16 obesity and metabolic syndrome aap.ppt

Pediatric obesity case study, risk factors, symptoms, complications and management.

1. PEDIATRIC OBESITY AND
THE METABOLIC
SYNDROME
Whitney Brown, M.D.
Division of Pediatric Endocrinology

2. LECTURE OBJECTIVES
Know the BMI percentile cutoffs for pediatric
overweight, obesity, and morbid obesity
Recall the co-morbidities associated with
pediatric obesity
Understand that there is no current accepted
definition for the metabolic syndrome in
pediatrics
Be familiar with the laboratory screening
recommendations in pediatric obese patients
Discuss the treatment options/recommendations
for pediatric obesity and some of its co-
morbidities

3. Calories In Calories Out

4. EPIDEMIOLOGY
National Health and Nutrition Examination
Survey (NHANES)
1
2007-2008

16.9% of children (age 2-19 years) obese
1970

5%
In South Carolina—26.9%
50% of obese children (>6 years) will become
obese adults
2
10% for nonobese children
1
Ogden CL, et al. JAMA. 2010; 303(3): 242–249
2
Whitaker RC, et al. NEJM. 1997; 337(13): 869-873

5. DEFINING PEDIATRIC OBESITY
Body Mass Index (BMI)
Weight (kg)/ [height (m)]
2
Preferred method for evaluating obesity

Age 2-19 years
Correlates strongly with body fat percentage

6. DEFINING PEDIATRIC OBESITY
(CONT.)
1994-Expert Committee on Clinical Guidelines
for Overweight in Adolescent Preventative
Services
Overweight

BMI > 30 kg/m
2

BMI ≥ 95
th
percentile for age and gender
“At risk for overweight”

BMI ≥ 85
th
but ≤ 95
th
percentile
2005-Institute of Medicine
Obese

BMI > 30 kg/m
2

BMI ≥ 95
th
percentile for age and gender

7. DEFINING PEDIATRIC OBESITY
(CONT.)
2007-American Academy of Pediatrics
Overweight

BMI ≥ 85
th
but ≤ 95
th
percentile
Obese

BMI > 30 kg/m
2

BMI ≥ 95
th
percentile for age and gender
Morbidly obese

BMI ≥ 99
th
percentile
If < 2yo
Overweight

Weight for lenth ≥ 95
th
percentile for age and gender

8. OBESITY-RELATED CO-MORBIDITIES
Cardiovascular Conditions
•Hyperlipidemia
•Hypertension (HTN)
Endocrine Conditions
•Dysmetabolic Syndrome
•Type 2 Diabetes
•Impaired Glucose Tolerance
•Menstrual Irregularities
•Polycystic Ovarian Syndrome
•Accelerated Growth
Gastrointestinal Conditions
•Non-Alcoholic Fatty Liver
Disease (NAFLD)
•Gallstones
Orthopedic Conditions
•Blounts Disease
•Hip Disorders (SCFE)
Psychological Conditions
•Depression/Self-Esteem
•Substance Abuse
•Disordered Eating
•Discrimination
Pulmonary Conditions
•Asthma
•Sleep Apnea

9. ACCEPTED DEFINITION OF THE
METABOLIC SYNDROME IN ADULTS
Zimmet P, et al. Diabetes Voice. 2005; 50(3): 31-33
International Diabetes Federation

10. WAIST CIRCUMFERENCE
102 cm
88 cm
ATP III

11. PREVALENCE OF THE METABOLIC
SYNDROME
Overall incidence
Age 12-19 years

3-4%
Age 20-29 years

6.7%
Adults ≥ 30 years

23.7%
NHANES III (n=2400)
Adolescents age 12-19 years

BMI ≥ 95
th
percentile

28.7%

BMI 85
th
-94
th
percentile

6.1%

BMI ≤ 84
th
percentile

0.1%
Cook S, et al. Arch Pediatr Adolesc Med. 2003; 157 (8): 821-827

12. PEDIATRIC METABOLIC SYNDROME:
NEED FOR A STANDARD
DEFINITION
Reviewed 27 articles
46 unique definitions of pediatric metabolic syndrome
Most emulated the NCEP approach

