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Childhood Obesity in Practice: A look at the obese & the extremely obese

Childhood Obesity in Practice: A look at the obese & the extremely obese. Robert Murray MD Marc Michalsky MD Nationwide Children’s Hospital. Aims of Presentation. a synopsis national guidelines the risk of extreme obesity bariatric surgery and resolution of health risk.

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Childhood Obesity in Practice: A look at the obese & the extremely obese

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  1. Childhood Obesity in Practice: A look at the obese& the extremely obese Robert Murray MD Marc Michalsky MD Nationwide Children’s Hospital

  2. Aims of Presentation • a synopsis national guidelines • the risk of extreme obesity • bariatric surgery • and resolution of health risk

  3. American Medical Association Dept of Health and Human Services CDC & Prevention American Academy of Pediatrics American Dietetics Association Natl Assoc of Pediatric Nurse Practitioners National Medical Association American Heart Association National Association of School Nurses American college of Sports Medicine The Obesity Society The Endocrine Society American College of Preventive Medicine American Academy of Child & Adolescent Psychiatry Association of American Indian Physicians The Expert Committee Pediatrics, December 2007, 120:supplement 4

  4. The Primary Physician’s Role PreventionIdentification Intervention

  5. Support exclusive breastfeeding 4-6 months Limit sweetened beverages Eat 5 servings per day of fruits & vegetables Participate in moderate to vigorous physical activity for 60 mins/ day Limit screen time to a maximum of 2hrs/ day Do not allow your child to have a television in his or her bedroom Eat a nutritious breakfast every day Engage in regular family meals 5-6 times/ week Limit portion sizes Nine Evidence-Based Messages For Prevention & Counseling

  6. An OUNCE of PREVENTION: Anticipatory Guidance for obesity prevention Ohio Chapter, American Academy of Pediatrics Ohio Department of Health Ohio Dietetics Association American Dairy Council, Mid-East www.NationwideChildrens.org/HealthyWeight/

  7. Normal at 10 yrs = 10% risk of obesity as adult “At risk” or overweight at 10 yrs = 80% risk

  8. Media SocietalLevel Policy CommunityLevel The Workplace Neighborhood Environment Food Industry Medical Community Family Schools Pre-schools Community programs CHILD Early ChildhoodProviders Out of school time/Faith Based Inter-personalLevel Health & Fitness Takes Many Teachers

  9. Parental Perceptions of their Overweight Child • Only 1/3 recognized it • Only 1/4 worried about it • Only 1/5 recalled MD concern In most studies parental recognition of overweight occurs around age 8-12 yrs -- Even later for boys Eckstein, Pediatrics 2006; 117:681

  10. know the number! BMI %-ile At every well-child visit, discuss weight nutrition, activity and health risk

  11. Pediatric Obesity Management Pocket Guide

  12. Create a Risk ProfilePlace the BMI in Context • Family health history • Obesity • Diabetes • Cardiovascular disease • Targeted review of systems • Targeted physical exam • Blood pressure

  13. Review of Systems • Abdominal pain • Joint pain • Snoring, apnea, daytime sleepiness • Polyuria, polydipsia • Irregular menses • Signs of mood disorder • Depression, anxiety • social or school avoidance • Exercise tolerance • Diet • Screen time

  14. Physical Exam • Papilledema on eye exam • Tonsillar hypertrophy • Abdominal pain • Hepatomegaly • Tibial bowing • Hip or knee pain • Signs of precocious puberty • Skin findings • acne, striae, hirsutism • acanthosis nigricans

  15. acanthosis nigricans insulin resistance hyperinsulinemia skin changes

  16. acanthosis nigricans = metabolic changes are already underway altered metabolism Fat mass insulin resistance Identify this early • diabetes • hypertension • abnormal lipids • inflammation • cardiovascular ds • asthma • liver disease • sleep apnea • orthopedic problems

  17. Blood Pressurea critical risk • Children >3 years of age • Auscultation is preferred • Use appropriate sized cuff • Must be plotted on curves adjusted for age, sex, and height • Measurements that exceed the 90th percentile should be repeated

  18. Do I have to check labs? Consider Fasting Lipid Profile age >=2 years, Additional hepatic function and fasting glucose should be considered at age >= 10years. Clinical judgment may dictate additional labs in the younger child with higher risk.

