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Prevention of Childhood obesity

Apr 26 | 2:00 PM

Childhood obesity has reached epidemic levels in developed as well as in developing countries. Environmental factors, lifestyle preferences, and cultural environment play pivotal roles in its rising prevalence. In addition to being implicated in numerous medical concerns, childhood obesity affects children's and adolescent's social and emotional health. Prevention can undoubtedly provide better chances for reducing long-term complications. Dr. Adarsh Somashekar, fitness enthusiast & renowned Pediatrician, joins us on Medflix in a passionate discussion on possible approaches to implement the necessary interventions!

[Music] all the doctors medical students and other health care professionals who joined in for the talk today which is being hosted on metrics my name is dr awanzika chaitanya and i'm a pediatric residency applicant passionate about child health care and the co-founder of the auto research initiative i will be your host and moderator for this enriching talk and prevention of childhood obesity childhood obesity is a serious medical condition that affects children and adolescents it's particularly troubling because extra pumps often start children on the paths to health problems that were once considered adult problems like diabetes high blood pressure and high cholesterol childhood obesity has reached epidemic levels in developed as well as developing countries of late impact on both physical and psychological health a women of these children are likely to stay obese in adulthood and are more likely to develop non-communicable diseases like cbd and diabetes at a younger age the mechanism is not fully understood and it is believed to be a disorder with multiple causes in general obesity and overweight are assumed to be the result of increased caloric and fat intake on the other hand there are supporting evidence that excessive sugar intake in soft drinks increased portion size and steady decline in physical activity have been playing major roles in the rising rates of obesity all over the world childhood obesity can profoundly affect children's physical health social and emotional well-being and also their self-esteem it is often associated with poor academic performance and a lower quality of life as experienced by the child to enlighten us further on this topic today we have with us dr aadhar soon shaker consultant neonatologist at obama hospitals bangalore dr adarsh is an entrepreneur fitness enthusiast and a renowned pediatrician who has worked in the united kingdom and in india he has more than two decades of work experience from some of the most prestigious hospitals in uk and in india he got his md in pediatrics from custer custodia medical college and is an alumnus of the royal college of pediatrics and child health in the uk he completed his executive mba in healthcare delivery at iim bangalore he has always been passionate and a visionary in his life his vision along with his friends of creating a high quality mother and newborn care service in india gave rise to open hospitals a maternity and newborn hospital which strives to deliver standardized high quality patient-centric and efficient health care solutions all across india currently he is serving as the chairman and executive director of home groups group of hospitals kalyan nagar he was also nominated as a most promising pediatrician of the year 2018-2019 a very warm welcome to you sir and over to you for today's talk so um today i i wanted to speak a bit about childhood obesity before that actually if i ask questions for the participants can can that can they press some buttons so first question okay how many of them exercise in the audience up that question let us see whether again yes or no uh dear doctors in the audience you can use the comment section to answer yes or no for search question it's quite a mixed response many yeses and many many no's but but see the many knows say the audience i have not seen them face to face but i have a feeling this audience are in the age group of 25 to 30. yeah they are saying yes so at least i am i'm addressing a group so let me also put some challenge in front of them so we got all the 68 responses roughly is it 30 30 14 120 s the moderator should tell me the answer i think it's um almost everywhere said i am 48 so at least there is somebody in the crowd who is my age i think almost everyone has said yes uh just a couple of notes and okay it's around 60 40. i can say okay fine so good there is a few people who are my age and i saw one age more than me so now apart from me being a pediatrician i have a general interest in obesity because i'm a fitness enthusiast to add to what is fitness the most recent competition have participated is in dubai in march which is about one and a half months ago it was called iron man competition or iron man 70.3 we had to swim about close to two kilometers in the sea followed by we had to cycle 90 kilometers followed by we had to run 21 kilometers so this took an effort i completed that in six hours 23 minutes so i'm just putting that to the audience to know to talk about this subject i really put in not my doctor hours of studying i've also put my personal time and effort to do it and study and be there also this coming august i also booked for a full ironman competition wherein i have to swim four kilometers in the sea then cycle 180 kilometers and then we have to run 42 kilometers that will take about 14-15 hours to complete i think the famous millions woman that done it a few years back and then that race was in the lime so let us now come back to children because i am a pediatrician so children are my favorite do you people know what is the prevalence of childhood obesity in india actually can you put up that question here so 45 have voted 30 uh the next or