PEDIATRIC OBESITY:ASSESSMENT, PREVENTION, &

TREATMENT

Selma Feldman Witchel, MD

Children’s Hospital of Pittsburgh of UPMC

disclosures

Ilene Fennoy, MD, MPHProfessor of Pediatrics

Columbia University, New York

Drugs and devices unapproved by the FDA will be discussed

I have no financial or other conflicts of interest

LEARNING OBJECTIVES

At the end of this activity, participants will be able to…

Define pediatric obesity

Recognize the many factors leading to obesity

Identify the co-morbidities associated with obesity

Evaluate the pedatric patient with obesity

Wojcicki JM, Heyman MB. N Engl J Med. 2010;362:1457-9

Prevalence of Overweight and Obesity among Low-IncomeU.S. Children 2 to 5 Years of Age Who Are Enrolled in

Federally Funded Health Programs.

The Financial Costs of Childhood Obesity

• Incremental lifetime medical cost of an obese child relative to a normal weight child who maintains weight throughout adulthood: $16,310- $19, 350.

Finkelstein EA, et al. Pediatrics 2014;133:854

Old Definition New Definition BMI percentile

Overweight Obese > 95th

percentile

At risk of overweight

Overweight 85th-95th

percentile

DEFINITIONS OF SEVERE/EXTREME/MORBID OBESITY

Class BMI percentile

1 >95th percentile to <120% of 95th centile

2 >120th percentile to <140% of 95th centile

3 >140th percentile of 95th centile

PREVALENCE OF OBESITY AND SEVERE OBESITY IN US CHILDREN

(2-17 YRS), 1999‐2014

14.615.2

17.1

15.7

17 17 17 17.4

4

5.4 5.3 5.1 5.15.9 5.9 6.3

0.9 1.3 1.6 1.3 1.7 1.7 2.1 2.4

0

2

4

6

8

10

12

14

16

18

20

1999-2000 2001-2002 2003-2004 2005-2006 2007-2008 2009-2010 2011-2012 2013-2014

PER

CEN

T

Class 1 Obesity Class 2 Obesity Class 3 Obeisty

Skinner AC, et al., Obesity 2016; 24:1116-1123.

OBESITY BMI GROWTH CHART, GIRLS 2-19 YRS

Gulati A, et al. Pediatrics 2012; 130:1136-1140

PREVALENCE OF SEVERE OBESITY BY ETHNICITY, 2-19 YR OLD 2011-

2014

0

1

2

3

4

5

6

7

8

9

Males Females

Wei

ghte

d P

reva

len

ce, %

Extreme Obesity, BMI ≥ 120% of 95th %ile

NonHispanic White NonHispanic Black NonHispanic Asian Hispanic

Ogden CL, et al. US Trends in Obesity Prevalence for 2 to 19yr olds. 2016, JAMA; 315, #21:2292-2299.

Prevalence and Incidence of Obesity between Kindergarten and Eighth Grade

Incident obesity between ages 5-14 years was more likely to have occurred at earlier ages….

…and just “gets worse”.

Cunningham SA, et al. N Engl J Med. 2014;370:403

RELATION OF CHILDHOOD BMI TO ADULT OBESITY

Freedman DS, et al. Obesity Res. 2005; 13, #5:928-935

N Childhood Adulthood (Xage=26±5yr)

BMI%ile Age BMIBMI ≥30

(%)BMI ≥35

(%)BMI ≥40

(%)

1161 0- 49 13 ± 2 22.7 ± 4 5% 1% 0

832 50- 84 12 ± 2 27.1 ± 5 23% 8% 2%

130 85- 89 13 ± 2 30.3 ± 5 47% 16% 5%

121 90- 94 12 ± 2 32.4 ± 6 64% 33% 13%

122 95- 98 13 ± 2 37.1 ± 7 84% 60% 34%

26 ≥99 12 ± 3 43.6 ± 9 100% 88% 65%

Values are mean ± SD.

Risk Factors for Pediatric Obesity

Parental and family obesity

Increased intake of sugar-sweetened beverages, fast food, & processed food

Decreased physical activity

Increased screen time

Shorter sleep duration

Parental stress

Mother’s pre-pregnancy BMI & gestational weight gain

High birth weight and rapid infant weight gain

ETIOLOGIC FACTORS IN CHILDHOOD OBESITY

Brown C, et al. Pediatr Clin North Am. 2015; 62: 1241–1261.

Gene

tics of Obesity

Hereditability of BMI is approximately 70%

Although monogenic obesity is rare, several genes have been associated with obesity.

