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No. Short stature can be a sign of various diseases as we have discussed earlier. Most of these children can be managed without the use of growth hormone. For example, a slowly growing kid with chronic bronchial asthma can achieve good growth when asthma is controlled. Many children have constitutional delay in growth and puberty which may improve spontaneously or with minimum medicines.
Some children can have normal growth hormone levels but can have improved heights with the use of growth hormone. These include:
A) Turner syndrome
B) Idiopathic Short stature
C) Small for Gestational Age who fail to have catch up growth
D) Prader Willi Syndrome
E) Chronic Kidney Disease
F) SHOX gene deficiency
So, do not be surprised when your endocrinologist may discuss growth hormone therapies with you even if your kid has normal growth hormone levels

Author
Dr Mathew John

If a child is suspected to have short stature the first step is to document the height and weight in a growth chart and assess the position on the chart with respect to the height of the parents and children of same age and sex.
Once short stature is established, it is always better to get evaluated by an endocrinologist who will proceed ahead with complete medical history and physical examination. Based upon relevance the child maybe advised investigations like:
· Xray of the hand which will help in assessing the bone age of the child (also to determine maturity and growth potential of bones).
· Blood tests (to rule out hormone or other disorders associated with growth failure)
· Chromosome/Genetic tests
· Examining the functions of the pituitary gland, which produces and secretes the growth hormone.
· Growth hormone stimulation tests: these are done under observation of the kid in the clinic.
· Imaging if necessary, to look for pituitary gland or brain tumours.
Depending on the degree of stunting, the doctor may decide on watching your kid for 6-12 months before deciding to investigate him/her.

Author
Dr. Titto Oommen

This is a particularly important question that need answers. There are growth charts which help to understand if a child is short in comparison to children of the same age and sex. Since children in different ethnicities have different growth rates, it is important that we compare children with other children of the same ethnicity. Some clues to understand if your child is growing normally is to
1. See if he/she is outgrowing his/her clothes
2. Is he/she significantly shorter than other kids of his/her age and class
3. Was he/she smaller than other kids at birth (say birth weight less than 2.8 kg)?
4. Is he/she funny looking? (as commented by others)
5. Their height is not in keeping with parent’s height
5. You have a gut feeling that he/she is not normal
Yes, it is important to get kids checked out for height. Although poor height apparently is a cosmetic problem, it could also be an important sign of many diseases. This could be related to nutrition, gastrointestinal diseases, kidney diseases, respiratory or cardiac diseases, thyroid diseases, growth hormone related problems or even a brain tumor. Most of these are uncommon. The most common reason is a constitution delay in growth and puberty. It is not only important to get the child examined by an endocrinologist, but also a 6-12 month follow up to understand the growth velocity. More delayed the visit for medical care, the lesser the options for treatment.

Author
Dr. Mathew John

Obesity causes a variety of problems like cardiovascular disease, respiratory problems, sleep apnea, musculoskeletal problems, varicose veins, gallbladder disease. The aim of bariatric surgery is to halt the progression or revert the same with weight loss. Surgical procedures can help more significant weight loss than other procedures. A BMI of more than 35 qualifies for surgery even in the absence of any other complications. A person with BMI > 30 in the presence of 2 or more complications also qualifies for surgical management. Some patients with uncontrolled type 2 diabetes mellitus and BMI > 27.5 may be considered for surgical weight loss. These criteria are applicable to people of Indian origin. For westerners, a higher threshold of BMI is considered.

Surgical weight loss is associated with improved lifespan, reduced risk of cardiac disease, improvement in hypertension and cholesterol problems and reversal of diabetes. Depending on the type of surgery, the complications are extremely low especially in experienced surgical hands.

The goal of obesity treatment is to reach and stay at a healthy weight. You may need to work with a team of health professionals — including a dietitian and obesity specialist — to help you understand and make changes in your eating and activity habits. In addition to a healthy diet and regular exercise, weight-loss medication may help in certain situations. The main purpose of anti-obesity medications is to help you to stick to the advised low-calorie diet. This is achieved by stopping the hunger and lack of fullness signals that appear when trying to lose weight. Before selecting a medication for you, your doctor will consider your health history, as well as possible side effects.

Anti-obesity medications approved by the Food and Drug Administration (FDA, USA) include Orlistat, Phentermine/topiramate, Bupropion/naltrexone, and Liraglutide. Of these, medications, orlistat and liraglutide are available in India. Orlistat is an oral medication that acts by preventing the absorption of fats from the diet. Liraglutide is an analog of the intestinal hormone GLP-1 ( a protein produced by the intestine), which delays gastric emptying and promotes a feeling of satiety. It must be injected daily. Some medicines are used by physicians to help people with obesity lose weight even if they are not approved for the same. These are called “off-label use. Metformin and SGLT2 inhibitors are medicines that are sometimes used in this manner. As of date, no ” herbal” medicines are approved for weight loss and some have even been associated with liver toxicities.

It is important that the patients have realistic expectations about the weight loss that can be achieved with medications.

