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Childhood obesity

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Causes, Pathophysiology and Management Strategies of Childhood Obesity

Publicado en: Salud y medicina
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Childhood obesity

  1. 1. Obesity in Children Dr. Bedangshu Saikia Registrar, Pediatrics and Neonatology St Stephens Hospital, New Delhi
  2. 2. Obesity is a condition of abnormal or excessive fat accumulation in adipose tissue to the extent that health may be impaired
  3. 3. An emerging problem reaching epidemic proportions. A big health problem which affects not only their childhood but also causes problems in their adult life. Between 3-7% of total health care costs can be attributed to overweight. It is prevalent not only in developed but also in developing countries
  4. 4. Indian Scenario Increasing prevalence of obesity in adolescents especially in urban affluent population (22% overweight in affluent schools as compared to 4.5% in poor section schools) Pune Study: (1228 boys between 10-15 Years) 25.1% overweight and 8.1% obese Delhi : 31% of children overweight and 7.5% obese (Private schools)  29% overweight with BMI >25 (In 5000 children between 4-18 Years showed)
  5. 5. International Scenario
  6. 6. Pathogenesis Thrifty genotype Sedantary lifestyle Good high calorie food
  7. 7. Measurement of obesity Fat cannot be measured. The best way to measure obesity is Body Mass Index in adults
  8. 8. Measurement of obesity But in children age and gender reference charts of BMI are available BMI > 85th percentile – Overweight BMI > 95th percentile (+2SD) – Obese In children < 2 Years wt. for length charts are used Other methods to measure obesity: Skin fold thickness Waist hip ratio (more in adults) Waist circumference (more in adults) Some imaging studies (DEXA, USG, CT scan, MRI, Bioelectrical impedance)
  9. 9. Do obese children grow into obese adults? ‘Tracking’ occurs throughout life 10-20% obese infants 40% obese children 60-80% obese adolescents “Adiposity rebound” Obese Adults
  10. 10. Types of Obesity Android Obesity/ Central Obesity - Fat accumulates in the upper segment - Apple shaped distribution - More likely to develop related disorders like NIDDM, HT, etc. - WHR (waist hip ratio) > 0.8 Gynecoid Obesity - More subcutaneous fat - Accumulates over thighs and lower segment - Pear shaped - Complications fewer
  11. 11. Causes of Obesity Endogenous causes comprise of genetic and endocrine causes – responsible for less than 10% cases (<5%- Nelson 18e) Should be ruled out before treating as exogenous obesity
  12. 12. Endogenous causes Endocrinal causes 1. Cushing’s syndrome 2. Hypothyroidism 3. Hyperinsulinism 4. Pseudo-hyperparathyroidism 5. Acquired hypothalamic syndrome Genetic Causes 1. Prader Willi syndrome 2. Alstrom 3. Carpenter 4. Cohen 5. Laurence Moon Biedl
  13. 13. Diseases Associated with Childhood Obesity (Endogenous obesity)
  14. 14. Exo – versus Endogenous Causes Endogenous Obesity 1. Family history uncommon 2. Short height 3. Low IQ 4. Retarded bone age 5. Physical defects common Exogenous Obesity 1. Family history of obesity 2. Tall child 3. Normal IQ 4. Normal bone age 5. Normal physical exam
  15. 15. Causes of Exogenous Obesity Genetic Environmental Dietary Neurochemical Malnutrition
  16. 16. Genetic Causes Strong correlation between the bodyweight of the child and biological parents Resting energy expenditure genetically determined – influences obesity A number of genes shown to be involved Discovery of leptin – big bang in the field of obesity
  17. 17. Genes for obesity Ob Gene Product – leptin Reduces appetite, increases metabolic rate, increases fat oxidation Mutation results in decreased leptin output leading to obesity
  18. 18. Genes of Obesity – Contd.. db Gene Regulates leptin binding site Establishes ‘set point’ Fat Gene Produces carboxypeptidases Causes miss processing of insulin – competes with leptin binding
  19. 19. Genes of Obesity - Contd.. tub Gene Unknown product – possibly mitochondrial uncoupling protein Agouti Gene Product – agouti signaling protein Suppresses appetite during weight gain
  20. 20. Pathway through which leptin acts to regulate appetite and body weight
  21. 21. Environmental Factors In the first year – duration of feeding - age of introduction of solid foods Second year – maternal weight (reflects the maternal influence on child’s intake and expenditure)
  22. 22. Environmental factors Vigorous feeding Sedentary lifestyle TV viewing - lowers the metabolic rate - increased caloric intake during viewing - Food advertisements and messages
  23. 23. Dietary Factors Reduced meal frequency and ‘gorging’ promotes weight gain, in contrast to ‘nibbling’ High calorie dense foods
  24. 24. Neurochemical Causes Feeding and appetite closely regulated – imbalance may lead to obesity Factors include insulin, neuropeptide Y, dopamine and other monoamines, serotinin, and gut hormones like CCK
