenditure and correcting energy imbalance.
Preventing the childhood obesity has the greatest
potential to counter that short and long term health
problems associated with obesity.
 CONCLUSION

Childhood obesity today contributes one

of the most serious health concerns, both in the
developed and developing would be obesity in
childhood is causative for many chronic diseases. It
also has psychological consequences and may
contribute to a delay in academic and social
functioning as well as poor self-esteem and
depression. The intervention for preventing and
controlling obesity are mainly aimed at limiting the
intake of sugar and high calorie snacks with higher
consumption of vegetables and fruit based diet. This
includes eating calcium-rich high fiber diet with
balanced micronutrients, daily healthy breakfasts and
home cooked family meals, smaller portion size, and
a curtailment in eating out last but not least
decreasing the duration of screen time and increasing
the level of physical activity and excising daily for
better improvement of musculature and maintaining
weight and fat mass patterns, while preserving the
lean mass are vital for preventing high risk of
childhood obesity. Multifaceted strategies involving
the public and private health sectors along with
community participation are required to gradually
reverse this trend.

“FITNESS IS NOT ABOUT BEING BETTER

THAN SOMEONE ELSE….. ITS ABOUT BEING
BETTER ONE USED TO BE.”

BIBLIOGRAPHY

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www.aafp.org
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www.pubmed.com
www.livestrong.com
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