1. *Look for Obesity-Associated Complications  Type 2 diabetes  Insulin resistance syndrome  Nonalcoholic fatty liver disease ( NAFLD)  Polycystic ovary syndrome  Skin  Acanthosis nigricans  Stretch Marks  Rashes, Boils  Idiopathic intracranial hypertension  Pulmonary disorders  Obstructive sleep apnea  Hypoventilation syndrome  Hypertension  Dyslipidemia  Proteinuria  Orthopedic  Blount’s disease  Slipped capital femoral epiphysis  Arthropathy  Psychological: depression, self esteem  Gallbladder disease

2. Approach to Obesity Primordial Prevention Primary prevention Secondary prevention BMI<85 th Infant of at risk mother BMI >85 th Cardio vascular risk ( HTN, Atherosclerosis) Metabolic risks (Diabetes) Other: Endocrine, ortho, sleep… BMI >85 th Disease is established. Prevention of Organ damage.

3. Expert Panel, 2011 http://www.nhlbi.nih.gov/files/docs/guidelines/peds_guidelines_full.pdf

4. Cardio-Metabolic risk and other complications BMI Environment GENES BMI

5. The Overweight or Obese but Metabolically Healthy patient Weight and BMI are not automatically synonymous with increased cardio metabolic risks. Genetic background is a major variable. Weight and BMI are the red flag which triggers evaluation for Cardio-Metabolic risks and Mechanical complications

6. BMI AND CARDIO-METABOLIC RISK

7. BMI From 85 th to…. Cardio-Metabolic risks

8. INSULIN RESISTANCE, HYPERINSULINEMIA, PREDIABETES, DIABETES.

9. Disease Timeline Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Sarah E. Barlow, MD, MPH.

10. Insulin resistance/Type 2 Diabetes: screening of the asymptomatic Pediatric patient WhoGuidelinesTests/ frequency Pt ≥ 10 years old or onset of puberty with a BMI≥ 85 th percentile + 2 criteria ►FMHx of DM first and second degree relatives ►High risk group (African American, Hispanic American, native Americans and pacific Islanders) ►Symptoms of Insulin resistance: Acanthosis, HTN, dyslipidemia, PCOS, NAFLD) Expert Panel on Integrated Guidelines for cardiovascular health and risk reduction in children and adolescent. 2012.  Fasting Blood Glucose every 2 years  Fasting Insulin level. ( above NL values) ( predictive in children but not in adolescent- Pediatrics, 2014)  FG/FI <7  Suggest OGTT Same with another at risk Group : SGA and a family history of Gestational Diabetes ADA, Diabetes care. 2014  Hg A1c  Fasting Glucose  Oral Glucose Tolerance tests. Same +: extreme ObesityWorld Journal of Diabetes. European Guidelines.2013  OGTT  Hg A1c

11. ATHEROSCLEROSIS/CV RISKS FOR CORONARY AND PERIPHERAL VASCULAR DISEASES.

12. From the third decade Children from age 2 may need to be evaluated or treated as time span for CV event has shortened to 20-25 years

13. Atherosclerosis: The lipid story What tests? : Lipid Panel  Non Fasting – Total C minus HDL-C= Non HDL-C – LDL-C calculation is not reliable non fasting.  Fasting: – LDL-C – HDL-C – Triglycerides – Total Cholesterol WhoGuidelinesTests/ frequency 2-8 and 11-16 year old ►FMHx of Cardiovascular event in first and second degree relatives under the age of 55(males)and 65(females) ►Parent with a TC ≥ 240 mg/dl ►child has Diabetes,BMI≥ 95 th, smokes cig. ►One Moderate to high risk condition Expert Panel on Integrated Guidelines for cardiovascular health and risk reduction in children and adolescent. 2012. Fasting Lipid profile 9-11 and 17-21 years old ► universal screening Fasting or Non fasting Lipid profile High level Risk factors for early CV event Moderate level Risk factors for early CV event Stage 2 HTN: ≥ 99 th percentile + 5mmh/hg BMI≥ 97 TH High risk condition: renal failure, DM(1-2), heart transplant, Kawasaki with aneurysm Stage 1 HTN BMI≥ 95 th HDL-C≤ 40mg/dl(males) or 50mg/dl ( females) Moderate –risk condition (nephrotic syndrome, chronic inflammatory conditions, HIV, Kawasaki with regressed aneurism)

