management of obesity in pediatrics .pptx

management of obesity in pediatrics

1. Management of pediatric obesity YASSIN ALSALEH

2. (eat and drink but waste not)

3. Definitions Percentile range (BMI) for age and sex ( 2 years and above ) class > 85 th – 95th Overweight ≥30 BMI ≥95th percentile Obesity I ≥35 BMI ≥120 percent of the 95th percentile (≈98th percentile. ) Severe obesity II ≥40 BMI ≥140 percent of the 95th percentile Severe obesity III

4. Epidemiology (obesity ) over 988 million in 2020. World Obesity Atlas 2023

5. SAUDI ARABIA Pediatric : (11.2%- 13.4%) overweight. (9.4% - 18.2% ) obese. Al‑ Hussaini A, et al. Overweight and obesity among Saudi children and adolescents: Where do we stand today? Saudi J Gastroenterol 2019;25:229-35. Aljassim and Jradi Journal of Health, Population and Nutrition (2021) 40:15

6. Al- Hazzaa HMPrevalence of overweight and obesity among saudi children: A comparison of two widely used international standards and the national growth references. Front Endocrinol (Lausanne). 2022 Aug

7. the Eastern Province among high school children obesity and overweight : 25.7% . 35% of the study’s students have either elevated blood pressure or hypertension. Albaker W,. What is the current status of childhood obesity in Saudi Arabia? Evidence from 20,000 cases in the Eastern Province: a cross-sectional study. Medicine 2022

8. prevalence : overweight :10.8% Obese : 18.8% Risk factors: early childhood obesity. parental obesity mother's employment number of snacks and fast food consumption physical inactivity, and time spent in watching television. Saleh AAA. Prevalence of obesity in school children and its relation to lifestyle behaviors in Al- Ahsa district of Saudi Arabia. Glob J Health Sci. 2017;9(12):1–80.8. BY SAJJAD

9. AlEnazi S, et al. Prevalence of obesity among children and adolescents in Saudi Arabia: A multicenter population‑based study. Saudi J Med Med Sci 2023.

10. Obese, chubby, fat unhealthy weight Diet Healthy eating

11. Case scenario children ≥2 years with BMI ≥85th percentile or obese . mostly exogenous (primary), familial. Monogenic causes excluded . Non syndromic . No endocrine disorders . No psychiatric disorders. No drug .

12. health behavior and lifestyle counseling

13. health behavior and lifestyle counseling Recreational screen time: <2 years – Little or no screen time ≥2 years – Maximum 1 hour daily

14. physical activity Preschool-aged : ≥2 hours of unstructured activity daily School-aged and older : ≥1 hour moderate or vigorous structured physical activity daily

15. SLEEP There is abundant evidence to support the relationship between sleep deprivation , sleep problems, and childhood obesity. up to an 80% increase likelihood of obesity Copyright 2023.sleepeducation.org Tung JYL, Obesity in children and adolescents: Overview of the diagnosis and management. Chronic Dis Transl Med. 2023 Veronica R. Johnson. Strategies in the Management of Adolescent Obesity. Curr Pediatr Rep. 2020 June ; 8(2): 56–65.

16. DIET

17. Diet red foods to be eaten sparingly. Yellow foods to be taken in moderation Green foods to be eaten often

18. Diet Intake of balanced diet, foods rich in fibre content. limited intake of high-calorie foods and sugar sweetened beverages. Having regular meals and increasing intake of water Avoid serving fried foods at meals. Eliminate high-calorie snack foods from the house encouraging the consumption of whole fruits rather than fruit juices 1 or fewer take-out or fast food meals weekly. Mittal M, Jain V. Management of Obesity and Its Complications in Children and Adolescents. Indian J Pediatr . 2021.

19. Juice drinks, flavored sweetened milk and yogurts, chocolate-coated cereals etc. that are commonly marketed as ‘healthy foods’ are laden with sugar. Skipping breakfast is associated with obesity in children.* * Monzani A, A Systematic Review of the Association of Skipping Breakfast with Weight and Cardiometabolic Risk Factors in Children and Adolescents. What Should We Better Investigate in the Future? Nutrients. 2019 Feb Diet

20. Controlling the portion size should be made a habit.

21. Diet Low‑calorie high‑protein diets Hyperlipidic low‑calorie diets vegetarian and vegan diets Maffeis et al. Italian Journal of Pediatrics (2023) no sufficient evidence to recommend in pediatric

22. Diet there is no emphasis on one particular diet or eating pattern to promote weight loss Johnson VR, Food as Medicine for Obesity Treatment and Management. Clin Ther . 2022 May;44(5):671-681..

