Download CHILDHOOD OBESITY: The Global Epidemic

APPROACH TO AN ADOLESCENT WITH
OBESITY
By: Camille-Marie A. Go
Objectives
 To present a case of a child with obesity
 To discuss the burden of disease,
pathophysiology, management and possible
complications of obesity
Our Patient
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P.N.
14 year old
Male
Filipino
Roman Catholic
San Mateo, Rizal
Chief complaint
Rapid weight
gain and
hyperglycemia
3 years PTC
1 year PTC
•Annual Physical Examination
•FBS (2.98 mmol/L) ; cholesterol (360 mg/dl)
•Low fat diet
•rapid weight gain + dark pigmentation of
skin creases and flexural areas
•FBS (5.78 mmol/L), SGPT 109 U/L,
cholesterol (240 mg/dl)
•Given Polyenylphosphatidylcholine
(Essentiale)
2 months
PTC
1 week PTC
•elevated fasting blood sugar, elevated
cholesterol, and elevated liver
transaminases
•Polyenylphosphatidylcholine (Essentiale) +
strict low fat and low cholesterol diet
•Persistence of weight gain
•Fasting Blood Sugar, transaminases,
cholesterol, triglyceride, LDL and HbA1c
•Referral to Pediatric Endocrinologist
Review of Systems
 General: (-) weight loss, (+) voracious appetite
 Cutaneous: (-) rashes, (-) discoloration, (-) jaundice
 HEENT: (-) blurring of vision, (-) nasoaural discharge,
(-) epistaxis, (-) gum bleeding
 Cardiovascular: (-) cyanosis, (-) chest pain, (-) orthopnea,
(-) easy fatigability (-) palpitation
 Respiratory: (-) cough, (-) colds, (-) difficulty of breathing,
(-) sneezing
 Gastrointestinal: (-) vomiting (-) abdominal pain, (-) diarrhea,
(-) constipation, bowel movement once a day
Review of Systems
 GUT: yellow urine, (-) edema of the hands and feet, (-) frothy
urine
 Metabolic: (-) polydipsia, (-) polyuria
 Extremities: (-) swelling, (-) joint swelling, (-) limitation in
movement
 Nervous/Behavioural: (-) headache, (-) dizziness, (-) nausea, (-)
tremors, (-) convulsions , (-) change in sensorium (-) behavioral
change
 Hematopoietic: (-) pallor, (-) easy bruisability (-) prolonged
bleeding
Family History
 (+) DM – both parents;
maternal GM
 (+) HPN - maternal GM
 (+) obesity - father
 (-) PTB
 (-) Heart disease
 (-) Thyroid disorders
 (-) Blood dyscrasia
 (-) Mental retardation,
 (-) Seizure
Immunization History
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BCG
3 doses of Hepatitis B
DPT x 3
OPV x 3
Measles
MMR
Boosters: of BCG and MMR
No untoward reactions
Birth and Maternal History
 Born to a 30 year old G2P1 (1001) nonsmoker nonalcoholic
mother
 Prenatal check up since 1 month AOG;
 (+) MVS, Feso4
 (+) GDM at 6 months AOG, advised diet modification; repeat
exam after 1 month normal
 Delivered Full term via NSD assisted by OB; (+) good cry and
activity
 (+) small for gestational age
 Newborn Screening and Hearing Screening not done;
Nutritional History
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Breastfed until two months old
Milk formula thereafter
Complementary feeding at 6 months
High carbohydrate and high fat diet prepared by the mother
Fastfood 2x – 3x weekly
Fond of junk foods and chocolates
Food
Food
CHO (g)
CHON (g)
Fats (g)
Kcal
Breakfast
3 pcs hotdog
4 cups of rice
Water
18g
184g
24g
16g
258 kcal
800 kcal
Snacks
6 pcs Biscuits
Orange juice
23g
10g
Lunch
2 cups Pork
Sinigang
vegetables
3 cups of rice
6g
138g
Snacks
6 pcs Biscuits
Orange juice
23g
10g
Dinner
3 cups
Chicken
Adobo
4 cups of rice
water
184g
2g
32g
2g
12g
100kcal
40 kcal
24g
2g
32 g
16g
344kcal
32 kcal
600 kcal
100kcal
40 kcal
24 g
344 kcal
800 kcal
Total ACI 3,458 kcal
RENI 2,800 kcal
% intake
123.5%
Psychosocial History
 Home:
 Concrete house with 6 household members
 Nuclear patriarchal clan
 Education:
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Second year high school at school in San Mateo, Rizal
Favorite subject: Math
Average grade - 89%.