BMI or waist circumference

Blood pressure

Lipid levels

Glucose abnormalities
Different cut-offs/percentiles were used in the various
definitions
Ford ES, et al. J Peds. 2008; 152(2): 160-164

13. PEDIATRIC METABOLIC SYNDROME:
WHAT TO SCREEN WITH AND
WHEN!
 
Obesity T2DM HTN Hyperlipidemia
Type
of Screening
BMI
 
FBG
or 2hr OGTT
(?
HbA1c)
 
Measure
BP
 
Fasting
lipid panel
  
Who
should be
screened? All
children >2yo
Children
≥ 10yo
All
children ≥ 3yo
All
children ≥ 2yo
  Or IF
  At
onset of puberty
Family
hx of premature CVD
  IF OR
  BMI
>85th %ile
If
other risk factors present:
  AND BMI>
95th percentile
  ≥

2
risk factors
Diabetes
  (+)family
hx for T2DM
Smoking

  Ethnic
minority
HTN
  Signs
of insulin resistance

14. Overweight/Obesity
Glucose abnormalities
Blood pressure
Fasting lipid levels
• Overweight: BMI ≥ 85
th
percentile
• Obese: BMI ≥ 95
th
percentile
• Morbidly BMI ≥ 99
th
percentile
• ADA criteria
• Impaired fasting glucose (IFG)
 ≥ 100 but <126
• Impaired glucose tolerance (IGT)
 ≥ 140 but <200
• At risk for developing T2DM
 HbA1c between 5.7 and 6.4%
• Norms varying depending on age, height,
and gender
• Norms very depending on age/gender

15. 2005 NIH—National Heart Lung and Blood Institute BP Tables
• Pre-HTN
 SBP and/or DBP
 Between 90-94
th
percentile
• HTN
 SBP and/or DBP
≥ 95
th
percentile
 On 3 or more occasions

16. Tamir I, et al. J Chronic Dis. 1981; 34(1): 27-39
AAP. Pediatrics. 1992; 89: 525-584

17. OFF THE RECORD:
No accepted definition of pediatric metabolic
syndrome
Clinically I use:
BMI ≥ 85
th
percentile plus ≥ 2 of the following

HDL <10
th
percentile (~40 mg/dL)

TG >95
th
percentile

IGT or IFG

BP ≥ 90
th
percentile

18. EVALUATION OF PEDIATRIC
OBESITY

19. HISTORY
Complete dietary history
Meals/snacks
Portion sizes
Dining out
Fried food
Drinks
Complete physical activity history
PE
Activity outside of school
Intensity
Number of hours per day
TV, video games, computer, talking/texting on phone
ROS
Geared toward the co-morbidities associated with
obesity

20. PHYSICAL EXAM

21. PATHOLOGIC CAUSES OF OBESITY IN
CHILDHOOD
Pseudohypoparathyroidism
Albright Hereditary Osteodystrophy
Cushing syndrome
Laurence Moon or Bardet-Biedel syndrome
Prader Willi syndrome
MC-4R mutation
Congenital leptin deficiency
POMC mutation
Fragile X syndrome
Trisomy 21

22. MEDICATIONS ASSOCIATED WITH
WEIGHT GAIN

23. LAB SCREENING
RECOMMENDATIONS
Overweight with no risk factors:
Fasting lipid panel
Overweight with risk factor(s):
Fasting lipid panel
AST/ALT
Fasting glucose
Obese (± risk factors)
Fasting lipid panel
AST/ALT
Fasting glucose
BUN/Cr
Risk Factors:
• Family Hx of obesity-
related diseases
• Elevated BP
• Elevated lipid levels
• Tobacco use

