Registration of subjects for dissertation

Name of the Candidate

and Address

Name of the Institution

Course of study and subject

Date of admission to Course

6

7

Puberty is a dynamic period of development marked by rapid changes in body size, shape, and composition, all of which are sexually dimorphic. The onset of puberty corresponds to a skeletal (biological) age of 11 yrs in girls and 13 yrs in boys. On average, girls enter and complete each stage of puberty earlier than do boys. The timing and tempo of puberty vary widely, even among healthy children. Puberty is also a time of significant weight gain; 50% of adult body weight is gained during adolescence. The changes in the distribution of body fat (central compared with peripheral, subcutaneous compared with visceral, and upper compared with lower body) results in the typical android and gynoid patterns of fat distribution of the older adolescent and adult.⁴

Another change during puberty happens in how the body is proportioned. Before puberty the bodies of girls and boys are very similar. During puberty, muscle and fat tissue increase and are re-distributed.1)Both boys and girls have increased fat/muscle growth.2)Boys have a faster increase in muscle tissue, and girls have a faster increase in fat tissue.3)For girls, fat moves from middle to the upper and lower body giving them a curvier appearance. 4)By the end of puberty, boys have 1.5 times as much muscle as girls. The muscle to fat ratio at the end of puberty is 3:1 in boys and 5:4 in girls.^4,5
Relation of Lung Function in Obese:

Obesity has a profound effect on physiology of breathing. The pattern of body fat distribution may influence the effect of obesity on lung function. It is generally believed that the upper body obesity carries a higher risk of cardiovascular and

Obese children have more respiratory symptoms than normal weight peer-groups and respiratory related pathology increases with increasing weight.⁷ The primary reason is due to a decrease in chest wall compliance associated with the obese individuals accumulation of fat in and around the ribs, diaphragm and the abdomen. Total respiratory compliance is markedly reduced by recumbence in the obese individuals compared with non-obese individuals. This reduction is almost entirely due to the decreased compliance of the chest wall , although it may also be due to an increase in respiratory resistance.⁶ One possible mechanism is a mechanical limitation of chest expansion during the forced vital capacity. Increased abdominal mass may impede the descent of the diaphragm and increase the thoracic pressure. Also, abdominal adiposity is likely to reduce expiratory reserve volume (ERV) by compressing the lungs and the diaphragm.³

Body mass index (BMI) is generally agreed to be the most appropriate proxy measure for defining and diagnosing childhood obesity and overweight. In childhood, because body fat and muscle mass alter with age and differ between the sexes, BMI is meaningful only when it is plotted correctly on age- and sex-specific BMI centile charts.^1,2 The 95^th percentile of BMI is used to define obesity in children and adolescents.⁸

Skinfold thickness evaluation is used as a valid anthropometric indicator of regional body fatness. Its evaluation, due to its low cost and non-invasive procedure, is one of the most widely used anthropometric methods for assessment of nutritional status during growth and the maturation period.⁹

Chest Expansion using inch tape is a method that is in-expensive, straight forward, and appropriate for use in both clinical and non-clinical settings. It is a highly reliable method to measure Thoracic excursion.¹⁰
Therefore, the need for the study is to correlate skinfold thickness with chest expansion in obese adolescent boys and girls.


6.2 Review of Literature:

1. 
   Swapnil J. Paralikar et al., (2012) have assessed lung functions in adolescent obese boys and determined the predominant lung function impairement is associated with obesity in adolescence.³
   

2. 
   Serap Semiz et al., (2008), have done a study to evaluate the clinical significance of body fat distribution in childhood obesity and investigated the associations of subcutaneous and intra-abdominal fat. They have come to a conclusion that the abdominal subcutaneous fat thickness might be a better predictor of the risk for hyper insulinemia in childhood obesity.¹⁰
   

3. 
   Susan E. Bockenhauer et al., (2007) have assessed the reliability of using the cloth tape measure technique for chest expansion and concluded that using inch tape for chest expansion is reliable to evaluate lung function.¹¹
   

4. 
   MC Gulliford et al., (2001) have evaluated the distribution of body mass index (BMI) and skinfold thickness in children and concluded that there is a relation between obesity and skinfold thickness.¹²
   

1. 
   To measure the skinfold thickness of subscapularis and the abdominals using skinfold calliper in mm in adolescents.
   
