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Download CHILDHOOD OBESITY: The Global Epidemic
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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 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 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 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: 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 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 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 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 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 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 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 Genetics Sedentary lifestyle Too much in Too little out