childhood obesity definitions obesity is: obesity is: excessive storage of fat (triglycerides) in...

Childhood ObesityChildhood Obesity

DefinitionsDefinitions

Obesity is:Obesity is:

excessive storage of fat excessive storage of fat ((triglyceridestriglycerides)) in adipose tissue. in adipose tissue.

BMI ( Body Mass Index )BMI ( Body Mass Index )

Weight (Kg) / Height squared Weight (Kg) / Height squared (m2)(m2)

The most important criterion of The most important criterion of appropriate fatness is healthappropriate fatness is health.. Upper limit of fat for :Upper limit of fat for :

Young men: 22%Young men: 22% Older men: 25%Older men: 25% Young women: 32%Young women: 32% Older women: 35%Older women: 35%

Body fat and health

BMI-for-Age PercentileWhat is BMI-for-Age Percentile?

• Obesity in children is determined by using BMI-for-age percentiles.

• BMI-for-age percentiles have emerged as the favored method to measure weight status in children.

• This method calculates a child’s weight category based on age and BMI, which is a calculation of weight and height.

WHO: Overweight and WHO: Overweight and ObesityObesity

For Adolescents & AdultsFor Adolescents & Adults

BMI between 18.5 & 24.9: Healthy weightBMI between 18.5 & 24.9: Healthy weightBMI between 25 and 29.9: OverweightBMI between 25 and 29.9: OverweightBMI 30 & above: ObeseBMI 30 & above: ObeseBMI 40 & above: Morbid obesityBMI 40 & above: Morbid obesity

For ChildrenFor Children

BMI between 5BMI between 5thth & <85 & <85th th percentile: Healthy percentile: Healthy weightweightBMI between 85BMI between 85thth & 95 & 95th th percentile: percentile: OverweightOverweightBMI >95th percentile: ObesityBMI >95th percentile: Obesity

25%25% of children who are obese at of children who are obese at age 6 will be obese as an adultage 6 will be obese as an adult

75%75% of children who are obese at of children who are obese at age 12 will be obese as an adultage 12 will be obese as an adult

Complications of Complications of childhood obesitychildhood obesity

PSYCHOSOCIALPSYCHOSOCIAL

Increased rates of depressionIncreased rates of depression Poor self esteemPoor self esteem

May carry over into adulthoodMay carry over into adulthood

Children are sensitized to obesity at Children are sensitized to obesity at young ageyoung age

Psychological ProblemsPsychological Problems

Discrimination can cause a negative Discrimination can cause a negative self-image and poor self-esteemself-image and poor self-esteem

Sadness can occur, which can lead to Sadness can occur, which can lead to depressiondepression

LonelinessLoneliness Eating disordersEating disorders

– more prevalent in femalesmore prevalent in females

Social problemsSocial problems

Obese childrenObese children……– May be considered as May be considered as ““unhealthy, unhealthy,

academically unsuccessful & lazyacademically unsuccessful & lazy””– May be teased or verbally abused by May be teased or verbally abused by

other childrenother children– Can become excluded from being a part Can become excluded from being a part

of social groups and/or other activitiesof social groups and/or other activities

Obese adolescent females as young adults had less education, less income, higher poverty rate, and decreased rates of marriage

EndocrineEndocrine

Non-insulin-dependent diabetes Non-insulin-dependent diabetes mellitusmellitus

– The incidence of NIDDM has increased The incidence of NIDDM has increased 10 fold10 fold

– One third of new diabetic children 10-19 One third of new diabetic children 10-19 years of age had Type II DMyears of age had Type II DM

– 92% of these had a BMI >90%92% of these had a BMI >90%

Pinhas-Hamiel 1994

EndocrineEndocrine

Insulin resistanceInsulin resistance– Elevated fasting insulin levels with Elevated fasting insulin levels with

normal Hgb A1Cnormal Hgb A1C– Ratio of fasting insulin to glucose Ratio of fasting insulin to glucose