Aspires to be a successful accountant when he grows up
Psychosocial History
 Activity:
 Fond of computer games
 Spends 4 to 6 hours per day
 Most of activities are sedentary
 Drugs:
 No intake of alcoholic beverage or cigarette use
 Does not know anyone using prohibited drugs
 Sexual:
 Has female crushes among his schoolmates
 No girlfriend. He has not courted any girl.
Psychosocial History
 Suicide:
 No personal history of attempted suicide
 Sees himself as overweight, not happy or proud of it
 Safety:
 Walks on the sidewalk to school
 Does not ride in cars with drivers who are intoxicated
 Spirituality:
 Hears mass every Sunday together with his whole family
 Actively participates in church activities
Past Medical History
 No previous history of hospitalization, or transfusions,
or allergies
 No history of communicable diseases (measles,
varicella)
 Underwent Circumcision at 10 years of age
Physical Examination:
 Conscious, coherent, oriented to 3 spheres, not in
cardiorespiratory distress, ambulatory, over-nourished, wellhydrated, well-looking
 Wt: 75kg (z> 3) ; Ht: 163cm (z<0); BMI: 28.2 (z>3)
 CR 110 beats/min; RR 30 breaths/min; T 36.5 C; BP 110/60 mmHg
(p 25)
 Warm and moist skin, dark pigmentation of skin creases and
flexural areas, most prominent along the nape
 Pink palpebral conjunctivae, anicteric sclerae
Physical Examination:
 No alar flaring, no nasoaural discharge, intact tympanic
membrane, AU
 Moist buccal mucosa, no dental carries, non-hyperemic posterior
pharyngeal walls, tonsils not enlarged
 Supple neck, no cervical lymphadenopathies, no thyroid
enlargement
 No retractions, symmetrical chest expansion, clear breath
sounds
 Adynamic precordium, PMI at 5th left intercostal space
midclavicular line, regular rate and rhythm no heaves, thrills, lifts
or murmurs
Physical Examination:
 Globularly enlarged abdomen, no striae, normoactive bowel
sounds, no organomegaly, no tenderness, no masses
 Grossly male, bilaterally descended testes, Tanner St. II
 Full and equal peripheral pulses, capillary refill time less than 2
seconds, no cyanosis, no edema
 No limitation in range of motion of all joints
Neurological Exam:
 Cerebrum: conscious, coherent, oriented to 3 spheres
 Cranial nerves: pupils isocoric, 2-3mm equally reactive to liht, (+)
direct and consensual light reflex, extraocular movements full
and intact, can clench teeth, (-) gross facial asymmetry, gross
hearing intact, (+) gag reflex, can turn head from side to side
against resistance, tongue midline
 Cerebellum: (-) no involuntary movements, able to do tandem
gait
Neurologic Examination
 Reflexes: ++ on all extremities
 Motor: (-) rigidity, (-) spasticity, (-) flaccidity, (-)
deficits
 Sensory: (-) deficits
 Meningeal Signs: (-) nuchal rigidity, (-) Brudzinski’s, () Kernig’s, (-) tonic neck reflex
Diagnosis:
Obesity
Hyperglycemia probably secondary to
Diabetes Mellitus Type II
Middle Adolescent with Psychosocial
Issues (Body Image)
Obesity
“Excessive storage of
energy as FAT relative
to lean body mass”
 Energy intake exceeds
expenditure
Definition based on BMI
 Pediatrics
 Obese - BMI> 95% for gender and age