highest number of votes is say that it's 40 and then a couple of people have also voted for 20 so i mean i'm happy that most of them are voted i mean 40 of indian children would be too high a mark it's it's close to twenty percent the right answer would be twenty percent see but twenty percent itself apart from the marking it we should actually be very surprised at that number 20 of india if we take the total children in india between 0 to say 16 years of age this population would be about 50 crore indians and in 50 crores if it's close to 20 crores somewhere 8 to 10 crore children are overweight it's extremely high that this should be a real real worry for us in the coming times and now if i were to divide rural india and urban india when i say our rural india and not my classification 65 percent of india based on either is supposed to be rural and 35 percent of us live in urban cities so if we take the obesity prevalence in that 35 percent can you put up that questionnaire what is the prevalence rate of obesity in urban india so i think a lot of people have voted for 30 and a couple of words for 40 as well so they are correct the 30 is the right answer um so in 15 to 20 is if you combine both the populations and it's around 30 percent in the urban india so again this is a big concern people who are there who are pediatricians we have to start thinking that if we are seeing um city clad children 3 out of 10 people walking into your clinic will be overweight so this is a real concern and and we'll talk more about it especially what has kovid done to our children and and if this is the way what can happen in 10 20 years okay so let's let's go to the presentation here so so this number which we already discussed and most of it people got it right 1.4 crore children in india are obese it is an extremely high number and 15 prevalence is there and upper income families is now touching 35 percent this there was a survey done and it was a very authentic survey and the survey numbers are out in times of india newspaper in 2021 the obesity in children every decade this survey comes there was a definite increase of obesity in 20 of the 22 states surveyed which which i am trying to tell that this increase in obesity is not into one particular state it is homogenized it is into most parts of india now i have written a very important point india is one of the countries which has a unique challenge in our country there can be children who are obese there can be children with under nutrition then there can be a combination where a child is over weight but with under nutrition so what do i mean by that see obesity just means you have more fat resource or your weight is much much more compared to your height but you could be stunted in growth because your protein you have may have protein deficiency or your protein intake may be so less you you have uh under nutrition your protein is deficient but you are overweight or there can be a scenario in india there's a completely underweight children in one end and there could be completely obese children in the other end next slide please so you will be able to swipe it thank you indians as you know we are genetically predisposed to higher cardiac issues heart attack is one of the highest in our country as compared to our western peers we are also predisposed to diabetes in india one in six is a diabetic and if you take the population above 50 years in india it is one in three so already we have two bad diseases with us and now with obesity coming it can cause a horrendous scenario we all know urbanization is leading to sedentary lifestyles and now more tour home delivery or doorstep delivery is causing miles modern foods we are always talking about this whichever food you take they all right how many calories are there because now most places that is becoming compulsory but they still are not writing how much of protein is there look an average indian let us take an adult for now a 70 kg man requires one gram of protein every day if we are not having good protein intake and we are having more of carbohydrates or fat intake we will end up becoming obese along with the side effects of under nutrition so most foods or many foods which we can we consume have high glycemic index um so that they might be high in sugar or the glycemic index is high so very quickly it is broken down and the carb the blood sugar becomes high blood has to push this to somewhere so it pushes it into adipose tissue that goes into a storage and our fat stores start going up physical activity has extremely come down not only in the adults but more so in children because schools has been closer for the last two years and parents have been paranoid about kobed so much so even in the apartment complexes you don't see children coming out to play at least now it has become slightly better in the apartment where i stay but if i take let us say three months back or six months absolutely no kid was venturing down so kids are not able to go to school it is online schooling they are not able to come out and play parents are very afraid even to send them to the neighbor's house to play because of this coveted fears children are all the time at home children are bored so parents don't know what to do to keep them happy mobile phones are readily available laptops are available tv is available and because they are at home they are more in touching distance of foods foods are readily available it could be chips it could be kurkure it could be cakes many parents or many mothers have learned baking i see lots of children eating high foods with high sugar content it could be cakes or it could be sweets so all this have added and and all these have definitely pushed this proportion up and if we don't control it now in the coming decades it this could become an alarming scenario in india probably we could go towards the western countries where