  19. Motivation/Attitude

  20. Support exclusive breastfeeding 4-6 months Limit sweetened beverages Eat 5 servings per day of fruits & vegetables Participate in moderate to vigorous physical activity for 60 mins/ day Limit screen time to a maximum of 2hrs/ day Do not allow your child to have a television in his or her bedroom Eat a nutritious breakfast every day Engage in regular family meals 5-6 times/ week Limit portion sizes Nine Evidence-Based Messages Prevention & Counseling

  21. Algorithm For Intervention

  22. Resources to Help You • Ounce of Prevention • Birth to 5 years • 6 to 19 yrs NEW! • Parent handouts • BMI wheels and tables • Parent Tip Sheets • Pocket management book • Coding sheet • Acanthosis training NEW! www.NationwideChildrens.org/HealthyWeight

  23. Extreme Obesity What to do with

  24. Hypertension Lipid disorders Diabetes Ischaemic heart disease Cardiomyopathy Pulmonary hypertension Asthma Hypoventilation syndromes Obstructive sleep apnea Gallstones NASH (Non-alcoholic steatohepatitis) Urinary incontinence Gastroesophageal reflux Arthritis – weight bearing Low back pain Infertility and menstrual problems Obstetric complications DVT and thromboembolism Depression Immobility Cancer Venous/stasis ulcers Intertrigo Accident prone Medical Sequelae of Obesity

  25. Adipocytes are Endocrine Cells • Secretion of > 50 Adipokines • Leptin • Adiponectin • Resistin • TNF- alpha • Adipose Actions • stimulate inflammation • increase insulin resistance (block receptor signaling) • attract macrophages into fat & vessels (foam cells) • alter metabolism • lower sensitivity to insulin’s actions • shift glucose-based to FFA-based metabolism • fat storage in non-adipose tissues

  26. Obesity & Endothelial Dysfunction Adipose Tissue leptin IL-6 FFA fibrinogen Angiotensin II TNF- alpha Adhesion Molecules Nitric Oxide Macrophage Chemoattractives • inflammation • thrombus formation • plaque destabilization • lipid accumulation • poor distensibility Vascular Endothelial Cell Pharmacol Reports 2006; 58: s81

  27. Extreme Obesity in Children • BMI > 99th percentile or BMI > 35 • 2-6% of all kids • > 50% have metabolic syndrome • Significant cardiovascular changes • Multi-organ complications

  28. Weight Loss - Pediatric Programs • NACHRI identified 80 pediatric centers with weight management programs • Only 15 had an associated surgical weight loss program • 6 to 8 “high” volume programs • August, 2008 – NACHRI formed Obesity Steering Committee

  29. The Bariatric Programat Nationwide Children’s • Surgeons: • Marc Michalsky, MD • Steve Teich, MD • Allen Browne, MD • Bradley Needleman, MD (OSUMC) • Scott Melvin, MD (OSUMC) • Medical Director • Robert Murray, MD

  30. “First 50 Patients”

  31. Co-Morbidities in Bariatric PatientsNCH and OSU Experience

  32. Resolution of Co-morbid Conditions 5 months post-pediatric bypass

  33. Gastric Bypass: Effect on HOMA Body Mass Index Insulin Resistance 4 wk 8wk 12wk 20wk 32wk 52wk 4 wk 8wk 12wk 20wk 32wk 52wk