Adult female: normal <1:4Adult female: normal <1:4 Normal for children not establishedNormal for children not established

– First step towards developing Type II DMFirst step towards developing Type II DM

Insulin Resistance

Obesity

Metabolic Syndrome SyndromeType 2DM

NASH

PCOSDyslipidemia

Hypertension

EndocrineEndocrine

Acanthosis nigricansAcanthosis nigricans– Velvety, hyperpigmented, thickened Velvety, hyperpigmented, thickened

skinskin– Associated with obesity and insulin Associated with obesity and insulin

resistanceresistance Not sensitive for insulin resistanceNot sensitive for insulin resistance

– Resolves with weight lossResolves with weight loss

EndocrineEndocrine

Increased linear growth initiallyIncreased linear growth initially– Growth plates may close earlierGrowth plates may close earlier

Advanced bone ageAdvanced bone age Earlier onset of pubertyEarlier onset of puberty

Endocrine: PCOSEndocrine: PCOS

Hyperandrogenism Hyperandrogenism Ovarian dysfunctionOvarian dysfunction

– OligomenorrheaOligomenorrhea– AmenorrheaAmenorrhea– 55% of adolescent females have polycystic 55% of adolescent females have polycystic

ovaries on USovaries on US Cutaneous manifestationsCutaneous manifestations

– HirsuitismHirsuitism– AcneAcne– Acanthosis nigricansAcanthosis nigricans

Endocrine: PCOSEndocrine: PCOS

Insulin resistanceInsulin resistance HyperlipidemiaHyperlipidemia InfertilityInfertility Premature adrenarchePremature adrenarche

CardiovascularCardiovascular

Primary hypertension uncommon in Primary hypertension uncommon in childhoodchildhood

– 60% of children with persistently 60% of children with persistently elevated blood pressure had weight elevated blood pressure had weight >120% IBW >120% IBW

Lauer J Pediatr 1975;86:697-706.Lauer J Pediatr 1975;86:697-706.

DyslipidemiaDyslipidemia

The atherosclerotic process beings in The atherosclerotic process beings in childhood (Bogalusa Heart Study)childhood (Bogalusa Heart Study)

Lipid levels tend to track with ageLipid levels tend to track with age

DyslipidemiaDyslipidemia

Overweight during adolescence Overweight during adolescence associated with associated with – 2.4 fold increase in prevalence of 2.4 fold increase in prevalence of

cholesterol >240mg/dl cholesterol >240mg/dl – 3 fold increase in LDL values >160mg/dl 3 fold increase in LDL values >160mg/dl – 8 fold increase in HDL values<35 mg/dl 8 fold increase in HDL values<35 mg/dl

in adults 27-31 yearsin adults 27-31 years

Srinivasan Metab 1996;45:235-240.

NAFLDNAFLD

Hepatic steatosisHepatic steatosis– Increased fat in the liverIncreased fat in the liver– Steatohepatitis associated with liver Steatohepatitis associated with liver

inflammation and elevated liver inflammation and elevated liver enzymesenzymes

– 20%-25% obese children have evidence 20%-25% obese children have evidence of steatohepatitisof steatohepatitis

Tazawa Acta Paeditr 1997;86:238-Tazawa Acta Paeditr 1997;86:238-241241

NAFLDNAFLD

NAFLD can progress to cirrhosisNAFLD can progress to cirrhosis

Obesity and type 2 diabetes are the Obesity and type 2 diabetes are the strongest predictors of progression of strongest predictors of progression of fibrosis fibrosis

Age is also a risk factor for cirrhosis which Age is also a risk factor for cirrhosis which may reflect increased duration of risk for may reflect increased duration of risk for the the ““second hitsecond hit”” thought to initiate fibrosis. thought to initiate fibrosis.