there could be overweight could be double of our size maybe in america and we could we could definitely reach there in couple of decades if we don't put a stop now all know this obese children how does the lifestyle happen a child who is fat school kids will make fun of this child so this child particularly moves away from anything which is physical this child most likely in the school itself is not going to go and compete with sporting activities it will be cricket it could be football or some other game but this child would be reluctant to go there so from school if that becomes a habit already somebody talked to me before the statement a child who is fat more likely he will become a obese k obese adult so he will carry this to his adulthood hypertension which would have been a disease after 50 years now we are starting to see it in younger generation probably 30 35 it's starting to come diabetes early 40s people are becoming diabetic high triglycerides people nowadays in corporate offices are doing routine routine checkups and i see many parents who come to me just to show the report because they brought their chain and they will be in early 30s or mid 30s showing high triglyceridemia coronary arteries as i said india itself we are genetically predisposed now with this obesity and sedentary life adding up coronary artery disease will only go up to become more and more obesity is also can cause stroke and it is also predisposed or obese people are predisposed to some sort of cancers so these are the things which can affect our children who are obese today in the next coming decades if we don't do something about it today so yeah what do we do what do we do this is standard but but very important to the young doctors who are sitting there when parents come to meet us we we have to push it into their mind all over india school time is eight to three i i'm hoping there is no more coveted waves and normal school starts at june tuition homework class work so many things will be there but when the child comes home at say 3 3 30 in the school bus they change their clothes they they have a glass of milk maybe have a fruit not necessarily chips but maybe a healthy fruit all children have to be pushed out of the house four o'clock to six o'clock they should be outdoors they should be playing what does this do a good play will make them hungry they can have a good dinner maybe early on maybe if the family has a dinner at 7 30 i am very very happy early to bed we should be able to put the child to bed by 9 9 30 so the next day morning if the child gets up at 6 30 there is a good nine hour gap a good sleep a good exercise and a healthy balanced diet these all components go in to make the child more healthy and less obese also when we push the child to go out and play this also means there is a less screen time or reduced tv see eight to three there in school they have come to home four to six you push them out to play six six thirty they come they study for an hour one month then they eat something then maximum you are giving some screen time half an hour in a day maybe one hour in the weekends nine nine thirty you are putting them to bed this should be the routine which which parents should follow fruits and vegetables somehow this seems to be getting missed in the diets these days so one of the thing which i always tell parents who come to see me a fruit in the morning compulsory if if the compulsory they are not able to impose let the child start eating a fruit then only let the breakfast come a breakfast in a child compulsory should have one egg at least most of the families should take even though they're vegetarian egg one glass of milk when i say a glass of milk it is about 200 ml and a fruit this should be compulsory when the child takes a carrier a different box to the school it has to have one fruit compulsory it has to have one vegetable subzi compulsory depending on the family they can have a bit of rice they can have bread or they can have roti and fine with it a cup of curds when they come back home a glass of milk again compulsory a fruit again compulsory so in this way we have ensured that the child gets at least three fruits that is morning one lunch time one and evening post school one dinner again let us make sure they have a good cup of vegetable so we have ensured a vegetable cup in the lunch time and another vegetable cup in the dinner time a cup of curds if there are non vegetarian eaters one of the meal could have non-veg chicken or fish is preferred uh i think fish is the best fish is the only non-veg item which can be eaten every day i'm not taking it as a non-vegetarian at all for me it can be even hard by vegetarians fish a child can have every day if there are chicken eaters maybe two or three times a week is permissible remaining protein should come from dal sprouts legumes beans double beans flavor beans okay peas dals like green gram bengal gram chana dal all these have are rich protein content so we should ensure the child has good protein so to keep this in the perspective a 5 year child will be about 20 kgs should have 20 gram protein daily a 10 year child will be 35 to 40 kgs should have about 40 gram protein a 15 year child will be 60 kgs 55 to 60 kgs and should have 60 gram protein remember this protein is our building blocks this makes it it holds the body tight it makes the body lean and it gives a shape to our physical body and i have told the importance of fruits in the diet vegetables in the diet milk milk concurs very much needed for their minerals vitamins probiotic activity and the calcium for the growing bones when they come to foods preferably whole processed foods are much better whole grain foods whole wheat olata that is whole wheat even rice which is half polished or even unpolished which comes as reddish is much preferred than fully polished white rice some place of india