2. Childhood Obesity

3. Definitions Obesity is: Obesity is: excessive storage of fat (triglycerides) in adipose tissue. excessive storage of fat (triglycerides) in adipose tissue.

4. BMI ( Body Mass Index ) Weight (Kg) / Height squared (m2) Weight (Kg) / Height squared (m2)

5. The most important criterion of appropriate 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

6. BMI-for-Age Percentile What 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.

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8. WHO: Overweight and Obesity For Adolescents & Adults BMI between 18.5 & 24.9: Healthy weight BMI between 25 and 29.9: Overweight BMI 30 & above: Obese BMI 40 & above: Morbid obesity For Children BMI between 5 th & <85 th percentile: Healthy weight BMI between 85 th & 95 th percentile: Overweight BMI >95th percentile: Obesity

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12. 25% of children who are obese at age 6 will be obese as an adult 25% of children who are obese at age 6 will be obese as an adult 75% of children who are obese at age 12 will be obese as an adult 75% of children who are obese at age 12 will be obese as an adult

13. Effects on the Child

14. Complications of childhood obesity

15. PSYCHOSOCIAL Increased rates of depression Increased rates of depression Poor self esteem Poor self esteem  May carry over into adulthood Children are sensitized to obesity at young age Children are sensitized to obesity at young age

16. Psychological Problems Discrimination can cause a negative self- image and poor self-esteem Discrimination can cause a negative self- image and poor self-esteem Sadness can occur, which can lead to depression Sadness can occur, which can lead to depression Loneliness Loneliness Eating disorders Eating disorders –more prevalent in females

17. Social problems Obese children … Obese children … –May be considered as “ unhealthy, academically unsuccessful & lazy ” –May be teased or verbally abused by other children –Can become excluded from being a part of social groups and/or other activities

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

19. Endocrine Non-insulin-dependent diabetes mellitus Non-insulin-dependent diabetes mellitus –The incidence of NIDDM has increased 10 fold –One third of new diabetic children 10-19 years of age had Type II DM –92% of these had a BMI >90% Pinhas-Hamiel 1994

20. Endocrine Insulin resistance Insulin resistance –Elevated fasting insulin levels with normal Hgb A1C –Ratio of fasting insulin to glucose  Adult female: normal <1:4  Normal for children not established –First step towards developing Type II DM

21. Insulin Resistance Obesity Metabolic Syndrome Syndrome Type 2DM NASH PCOS Dyslipidemia Hypertension

22. Endocrine Acanthosis nigricans Acanthosis nigricans –Velvety, hyperpigmented, thickened skin –Associated with obesity and insulin resistance  Not sensitive for insulin resistance –Resolves with weight loss

27. Endocrine Increased linear growth initially Increased linear growth initially –Growth plates may close earlier Advanced bone age Advanced bone age Earlier onset of puberty Earlier onset of puberty

28. Endocrine: PCOS Hyperandrogenism Ovarian dysfunction Ovarian dysfunction –Oligomenorrhea –Amenorrhea –55% of adolescent females have polycystic ovaries on US Cutaneous manifestations Cutaneous manifestations –Hirsuitism –Acne –Acanthosis nigricans

29. Endocrine: PCOS Insulin resistance Insulin resistance Hyperlipidemia Hyperlipidemia Infertility Infertility Premature adrenarche Premature adrenarche

30. Cardiovascular Primary hypertension uncommon in childhood –60% of children with persistently elevated blood pressure had weight >120% IBW Lauer J Pediatr 1975;86:697-706.

31. Dyslipidemia The atherosclerotic process beings in childhood (Bogalusa Heart Study) The atherosclerotic process beings in childhood (Bogalusa Heart Study) Lipid levels tend to track with age Lipid levels tend to track with age

32. Dyslipidemia Overweight during adolescence associated with Overweight during adolescence associated with –2.4 fold increase in prevalence of cholesterol >240mg/dl –3 fold increase in LDL values >160mg/dl –8 fold increase in HDL values<35 mg/dl in adults 27-31 years Srinivasan Metab 1996;45:235-240.

33. NAFLD Hepatic steatosis Hepatic steatosis –Increased fat in the liver –Steatohepatitis associated with liver inflammation and elevated liver enzymes –20%-25% obese children have evidence of steatohepatitis Tazawa Acta Paeditr 1997;86:238-241

34. NAFLD NAFLD can progress to cirrhosis NAFLD can progress to cirrhosis Obesity and type 2 diabetes are the strongest predictors of progression of fibrosis Obesity and type 2 diabetes are the strongest predictors of progression of fibrosis Age is also a risk factor for cirrhosis which may reflect increased duration of risk for the “ second hit ” thought to initiate fibrosis. Age is also a risk factor for cirrhosis which may reflect increased duration of risk for the “ second hit ” thought to initiate fibrosis. Angulo P, Keach JC, Batts KP, Lindor KD. Hepatology 1999;30(6):1356-62

35. Cholelithiasis Uncommon in children Uncommon in children –Increased risk in those with hemolytic disorders Obesity accounts for 8%-33% of gallstones in children Obesity accounts for 8%-33% of gallstones in children May be associated with weight loss May be associated with weight loss Friesen Clin Pediatr 1989.7:294 Crichlow Dig Dis. 1972;17:68-72