 At risk/overweight - BMI=85-95%
 Adults
 Obese – BMI> 30
 Overweight – BMI=25-30
Measurement
 Weight
 Weight:Height
 BMI
 kg÷m2
 Skin Thickness
 Waist:Hip Ratio
 Growth Charts
Patient
Incidence: Worldwide
 Variable definitions
 Increasing incidence in developed and developing
nations
 Similar prevalence to US: Latin America, Caribbean,
Middle East, Northern Africa, Central-Eastern Europe
 Asia and Africa: no increase in incidence
Worldwide
Gayya et. al (2008) FNRI – DOST digest January 2014
Asian Prevalence
 Thailand – 23%
 Taipei – 28%
 Vietnam – 14 – 16%
Gayya et. al (2008) FNRI – DOST digest January 2014
Trends in children and adolescents
20%
15%
2 -5 yrs
6 - 11 yrs
12 - 19 yrs
10%
5%
0%
1963- 1965
1966- 1970
1971- 1974
1976- 1980
1988- 1994
1999- 2002
Gayya et. al (2008) FNRI – DOST digest January 2014
Etiology
 Heterogeneous and
Multifactorial
 Environmental
 Psychosocial
 Genetic
Sex Difference
 Males – Increased visceral fat
 Females – Increased hip fat
 At all ages females have more adipose tissue than
males
Genetics vs. Environment
 Weights of adopted children correlate better with
biological parents
 BMIs of identical twins reared apart= together
 Monozygotic twins more similar in fat deposition and
weight than dizygotic twins
Reference
Obesity
Differential Diagnosis
 Idiopathic
 Endocrine:
 Hypothyroidism
 Hypercortisolism
 Growth hormone
deficiency
 Genetic
 Prader-Willi
 Turner
Differential Diagnosis
 CNS conditions: hypothalamic damage
 Medications
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Glucocorticoids
Phenothiazines
Lithium
Amytryptiline
Estrogen/progesterone
Physiology of Regulation Of Energy
Expenditure
 Polypeptide Y
 From L cells of small intestine
 Reduce food intake
 Ghrelin
 Stimulates food intake
 Elevated in Prader Willi
Pathogenesis
 LEPTIN - Adipostatic signal
(1994)
 produced by adipose tissue
 Acts on Hypothalamus
 Decreases food intake
 Increases energy
expenditure
Leptin
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Low neuropeptide Y  stimulates appetite
High MSH  inhibits appetite
Fasting  decreases Leptin
Eating  increases Leptin
Leptin and Obesity
 Common obesity due to multiple allelic variations in
hundreds of genes
 Monogenic obesity
 Leptin deficiency
 Leptin insensitivity
Hypothalamus
 Central role of energy intake
 Lesions cause hyperphagia and obesity
Environmental Factors:
Increased Energy Input
 High caloric-density
food
 Supersized portions
 Eating out
 Working parents
 Advertising
Environmental Factors:
Decreased Energy Expenditure
 TV
 Computers
 Transportation
 Inadequate safe areas
for physical activity
 Sedentary Lifestyle
Complications
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Diabetes (Type 2)
Hypertension and Heart Disease
Neurologic Complications
Respiratory Disease
Orthopedic Condition
Psychosocial Disorders
Hyperlipidemia
GI Manifestations
Menstrual Disorders
Metabolic Syndrome
 Clustering of CV risk factors related to insulin
resistance
 Not well defined in Pediatrics
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Insulin resistance
Dyslipidemia
Hypertension
Obesity
 DOES OUR PATIENT HAVE MS?