  34. Homeostatic Model Assessment (HOMA)β Cell Activity vs. Insulin Sensitivity 4 wk 8wk 12wk 20wk 32wk 52wk

  35. Quality of Life Measures 6 months post- bypass

  36. Washington State Healthcare Authority

  37. Health Technology Clinical Committee • Evaluated healthcare coverage for adolescent bariatric surgery • Assessment of the strength of current peer-reviewed evidence • Determine safety, efficacy and cost • Guide decisions regarding state program coverage

  38. Health Technology Clinical Committee • 2004: Estimate 2000 bariatric procedures were performed in patients under 21 years • 75% of bariatric surgeons surveyed report planning to perform a procedure on an adolescent in the near future

  39. Health Technology Clinical Committee • Review 17 peer-reviewed studies • 553 pediatric patients • Studies were assessed for validity/quality

  40. Meta-analysis Results • Majority: academic medical centers • Mean age 15.6 to 18.1 years • Average BMI • RYGB 51.8 kg/m2 • LAGB 45.8 kg/m2

  41. Questions • Does PBS lead to significant (> 7%EBWL) and durable weight loss? • Does PBS improve co-morbidities, QOL and survival compared to medical therapy? • Safety Profile (surgical v. medical) • Cost Profile (surgical v medical) • Does efficacy, safety and cost vary according to demographics (age, sex, BMI)

  42. Conclusion

  43. Clinical ResearchNIH Sponsored • TeenLABS (Longitudinal Assessment of Bariatric Surgery) • NIH-sponsored, • Multi-centered observational study • 2 year follow-up • 5 centers • N = 200 teens

  44. Clinical ResearchNIH Sponsored • Teen-Intake (Nutritional Assessment of Bariatric Surgery) • NIH-sponsored, • Multi-centered observational study • 2 year follow-up • N = 200 teens • TeenVIEW (Controlled Longitudinal of Psycho-social Development) • NIH-sponsored, • Multi-centered observational study • 2 year follow-up • N = 200 teens

  45. Clinical ResearchIndustry Sponsored • LBA 001 (Allergan) • Industry-sponsored IDE, 5 year follow-up • Multi-institutional safety/efficacy trial • n = 150 subjects (14 to 17 years) • Local: n = 26, enrollment closed Dec, 2007

  46. Reversal of Type II Diabetes • 11 teens > 1 year after Roux-en-Y bypass • Mean BMI 50 + 5.9; 50% metabolic synd • Post-op • BMI fell by 34% to 33 + 7 kg/m2 • Improvement of fasting glucose, insulin, HOMA-IR, Hb A1C, AST, ALT, LDL, triglycerides, total cholesterol, blood pressure • Remission of diabetes in 10 of 11 cases • Removal of oral hypoglycemics in 10 cases Inge et al, Pediatrics 2008; 123:214

  47. Cardiovascular Risk &Extreme Obesity in Teens • BMI > 99th %ile or BMI > 40 • N=38 13-19 yrs old • Pre- and post- gastric bypass surgery • Echocardiogram, doppler studies • Adequate studies in only 38 of 67 cases • LV geometry (size, ventricular shape, mass, wall thickness) • LV systolic function (contractility, wall thickness) • Diastolic function (atrial size, pulsed doppler assessment) Ippisch et al, J Am Coll Cardiol 2008; 51:1342

  48. Weight Loss & Cardiovascular Risk • ¼ showed high risk concentric LVH • Adults: with concentric LVH, 53% had a cardiovascular event • Teens: 28% had concentric LVH pre-op, only 3% post-op • LV mass increased • Adults: > 51 g/m2.7 had 4-fold higher CV mortality • Teens studied: averaged > 54 g/m2.7, max 86 g/m2.7 • LV dimensions, systolic function: abnormal • Normal LV geometry: only 36% pre-, up to 79% post-op • Elevated cardiac workload, BP • Decreased HR and systolic BP, rate-pressure product • Abnormal diastolic function • Improved mitral valve and filling dynamics post-op Ippisch et al, J Am Coll Cardiol 2008; 51:1342

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