pcos

1: PCOS � Obesity The Present Day Menace

2: Epidemiology There is an epidemic of Childhood obesity in the world From 1963-91 -Doubling of the incidence of children with BMI of more than 95th centile Overall scales are going up. Children with the same BMI centiles are now heavier Genetic shift unlikely. Profound environmental effect

3: Definition Weight centile alone is useless as it does not consider height Height for weight is better but does not differentiate between increased muscle or fat BMI reflects the degree of fat content best BMI = Weight in Kgs / Height in m 2

4: Obesity is not overweight. Obesity is excess body fat In adults BMI > 25 is overweight BMI > 30 is obese In children BMI > 85 centile for the age is overweight BMI > 95 centile is obese Definition

5: Lab methods Underwater weighing DEXA Air displacement plethysmography Skin fold thickness Bioelectric impedence Not useful in clinical practice Country specific BMI charts Should be prepared and then 85 and 95 centile limits should be used Definition

6: BMI Centile Charts

7: Definition and Epidemiology Increased prevalence is now seen in countries where the major problem used to be malnutrition Now obesity is caused by poor food choice and decreased activity Indeed we are seeing this more and more commonly in urban areas in India !

8: Tracking of Obesity Three crucial periods determine the chance of obesity during adulthood Gestational period � Infant�s of Diabetic Mother�s have higher chance of becoming obese at 6-10 years and persist into adulthood Adiposity rebound - Early adiposity rebound was related to parental obesity and persistence of obesity in adulthood Adolescent period

9: Childhood onset obesity Has worse prognosis than adult onset obesity Associated with High BP Increased risk of cardiovascular morbidity Insulin resistance and dyslipidemia Lipid profile reveals High triglyceride levels Low HDL levels Visceral fat is most metabolically active Tracking of Obesity

10: Sequel of Obesity Obese children have . . . 2.5 times risk of having high BP 8.5 times risk of being hypertensive adults Increased left ventricular mass Higher chance of being insulin resistant May develop Type 2 diabetes as early as 6 years

11: Functional ovarian hyperandrogenism Restrictive airway disease Obstructive airway disease Snoring, Sleep apnea, Right ventricular hypertrophy Heart failure High incidence of asthma Sequel of Obesity

12: Gynaecological Consequenses Of Obesity PCOD- Hair-An syndrome Anovulation Amenorrhoea D.U.B. Fibroid Uterus Fungal Infections Infertility

13: Evaluation of Obese Youth Family history SMR, acanthosis and striae, goitre Blood pressure Cholesterol, Blood sugar and HbA1c Liver function tests

14: Evaluation of Obese Youth - Endocrine tests T3, T4, TSH Cortisol Dexamethasone suppression test - Low dose 1.5 mg/m2 of Dexamethasone given at 10 p.m. If short metacarpal, cataract etc. then Ca, Phosphorus, PTH Bone age

15: Therapy Dietary restriction Increase physical activity and exercise Reduce sedentary behavior Modify behavior Change of life style for the whole family Reduce TV viewing and computer games

16: Intensive Therapies - Indications BMI > 95 Centile and one medical complication ( co morbidity) Co morbid conditions include Dyslipidemia Disorders of glucose metabolism Hepatic enzyme derangement Hypertension ( Systolic or Diastolic) Pseudotumour Sleep apnea Orthopedic problems

17: Intensive Diet Calorie intake 2400 to 2940 KJ per day Aim is to induce a weight loss of 0.5 kg per week Protein sparing modified fast (PSMF) 2520-3360 KJ/day 1.5 -2.5 g/kg of IBW / day of high quality protein Carbohydrate 20-40 gms/day Does not lead to cardiac arrhythmia as was observed earlier

18: Not prescribed for more than 12 weeks Risks: Cholelithiasis, hyperuricemia, hypoproteinemia, orhthostatic hypotension, halitosis, diarrhea PSMF produce rapid weight loss in the short term In the long term does not seem to be superior to restrictive diet programmes Intensive Diet

19: Pharmacotherapy Limited data available in children and adolescents Medications reducing energy intake Fenfuramine Phenteramine Diethylpropion Sibutramine

20: Leptin A hormone secreted by adipocytes in relation to lipid content It is a peripheral signal to the hypothalamus of inadequate food intake but NOT of Satiety Leptin deficiency causing obesity is VERY VERY RARE Leptin therapy to Leptin sufficient adults is not very impressive in terms of weight loss No studies in children are available

21: Metformin Stops hepatic glucose production Reduces insulin resistance Several studies have shown impressive weight reduction in dosages varying from 500 mg to 2 gm per day in children of 8 - 14 years Side effects Nausea, flatulence, bloating Diarrhea, Vitamin B12 deficiency Lactic Acidosis - Rare

22: Contraindications Renal failure, creatinine > 1.4 mg/dl CCF, cardiac and pulmonary insufficiency Liver disease Metformin

23: No medications are approved for use in children in routine clinical practice except Leptin in Leptin deficiency children

24: Bariatric Surgery Limited experience in children and adolescents Balloons placed in the stomach are shown to be ineffective Jejunoileal bypass is not done now due to high complication rate Roux-en-Y gastric bypass (RYGB) is performed now

25: RYGB Post op complications are many (8.5%) Post op mortality is 1.5% In a recent study by Strauss - Adolescents were treated with bariatric surgery 90% lost > 30 kgs and co morbid conditions improved Complications include iron deficiency, folate deficiency, small bowel obstruction

26: This is the only treatment with evidence that it can induce sustained significant weight reduction in adolescents who have severe obesity Can only be recommended to those with highest morbidity As Strauss concluded: �Gastric bypass remains a last resort option for severely obese adolescents� Bariatric Surgery

27: Education and awareness programs for parents are required to prevent adolescent obesity At risk individuals can be identified with BMI curve The mainstay of treatment is diet, exercise and behaviour modification At present no medicine is routinely used in clinical practice to prevent or treat obesity Take Home Message

28: Concept � Dr. Duru Shah Contributors Dr. Suvarna Khadilkar Dr. Vaman Khadilkar

29: We acknowledge the efforts of our : Coordinators : Dr. Sangeeta Agrawal - Central Dr. Narendra Malhotra - North Dr. Hema Divakar - South Dr. P. C. Mahapatra - East Dr. Uday Thanawala - West In bringing the FOGSI YOUTH EXPRESS to your city.

30: This Youth Express has been possible through an educational grant from Charak Pharma Pvt. Ltd CIPLA Ltd. Emcure Pharmaceuticals Ltd GlaxoSmithKline Pharmaceuticals Limited Glenmark Pharmaceuticals Ltd. Metropolis Health Services (India) Pvt.Ltd. Organon India Ltd Roche Pharmaceuticals Ltd. Sandoz Private Limited USV Limited Wyeth Limited