  25. 25. Control of appetite
  26. 26. Malnutrition Prenatal malnutrition predisposes to obesity – due to altered development of hypothalamus and the sympathetic system  Dutch famine of the Second WW Undernutrition in later life – tendency to accumulate fat more rapidly and intra abdominally
  27. 27. Complications of Obesity Medical Orthopedic Dermatologic Psychosocial Endocrinologic
  28. 28. Medical Complications Hypertension Hyperlipidemias Coronary heart disease Cholelithiasis and steatohepatitis Respiratory infections Obesity hypoventilation syndrome Obstructive sleep apnea
  29. 29. Orthopedic Complications IN CHILDREN Slipped femoral epiphysis Legg-Calves-Perthes’ Disease Genu valgum IN ADOLESCENT Blount disease (slipped tibia vara) Slipped femoral epiphysis
  30. 30. Dermatologic Complications Heat rash Intertrigo Monilial dermatitis Striae Acanthosis nigricans
  31. 31. Psychosocial Complications Most serious consequence Lower self image, heightened self consciousness, impaired social functioning Negative stereotype attributed by peer group and even trained physicians Less likely to be successful in life
  32. 32. Endocrinologic Complications Hyperinsulinemia with insulin resistance - Overt diabetes - Stimulates lipogenesis and maintains obesity - Hyperplasia and hypertrophy of fat cells
  33. 33. Endocrinologic Complications Decreased SHBG (Sex hormones binding globulin) ↓ Increase free sex hormones ↓ Early puberty and advanced skeletal age
  34. 34. Endocrinologic Complications Increased urinary clearance of cortisol ↓ Compensatory increase in ACTH ↓ Increased adrenal sex steroids ↓ Early adrenarche
  35. 35. Office evaluation of an obese child Objective : differentiate between Organic causes and Idiopathic obesity and early detection of complications History Physical Examination Laboratory Studies
  36. 36. History Duration of disease Previous attempts at weight reduction Daily caloric intake and expenditure Family history - attitudes and practices - weight status of parents and siblings - meal patterns and recreational habits
  37. 37. History Family history of CHD, cancer, diabetes, hypertension, hyperlipidemia and thyroid disorders History of complications Psychosocial history and evaluation
  38. 38. Physical Evaluation Assessment of growth of the child Distribution of fat - gynecoid or android Sexual Maturity Rating (SMR) scoring Blood Pressure Other clinical features of organic causes
  39. 39. Laboratory Studies Evaluation of pituitary, adrenal, and thyroid hormones for endocrine dysfunction (selective) Blood glucose and insulin levels Plasma lipids Serum cholesterol in all >2 years (NCEP expert panel)
  40. 40. Simplified Laboratory Norms for Assessing Overweight Children
  41. 41. Comorbidity H & PE Testing
  42. 42. Management of Obesity Goals of treatment Dietary management Exercise Behaviour modification Other treatments Complications of treatment
  43. 43. Management of Obesity Successful treatment of obesity is challenging Treatment goals vary- depending on the age of the child and the severity of complications
  44. 44. Goals of Treatment Achieve lifelong weight control Avoid weight cycling Maintain normal growth Metabolically safe Minimal hunger Preserve lean body mass No psychological problems IAP
  45. 45. Goals of treatment In most children these goals can be attained by just maintaining weight, rather than weight loss Weight loss should be slow (1 lb or 0.5 kg or less/wk) It should be attempted only in skeletally mature children or in those with serious complications from obesity. An initial goal -10% reduction in weight Once achieved, the new weight should be maintained for 6 mo before further weight loss is attempted.
  46. 46. Goals of treatment Most successful approach to weight maintenance or weight loss requires substantial lifestyle changes that include  increased physical activity and  altered eating habits
  47. 47. Proposed Algorithm for Weight Management 2-7 Yrs > 7 Yrs BMI 85-94 %ile BMI > 95%ile BMI 85-94 %ile BMI > 95%ile Weight maintenance Complication No Yes Weight loss Complication No Weight maintenance Yes Weight loss
  48. 48. Multidisciplinary and community based management 1  Severely overweight children and adolescents with complications from obesity are best managed by a multidisciplinary team.  Teams may include a physician, a psychologist, a dietitian, an exercise specialist (physical therapist, exercise physiologist, educator), a nurse, and counselors. Management consists of dietary counseling, exercise therapy, and behavioral management.  The treatment models used in most pediatric centers feature family-based behavioral treatment, which is the only approach shown to have long-term efficacy.
  49. 49. Dietary Management Recommending healthy eating - should be age specific and flexible enough The parents should be educated about approaches to deal with food refusals Often more than 10 repeated exposures are required to a new food before a child will regularly accept it as part of the regular diet.