2. 
   To measure the chest expansion using inch tape in cms in adolescents.
   

There is a correlation between skinfold thickness and chest expansion in obese adolescent boys and girls.

There is no correlation between skinfold thickness and chest expansion in obese adolescent boys and girls.

Students will be selected from schools in and around Bangalore.

120 Students are selected.

Correlational study.

6 months.

The data collected will be analyzed using Spearman’s Rank Order Correlational Coefficient and Anova.

Sample size is 120.

Convenient sampling.

The sample size will be 120 subjects from school, out of which 60 are obese and the rest 60 are age-matched control group.
CRITERIA FOR SELECTION:
INCLUSION CRITERIA:

1. 
   BMI greater than or equal to 95^th percentile.¹³
   
2. 
   Age between 10-19 years.¹⁴
   

1. 
   Age below 10 years and above 19 years.
   
2. 
   History of Cardiac problems.
   
3. 
   History of Chest Deformity.
   
4. 
   History of Neurological Dysfunction.
   
5. 
   History of Chest Surgeries.
   
6. 
   History of Respiratory Pathologies.
   
7. 
   History of any chronic illness.
   

120 subjects who fulfill the inclusion criteria will be included for the study. Written consent will be obtained from the parents/guardians prior to the study.

Centre for Disease Control and Prevention (CDC) growth reference chart is used to evaluate each subject’s BMI. The subject’s with BMI greater than 95^th percentile in the growth chart will be considered obese and the subject’s BMI between greater than and equal to 85^th percentile and less than 95^th percentile in the growth chart will be considered as age matched group.

The skinfold thickness measurement will be measured for every subject using the skinfold thickness caliper in mms. The skin fold thickness measurement will be done for subscapular and the abdominals.

Firstly to measure subscapular skinfold thickness, the subject should be standing erect with the arms by the side, anatomical position. The thumb palpates the inferior angle of the scapula to determine the undermost tip. The skin fold is raised with the left thumb and the index finger at the marked site 2 cm along a line running laterally and obliquely downwards from the subscapular landmark at an angle (approx. 45⁰) as determined by the natural fold lines of the skin.

Secondly, for the abdominal skinfold thickness, this is a vertical fold raised 5 cms (approx. in the midline of the belly of the Rectus Abdominis) towards the right side of midpoint of the navel. It is particularly important at the site that the measurer is sure of the initial grasp must be firm and broad since often the underlying musculature is poorly developed. This may result in an underestimation of the thickness of the subcutaneous layer of the tissue.¹⁵

The subjects are then made to stand with a loose clothing and the room is maintained warm prior to measuring the chest expansion.

The chest expansion will be measured using an inch tape in cms, held around the circumference of subjects’ chests at two levels.

Upper thoracic excursion measurements will be taken at the level of the fifth thoracic spinous process and the third intercostal space at the midclavicular line. Lower thoracic excursion measurements will be taken at the level of the 10th thoracic spinous process and the xiphoid process. The patient is asked to take a deep breath and the tape will surround the chest to know the initial reading followed by this the subject is asked to exhale deeply by which the measurement is now noted and the difference between the initial and final reading will be noted to measure the chest expansion. Thoracic excursion equals thoracic circumference at the end of forced inspiration minus thoracic circumference at the end of forced expiration.¹⁶ These areas of measurement yields useful information about the chest expansion.

The whole procedure will be repeated in the age matched subjects of 60 adolescent boys and girls and the values will be compared with that of the rest 60 obese adolescent boys and girls.