Angulo P, Keach JC, Batts KP, Lindor KD. Hepatology 1999;30(6):1356-62

CholelithiasisCholelithiasis

Uncommon in children Uncommon in children – Increased risk in those with hemolytic Increased risk in those with hemolytic

disordersdisorders Obesity accounts for 8%-33% of Obesity accounts for 8%-33% of

gallstones in childrengallstones in children May be associated with weight lossMay be associated with weight loss

Friesen Clin Pediatr 1989.7:294

Crichlow Dig Dis. 1972;17:68-72Crichlow Dig Dis. 1972;17:68-72

Slipped Capital Femoral Slipped Capital Femoral Epiphysis Epiphysis

50%-70% patients with SCFE are obese.50%-70% patients with SCFE are obese.

Suspect and immediately evaluate in an Suspect and immediately evaluate in an obese patient who presents with limp.obese patient who presents with limp.

Can also present with complaints of groin, Can also present with complaints of groin, thigh, or knee painthigh, or knee pain

Wilcox J Pediatr Orthop 1988:8:196-200

Slipped Capital Femoral Slipped Capital Femoral EpiphysisEpiphysis

DiagnosisDiagnosis– Physical examinationPhysical examination

Motion of the hip in abduction and internal rotation is Motion of the hip in abduction and internal rotation is limited on examination.limited on examination.

– XrayXray AP view of pelvis to include both hips AP view of pelvis to include both hips Bilateral disease occurs in up to 20% of patientsBilateral disease occurs in up to 20% of patients Medial and posterior displacement of the femoral Medial and posterior displacement of the femoral

epiphysis through the growth plate relative to the epiphysis through the growth plate relative to the femoral neck femoral neck

Blount DiseaseBlount Disease Diagnosis

– Bowing of tibia and femur either unilateral or bilateral.

Etiology– Results from overgrowth of the medial aspect

of the proximal tibial metaphysis– 2/3 of patients with Blount’s disease are obese

Treatment– Surgery associated with weight loss

Obstructive sleep apneaObstructive sleep apnea

40% of severely obese children demonstrated central hypoventilation

Abnormal sleep patterns reported in 94% of obese children studied


OSAS in children:– prolonged partial upper airway

obstruction

– and/or intermittent complete obstruction (obstructive apnea)

– that disrupts normal ventilation during sleep and normal sleep patterns


Symptoms: Symptoms: – Nighttime awakening / restless sleepNighttime awakening / restless sleep– Excessive snoring / apneaExcessive snoring / apnea– Difficulty awaking in the morningDifficulty awaking in the morning– Daytime somnolenceDaytime somnolence– Nocturnal enuresisNocturnal enuresis– Decreased ability to concentrateDecreased ability to concentrate

Poor school performance.Poor school performance.

Obstructive sleep apneaObstructive sleep apnea History, audio and video taping, and

overnight oximetry are poor predictors

The definitive diagnosis of OSAS is made by nighttime polysomnography

Severity of obstruction may not correlate with either degree of obesity or severity of sleep symptoms


DD: Pulmonary hypertension,systemic

hypertension, right heart failure

OSAS - TREATMENTOSAS - TREATMENT

Weight loss Weight loss – Willi SM, Oexmann MJ, Wright NM, Collop Willi SM, Oexmann MJ, Wright NM, Collop

NA, Key LL Jr. Pediatrics 1998;101(1 Pt NA, Key LL Jr. Pediatrics 1998;101(1 Pt 1):61-71):61-7

Continuous positive airway pressure Continuous positive airway pressure (CPAP) or bilevel positive airway (CPAP) or bilevel positive airway pressure (BPAP)pressure (BPAP)

TonsilladenoidectomyTonsilladenoidectomy

Psuedo tumor cerebriPsuedo tumor cerebri

Definition– Raised intracranial pressure with

papilledema and a normal cerebrospinal fluid in the absence of ventricular enlargement

Obesity occurs in 30%-80% of children with psuedotumor cerebri


Symptoms :– headaches, vomiting, blurred vision or

diplopia– Neck, shoulder, and back pain have also

been reported

Papilledema is part of pathology but may not occur at presentation

John A Moran Eye Center, Salt Lake City UT


Loss of peripheral visual fields and reduction in visual acuity may be present at diagnosis

Increased intracranial pressure may lead to visual impairment or blindness.