23. Focus more on what the child should eat, rather than only listing foods to be avoided

24. Involvement of entire family in adopting healthy lifestyle is the initial strategy to manage overweight or obesity in children role modelling. reinforcement, restriction and monitoring Avoiding pressure and criticism Herouvi , D.; Paltoglou , G.; Soldatou , A.; Kalpia , C.; Karanasios , S.; Karavanaki , K. Lifestyle and Pharmacological Interventions and Treatment Indications for the Management of Obesity in Children and Adolescents. Children 2023

25. Intermittent fasting is another nutrition intervention for treatment of obesity

26. Economic and cultural considerations Income Misperception

27. Economic and cultural considerations

28. combination of improving diet and physical activity for a higher chance of success. 1 + 1 = 3

29. Goals of weight loss 6–11 y: 0.5–2 kg per month ≥ 12 y : 1 kg per week targeting 10% weight reduction

30. no improvement in BMI trend despite a basic counseling intervention OR For children with severe obesity (BMI ≥120 percent of the 95th percentile)

31. maximum intensity of health behavior and lifestyle modification

32. Veronica R. Johnson. Strategies in the Management of Adolescent Obesity. Curr Pediatr Rep. 2020 June ; 8(2): 56–65. Stage lifestyle interventions provided by primary care provider Prevention Plus Stage 1 monthly visits with a primary care provider and support from registered dietitian Structured Weight Management Stage 2 intensive weight loss program composed of weekly visits for a minimum of 8–12 weeks at a pediatric weight management center Comprehensive Multidisciplinary Intervention Stage 3 use of medical diets, medications, and surgery in addition to Stage 3 interventions Tertiary Care Intervention Stage 4

33. Pharmacotherapy Weight loss surgery

34. Pharmacotherapy

35. No evidence supports weight loss medication as therapy alone . it is recommended as an adjunct when intensive behavior interventions alone have failed.

36. Indications of pharmacotherapy have not properly responded to lifestyle modification

37. GLP-1 Glucagon like peptide

38. Copyright © 2023 Paleo Leap ↑Insulin ↓glucagon delayed gastric emptying acting on hypothalamus, amygdala, and the cortex

39. Daily GLP Liraglutide

40. Liraglutide a GLP-1 analog. weight loss : (modest) BMI -1.58 kg/m2 change in weight -4.50 kg daily subcutaneous injections approved for weight loss in adolescents 12 years and older with obesity and weight ≥ 60 kg saxenda December 2020

41. Common side effects : nausea, abdominal pain Hypoglycemia pain at the injection site. Other side effects : angioedema, pancreatitis. Side effects

42. contraindicated in patients with: 1- personal or family history of medullary thyroid carcinoma (MTC) 2- multiple endocrine neoplasia syndrome type 2. (MEN2) Contraindicated in pregnancy Contraindication Vandana Raman, Pharmacologic Weight Management in the Era of Adolescent Obesity, The Journal of Clinical Endocrinology & Metabolism, Volume 107, Issue 10, October 2022

43. Weekly GLP Semaglutide

44. (GLP-1) analog FDA approves December 23, 2022. once-weekly subcutaneous injection change in BMI -6 kg/m2 approved for weight loss in adolescents 12 years and older with obesity Semaglutide Wegovy December 2022

45. The mean change in BMI from baseline to week 68 was -16.1% with semaglutide At week 68, a total of 95 of 131 participants (73%) in the semaglutide group had weight loss of 5% or more. Weghuber . Once-Weekly Semaglutide in Adolescents with Obesity. N Engl J Med. 2022 Dec 15;387(24):2245-2257. doi : 10.1056/NEJMoa2208601. Epub 2022 Nov 2.

46. Side effect : Gastrointestinal disorders :nausea, vomiting, and diarrhea) ( 62%) Contraindication: Similar to liraglutide

47. An oral form of semaglutide ( Rybelsus ) is available approved for type 2 diabetes in adults.

48. Metformin is a biguanide MOA: drug that reduces blood glucose levels 1- decreasing blood glucose production in the liver 2- decreasing intestinal absorption 3- Increasing insulin sensitivity is a first-line treatment in 10 years and older with type 2 diabetes. patients modest reductions in BMI: -1.3 -2.70 kg/m2 this is an off-label use in obesity . Hampl SE. Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity. Pediatrics. 2023 Feb

49. Metformin is generally well tolerated D-lactic acidosis .(very rare) the recommended starting dose is 500 mg, once or twice daily, maximum total daily dose of 2500 mg. Hampl SE. Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity. Pediatrics. 2023 Feb