24. OBESITY: PREVENTION
Breastfeeding alone until age 6 months, and
encourage BF even after intro of solid foods
Do not skip meals
Eat meals as a family; Dining out ≤ 2x/week
Avoid high sugar beverages
≤ 12 oz of 100% fruit juice daily
Drink 3-4 8-oz glasses of skim milk daily
Ca and Vit D fortified
Portion sizes should be limited to the amount of
recommended calories for age
Keep TVs and other electronics out of bedrooms
≤ 2 hours of screen time daily
1 hr of moderate intensity aerobic exercise daily
American Heart Association 2008 Policy Statement

25. OBESITY: TREATMENT STAGES
Prevention (P)
All children

Promotion and support for:

Breastfeeding

Family meals

Limited screen time

Regular physical activity

Yearly BMI monitoring
Prevention Plus (PP)
BMI between the 85th - 94th
percentiles

5 servings of fruits and vegetables/day

2 hours or less of screen time

1 hour or more of physical activity

0 sugared drinks
Structured Weight Management
(SWM)
If PP fails

BMI is between 95th - 98th percentiles

More frequent follow-up with written
diet and exercise plans
Comprehensive Multidisciplinary
Intervention (CMI)
When 3 - 6 months of SWM fails

More frequent visits with an MD and a
dietician

May include exercise and behavioral
specialists
Tertiary Care Intervention
BMI ≥ 99th percentile with associated
comorbidities
SWM and CMI failed

Incudes everything else plus:

Meal replacements

Pharmacotherapy

Bariatric surgery
Barlow SE and the AAP Expert Committee. Pediatrics. 2007; 120(4): S164-S192

26. HEALTHY LIFESTYLES CLINIC:
PALMETTO HEALTH RICHLAND
Group
education
Individual
Session

27. Breakfast Everyday
5 servings of fruits/veggies
3 structured meals daily
≤ 2 hrs daily of TV/video time
≥ 1 hr/day of moderate activity
Almost no high sugar beverages

28. OBESITY: PHARMACOTHERAPY
Orlistat (Xenical or Alli)
FDA-approved for
children ≥ 12yo
Inhibits GI lipases
Dose: 120 mg TID

During or up to 1hr after
meal

MVI 2 hrs before or after
orlistat
GI side effects common
Metformin
Not FDA approved for obesity
For T2DM

Approved in children ≥ 10yo
Metformin ER

FDA approved ≥ 17yo
Major effects:

↓ hepatic gluconeogenesis

↑ peripheral insulin sensitivity

29. METFORMIN (CONT.)
Starting dose
500 mg Qday, increased to a max of 1000mg BID
Titrating slow can limit GI-side effects
MVI with vit B12
Contraindictaed in:
Renal failure
Chronic hypoxic states
Use of radiocontrast dye
Very rare side effects: decreased platelet aggregation
and hemolytic anemia
Check BUN/Cr and CBC
Before initiation
Every 2 years

30. METFORMIN USE IN PEDIATRIC
OBESITY
Review of 5 RCTs from 2001-2008
Children age 6-19 years (n=320)
All trials lasted 6 months
Metformin 1000-2000 mg/day or placebo
BMI reduction of 1.42 kg/m2
Improved insulin sensitivity
Park MH, et al. Diabetes Care. 2009; 32(9): 1743-1745
Need larger, long term studies

31. ELEVATED LDL: TREATMENT
RECOMMENDATIONS
Daniels SR, et al. Pediatrics. 2008; 122: 198-208
Recommended
LDL Concentrations for Pharmacologic Treatment of Children and Adolescents 10 years and Older
Patient
Characteristics
Recommended
Cut Points
No
other risk factors for CVD
LDL
concentration is persistently > 190 mg/dL despite diet therapy
Other
risk factors present, including obesity
HTN,
tobacco use, or positive family hx
LDL
concentration is persistently > 160 mg/dL despite diet therapy
or
premature CVD
Children
with diabetes mellitus
Pharmacologic
treatment should be considered when LDL
concentration
is ≥ 130 mg/dL