Syndromes associated with obesity include Prader-Willi andBardet-Biedl Syndromes.

Genes include leptin, leptin receptor, & melanocortin 4 receptor.

Common phenotypic features include markedly increased appetite, reduced duration of satiety, & increased food-seeking behavior.

? Neurobehavioral effect

Venus of Willendorf~25,000 BCE

Obesity is not new disease

O’Rahilly S. Clin Med 2016;16:551

Congenital Leptin Deficiency

O’Rahilly S. Clin Med 2016;16:551

COMORBIDITIES ASSOCIATED WITH PEDIATRIC OBESITY

MEDICAL COMPLICATIONS OF OBESITY IN CHILDHOOD

• Abnormal Glucose metabolism• Insulin resistance• Acanthosis nigricans• Type 2 diabetes • Hypertension• Hyperlipidemia• Metabolic Syndrome• Polycystic ovarian disease• Nonalcoholic fatty liver disease• Sleep apnea• Pseudotumor cerebri• Cholelithiasis• Psychosocial complications• Orthopedic complications• Focal segmental glomerulosclerosis

0

5

10

15

20

25

30

35

Overweight Class 1 Obesity Class 2 Obesity Class 3 Obesity

Pre

vale

nce

(%

)

Total Cholesterol>=200mg% HDL Chol<35mg% LDL Chol>=130 mg%

Triglyceride >=150mg% HgbA1c>5.7% FBS>100mg%

Skinner AC et al. NEJM 2015;373,:1307-1317

Prevalence of Abnormal Values by Weight Category,

3-19 yrs of age

Changing Incidence: Type 2 DM and Obesity

Alberti G et al. Diabetes Care 27,#7:1798-1811, 2004

Polycystic Ovary Syndrome

Heterogeneous familial disorder characterized by hyperandrogenismand chronic anovulation.

In adolescent girls, persistent menstrual irregularity beyond 2 yearsafter menarche or primary amenorrhea with complete pubertymay suggest androgen excess

Insulin resistance and obesity are common features. But, theyshould not be used as diagnostic criteria for PCOS.

Witchel SF, et al. Horm Res Paediatr. 2015 Apr 1.Ibáñez et al. Horm Res Paediatr. (in press).

O’Rahilly S. Clin Med 2016;16:551

Insulin Resistance

Prevalence Metabolic Syndrome: Adolescents (12-19yrs), NHANESIII

0

5

10

15

20

25

30

35

DeFerranti Cook

Overall

Elevated BMI

BMI≥95%ileBMI ≥ 85%ile

N=1960 N=2340

**deFerranti SD. et.al. Circulation 110:2494-2497, 2004* Cook, S. et al. Arch Pediatr Adolesc Med 157:821, 2003

Body-Mass Index (BMI) z Score (N=477)Children (4-11ys), RCT x 18 Mos, SSB vs no SSB

de Ruyter JC et al. N Engl J Med 2012;367:1397-1406

• Study in Netherlands

• Primarily normalweight children

• Beverages distributedat school

Copyright ©2008 The Endocrine Society

McGovern, L. et al. J Clin Endocrinol Metab 2008;93:4600-4605

Results of randomized trials of treatments

for pediatric obesity

Sibutramine resulted in a relevant increase in both systolic and diastolic pressure and was

withdrawn from the US market because of an increased risk of serious cardiovascular

events.

Metformin appears to have similar minimal weight loss effects as in adults and should only

be used in children aged ≥10 years.

Orlistat remains the only FDA–approved drug for treatment of childhood obesity for those

aged ≥12 years.

Rajjo T, et al J Clin Endocrinol Metab. 2017;102:763-775

Bariatric Surgery

Adjustable Gastric BandRoux-en-Y Gastric BypassSleeve Gastrectomy

Bariatric surgeryBariatrics: a branch of medicine that deals with the treatment of obesity.

Malabsorptive proceduresRestriction of absorption in GI tractRarely used due to lifelong management and complicationsBiliopancreatic diversion with Duodenal switch

Restrictive proceduresRestriction of food intake

Vertical banded Gastroplasty (Stomach Stapling)

Adjustable Gastric Band

Sleeve Gastrectomy

Combination proceduresWeight loss both through restriction of intake and absorption

Roux-en-Y Gastric Bypass

http://www.homerton.nhs.uk/uploaded_files/Our_services/duodenal_switch_illus.jpg

http://www.amh.org/images/healthsrv/Roux-en-Y_GBP.jpg

http://www.overcomingobesity.net/adjust

able-gastric-banding.cfm

Vertical Sleeve Gastrectomy

http://www.winh.org/bariatric-surgery

Outcome Adolescent Bariatric Surgery

Treadwell J. et al. Ann Surg 2008;248,#5:763-776.

