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Transcript of Obesity in children and Annual Conference/Saturday_Khater.pdf · PDF file of ALAT (NAFL)...

  • Obesity in children and adolescents

    Dr Beatrice Khater Menassa Family Medicine Department

    AUB-MC October 2012

  • OBJECTIVES  Understand the impact of obesity

     Review some causes

     Learn tips to deal with patients

  •  A 9 year old girl is worried that she is fat. She seems a little overweight to you so you decide to assess her. Which tool should you use to assess her weight?

    A- Waist circumference B- Bioimpedance C- BMI (adjusted for age and

    gender) D- Your experience “she looks fat”

  • BMI  BMI (adjusted for age and

    gender) is recommended as a practical estimate in children

     Correlates with adiposity and complications of childhood overweight

     All children > 2 years should have their height and weight measured and BMI calculated at least yearly

     Waist circumference : not recommended as a routine but information about the risk of developing other long term health problems.

  • Warning

     If the BMI < 85th percentile but has increased more than 3 to 4 units (kg/m2) per year and begins to cross percentile lines, particularly if the child > 4 years the child is at risk of becoming overweight

  •  BMI percentile can be plotted on a chart or obtained from online calculators.

     Overweight = BMI between the 85th and 94th percentile

     Obesity = age- and gender-specific BMI at or above the 95th percentile

  • Public health problem in the US.

     Since the 70s, childhood and adolescent obesity has increased three- to sixfold.

     Approximately 12 to 18 % of children and adolescents 2 to 19 y. of age are obese ( [BMI] >95th percentile).

    Ogden et al. JAMA. 2012

  •  If current trends in childhood obesity continue, there will be an additional

    65 million obese adults in the US by 2030.

  • This translates into a potential 6 - 8.5 million new cases of diabetes

    5 - 7.3 million new cases of heart disease,

    an estimated direct medical cost of $48 to $66 billion

  • As the prevalence of obesity increases, so does the prevalence of the comorbidities associated with obesity

  • Psychosocial and Societal Consequences of Childhood Obesity

     decreased health-related quality of life

     lower body satisfaction and physical appearance–related self-concept

     experience more teasing

     vulnerability to bullying

     decreased probability of employment and less financial support for college among women, as well as lower household incomes

    Circulation. 2009 American Heart Association Childhood Obesity Research Summit Report

  • From child to adult A general rule : sedentary obese child who does not alter his or her caloric intake and lifestyle is unlikely to be of normal weight as an adult.

     The severity of obesity during adolescence is an important predictor


    ADULT OBESE POPULATION  Nauru 78.5%  Tonga 56.0%  Saudi Arabia35.6%  U.A.E 33.7%  U.S. 32.2%  Bahrain 28.9%  Kuwait 28.8%  Seychelles25.1%  United Kingdom24.2%

    DIABETES IN ADULTS Nauru 30.7% U.A.E19.5% Saudi Arabia 16.7% Bahrain 15.2% Kuwait 14.4% Oman 13.1% Tonga 12.9% Mauritius 11.1% Egypt 11.0% Mexico 10.6%

  • Medical consequences of childhood obesity

     high blood pressure, early development of atherosclerosis, type 2 diabetes mellitus

     nonalcoholic fatty liver disease

     polycystic ovary disorder

     disordered breathing during sleep

  • High cardiovascular risk in severely obese children and adolescents

     Nearly two thirds of young (=12 years of age) severely obese children already have cardiovascular risk factors.

     (50%) of young (=12 year) severely obese children already have hypertension.

     Up to 54% of severely obese children have low HDL- cholesterol and up to 20% have high fasting glucose.

    van Emmerik et al. Arch Dis Child2012.

  • The pandemic attributable to:  relatively recent (from an evolutionary perspective)

    adoption of a sedentary lifestyle,  high availability of foods with high caloric content in

    Western cultures + portion size  dated genotypes  diminishing family presence at meals,  increasing use of computer-oriented play activity

  • Sugar sweetened beverages  Increase in consumption of

    SSB : potential contributor to the obesity pandemic

     by virtue of the high added sugar content, low satiety, and incomplete compensation for total energy

     Initiatives focusing on reducing the consumption of these drinks may help to prevent a further increase in childhood obesity

     Caprio et al. N Engl J Med. 2012 Sep 21 James, Kerr Int J Obes (Lond). 2005 Sep.

  •  proposed policy solutions: -taxes on SSB - controversial and opposed strongly by the food industry.

    - to prohibit SSB from being sold in containers larger than 16 oz in public

    Pomeranz et al. N Engl J Med. 2012 Sep 21

  • More obesity, less sleep

     Obesity ↑ and hours of sleep↓  Coincidence or association?  Meta-analyses demonstrate that insufficient

    sleep during childhood increases by 58- 89%risk of obesity

     Potential pathways:regulation of neuropeptides, decreased energy, circadian rhythm….

    Capuccio et al. Sleep 2008  Levin F et al. J Clin Endocrin Metab 2006

  • Examination  As with the history, the examination of the

    overweight child or adolescent should evaluate the presence of comorbidities and underlying etiologies.

     Assessment - dysmorphic features, suggesting a genetic syndrome

    - affect, - fat distribution

  • Laboratory studies  Not standardized

     Evaluation of comorbidities

     Stimulation for weight loss

     Basic screening: lipid panel and measurement of ALAT (NAFL)

     > 10 years of age + 2 or more risk factors (FH of DM2, high-risk ethnicity, acanthosis nigricans, or PCOS): screen for diabetes

  • Do interventions for preventing obesity in

    children work?

  •  Cochrane review examined the effectiveness of multiple interventions: diet and nutrition, physical activity, and lifestyle, alone or in combination

     Dietary interventions alone showed no difference in BMI

     When all the studies combined in a meta-analysis, children in the intervention groups had a -0.15 95% C.I -0.21 to -0.09) standardized mean change in BMI compared with control patients

     Pooled analysis : interventions were effective in children up to 12 years of age, but no statistically significant benefit in adolescents 13 to 18 years of age.

  •  interventions that promoted physical activity, alone or in combination with diet, are effective in slowing or preventing increases in BMI when compared with control interventions

    (Strength of Recommendation: C)

  •  The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians offer children or refer them to comprehensive, intensive behavioral interventions to promote improvement in weight status

    B Recommendation


  • PREVENT and TREAT in clinical practice  PREVENTION





  • Prevention plus  For children with BMI 85-95th

     5 -2-1-0

     Self monitoring

     Family involvement

     F/U Q1-3 months, if no improvement….

  • Structured weight management  BMI 95-98th

     Serving portions, supervised exercise

     Monitor logs

     F/U Q 1 month

     If 3-6 month failure to target….

  • Comprehensive Multidisciplinary Interventions

     Frequent visits to MD and dietitican Q week

     Behavioral support

     Motivational interview

  • Tertiary Care Intervention  BMI>99th with comorbidities

     All the previous + meal replacement + pharmacotherapy + bariatric surgery

    Multidisciplinary team

  • Communication tips

  • Person-centered care: principles for health professionals

     Advice, treatment and care should take into account child and family needs and preferences

    .  People should have the opportunity to make

    informed decisions about their care and treatment,

     Build partnership

     Balance between the importance of involving parents and the right of the child to be cared for independently.

  •  Avoid blaming approach (obesity is not a character flaw)

     Be supportive

     Use words as “unhealthy weight” or “weight problems”

     Focus on health rather than appearance

  •  Avoid discussing “ideal weight”

     Initiate discussion with “some people are easy gainers” and need to “work extra- hard”

  •  underst