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10/2/17
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PEDIATRIC OBESITY
Vanessa Curtis, MD Pediatric Endocrine and Diabetes
IPAS Fall CME
October 10, 2017
Obesity continues to be a problem
Obesity continues to be a problem
National Health and Nutrition Examination Survey. 2011-2014
How is Pediatric Obesity Different?
l Use BMI percentiles to define weight status n BMI is plotted on the CDC BMI-for-age growth charts (separate
for girls and boys) to obtain a percentile ranking
Weight Status Category Percentile
Underweight Less than the 5th percentile
Healthy Weight 5th percentile to less than the 85th percentile
Overweight 85th to less than the 95th percentile
Obese Equal to or greater than the 95th percentile
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BMI (kg/m2) – kids are still growing! BMI as a marker of Adiposity
l Good Screening tool, has limitations
Example BMI Growth Chart
l Example Patient n 12 year old female n Weight 65kg (144lb) n Height 155cm (61”) n BMI 27 kg/m2
Why Worry about Pediatric Obesity?
l “…we may see the first generation that will be less healthy and have a shorter life expectancy than their parents.” -Surgeon General Richard H. Carmona, MD: Testimony to US Senate 3/2004
l Reduced QOL l Stigmatization
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Why Worry about Pediatric Obesity?
l Yearly US spending attributable to obesity = $150+Billion l The average total annual health cost for a child treated for
obesity is $3,743 (compared to $1,108 for all). l Childhood obesity tracks into adulthood l Overweight kindergartener is 5x more likely to become
obese by 8th grade than healthy weight � Infant à 14% chance of being obese adult � Preschooler à 17% � 7 years old à 41% � 12 years old à 75% � Adolescence à 90%
l *Marder W and Chang S. Childhood Obesity: Costs, Treatment Patterns, Disparities in Care, and Prevalent Medical Conditions. Thomson MedStat Research Brief, 2005 (accessed May 2016).
Why Worry about Pediatric Obesity?
Bi-Directional relationship between adiposity and activity: l 326 children participating in Iowa Bone Development Study l Prospective, non-interventional l Exams at ages 5, 8, 11years l Physical Activity measured by accelerometer l Body fat % and mass measured by DXA l Results: BF% at age 8 was negatively associated with PA
at age 11
Metabolic Syndrome
l Adults n Central Obesity
� WC > 102 cm (88 cm) � BMI >30 kg/m2
n Hypertriglyceridemia � >150 mg/dL
n Depressed HDL � <40 mg/dL (50)
n Hypertension � Varies, >135/85
n Impaired glycemic control � IR or T2DM � IFG (>100 mg/dL) � IGT on OGTT
l Pediatrics n No clear consensus n Need to use height/age/
sex/racial norms
Dyslipidemia
l Process of atherosclerosis begins in childhood and is progressive throughout life
l Prevalence of lipid abnormalities is increasing l Lab findings:
n Elevated TG levels n Low HDL levels n Elevated LDL levels
Lipid Research Clinics Program. The Lipid Research Clinics Population Studies Data Book. 1980;DHHS publication no. (NIH) 80-1527. National Cholesterol Education Program. Pediatrics. 1992;89(3):509-511. Daniels SR et al. Pediatrics. 2008;122:198-208. NHLBI Expert Panel. Pediatrics. 2011;128:S213-S256.
TC = total cholesterol; TG = triglycerides † Not established by NCEP, these values are taken from NHANES study values ‡ Values are for children <10 years and children ≥10 years
PERCENTILE TC LDL TG † ‡ HDL † NON-HDL Acceptable < 75th <170 <110 <75 (<90) ≥45 <120
Borderline 75th-95th 170-199 110-129 75-99 (129) 40-44 120-144
Elevated > 95th ≥200 ≥130 ≥100 (≥130) <40 ≥145
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Dyslipidemia- When to Treat
LDL • >190 mg/dl • >160 mg/dl if +FH or 1+ high risk factor or
2+ moderate risk factor • >130 mg/dl if +CVD, 2+ high level risk
factors, or 1 high and 2 moderate
TG’s • >500 mg/dl: fish oil, fibrate • 200-499 mg/dl: Lifestyle, +/- Fish Oil • 150-199 mg/dl: Lifestyle, Increase dietary
fish .
