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 .

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

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

Eat too much and Move too little

PATHOGENESIS

Enviromental changes: the type &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.

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…

Endogenous weight control mechanisms:

Super Sized Fast Food

1610 Calories

1610 Calories

63 gm fat63 gm fat

Disease associated with childhood obesity

AlstromBardet-biedl syndromeCarpenter syndromeCohen syndromeCushing syndromeDeletion 9q34Frohilich syndromeHyperinsulinismMelanocortin 4 receptor gen mutation Muscular dystrophyMyelodysplasiaPrader-willi syndromePseudohypoparathyroidismTurner syndrome

Excessive weight Gain or BMI ininfant&toddler

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)

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.

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 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….

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

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

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

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

1.Asthma

shothness of breath,wheezing,couqh

pulmonary function test

2.Gallstone

abdominal pain ,vomiting, jaundice

ultrasound

3.Obstructive sleep apnea snoring,daytime somnolence,enuresis polysomnography,hypoxia,electrolyte4.Blount disease knee pain,limp,bowing of legs knee x-ray5.Slipped capital femoral epiphysis hip pain,limp hip x-ray

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

8.Nonalcoholic fatty liver disease

hepatomegaly,abdominal pain,dependent edema

AST,ALT,ultrasound,CT,MRI

9.Hypertension

elevated BP>95th percentile for age,sex,height

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

10.insuline resistance family history,polyuria,polydypsia,unintentional↓weight Fasting glucose,Hb A1c ,insuline level,oral GL tolerance

test

11.Dyslipidemia family history(high cholesterol,early onset heart

disease) fasting total cholestrol,HDL,LDL,TG

Make Your Own Lunch From These Choices

Physical finding

Hypertension

Acantosis nigricans-insulin resistance

Tanner staging -premature adrenarcheHirsutism,male pattern baldness,severe acne-

( polycystic ovary syndrome)

Simplified laboratory norms for assessing overwieght children

Glucose <110mg/dlInsulin <15mu/lHemoglobin A1c <6.0%AST 2-8yr <58u/l 9-15yr <46u/l 15-18yr <35u/lALT <35u/lTotal cholestrol <170mg/dlLDL <110mg/dlHDL <35mg/dlTriglycerides 2-15yr <100mg/dl 15-19yr <125mg/dl

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.

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

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.

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

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

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.

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.

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.

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.

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.

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

Color green light food yellow light food red light food

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 fatty meats

foods vegetables starches,grain suger,fried

foods

Quantity unlimited limited infrequent or

avoided

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.

Continued…

Prescribed exercise regimens can be useful.

Simple measures such as daily walks can be useful.

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.

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.

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.

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

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.

Continued…

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

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.

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.