Course in the Clinics
 First consult
 Laboratories:
 Type 2 Diabetes Mellitus with
Obesity
 Metformin (20 mkday)
 Referred to Nutrition Clinic for
dietary modification
 Increase physical activity
Universal Assessment of Obesity Risk: Steps to Prevention and Treatment
American Academy of Pediatrics. Pediatric Obesity Clinical Decision Support Chart.
Elk Grove Village, IL: American Academy of Pediatrics; 2008.
Steps to Prevention and
Treatment of Pediatric Obesity
Steps to Prevention and
Treatment of Pediatric Obesity
Prevention Plus BMI >85%
Diet Modification
 Build on prevention
 Eating behaviors
 Family meals at least 5 to 6 times per week
 Allow child to self-regulate his or her meals
 Avoid overly restrictive behaviors—“Parents provide,
child decides.”
 Structured activity
American Academy of Pediatrics. Pediatric
Obesity Clinical Decision Support Chart, 2008
Prevention Plus BMI >85%
Diet Modification
 Goal: weight maintenance with growth  a
decreasing BMI as age increases
 Monthly follow-up for 3 to 6 months
 If no improvement go to Stage 2
American Academy of Pediatrics. Pediatric
Obesity Clinical Decision Support Chart, 2008
Prevention Plus BMI >85%
Physical Activity/Inactivity
 60 minutes of moderate physical activity per day or
20 minutes of vigorous activity 3 times a week
 Community activity programs
 Family activities
 Pedometer use
 Limit screen time to <2 hours per day
 No TV/computer in bedroom
American Academy of Pediatrics. Pediatric
Obesity Clinical Decision Support Chart, 2008
American Academy of Pediatrics. Pediatric
Obesity Clinical Decision Support Chart, 2008
Global IDF/ ISPAD Guideline
Pharmacotherapy: Metformin
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Approved for Type 2 diabetes and hyperinsulinemia
Decreases hepatic glucose production
Enhances insulin sensitivity
Results in modest weight loss
Side effects: nausea, flatulance, bloating, diarrhea,
lactic acidosis
Pharmacotherapy
 Not approved for pediatrics
 Drug options
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Appetite suppressants
Serotonin agonists
Inhibitors of fat absorption
Antihyperglycemic agents
Course in the Clinics
 Second consult
 Gradual weight loss of 1.8%
 75 kilograms to 73.6 kilograms
 BMI from 28.2 to 27.7 (z > 2)
 TABLE OF LABS
Steps to Prevention and
Treatment of Pediatric Obesity
Structured Weight Management
 Dietary and physical activity behaviors
 Balanced macronutrient diet with low amounts of
energy-dense foods
 Increased structured daily meals and snacks
 Supervised active play: 60 minutes a day
 Screen time: 1 hour or less a day
 Increased monitoring
Structured Weight Management
 Weight maintenance
 Decreases BMI as age and height increases
 Weight loss
 1 lb/month: 2–11 years old
or
 2 lb/week: older overweight/obese children and adolescents
 If no improvement in BMI/weight after 3 to 6 months 
Stage III
Counseling
Steps to Prevention and
Treatment of Pediatric Obesity
Obesity
Treatment: Surgery
 Gastric bypass
 Gastic plication
 Gastric banding
 Jejuno-ileal bypass no
longer performed
 Not routine for children
Course in the Clinics
 Sustained weight loss
 73.6 kilograms to 72.7 kilograms
 BMI
 27.7 to 27.3 (z >2)
Course in the Clinics
 Regular follow up at the
Endocrinology clinic
 every three months
 Continuation of weight
loss
 70kg, with a BMI of 25.9
(z > 1)
 Disappearance of the
skin hyperpigmentation
around the nape area
Final Diagnosis:
Overweight
Diabetes Mellitus Type II,
controlled
ADOLESCENT?
Childhood Obesity
Conclusion
 Heterogeneous
disorder
 Multifactorial causes
 Global epidemic
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Genetics
Sedentary lifestyle
Too much in
Too little out