Exercise, a subcategory of physical activity, refers to planned, structured, and repetitive- activities aimed at improving physical fitness and health. Exercise results in energy expenditure. Increased energy expenditure leads to weight loss. In addition to weight loss, regular exercise will help control diabetes, hypertension, and dyslipidemia in people with obesity.
300 minutes per week of moderate physical activity (or 150 minutes of high-intensity exercise) is recommended for weight loss. Resistance exercises 2 days a week will be an added benefit. Exercise plans combined with calorie curbed diet plans will work better. All attempts should be made to reduce physical inactivity time (sitting time). People with obesity should be examined by a cardiologist before doing intensive exercise. Clinicians should also address physical limitations while recommending exercise. It is also important to discuss “cardiorespiratory fitness” as an attainable goal than significant weight loss. People with obesity with good cardiorespiratory fitness have less mortality than normal-weight individuals. Any increase in physical activity should be appreciated and encouraged.

Various studies have indicated that increased consumption of unhealthy food is one of the major factors contributing to obesity. So, it is logical that making changes in diet will help reduce weight. But before modifying the diet, various factors such as BMI, weight loss goals, comorbidities, and socioeconomic status need to be considered. Individualizing the diet will cater to the person’s needs, making it easier for them to achieve long-term weight loss.
Different dietary approaches lead to weight loss if people adhere to them since they are all calorie deficient. Some of these diets reduce carbohydrates and some reduce fat. It is still not clear if one is truly better than the other in long term. In most cases, weight loss of approximately 0.5 kg per week can be achieved with a 500 kcal deficit diet that is adequate in carbohydrates and proteins, low in fat, and high in fiber. Individuals will find this diet effective as it is easier to follow in the long run, but this may not be applicable for those with higher degrees of obesity (say BMI of > 35).

For people with a BMI of > 35, a much more intensive diet restriction under the regular supervision of a dietitian is required. This would mean a higher restriction of calories (mainly from carbohydrates) replacing it mostly with proteins and lesser so with fat. These diets must be supervised by a dietician.

Another restrictive diet is the ketogenic diet which consists of high fats (55-60%), moderate proteins (30-35%), and a very low content of carbohydrates (5-10%). The ketogenic diet is superior in producing rapid weight loss in otherwise healthy patients with obesity. The clinical impacts, safety, tolerability, efficacy, and duration of treatment with these diets and potential for weight regain after discontinuation is not well understood. A ketogenic diet may be followed for a minimum of 2 to 3 weeks up to 6 to 12 months. Close monitoring of renal functions while on a ketogenic diet is imperative, and the transition from a ketogenic diet to a standard diet should be gradual and well-controlled. Your dietician is the best person to help you understand the diet and suggest appropriate personalized modifications.

Obesity is associated with an increased risk of heart disease. Many factors contribute to this. People with obesity have a higher risk of developing diabetes, abnormal cholesterol levels, and hypertension. People who are obese also have a high risk of obstructive sleep apnea which can trigger various forms of heart diseases. The risk of various forms of heart disease increases in obesity.

• Coronary artery disease
• Heart failure
• Heart rate abnormalities like atrial fibrillation
• Sudden death
• Stroke

It is important that people with obesity attempt to lose weight and reduce the risk. Appropriate management of diabetes, hypertension, and dyslipidemia is important to cut the risk of heart disease and stroke.

Overweight and obesity causes a host of musculoskeletal problems that can affect the quality of life. There is increased risk of low back pain in people with obesity. Around 20 % of people experience low back pain. This is due to biomechanical changes in the lumbar region. Further there is an increased incidence of DISH in people with obesity. In DISH, there is a calcification of ligaments and tendons around the spine resulting in pain and stiffness. Other joints like hip, knee and shoulders may get affected.

Increased weight puts strain on the weight bearing joints of the lower back, hip, and knee joints. The joints can have damage due to overloading and lead to joint degeneration(osteoarthritis). Excessive body weight can lead to foot pain due to flattening of foot arches. There is an increased risk of plantar fasciitis resulting in heel pain.

There is an increased risk of carpal tunnel syndrome in people with obesity. Obesity can be associated with gout, an inflammatory condition associated with joint swelling and pain. Rheumatological diseases like fibromyalgia and rheumatoid arthritis are also more common in people with obesity.

Obesity impacts an individual’s quality of life and has a positive links with various mental health issues like depression, eating disorders, anxiety and substance abuse. People with obesity experience increased social stigma and discrimination due to their weight. They are forced to undergo unrealistic weight loss programs, indulging in fad diets being the most common one which leads to unrealistic weight loss expectations which in turn leads to depression, suicide and substance abuse. The most common eating disorder in people with obesity is binge eating, but significant others indulge in eating for emotional reasons. Body image dissatisfaction is common among people with obesity and may result in seeking treatment. Futher there is increased risk of developing obesity in people with depression, especially among women. Active weight loss programs are associated with reduction in depressive symptoms.

It is important that healthcare workers taking care of people with obesity discuss and recognize their mental health problems and address them. Awareness of obesity as a medical issue, education of society starting with schools, and educating healthcare professionals on recognition and management of obesity will help reduce the bias and stigma associated with the disease. This could assist the vulnerable group of people to seek help for obesity and any problems that accompany it.