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OVERWEIGHT AND OBESITY. DR.MOEZZI. Overweigth &obesity are terms that are commonly used interchangably in children,with overweigth being the preferred term. EPIDEMIOLOGY. NHANES documents that 16% of children are overweight and 31% are at risk for becoming overweight .

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slide2
Overweigth &obesity are terms that are commonly used interchangably in children,with overweigth being the preferred term.
epidemiology
EPIDEMIOLOGY

NHANES documents that 16% of children are overweight and 31% are at risk for becoming overweight .

The first predictor of overweight is high birthweight,probably linked to maternal obesity or maternal diabetes.

Children who are overweight are more likely to be over weight as adults.

The Strongest predictor of childhood overweight is parental obesity.

pathogenesis
PATHOGENESIS

OVERWEIGHT RESULTS FROM A DYSREGULATION OF CALORIC INTAKE AND ENERGY EXPENDITURE.

pathogenesis1
PATHOGENESIS

Enviromentalchanges: thetype &cost of food has dramatically changed over last several decades .snacking between meals has risen steadily the last 2 decades ,with many snacks being high in fat ,sugars, or both.

1/3 children in USA eat fast food daily;

a typical single meal can contain 2000 kcal 84 gr fat &only 12gr fiber.

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Decrease in activity &a lack of exersise also contribute to an increase in the prevalence of overweight.

Wacth of TV-video games-internet computer use-telephone use

continued
Continued…

Endogenous weight control mechanisms:

slide9

Super Sized Fast Food

1610 Calories

63 gm fat

disease associated with childhood obesity
Disease associated with childhood obesity

Excessive weight

Gain or BMI in

infant&toddler

Alstrom

Bardet-biedl syndrome

Carpenter syndrome

Cohen syndrome

Cushing syndrome

Deletion 9q34

Frohilich syndrome

Hyperinsulinism

Melanocortin 4 receptor gen mutation

Muscular dystrophy

Myelodysplasia

Prader-willi syndrome

Pseudohypoparathyroidism

Turner syndrome

diagnostic criteria for overweight
Diagnostic criteria for overweight

The calculated BMI can overestimated adiposity in trained athletes or muscular children ,but it is generally recognized as the most reliable method to dtermine healthy&unhealthy adiposity.

Other methods of determining adiposity are usefull . But are either too expensive to of practical use in a clinical setting(ulrasound,CT,MRI,DEXA,total body conductivity,air displcement plethymography),require specialized training (skinfold thickness),have poor reproducibility(waist-hip ratio),or lack extensive normative data in children(bioelectric impedence analysis)

continued1
Continued…

BMI in combination with clinical assement is sufficient to make the diagnosis .

Children adiposity rises in the 1st year of life, reaches a nadir around 5-6 yr of age,and then increases again throughout chilhood.this is called adiposity rebound.

continued2
Continued…

The 95th percentile BMI for a 4 yr old is approximately 19,but it is 25 in a 13 yr old.

BMI classification of children &adolescents:

<5th percentile under weight

5th -84th percentile normal weight

85th -94th percentile at risk overweight

≥95th percentile overweight

evaluation of the overweight child
Evaluation of the overweight child

Evaluation of overweight children & families requires sensitivity &compasion, because the general puplic often percieves overweight individuals as un healthy ,uninteligent, unhygienic&hazy.

Obesity is chronic medical problem that requires management in a manner similar to that of other chronic disorders.

contineud
Contineud….

The initial evaluation is focused exploring dietary practices ,family structures &habits because alteration of these factors is usually the basis of successful treatment.

continued3
Continued…

cushing syndrome:

1.The onest of relatively rapid weight gain

2.Increase in BMI percentile

3.Centeral obesity

Other symptoms:muscle weakness-eccymoses-unexplained osteoporesis-hypokalemia

continued4
Continued…

Hypothyroidism can be associated with obesity but usually weight gain is modest ,because appetite is often reduced and problems of poor linear growth ,delayed skeletal development ,delayed puperty are more prominent feature.

endocrinologic disease
Endocrinologic disease

1.Normal linear growth alone generally precludes the diagnosis of endocrinologic disease.