14. HYPERTENSION

15. HTN prevalence in the pediatric population: 5% 0.025% Increased BPs in 2% to 5% of American children and adolescents BMI≥90th BMI≥99th

16. Left Ventricle (Cardiac) Remodeling Left ventricular hypertrophy Left ventricular Failure

17. Hemoglobin A1c: Diabetes diagnosis: Adult guidelines by the ADA  Glycolated hemoglobin reflects 3 months of average blood glucose.  In 2010, A1c > or = 6.5%.  Or Fasting plasma glucose (FPG) $126mg/dL (7.0 mmol/L).  Or Two-hour plasma glucose $200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test (OGTT).  Or In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose $200 mg/dL (11.1 mmol/L).  In the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing  Caution: Laboratory values refer to adult standards  A1C:  NL <5.7%  Prediabetes: 5.7-6.4  Diabetes: 6.5% or greater.

18. A1c in asymptomatic children or adolescent screened for Diabetes 1)Hg A1c is falsely increased in iron deficiency anemia or unreliable in hemoglobinopathies 2)Not reliable ( more variability in serum blood glucose at early stages of hyperglycemia) 3)No cut off presently for Pediatric age group 4)At present A1c at 6.5% does not indicate automatically Diabetes in children specifically in the absence of UNEQUIVOCAL hyperglycemia (>200mg)

19. *Select appropriate BP cuff size, *auscultation is preferred, *replicate measurement and *average the numbers. Hypertension is diagnosed with persistent elevation ( 4 th report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents, 2013) Systolic / Diastolic Classifica tion EvaluationOther co-morbidities ( the MetSyn) End organ target (use SOB:786.05) 90-95thPre HTNAmbulatory BP (white coat HTN: ICD9 796.2, ) Lipid Profile, fasting Insulin Fasting Blood Glucose 95th-99th+5 Replicate X2 Stage 1 HTN Basic work up: CBC, renal Panel, U/A Lipid Profile, fasting Insulin Fasting Blood Glucose Cardiac Echo EKG 99th+5 Replicate X3 Stage 2 HTN Treat and evaluate: cardiac, Renal, Endocrine, Tumor Lipid Profile, fasting Insulin Fasting Blood Glucose Cardiac Echo EKG

20. BMI From 85 th to…. Other Cardio Metabolic risks

21. From a GI specialist perspective, this is a diagnosis of exclusion after we rule out other causes. This can be extensive. Only a liver biopsy can determine these different levels of liver disease. BMI >85 th percentile 1)Asymptomatic: ALT (CMP)during screening. 2)Symptomatic: ALT/ US BMI + NAFLD= look for Metabolic syndrome  Lipid profile  Insulin resistance  Blood Pressure

22. Menstrual period: the “other Vital sign” absence, increased flow ( 3 pads/day), painful, irregular, delay between telarche and menarche… BMI + abnormal menses +/- hair growth 1)Serum Total Testosterone, Free testosterone, SBG 2)Measure Insulin resistance (fasting Insulin Level, FBG, Hg A1c) 3)LH/FSH ( optional, >3:1) 4)Pelvic ( surface) US if indicated

23. SPECIAL CASES

24. Acanthosis Nigricans

25. Acanthosis Nigricans = evidence of hyperinsulinemia hence insulin resistance (my suggestions based on American Diabetes Association guidelines for diabetes screening of asymptomatic patients) BMIFamily historyTests > 85 th % or >25 + for diabetes, Gestational Diabetes, Insulin resistance such as PCOS A1c, Fasting Insulin, Fasting Glucose Suggest strongly a 2 hours Oral Glucose tolerance test. (With or without insulin level.) > 85 th % or >25No family historyFastingNon fasting A1c, Glucose, insulinA1c, Glucose, Also perform a Lipid profile Fasting or non Fasting, to complete evaluation of the Metabolic Syndrome. ALT/AST every 2 years in patient ˃˃10 years

26. ABDOMINAL PAIN

27. Abdominal Pain in the Patient with elevated BMI symptomsPossible DxTesting RUQ/epigastricNAFLD / HepatomegalyAbdominal US Cholecystitis ( with or without stones) Abdominal US Generalized Abdominal pain ConstipationKUB (L sided/rectal masses) Vomiting (acute or recurrent) Pancreatitis (secondary to hypertriglyceridemia) Abdominal CT scan Amylase, lipase, triglycerides level (usually around 1000mg/dl) Lower abdominal Pain + abnormal period Consider PCOSPelvic Ultrasound