Dyslipidemia- When to Treat
High Risk • DM, ESRD, s/p heart transplant,
Kawasaki with aneurysm, HTN, BMI >97
Moderate Risk • Mod risk: chronic inflammatory
disease, SLE, JIA, Kawasaki without aneurysm, nephrotic syndrome, BMI >95, HDL <40 .
Hypertension
l Prevalence has been increasing with a 10-year lag behind obesity trend
l Causes of elevated blood pressure n Primary hypertension (essential) n Secondary hypertension
� Coarctation of the aorta � Kidney disease � Obesity
l Need 3 separate measurements to diagnose HTN n 24 hour ambulatory blood pressure monitor n School nurse and/or other health provider n Search medical records
Din-Dzetham al. Circulation. 2007;116:1488-1496.
Insulin Resistance is Common in obese kids
FPG 2h OGTT HbA1c <5.7% 5.7-6.4% >6.5%
<100 101-125 >125
<140 140-199 >200
Normal IGT IFG T2DM
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Type 2 Diabetes is still rare in kids
SEARCH for Diabetes in Youth
l FDA Labeled Indications: T2DM n Adult and Pediatric > 10yo
l Non-FDA Labeled Indications n Diabetes mellitus; Prophylaxis n Hyperinsulinar obesity n Hypersecretion of ovarian androgens; Adjunct n Polycystic ovary syndrome n Weight gain, Antipsychotic therapy-induced
T2DM and Metformin
Metformin and T2DM Prevention Cumulative Incidence of Diabetes by Study Group
N Engl J Med. 2002. Vol. 346, No. 6
.
High Failure Rate in Pediatric T2DM
.
TODAY Study Group. NEJM 2012
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Non-Alcoholic Fatty Liver Disease
l No treatment for fatty liver disease l Projections from UNOS indicate NAFLD will overtake HCV
as the most common primary diagnosis of liver failure in liver transplant recipients by 2020
Genetic Factors à Energy Excess à Insulin resistance à
Challenges in Pediatric Obesity
Children don’t control their environment
Food sources Activity opportunities
Focus needs to be on family Need to consider normal growth and development: Weight loss is not always the goal Barriers to Counseling:
Child’s weight gain is “just a phase” and “will grow out of it” Discomfort about weight-related issues Time constraints Lack of resources Receptiveness of family to discussion
What do you DO?
Ideally, You counsel this family regarding her weight, current status of obesity-related disease, and assist in referrals for additional support and/or counseling. IA AAP Obesity Toolkit
Role of Pediatric Providers
l Prevention and early identification is key l Provide assessment of growth
n Measurement of BMI (AND PLOT PERCENTILE!) l Evaluate for complications related to obesity
n Blood pressure n Laboratory evaluations as indicated
l Guidance regarding healthy eating, physical activity, and consequences of obesity
l Referrals as necessary
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Lifestyle Change
l Improve Diet l Start with low-hanging fruit l Family Focus l Mindful eating l Mindless eating l HyVee dietitians l Choosemyplate.gov l CalorieKing.com l Myfitnesspal.com
Lifestyle Change
l Increase Activity l Use the school l Sedentary time l Apple Health l Wearable activity trackers l Marathonkids.org l PT (ex: Athletico)
Metformin and Weight Loss
JAMA Pediatr. 2014;168(2):178-184
Metformin and Weight Loss
Pediatrics. 2017;140(1):e20164285
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Bariatric Surgery
l A Surgical Treatment for a Societal Problem? l First done in 1954 l Gastric bypass was developed in 1966, by Dr. Edward E.
Mason of the University of Iowa l 1991: NIH establishes guidelines for the surgical therapy
of morbid obesity = “bariatric surgery” n Recommends BMI criteria
� BMI > 40 � BMI > 35 + significant comorbidities
l Benefits extend beyond weight loss
Adolescent Criteria- The patient
n BMI ≥ 40 with comorbidity n BMI ≥ 50 without comorbidity n Tanner Stage ≥ 4 n Emotional and cognitive maturity n Supportive environment n Patients with PWS, unresolved eating disorders, un-
treated psychiatric disorders excluded
Prevention and Treatment of Pediatric Obesity: An Endocrine Society Clinical Practice Guideline Based on Expert Opinion. Journal of Clinical Endocrinology & Metabolism, December 2008
UI Pediatric Cardio-Metabolic Clinic
l UI Hospitals and Clinics - Iowa River Landing 105 East 9th Street Coralville, Iowa 52241
l Free Parking l Mondays
8 am to 5 pm l Appointments:
n 319-356-2229