50. Orlistat

51. it has low efficacy (BMI reduction of <1 kg/m2) MOA : inhibiting pancreatic lipases. gastrointestinal side effects . limit its acceptability for many patients. Deficiency of fat-soluble vitamin Orlistat → O r li stat → Oily stool

52. its clinical use is fairly limited due to its modest efficacy about a 2.61 kg reduction after 1 year of treatment) BMI had decreased by 0.55 kg/m2 with orlistat Chung YL, Rhie Y. Severe Obesity in Children and Adolescents: Metabolic Effects, Assessment, and Treatment. JOMES 2021

53. Phentermine amphetamine analog is a norepinephrine reuptake inhibitor MOA: reduces appetite and may increase energy expenditure. it is approved for short-term use (12 weeks) in adolescents older than 16 years of age. modest effect on BMI. side effects : increased heart rate and blood pressure

54. Qsymia( Phentermine - topiramate )

55. Qsymia The combination of phentermine and topiramate topiramate : suppress appetite through an increase in gamma aminobutyric acid (GABA) activity. Treatment resulted in a modest BMI reduction for the higher dose (15 mg/92 mg: BMI -5.3 kg/m2. Phentermine-topiramate is approved in for treatment of obesity in individuals 12 years and older 27 June 2022

56. Weight loss: 8% for mid-dose and 10% for high- dose in 1 year Recommended starting dosage is: 3.75 mg/23 mg (phentermine mg/topiramate mg) daily for 14 days; then increase to 7.5 mg/46 mg daily Kim A, Nguyen J, Babaei M, Kim A, Geller DH, Vidmar AP. A Narrative Review: Phentermine and Topiramate for the Treatment of Pediatric Obesity. Adolesc Health Med Ther . 2023 Aug 23

57. Side effect : paresthesia, dizziness, dysgeusia, insomnia, constipation, and dry mouth. Depression suicidal ideation Ophthalmologic Adverse Reactions CONTRAINDICATIONS: Pregnancy Glaucoma Hyperthyroidism History of CVD

58. melanocortin-4 receptor (MC4R) agonist

59. analog of endogenous melanocortin peptide alpha-melanocyte stimulating hormone acting on MC4 receptors. MC4 receptors in the brain are involved in regulation of hunger, satiety, and energy expenditure. MOA : reverse hyperphagia and promote weight loss through decreased caloric intake and increased energy expenditure Setmelanotide

60. Indications chronic weight management in pediatrics 6 years of age and older November 25, 2020

61. Bardet-Biedl syndrome (BSS) © 2008-2023 ResearchGate GmbH. All rights reserved Obese + polydactyl + blind

62. proopiomelanocortin (POMC) Copyright © 2023 Elsevier B.V. Obese + red hair

63. proprotein convertase subtilisin / kexin type 1 (PCSK1) Early malabsorptive diarrhea + Obese + endocrinopathy

64. Setmelanotide Dose :SUBQ: Children ≥6 years to <12 years: Initial: 1 mg once daily for 2 weeks, Maximum daily dose: 3 mg/day. Children ≥12 years and Adolescents: Initial: 2 mg once daily for 2 weeks. Adjust every 2 weeks.

65. Weight loss target : 1 to 2 kg/week Medication should be continued if ≥ 5% BMI reduction from baseline at 12 weeks Discontinue therapy if ≥5% of baseline body weight or 5% of baseline BMI has not been lost after 12 to 16 weeks of therapy Setmelanotide

66. Side effects injection site reaction (96%), skin hyperpigmentation (78%), nausea (56%) disturbances in sexual arousal New or worsened depression or suicidal ideation . Pressley H, Cornelio CK, Adams EN. Setmelanotide : A Novel Targeted Treatment for Monogenic Obesity. Journal of Pharmacy Technology. 2022; Trapp CM, Censani M. Setmelanotide : a promising advancement for pediatric patients with rare forms of genetic obesity. Curr Opin Endocrinol Diabetes Obes . 2023 Apr 1;

67. Withdrawn medication 1- a methionine aminopeptidase 2 (MetAP2) inhibitor ( Belorani ), 2- Rimonabant (endocannabinoid receptor CB1 antagonist) Kühnen P, Biebermann H, Wiegand S. Pharmacotherapy in Childhood Obesity. Horm Res Paediatr . 2022;95(2):177-192.