they eat parboiled rice parboiled rice again is much better than our fully polished white rice some places they use millets again all whole grain millets are very good they can be a very good alternative replacement for rice tv time mobile time most parents keep asking me for a child let us take a child from three years to say slc 16 years i think not more than one hour a day because they have lots of class work to do homework to do they have to sleep at least nine ten hours because a growing child requires a lot of sleep maybe in the weekends if somebody wants to give them two hours of tv it is fine weekend i'm saying as saturday and sunday monday to friday maybe one hour maybe the weekends they get a saturday sunday maybe two hours occasionally once a month they may be entitled to have a watch a movie beyond that no if they have more free time push them for more physical activity so there are two physical activities which a child should definitely do both one of course is one hour whether they cycle they run they swim they do skipping jogging even walking this is a single activity they do for their personal physical development apart from this parents should actively encourage them to also to take part in group activities group activities say cricket it needs 11 people to play football it needs 11 people to play hockey group sports in group sports there will be other children so these people can look at the other children and grow also playing in a group always increases the amount of time see if you allow a child to walk or run they get bored 30 minutes 45 minutes but if you leave them out to play cricket they may be playing three four hours on a weekend which is very good so parents should advise single based activities at least half an hour one hour and whenever they get a chance to play another one to two hours group activities or group sports these will enormously help the child maintain all the things in control a child who is playing well will have less junk food will sleep on time a child who sleeps well on time will always wake up well on time parents as role models again many times we miss this a parent can't be sitting in front of a tv watching the tv and telling others to go out and play it doesn't happen if we are talking about a child of 5 to 15 years i am just adding another 25 to 30 years so the father or mother are between 40 to 50 years so they also should have some exercise whatever way one hour of jog one hour of walk cycling i am actually pushing a lot of mothers for swimming because if they are already overweight and and they try to run there is a risk of causing arthritis in knee joints so swimming it's one of the best sport it is a whole body sport it doesn't hurt your knees or it doesn't hurt your shoulder joints and weight loss is very good sleep is very very good so parents also should actively exercise at least they should spend half an hour to one hour daily maybe more in the weekends if parents can accompany the children to the park or to the play area nothing like it um even even myself when my children are playing games like football in the weekends i do join them half an hour to one hour i'm not good at it but at least i'm happy to be a part of students who are slc they are pretty good and quicker than me but i do participate with them so when when they see an adult or a parent that acts as a role model that triggers it they are so happy there are neighboring children who will come and ask me uncle are you coming today or not so that that's the bon homie we pick up when we mix with kids healthy eating again parents should promote parents should ensure they are eating their vegetable they are eating their fruit they are eating their curd they are eating one to two eggs so this as the child more than talking or telling them if they see the parent doing that they automatically pick it up and and you don't have to preach them automatically they will do and one of the worst things is mid-mill snacking somehow we have this wrong habit we somehow sit in front of the tv and we are bored we are looking for something and somehow fried items will come into our mind so this is something which parents should avoid seeing parents avoid children will avoid this is something and skimmed milk yeah so if if people are used to using karnataka milk there are two kinds of packets the orange color packet is the full cream milk children less than two years can use that about two years i recommend skimmer milk even in children okay and of course parents should definitely use skimmed [Music] meal so i think this is probably easy to preach very difficult to practice but we here there are some of you here who are youngsters some of you here could be parents i think we have to become role models we need to follow these three or four steps uh the four steps i'm just repeating seven eight hours of sleep is compulsory one hour of exercise daily is recommended eating 2-3 fruits compulsory eating a couple of bowls of vegetables compulsory milk either you want to use milk in coffee or tea we need to get this 400 ml of milk because we need to keep our bones strong you don't want to drink so much of milk 200 ml of milk but then another 200 ml of curds because curds also is very rich in calcium we need to ensure 400 ml of dairy products has to go to us every day we need to spend minimum one hour in sunlight because sunlight gives us vitamin d we should we cannot escape either in the morning if we do not have time in the morning wherever we are working post lunch we have to take a walk in the sunlight if if that option is not there because you have a busy office then evening you you you cut down your practice and go for a walk between 4 30 to 5 4 to 5 actually even in our hospital two to five is a lean period where we have less patients it's easy to go out for a walk for half an hour in the sunlight so once we imbibe this