  50. 50. Dietary Management Simple measures: For older than 2 yrs: Changing to skim milk, exposure to a wide variety of less calorie-dense foods and limitation of between-meal snacking. Sweetened beverages should be limited and parents should continue to offer healthy foods
  51. 51. Dietary Management Encouraging breakfast, decreasing sweetened beverages, and teaching the principles of balanced nutrition (eating from all food groups) are useful strategies for school going and overweight adolescent.
  52. 52. Dietary Management Diet must provide all essential nutrients Calculate caloric intake on the principle that O.5 Kg of wt loss = 3500 kcal deficit Replace fat with complex carbohydrates (Low glycemic Index) Increase fiber (intake = age + 5-10 gm/day)
  53. 53. Dietary Management  Special Diets: 1. Balanced Hypocaloric diet - Provide 30-40% less than usual intake with lower fat (25-30%), more (50-55%) complex carbohydrate, and sufficient protein (20-25%) - ensures normal growth with weight loss of upto 0.5 kg/week
  54. 54. Dietary Management  Special Diets: for severe obesity 2. Restrictive protein sparing modified fast diet (ELCD) - Provides only 600-800 kcal/day (1.5-2 g/kg protein, 2 L water, 2-4 cup low starch veg - Achieves faster weight loss - More side effects like orthostatic hypotension, arrhythmias, hair loss etc.
  55. 55. Dietary Management  Needs a multidisciplinary approach:  identify problem areas in a child's and family's regular diet  teach them about healthier alternatives and eating patterns  Traffic light or stoplight diet:  successful approach used in preschool and preadolescent children.  limit calories  achieve good nutrient balance and  easily adaptable to fit particular ethnicities and nutrition plans
  56. 56. Dietary Management
  57. 57. Exercise Decreasing sedentary activity is essential for achieving weight control. Increased activity not only increases calorie use but also appears to decrease appetite. Children younger than 2 yrs, avoiding television and computers Children 2–18 yr of age should have <2 hr/day of “screen time” (television, video games, computer), and televisions should be removed from children's bedrooms
  58. 58. Exercise Preserves lean body mass Prevents the reduction in BMR associated with weight loss Improvement in mood Promotes a more active lifestyle in adulthood
  59. 59. Exercise – Contd.. Long term compliance poor with vigorous exercise Better option to decrease inactivity - Less time on computer/ TV - Using stairs in place of elevators - Walking to perform daily errands - Playing outdoor games In the severely overweight, problems of exercise tolerance, referral to an experienced physical or exercise therapist for a safe and graded exercise regimen
  60. 60. Behavior Modification Psychologists screen families for underlying problems that led to child's overweight, problems arising from health complications of overweight, and barriers to successful adaptation of a healthier lifestyle. Once problems are identified, psychologists and counselors can use cognitive behavioral and family therapy to address such issues. The treatment models used was family-based behavioral treatment, which is the only approach shown to have long-term efficacy.
  61. 61. Behavior Modification Techniques Changes in the home and family environment Nutrition education Self monitoring Goal setting Stimulus control procedures Contracting Parenting skills training Positive reinforcement,,
  62. 62. Other Treatments Anti-obesity drugs Surgery Leptin therapy
  63. 63. Medication of overweight children and adolescents is reserved for those with severe medical complications.
  64. 64. Bariatric Surgery Surgery to be considered only in children with a BMI > 40 and a medical complication of obesity after they have failed 6 mo of a multidisciplinary weight management program. American Pediatric Surgical Association Guidelines Monitoring for nutritional complications is mandatory Deficiencies of iron, vitamin B12, folate, thiamine, vitamin D, and calcium have been reported
  65. 65. Bariatric Surgery Timing of surgical Treatment Sexual maturation –Tanner 3 or 4 Skeletal maturation – Age 13 – 14 girls, 15-16 boys or has attained mid parental height. Congenital maturation – acquired formal operations – thinking about possibilities consequences Contradictions: Substance abuse Psychiatric disabilities include severe eating disorders Inability or unwillingness to follow medical or nutritional recommendations
  67. 67. Complications of Treatment Gall bladder disease in cases of rapid weight loss Slowing of linear body growth Loss of lean body mass Eating disorders Emotional and psychological problems
  68. 68. Prevention of Obesity Treating difficult so prevention better Parents taught to respect the child’s appetite Food not to be used for comfort or reward Avoid sugared foods and encourage fiber intake Restrict sedentary activities like TV viewing Promote healthy lifestyle by acting as role models
  69. 69. Multidisciplinary and community based management 2 Community-based programs to inform families regarding age-appropriate healthy  eating choices,  meal and portion size planning,  decreasing “screen time,” and  approaches to increasing physical activity provide an important service for families with children at risk for becoming overweight or mildly to moderately overweight without comorbidities
  70. 70. Proposed Suggestions for the Prevention of Obesity
  71. 71. Proposed Suggestions for the Prevention of Obesity
  72. 72. Thank you