Weight loss Acetazolamide Lumboperitoneal shunt in severe

cases

CONCLUSIONS CONCLUSIONS REGARDING REGARDING

PEDIATRIC OBESITYPEDIATRIC OBESITY

PsychosocialPsychosocial

IsolationIsolation DiscriminationDiscrimination Decreased self-esteemDecreased self-esteem Learning difficultiesLearning difficulties Body image disorderBody image disorder bulimiabulimia

Clinical AssessmentClinical Assessment

Clinical historyClinical history AnthropometryAnthropometry Physical examinationPhysical examination Laboratory investigationsLaboratory investigations

AssessmantAssessmant

BMI:BMI: Does not measure body fatness per Does not measure body fatness per

sese In under 15 :is not totally In under 15 :is not totally

independent of height,independent of height,

AssessmentAssessment

Treatment strategiesTreatment strategies

- DietDiet- ExerciseExercise- Behavior modificationBehavior modification- DrugDrug- SurgerySurgery

Intervention levelIntervention level

Multilevel systems focus on:Multilevel systems focus on:– IndividualIndividual– FamilyFamily– SchoolSchool– CommunityCommunity

TreatmentTreatment

No intervention for children <2 yrNo intervention for children <2 yr Treatment indication for children >2yr:Treatment indication for children >2yr:

– Severity of the overweightSeverity of the overweight– AgeAge– ComorbiditiesComorbidities– Rare primary causeRare primary cause

Treatment: some examplesTreatment: some examples

Dietary changes sufficient to create Dietary changes sufficient to create energy deficitenergy deficit

Eliminating high sugar drinksEliminating high sugar drinks in favor in favor of waterof water

Eliminating candy, cookies, cakes Eliminating candy, cookies, cakes and chips in favor of fruits and nutsand chips in favor of fruits and nuts


Sedentary behaviors such as TV, Sedentary behaviors such as TV, computer games should be restricted computer games should be restricted to less than 2 hto less than 2 h

Should be tailored to family’s cultural Should be tailored to family’s cultural and resource and resource

Exercise interventionsExercise interventions– Eg sixty minutes of enjoyable and Eg sixty minutes of enjoyable and

developmentally appropriate activity per developmentally appropriate activity per dayday

1010 practical recommendations: practical recommendations: Swedish experienceSwedish experience

1.1. Reduce sedentary activitiesReduce sedentary activities

2.2. Encourage spontaneous playEncourage spontaneous play

3.3. Discover daily activitiesDiscover daily activities

4.4. Discuss physical education classDiscuss physical education class

5.5. Increase variety of activitiesIncrease variety of activities

6.6. Promote sportsPromote sports

Nowicka P, Acta Paed. 2006

7.7. Encourage hobbiesEncourage hobbies

8.8. Be flexible and patientBe flexible and patient

9.9. Involve family and friendsInvolve family and friends

10.10.Set realistic goalsSet realistic goals


Parents behaviour modificationsParents behaviour modifications– Increases the rate of success compared Increases the rate of success compared

to child-only treatments e.g. not to child-only treatments e.g. not purchasing snackspurchasing snacks

– Parenting behaviour skills include Parenting behaviour skills include rewarding positive behaviourrewarding positive behaviour

Non-conventional therapiesNon-conventional therapies

Very low calorie diets: non-conclusive Very low calorie diets: non-conclusive studiesstudies

Pharmacotherapy:Pharmacotherapy:– Not licensed for kids/Little national Not licensed for kids/Little national

guidelinesguidelines– Sibutramine in small kids is more Sibutramine in small kids is more

effective but?effective but?– Orlistat in snackersOrlistat in snackers– Metformin ?Metformin ?

Bariatic surgeryBariatic surgery

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