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Pediatric Obesity and the Metabolic Syndrome

Pediatric Obesity and the Metabolic Syndrome. Whitney Brown, M.D. Division of Pediatric Endocrinology. Lecture Objectives. Know the BMI percentile cutoffs for pediatric overweight, obesity, and morbid obesity Recall the co-morbidities associated with pediatric obesity

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Pediatric Obesity and the Metabolic Syndrome

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  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 adults2 • 10% for nonobese children 1Ogden CL, et al. JAMA. 2010; 303(3): 242–249 2Whitaker 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/m2 • BMI ≥ 95th percentile for age and gender • “At risk for overweight” • BMI ≥ 85th but ≤ 95th percentile • 2005-Institute of Medicine • Obese • BMI > 30 kg/m2 • BMI ≥ 95th percentile for age and gender

  7. Defining Pediatric Obesity (cont.) • 2007-American Academy of Pediatrics • Overweight • BMI ≥ 85th but ≤ 95th percentile • Obese • BMI > 30 kg/m2 • BMI ≥ 95th percentile for age and gender • Morbidly obese • BMI ≥ 99th percentile • If < 2yo • Overweight • Weight for lenth ≥ 95th percentile for age and gender

  8. Obesity-Related Co-morbidities • Orthopedic Conditions • Blounts Disease • Hip Disorders (SCFE) • Psychological Conditions • Depression/Self-Esteem • Substance Abuse • Disordered Eating • Discrimination • Pulmonary Conditions • Asthma • Sleep Apnea • 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

  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 ATP III 88 cm

  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 ≥ 95th percentile • 28.7% • BMI 85th-94th percentile • 6.1% • BMI ≤ 84th 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!

  14. Overweight: BMI ≥ 85th percentile • Obese: BMI ≥ 95th percentile • Morbidly BMI ≥ 99th percentile Overweight/Obesity • 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% Glucose abnormalities Blood pressure • Norms varying depending on age, height, and gender Fasting lipid levels • Norms very depending on age/gender

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

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

  17. Off the Record: • No accepted definition of pediatric metabolic syndrome • Clinically I use: • BMI ≥ 85th percentile plus ≥ 2 of the following • HDL <10th percentile (~40 mg/dL) • TG >95th percentile • IGT or IFG • BP ≥ 90th 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. B 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 None 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 Need larger, long term studies Park MH, et al. Diabetes Care. 2009; 32(9): 1743-1745

  31. Elevated LDL: Treatment Recommendations Daniels SR, et al. Pediatrics. 2008; 122: 198-208

  32. Hyperlipidemia Pharmacotherapy

  33. Fish oil: Coromega

  34. Stages of Pediatric HTN • Normal • < 90th percentile • Pre-hypertension • ≥ 90th percentile and < 95th percentile • Stage 1 hypertension • ≥ 95th percentile and ≤ 99th percentile +5 mmHg • Stage 2 hypertension • > 99th percentile + 5 mmHg

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

  36. 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 • Familyfunction • Ambulation Buchwald, H. Surgery for Obesity and Related Diseases. 2005; 1: 371–381

  37. 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

  38. 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

  39. 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

  40. 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 ≥ 95th percentile with co-morbidity • BMI ≥ 99th percentile

  41. Any Questions?

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