2.A family history of endocrinopathy

3.height/age <50th percentile

4.T4 –TSH evaluation

5.The 24hr urinary free cortisol level.

comorbities of overweight
COMORBITIES OF OVERWEIGHT

1.Asthma

shothnessofbreath,wheezing,couqh

pulmonary function test

2.Gallstone

abdominal pain ,vomiting, jaundice

ultrasound

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3.Obstructive sleep apnea

snoring,daytime somnolence,enuresis

polysomnography,hypoxia,electrolyte

4.Blountdisease

knee pain,limp,bowing of legs

knee x-ray

5.Slipped capital femoral epiphysis

hip pain,limp

hip x-ray

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6.Pseudotumor cerebri

headache,dizziness,diplopia,papilledema

CT,MRI,cerebrospinal fluid opening pressure

7.Behavioral complication

disordered eating,sign of depression ,social isolation , low self –steem,worsening school performance

Behavioral survey

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8.Nonalcoholic fatty liver disease

hepatomegaly,abdominalpain,dependentedema

AST,ALT,ultrasound,CT,MRI

9.Hypertension

elevatedBP>95thpercentileforage,sex,height

serial testing,U/A,electrolyte,BUN,creatinine

slide25
10.insuline resistance

familyhistory,polyuria,polydypsia,unintentional↓weight

Fastingglucose,Hb A1c ,insuline level,oral GL tolerance test

11.Dyslipidemia

family history(high cholesterol,early onset heart disease)

fasting total cholestrol,HDL,LDL,TG

physical finding
Physical finding

Hypertension

Acantosis nigricans-insulin resistance

Tanner staging -premature adrenarche

Hirsutism,male pattern baldness,severe acne-

( polycystic ovary syndrome)

simplified laboratory norms for assessing overwieght children
Simplified laboratory norms for assessing overwieght children

Glucose <110mg/dl

Insulin <15mu/l

Hemoglobin A1c <6.0%

AST 2-8yr <58u/l

9-15yr <46u/l

15-18yr <35u/l

ALT <35u/l

Total cholestrol <170mg/dl

LDL <110mg/dl

HDL <35mg/dl

Triglycerides

2-15yr <100mg/dl

15-19yr <125mg/dl

treatment
TREATMENT

Successful treatment of obesity is challenging and trearment goals vary ,depending on the age and severity complication.

Children of still growing ,so severe caloric restriction and weight loss maybe detrimental.

Weight loss should be slow (0.5kg or less per week),because more rapid weight loss requires overly restrictive dieting.

Initial goal of a 10% reduction in weight is reasonable because this amount of weight loss has been shown to significant improve overal health.

continued5
Continued….

The new weight should be maintained for 6month before furture weight loss is attemptemed.

The most successful approach to weight maitenance or weight loss requires substatial lifestyle changes that include increased physical activity and altered eating habits.

Therapies often combine diet ,exercise ,behavior modification,medication,and rarely ,surgery.

office based managment
Office-Based Managment

Anticipatory guidance:establishing healthy eating habits in children

Do not punish a child during mealtimeswith regard to eating.

Do not use foods for reward.

Parents,sibling should model healthy eating.

Children should be exposed to a wide range of foods,tastes,and textures.

Foods should be offered multiple time.

Offering a range of foods with low energy density helps children balance energy intake.

continued6
Continued…

Rectricting access to foods will increase than decrease a child preference for that food.

Forcing a child to eat a certain food will decrease his or her preference for that food.

Children tend to be more aware of satiety than adult.

Do not force children to clean their plate.

multidisiplinary and community based managment
Multidisiplinary and community-based managment

Severely overweight children and adolescents with complication from obesity are best managed with multidisiplinary team.

Teams may include a physician,a psychologist,a dietian,exercise espcialist,a nurse, and counselors.

Management consists of dietary counseling,exercise therapy,and behavioral mangement.

dietary counseling
Dietary counseling

Recommendations for healthy eating should be age-specific and flexible enough to accommodate family and ethnic food preferences.

In toddlers ,limiting sweetened beverages is usually the most useful initial strategy.the American Academy Of Pediatrics(AAP) recomeds a maximum intake of 4-6 oz of fruit juice/day for children 1-6 yr and 8-12 oz for 7-18 yr olds.

continued7
Continued….