36. Slipped Capital Femoral Epiphysis 50%-70% patients with SCFE are obese. 50%-70% patients with SCFE are obese. Suspect and immediately evaluate in an obese patient who presents with limp. Suspect and immediately evaluate in an obese patient who presents with limp. Can also present with complaints of groin, thigh, or knee pain Can also present with complaints of groin, thigh, or knee pain Wilcox J Pediatr Orthop 1988:8:196-200

37. Slipped Capital Femoral Epiphysis Diagnosis Diagnosis –Physical examination  Motion of the hip in abduction and internal rotation is limited on examination. –Xray  AP view of pelvis to include both hips  Bilateral disease occurs in up to 20% of patients  Medial and posterior displacement of the femoral epiphysis through the growth plate relative to the femoral neck

38. Blount 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

39. Obstructive sleep apnea 40% of severely obese children demonstrated central hypoventilation Abnormal sleep patterns reported in 94% of obese children studied

40. Obstructive sleep apnea 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

41. Obstructive sleep apnea Symptoms: Symptoms: –Nighttime awakening / restless sleep –Excessive snoring / apnea –Difficulty awaking in the morning –Daytime somnolence –Nocturnal enuresis –Decreased ability to concentrate  Poor school performance.

42. Obstructive 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

43. Obstructive sleep apnea DD: Pulmonary hypertension,systemic hypertension, right heart failure

44. OSAS - TREATMENT Weight loss Weight loss –Willi SM, Oexmann MJ, Wright NM, Collop NA, Key LL Jr. Pediatrics 1998;101(1 Pt 1):61-7 Continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BPAP) Continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BPAP) Tonsilladenoidectomy Tonsilladenoidectomy

45. Psuedo 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

46. Psuedo tumor 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

47. John A Moran Eye Center, Salt Lake City UT

48. Psuedo tumor cerebri 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.

49. Psuedo tumor cerebri Weight loss Acetazolamide Lumboperitoneal shunt in severe cases

50. CONCLUSIONS REGARDING PEDIATRIC OBESITY

51. Psychosocial Isolation Isolation Discrimination Discrimination Decreased self-esteem Decreased self-esteem Learning difficulties Learning difficulties Body image disorder Body image disorder bulimia bulimia

52. Physical Consequences Type 2 Diabetes Type 2 Diabetes –used to be virtually unrecognized in adolescence –almost entirely attributable to obesity –obese children are reported to be 12 times more likely to have high fasting blood insulin levels Orthopedic complications Orthopedic complications –bone and cartilage in the process of development are not strong enough to bear excess weight Hypertension Hypertension –Elevated blood pressure levels have been found to occur about 9 times more frequently among obese children

53. Clinical Assessment Clinical history Clinical history Anthropometry Anthropometry Physical examination Physical examination Laboratory investigations Laboratory investigations

54. Assessmant Anthropometry : Anthropometry : Height and weight, Height and weight, Body proportions, Body proportions, Circumferences or girth measures, Circumferences or girth measures, Skinfold thickness, Skinfold thickness, Skeletal diameters, Skeletal diameters, Segment lengths Segment lengths

55. Assessmant BMI: BMI: Does not measure body fatness per se Does not measure body fatness per se In under 15 :is not totally independent of height, In under 15 :is not totally independent of height,

56. Assessment

57. Treatment strategies - Diet - Exercise - Behavior modification - Drug - Surgery

58. Intervention level Multilevel systems focus on: Multilevel systems focus on: –Individual –Family –School –Community

59. Treatment No intervention for children <2 yr No intervention for children <2 yr Treatment indication for children >2yr: Treatment indication for children >2yr: –Severity of the overweight –Age –Comorbidities –Rare primary cause

60. Treatment: some examples Dietary changes sufficient to create energy deficit Dietary changes sufficient to create energy deficit Eliminating high sugar drinks in favor of water Eliminating high sugar drinks in favor of water Eliminating candy, cookies, cakes and chips in favor of fruits and nuts Eliminating candy, cookies, cakes and chips in favor of fruits and nuts

61. Treatment: some examples Sedentary behaviors such as TV, computer games should be restricted to less than 2 h Sedentary behaviors such as TV, computer games should be restricted to less than 2 h Should be tailored to family’s cultural and resource Should be tailored to family’s cultural and resource Exercise interventions Exercise interventions –Eg sixty minutes of enjoyable and developmentally appropriate activity per day

62. 10 practical recommendations: Swedish experience 1. Reduce sedentary activities 2. Encourage spontaneous play 3. Discover daily activities 4. Discuss physical education class 5. Increase variety of activities 6. Promote sports Nowicka P, Acta Paed. 2006

63. 7. Encourage hobbies 8. Be flexible and patient 9. Involve family and friends 10. Set realistic goals

64. Treatment: some examples Parents behaviour modifications Parents behaviour modifications –Increases the rate of success compared to child-only treatments e.g. not purchasing snacks –Parenting behaviour skills include rewarding positive behaviour

65. Non-conventional therapies Very low calorie diets: non-conclusive studies Very low calorie diets: non-conclusive studies Pharmacotherapy: Pharmacotherapy: –Not licensed for kids/Little national guidelines –Sibutramine in small kids is more effective but? –Orlistat in snackers –Metformin ? Bariatic surgery Bariatic surgery

66. متشکرم