AGB

RYGB

BMI >85th percentile

History and physical examination

Evaluate for obesityco-morbidities

Additional evaluations based on findings

Initiate lifestyle changes

Initiate lifestyle

changes and specific

treatment of co-morbidity

Maintain support for lifestyle changes and

co-morbidity treatment

Consider pharmacotherapy and/or surgery

Continued weight gain > 6months

Weight loss or stabilization

CNS injuryNeuro-

developmental abnormalities

Attenuated growth velocity

NormalAbnormal

Hypothalamic obesity

Genetic evaluation

Endocrine evaluation

AbsentPresent

Reevaluate pituitary function and/or hormone

therapy

Anti-psychotic drug use

Reevaluate drug

therapy/choice

Data supporting use of these interventions are

limited to pubertal individuals

Diagnosis and Management Flow Chart

Summary (1)

Childhood obesity is associated with family, community, racial, and SES factors in addition to sugared beverage intake,

physical activity level, and sedentary activity.

Obesity and extreme obesity have increased over the past 3 decades particularly among African American

and Hispanic Youth.

Obesity in childhood tracks into adult life.

Comorbidities include diabetes, hypertension, dyslipidemia, PCOS, and metabolic syndrome.

Prevalences of these comorbidities have increased in children and adolescents

Summary (2)

Lifestyle interventions focused on the family and including both dietary and physical activity changes have

therapeutic efficacy in reducing obesity but of small effect (approx. 3 to 4 Kg on average).

There are limited pharmacological agents currently available for use in the pediatric population and their efficacy above and beyond lifestyle intervention is

marginal at best.

Surgical interventions have proven to be most effective for extremely obese pediatric patients

Prevention (BMI 5th to 85th%ile)

Dietary Intake

Limit consumption of sugar sweetened beverages

Encourage 5-a-day fruits and vegetables

Physical Activity

Limit screen time to 1-2hrs/day starting age 5yrs

No TV/computer screens in bedroom

Encourage 60min moderate to vigorous physical activity/day

Eating Behaviors

Daily breakfast

Limit restaurant eating

Encourage family meals

Limit portion size

Barlow SE. Pediatrics 2007; 120, Suppl #4: S164-S192

Role of Primary Care Physician

Measure height and weight and calculate BMI at least annually

Observe for trends such as rapid weight gain

Offer anticipatory guidance about nutrition and physical activity at every well child check

Help families make better food choices

Advocate for children on local, state, and national levels

Brown C, et al. Pediatr Clin North Am. 2015; 62: 1241–1261.

Interventions

• Stage 1: Prevention+ program• General recommendations + monthly follow-up • Target: Weight maintenance

• Stage 2: Structured weight management program (failed prevention+)• Balanced macronutrient diet, • Supervised active play of 60 min/day, • Decreased screen time ≤ 1 hr/day• Target: Weight loss 1 lb/month in 2-11 yr olds, maximum 2 lbs/week in older obese children and adolescents

Barlow SE. Pediatrics 2007; 120, Suppl #4: S164-S192

Conclusions (1)

Lifestyle interventions are the cornerstone of all therapeutic interventions for obesity in childhood.

Recognition of comorbidities in children with obesity demands both a therapeutic intervention for the

comorbidity as well as targeting the obesity.

Pharmacotherapy and surgical interventions are currently recommended only for those who have failed lifestyle

approaches and continue to gain weight at an accelerated rate.

Conclusions (2)

Given our limited armamentarium for treating obesity, prevention represents the best course to

control the epidemic.

Research into non-surgical interventions to treat those children already obese is an important unmet

need.

Conclusions (3)

Successful lifestyle change requires family interventions with community advocacy to support those changes.

Shared agreements for use of physical activity spaces

Establishing/maintaining recess and gym classes

Subsidies for schools to provide healthy foods

Menu labeling in restaurants

Laws addressing food advertising to children

Food and beverage industry incentives

Brown C, et al. Pediatr Clin North Am. 2015; 62: 1241–1261.

Prevention

A collective responsibility requiring

individual

family

physician

community

corporate

government

COMMITMENT

THANK YOUSelma Feldman Witchel, MD

Pediatric Endocrinology

Children’s Hospital of Pittsburgh of UPMC

Phone: 412-692-5170

“Endocrine Wellness”