and we follow this with conviction we can tell to the parents of children and with conviction we can tell to children as well if we do we can tell if we advise them they will be excited and and hope they follow it right okay i think uh i've spoken now i will i will stop and pause i i would like you people to ask me if there is some questions i would request all the audience members if they have any questions kindly put up in the comment section or yeah they can yeah they can type it in the comment section and you you can ask the question for me no issues at all yes and also if anyone wants to come on stage you can use the raise and option as well uh so we had a third poll which we had do you want me to run it i put the poll now yeah although unfortunately i've given the answer but yes so i think almost everyone has voted for the last option yeah okay uh so i think we have a couple of questions um prepared a question by dr nitin asking what is exogenous obesity exogenous obesity means there is a alteration between our food and exercise we our food intake is not good and our exercise is not good our body is good but the the what it needs we are not giving it balanced leading to obesity endogenous obesity means the main problem is their basal metabolic rate is very very low for example you have hypothyroidism so your basal metabolic rate is low so your burnout daily is low see this endogenous obesity is lesser largely our population will be exogenous means our body is perfect in condition but however our food intake is more than what we require our exercise is less than what we require leading to this problem right so the next question is would you recommend multivitamins for children no yeah why give fruits give vegetables and curds curds and milk between my my dairy product fruit and vegetable i will cover all their requirement see most vitamin supplements because they have to have a higher shelf life they have to mix it with a preservative there cannot be a product which is made without preservatives so unnecessarily life long you're going to see if you give something for children for a few years it becomes a habit till the day they will carry that with them push them to fruits push them to vegetables push them for 400 ml of milk or milk plus curds agreed at least the next question is by dr rishab and my doctor um asking about what would you recommend if a child is facing an issue of hypothyroidism how would you recommend treating the problem with basically in such a time so let us take my own example i am a pediatrician let us say i have seen somebody who has a high psh or hypothyroidism we have pediatric endocrinologists around i'll send to one of my close colleagues immediately they will check everything and they'll start them on thyroxine 25 mg or 50 mg once their basal metabolic rate is stabilized and tsh comes to normal that child is a normal child except for that they have to take a pill every day for rest of the life as i told in children once they follow it for a few months it becomes a habit they won't give it up i have children who are even taking insulin for type 1 diabetes but but they're so used to it they themselves know that if they have a illness they will take a few minutes more if they have not eaten much for whatever reason they will take a few minutes less so they're quite smart and i'm not talking of big elder children i'm talking of nine-year boys so i think you almost answered the next question as well because the next question was what would you recommend for a type 1 diabetic child like what kind of diet would you recommend especially with weight management like how would you recommend that no so type 1 diabetes is is different they are not obese type 1 diabetics lose weight they are thin so it is what is important is you need to give them enough protein so let us say you have got a 20 kg child i am telling as an example a normal child would require 1 gram per kg protein that is 20 this child will require at not 30 maybe 1.2 to 1.3 25 grams of protein so ensure that this child takes higher protein intake ensure that this child has low glycemic index fruits i'm not saying they should not have high glycemic index fruits once in a while is okay but identify the low glycemic index fruits they can have fruits all vegetables are low glycemic index ensure that they have carbohydrates what they eat ensure that they're eating whole grain okay so our question is by dr muthu asking about uh what would you recommend uh if a child is uh you know constantly complaining of a loss of appetite like what would be your recommendation as a pediatrician so i mean in in children the loss of appetite of course if their weight at night is good there is nothing much to do the commonest cause in india at least is anemia the recent survey is showing 40 percent of indian kids are anemic being iron deficiency itself can cause loss of appetite so get a cbc if you see low hemoglobin start some iron supplement immediately they will improve second if anybody is not exercising and sedentary lifestyle you won't feel like eating so push them out for exercise hunger will improve third you have to avoid meat meal snacking see for example let us talk about adult itself if you are sitting in your practice unless you say no to your nurse five o'clock she will give one coffee six o'clock she'll give one coffee 7 30 she'll give you one tea nine o'clock you'll have no interest to eat any food when you go home for dinner there has to be three to four hours of empty stomach between meals then only your ability to have food will be there so avoid meal snacking give one hour of exercise to the kid yeah the last question is by dr nitin is asking about the role of drugs in the management of childhood obesity like do you have any no definitely it's not like uh yeah not only in children even in others just using amphetamines increasing your