32. HYPERLIPIDEMIA
PHARMACOTHERAPY

33. FISH OIL: COROMEGA

34. STAGES OF PEDIATRIC HTN
Normal
< 90
th
percentile
Pre-hypertension
≥ 90
th
percentile and < 95
th
percentile
Stage 1 hypertension
≥ 95
th
percentile and ≤ 99
th
percentile +5 mmHg
Stage 2 hypertension
> 99
th
percentile + 5 mmHg

36. Horizontal gastric stapling
with Roux gastrojejunostomy
Vertical gastric division with
interposed Roux
gastrojejunostomy
Gastric Band
Vertical-banded
gastroplasty
Bariatric Surgery

37. OPTIONS FOR OBESITY
MANAGEMENT: BARIATRIC
SURGERY
ASBS 2004 Consensus Statement
Adolescent candidates
BMI ≥ 40 kg/m2
BMI of 35.0 kg/m2 to 39.9 kg/m2 in the presence of severe
comorbidities
Type 2 diabetes
Life-threatening cardiopulmonary problems
Severe sleep apnea
Pickwickian syndrome
Obesity-related cardiomyopathy
Obesity-induced physical problems interfering with a
normal lifestyle
Joint disease treatable but for the obesity
Body size problems precluding or severely interfering with
Employment
Family function
Ambulation
Buchwald, H. Surgery for Obesity and Related Diseases. 2005; 1: 371–381

38. BARIATRIC SURGERY (CONT.)
Adolescent candidates (cont.)
Puberty complete
Obtained 95% of predicted adult stature
Need to understand that:

Long term efficacy and potential adverse consequences
related to decreased absorption of nutrients unknown

Degree of recidivism remains unknown
Buchwald, H. Surgery for Obesity and Related Diseases. 2005; 1: 371–381

39. AN UPDATE ON 73 US OBESE PEDIATRIC PATIENTS
TREATED WITH LAPAROSCOPIC ADJUSTABLE
GASTRIC BANDING: COMORBIDITY RESOLUTION
AND COMPLIANCE DATA
NYU Division of Pediatric Surgery
First 73 patients to undergo lapband

Aged 13 to 17 years (mean 15.8 ± 1.2 years)

54 females and 19 males

Mean preop wt: 298 lb, with a BMI 48 kg/m2

Mean estimated wt loss post-op:

6 months: 35% ± 16%

1 year: 57% ± 23%

2 years: 61% ± 27%
Nadler, EP, et al. J Pediatr Surg. 2008 Jan; 43(1): 141-6

40. AN UPDATE ON 73 US OBESE PEDIATRIC PATIENTS
TREATED WITH LAPAROSCOPIC ADJUSTABLE
GASTRIC BANDING: COMORBIDITY RESOLUTION
AND COMPLIANCE DATA (CONT.)
Complications
Band slippage (6)

Gastric perforation (1)
Symptomatic hiatal hernias (3)
Asymptomatic iron deficiency (13)
Asymptomatic vitamin D deficiency (4)
Mild subjective hair loss (14)
Nadler, EP, et al. J Pediatr Surg. 2008 Jan; 43(1): 141-6

41. FINAL THOUGHTS
Childhood obesity has reached epidemic
proportions
There is no current accepted definition for
pediatric metabolic syndrome
Mainstay of treatment is DIET/EXERCISE
counseling
The counseling should start in early childhood
and BEGINS with the caregivers
Pediatrician or Family practitioner
Consider referral to weight management program
After age ≥ 6 years if
Prevention and prevention plus fail
BMI ≥ 95
th
percentile with co-morbidity
BMI ≥ 99
th
percentile

42. ANY QUESTIONS?