The data which is obtained will be further statistically evaluated to find the correlation between skinfold thickness and chest expansion in

adolescents and will be compared with the age matched subjects.
INSTRUMENTATION:

1. 
   To measure BMI percentile, growth charts will be used;
   
2. 
   To measure skinfold thickness, Skinfold Thickness Caliper is being used;
   
3. 
   To measure chest expansion, inch tape is used.
   

Ethical clearance for the study has been obtained from the ethical committee of our institution.

1. 
   World Health Organisation. Diet, nutrition and the prevention of chronic diseases. WHO TRS 916. Geneva: WHO/FAO, 2003.
   
2. 
   Lobstein T, Baur L, Uauy R, IASO International Obesity Task Force. “Obesity in children and young people: a crisis in public health”. Obes Rev May 2004; 5(suppl 1): 4e85.
   
3. 
   Swapnil J. Paralikar, Rajesh G. Kathrotia, Narendra R. Pathak, and Madhusudan B. Jani. “Assessment of Pulmonary Functions in Obese Adolescent boys.” Lung India 2012;29:Pages 236-240.
   
4. 
   Alan D Rogol, Pamela A Clark, and James N Roemmich, “Growth and Pubertal Development in Children and Adolescents: Effects of Diet and Physical activity”. The American Journal of Clinical Nutrition;72:521S-528S.
   

5. 
   Maria R. de Guzman, “Understanding the Physical Changes of Puberty”. Neb Guide 2007;1701-1702.
   
6. 
   Krishnan Parameswaran, David C Todd, Mark Soth, “Altered respiratory physiology in obesity”. Canada Respiratory Journal 2006;13,4:203-210.
   
7. 
   Farida M. El-Baz, Eman A. Abdelaziz, Amal A Abdelaziz, Terez B. Kamal, Aza Fahmy. “Impact of Obesity and Body Fat Distribution on Pulmonary Function of Egyptian Children”. Egyptian Journal of Bronchology, 2009;3:49-58.
   
8. 
   Aviva Must, Gerard E Dallal and William H Dietz. “Reference data for Obesity: 85^th and 95^th percentiles of body mass index and triceps skinfold thickness”. American Journal of Clinical Nutrition 1991;53:839-846.
   
9. 
   Maciej Jaworski, Zbigniew Kulaga, Pawel Pludowski, Aneta Grajda, Beata Gurzkowska, Ewelina Napieralska, Anna Swiader, Huiqi Pan, Mieczyslaw Litwin. “Population-Based centile curves for Triceps, Subscapular and Abdominal skinfold thickness in Polish children”. European Journal of Paediatrics 2012;171:1215-1221.
   
10. 
    Susan E. Bockenhauer, Haifan Chen, Kell N. Julliard, and Jeremy Weedon. “Measuring Thoracic Excursion: Reliabilty of the Cloth Tape Measure Technique”. Journal of American Osteopath Assosiation 2007;107:191-195.
    
11. 
    Serap Semiz, Ercin Ozgoren, Nuran Sabir, and Ender Semiz, “Body Fat Distribution in Childhood Obesity: Assosiation with Metabolic Risk Factors”. Indian Paediatrics, 2008;45:457-462.
    
12. 
    Mc Gulliford, D Mahabir, B Rocke, S Chinn and R Rona, “Overweight, Obesity, and skinfold thickness of children of Africa or Indian descent in Trinidad or Tobago”. International Journal of Epidemology 2001;30:989-998.
    

13. 
    World Health Organisation. “Use and Interpretation of WHO and CDC Growth Charts for Children from birth to 20 years in United States”. WHO 2013.
    
14. 
    www.who.int/topics/adolescent_health/en/ 05/12/2013.
    
15. 
    Kevin Norton and Tim Olds, “A Textbook of Body Measurement for Sports and Health Education-Anthropometrica” 2006: 46-51.
    
16. 
    Susan E. Bockenhauer, Haifan Chen, Kell N. Julliard, and Jeremy Weedon, “Measuring Thoracic Excursion-Reliability of using Cloth Tape Measure Technique”. The Journal of the American Osteopathic Association 2007;191-195.