Other simple intervention include changing to skim milk in children older than the age of 2 yr and assuring exposure to a wide variety of foods;including less caloric dense food choices and limitation of between –meal snacking.

For preschool-aged children ,sweetend beverages should be limited and parents should continue to offer healthy foods.

As children reach shool age ,busy schedules and exposure to food advertisements often increase fast food intake.education regarding meal planning and the value of family mealtimes in maintaining family structures can decrease the number of meals eaten away from home.

continued8
Continued….

Encouraging children to eat breakfast decreasing their intake of sweetend beverage ,and teaching them the principles of balanced nutrition are useful strategies for the overweight adolescent.

continued9
continued

More severe dietary restriction should be used only in supervised program.

An extremely low-caloric diet(800kcal/24hr) is used for children with severe obesity needing rapid weight loss.

Low carbohydrate or controlled-carbohydrate diets show superior weight loss compared with low fat diet in adolescent.

Nutrition plans based on the glycemic index of foods has shown great promise in overweight children.

continued10
continued

Glycemic index is based on the insulin response to a carbohydrate,with simple carbohydrates having a higher ,and therefore less desirable,glycemic index compared with complex carbohydrates.

Complex carbohydrates such as non-starchy vegetables and whole grains.

continued11
Continued….

A successful approach used preschool and preadolescent children is the traffic light or stoplight.it is designed to limit calories ,yet achieve good nutrient balance and is easily adaptable to fit particular ethnicities and nutrition plans,such as low carbohydrate or glycemic index diets.

stoplight diet plan
Stoplight Diet Plan

Color green light food yellowlightfoodredlightfood

Quality low calorie nutreint dense high in calorie

high fiber but higher in suger&fat

low fat calories&fat

Types of fruits lean,meats,dairy fattymeats

foods vegetables starches,grain suger,fried

foods

Quantity unlimited limited infrequent or

avoided

physical activity
Physical Activity

Increased activity not only increases calorie use bul also appears to decrease appetite.

In children younger than 2 yr of age ,AAP recommends avoiding TV computers.

children 2-18yr of age should have <2hr/day of “screen time”(TV,video games,computer)and TVshould be removed from children bedrooms.

continued12
Continued…

Prescribed exercise regimens can be useful.

Simple measures such as daily walks can be useful.

medication
Medication

Pharmacologic treatment is sometimes indicated as an adjunct to diet and physical activity in overweight adult with obesity –related complication.

Medication of overweight children &adolescent is reserved for those with sever medical complication.

The use of sibutramine isnot recommended in children younger than 16 yr of age.

continued13
Continued…

Olistat has been effective in adolescents older than 12 yr of age,but GI side effects of diarrhea and abdominal pain are common,and the potential effects on fat-soluble vitamin and mineral absorption in growing adolescent are a concern.

Topiramat an antiepileptic ,has marked anorectic effects.

slide46
Metformin is being studied in adult patients and appears to promote weight loss and prevent development of metabolic syndrome.although metformin does appear to have some efficacy in promoting weight loss and lifestyle changes .

Octreotide has shown promise for weight control in children with hypothalamic obesity.

continued14
Continued….

Rimonabant a cannabinoid type 1 receptor antagonist ,has been effective in obese adult in reducing weight and ameliorating abnormal metabolic parameters.

At this time,the use of pharmacologic agents for the treatment of overweight children and adolescents is of marginal value ,with unclear risk.

bariatric surgery
Bariatric surgery

There is some efficacy of bariatric surgery in adolescents,the long term safety has not been adequately studied.

In USA roux-en-y gastric bypass is one approach for weight control surgery.weight loss that approaches 60-70% of excess body weight is often achieved.monitoring for nutritional complications is mandatory because deficiencies of iron,vit B12,folate ,thiamine,vit D and calcium has been reported.

continued15
Continued…

Cases of wernicke encephalopathy have occurred in some patients who have not complied with the recommended dietary supplement after surgery.

slide50
The American Pediatric Surgical Association Guideline recommend that surgery be considered only in children with a BMI>40 and medical complication of obesity after they have failed 6 mo of multidisiplinary weight management program.
slide51
Less invasive procedure than the Roux-en-y gastric bypass are available and include the adjustable gastric band that functions only by extrinsic gastric restriction.

One benefit is the band canbe removed.