68. Vandana Raman, Pharmacologic Weight Management in the Era of Adolescent Obesity, The Journal of Clinical Endocrinology & Metabolism, Volume 107, Issue 10, October 2022

69. Bariatric surgery

70. Bariatric surgery is the ultimate solution surgery is undertaken only after sustained efforts to manage obesity through lifestyle and counseling interventions

71. Indication comorbidity of obesity : type 2 diabetes mellitus, idiopathic intracranial hypertension, obstructive sleep apnea nonalcoholic steatohepatitis, Blount disease, slipped capital femoral epiphysis, gastroesophageal reflux disease, arterial hypertension, insulin resistance, or reduced health-related quality of life

72. anatomically reducing the caloric intake of the individual. decrease levels of ghrelin increase anorexigenic glucagon like peptide-1 (GLP-1) Decreasing appetite and improving insulin sensitivity Bariatric surgery Peripheral and central

73. Sleeve gastrectomy The SG (also known as vertical sleeve gastrectomy) removes 80% of the stomach creating a sleeve volume of 60–100 mill-liters. accounts for more than 80 % of bariatric procedures in adolescents. less complex than RYGB lower theoretical risk of micronutrient deficiencies.

74. 91 morbidly obese adolescents in Qatar who underwent LSG (2011–2014), with 1- and 5-year follow-ups. a mean total weight loss of 35.8% No patients developed postoperative leaks, 64% of obstructive sleep apnea patients were cured, all prediabetic patients had total remission 50% of the diabetic patients were cured. At 5 years, 75% of the diabetic adolescents had complete remission. The only patient with hypertension showed complete resolution three patients had endoscopic dilatation due to stenosis. El- Matbouly , M.A., Khidir , N., Touny , H.A. et al. A 5-Year Follow-Up Study of Laparoscopic Sleeve Gastrectomy Among Morbidly Obese Adolescents: Does It Improve Body Image and Prevent and Treat Diabetes?. OBES SURG 28, 513–519 (2018). Sleeve gastrectomy

75. Roux-en-Y gastric bypass creates a small (less than 30 mL) proximal gastric pouch that is divided and separated from the distal stomach and anastomosed to a Roux-limb of small bowel The surgery was the most commonly performed bariatric procedure. The rate of abdominal reoperations was significantly higher among adolescents than among adults Inge TH, et al.Five -Year Outcomes of Gastric Bypass in Adolescents as Compared with Adults. N Engl J Med. 2019;380(22):2136–2145.

76. Laparoscopic gastric banding BMI loss: - 11.40 kg/m2, Weight loss : -31.60 kg A total of 28% of the adolescents undergoing gastric banding required a 'revisional procedure.* 50% of patients requiring additional surgery LAGB is not an ideal option for treatment of adolescent obesity only approved for patients aged 18 or older * TorbahnG ,. Surgery for the treatment of obesity in children and adolescents. Cochrane Database of Systematic Reviews 2022, Issue 9.

77. Paulus GF, de Vaan LE, Verdam FJ, Bouvy ND, Ambergen TA, van Heurn LW. Bariatric surgery in morbidly obese adolescents: a systematic review and meta-analysis. Obes Surg. 2015 May Mean BMI loss

78. Prevention is better than cure

79. Fecal microbiome transfer (FMT) No evidence no effect on weight loss was observed Leong KSW, Jayasinghe TN, Wilson BC, et al. Effects of fecal microbiome transfer in adolescents with obesity: the gut bugs randomized controlled trial. JAMA Network Open. 2020;3(12): Tung JYL, Poon GWK, Du J, Wong KKY. Obesity in children and adolescents: Overview of the diagnosis and management. Chronic Dis Transl Med. 2023

80. Herbal and other مدرة مخزنية أو الزهرة المدرة أو سذاب الماعز أو مكنانة مخزنية أو كاليكة Galega officinalis) ) جذر كرمة إله الرعد أو Tripterygium Wilfordii جنكو أو جنجو بيلوبا الجِنْكَة أو جنكو ذو الشقين أو جنكو ذو الفصين أو شجرة المعبد أو المَعْبَلَة أو الجنكو الثنائي الفلقة أو الشفتين ( ( Ginkgo biloba زيت كالانوس هو زيت طبيعي يتم الحصول عليه من نوع خاص من العوالق الحيوانية، (Calanus finmarchicus ) Gasmi , A.; Pharmacological Treatments and Natural Biocompounds in Weight Management. Pharmaceuticals 2023, 16, 212.

81. BMI LOSS kg/m2 in adolescent 0.55 orlistat 1.3-2.7 metformin 1.8 liraglutide 6 semiglutide 3.7-5.3 Qysemia 11.6 Gastric banding 14.1 Sleeve 16.6 RYGB

82. أعلِّلُ النفس بالآمالِ أرقُبُها ما أضيقَ العيشَ لولا فسحةُ الأمَلِ