heart rate artificially so that your basal metabolic rate goes up and you lose weight that's not the way see if you put don't do anything just put them to football let them play that their basement always will improve they will start burning more and once your sleep is good always your bmr goes higher children who don't sleep well their bmr is lower so anyway as a pediatrician i don't recommend any drugs it is easily solvable issue if you give me a child and give me a couple of years we can get them on track all three things balance it diet balance its sleep balanced exercise so we have another question uh from dr alan uh he says he's describing a case of a 13 year old female child with a bmi of 31 who was diagnosed to have hypertension of 150 by 90 and um with heart rate of over 100 and absent secondary sexual characters diet control and exercise was advised but repeat vp was still 130 over 90. so in this case what would you recommend as an approach emotional disturbance 13 years overweight girl periods must have started and depression would be there psychological counseling is most important the the bp of 150 is not obesity related obesity causes hypertension but not at 13 years a 13 year child which is water-based check out our hormones check out get her to a cardiologist see that there is no renal artery stenosis means there is no secondary hypertension see primary hypertension occurs in 95 population 5 percent still have secondary potential just rule out the secondary cause of hypertension get them into a good psychologist get them somebody who gives them confidence it does very difficult to run or anything they will feel shy best sport for them is swimming okay they do very well right and i think there is a follow-up question uh yeah so um please suggest how to control the food habit of sedentary lifestyle of kids age 12 uh years every two hours either they crave to eat food savory or sweet so how would you recommend craving i mean you know to cut down the cravings for a child see yeah it's it's not craving see the thing is see okay a simple thing your body is not supposed to have very high sugary foods when you start having your body automatically gets ready it knows that every two hours sweet is coming it starts producing insulin in advance so it's like waiting as soon as this comes it quickly has to reduce the blood sugar so it will start sending it to a muscle it can make it to muscle glycogen you can make it to liver glycogen you can send it to adipose tissue and make it fat it can go on doing many many multiple things with it because but it doesn't want the blood sugar to be high so the insulin levels is high now with the insulin levels being high and you are not going to give high glycemic index foods the craving will come there is no one way to stop it so first is push these vegetables what the vegetables does is it fills the stomach but its glycemic index is very very pathetic if your body within four to eight weeks it comes to know it is not getting high glycemic index foods automatically the insulin levels will come down we can we can play up with insulin for example if i want to fast let us say next day 24 hours it will understand and insulin will fall flat at the same time if i go to a party and eat twice of what i am supposed to eat again our insulin will quickly add and make sure our blood is in euglycemic state so the only way is to give a long low glycemic index foods so they are not the stomach is getting full but not higher glucose levels so slowly the insulin levels of the body will drop all right so i think yeah i think those are the questions as that's all the questions that we have for today so thank you so much once again talk radhash for this really enriching enlightening talk about something that is genuinely taking uh a lot like a lot of developed and developing countries like the epidemic of obesity and i really hope that almost i mean everyone here learned a lot as to like how important it is to actually curb diet and portion control and you know focus on actually having nutritional elements in our code so thank you so much for that and uh there is one last question um i'm able to see a reminder if i ask us yeah one second um so um nowadays bariatric surgery is are to be seen a house have you ever is it have you have you ever recommended bariatric surgery for an extremely obvious child no children others so extremely obese they are not able to work out i can go on telling workouts how will extremely always do so either you want to do some bariatric surgery and lose a few kilos so that you don't have to get into an osteoarthritis or ask you knee joint problems it's fine but not for children children we can manage children i start with swimming once they get into swimming they get some strength in their muscles good diet six months one year then slowly push them to some group sport cricket football once they like it then they're back into norm being normal so thank you then i'm switching off now yeah thank you so much sir thank you dr rishali if you can share in the meantime just yes thank you dr adash for this talk we know you were stuck in traffic and you still managed to reach and give such an enlightening talk we have very good comments coming in for the things that they have learned something new as well uh thank you dr avantika for the excellent moderation we always love having you on mad place any of the doctor there wants to become an iron man you can send them to me yeah definitely definitely thank you so much

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dr. Adarsh Somashekar

Dr. Adarsh Somashekar

Consultant Pediatrician & Neonatologist | Ovum Hospitals, Bangalore.

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dr. Adarsh Somashekar

Dr. Adarsh Somashekar

Consultant Pediatrician & Neonatologist | Ovu...

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