Pediatric Obesity diagnosis and treatment Yelena Nicholson DO

Pediatric Obesity diagnosis and treatment Yelena Nicholson DO

Pediatric Obesity diagnosis and treatment Yelena Nicholson DO Pediatric Endocrinologist Dayton Childrens Medical Center Objectives

Discuss increase in incidence and prevalence of type of obesity in pediatric population in US Discuss patient screening and diagnosis Discuss current management strategies its use in pediatric office visits Discuss resources and referrals (when, where, why) Adult obesity rates in US Adult obesity Worldwide Pediatric Obesity US

CDC Pediatric Obesity Data Worldwide pediatric obesity Pediatric obesity worldwide comparasion Pediatric Obesity in US over 30 years Scope of the problem

World wide epidemic of obesity Obesity is defined as BMI>95% Overweight is BMI>85% 250 million people (7%) of world population are obese and 2-3 times that overweight. Prevalence among 6 to 11 year old doubled and among 12 to 17 year old

tripled between in US between 1976 and 2000. and continues to grow 17% of all children in US age 2 to 19 years were obese by CDC data of 2000. Cost of Obesity Why Obesity is increasing Man has evolved under conditions of

stress in which it was advantageous to be able to store fat. It is this genetic propensity to store fat in response to insulin, paired with our lifestyles with too much sedentary activity and processed energy-dense foods, that has contributed to the problem of overweight (energy sure-plus). Obesity caused by known hormonal, syndromic, or molecular genetic abnormalities can presently account for less than 5% of obese individuals. Causes of pediatric obesity

Indian journal of Endocrinology and Metabolism. Determinants, consequences and prevention of childhood overweight and obesity. ( vol 18, issue 7 2014) Source of guidelines on diagnosis and treatment of

childhood obesity There very few guidelines AAP 2007 guidelines on prevention of pediatric obesity. 2008 Prevention and Treatment of Pediatric Obesity: An Endocrine Society Clinical Practice Guidelines. 2010 US preventive Services Task Force Recommendation Statement. 2011 Institute of Medicine June 2011 new guidelines targeting early childhood obesity 2017 Screening for Obesity in children and Adolescents US preventive Services Task

Screening for Obesity in Children and Adolescents US Preventative Service Task Force Recommendation (2017 update) 1) USPSTF recommends screening of all children age 6 and up for obesity by measuring height, weight and calculating BMI. BMI should be calculated and recorded at routine health visits.

BMI is calculated by weight in kg divided by square of the height in meters. BMI percentile can be plotted on a Overweight/Obesity Definitions in pediatric population Overweight =age and sex specific

BMI>85% Obese=age and sex specific BMI>95% Height, weight and BMI are calculated and plotted on CDC growth charts developed in 2000. Evidence shows that biggest increase in obesity is affecting 2 to 5 year old children. Based on that pediatrician should pay attention to height and weight of younger

Who to screen recomendations BMI chart is available for children age 2 and above. However guidelines caution that BMI is particularly impressive in children younger then age 4 because of their body proportions. Much research has focused on using the waist circumference or waist to height ratio as a marker of obesity and insulin resistance.

Waist circumference standards for American children of different ethnic Diagnostic test in screening for obesity USPSTF made no recommendation on doing routing diagnostic lab testing in obese or overweight children. Endocrine society 2007 guidelines recommend against routine laboratory evaluations for endocrine

causes of obesity unless height velocity is decreased over period of time. Primary Obesity It is important to distinguish between primary or idiopathic obesity and the rarer situation of secondary obesity owing to genetic disorders, endocrine disease, central nervous system lesions, or iatrogenic causes.

Detailed medical history, physical examination, and laboratory tests are helpful. Endocrine causes of Pediatric obesity Growth hormone deficiency, Hypothyroidism, Cushion disease or pseudohypoparathyroidism are all associated with drop in height

velocity and decrease of height. Hypothalamic obesity is obesity caused by insult to nervous system resulting in damage to hypothalamus and decrease energy expenditure. Hypothalamic obesity is not Growth chart of child with Acquired Hypothyroidism Hypothyroidism Obesity and genetic syndromes Obesity in some genetic syndromes is

common. However genetic syndrome associated with obesity are rare. Prader-Willi syndrome is the most common genetic obesity caused by deletion of paternally expressed genes on chromosome 15q. 40 to 50% of children and 80 to 90% of adults with Prader-Willi syndrome are obese. Causes of Pediatric Obesity

Genetic rare, includes, monogenic obesity Leptin deficiency is one of the know causes of extreme obesity. However majority of overweight patients have high leptin level. Details of leptin regulation remain sketchy. Several monogenic obesity syndromes have been identified, and most involve the leptin-melanocortin regulation pathway.

PWS (Prader-Willi syndrome) Genetic syndrome involving obesity Identifying patients with genetically caused obesity Current recommendation is to refer

patients with obesity and syndromic features to geneticist (especially if patient also has developmental delay). Children with BMI above 97% by age 3 may benefit form genetic testing for MCR4R genetic testing. Leptin level can also be helpful in children with early onset obesity Both MCR4R deficiency and Leptin deficiency are very rare. Screening for Comordidities and complications of

obesity Routine lab tests for children with obesity is not recommended. However it is recommended that all children with BMI>85% are screened for complications and comorbidities of obesity. Most concerning is risk for CV complications and early onset heart disease.

Hyperlipidemia, Impaired fasting Laboratory testing in children with BMI >85% Children with BMI>85% and age of 6 and above should have baseline fasting lipid profile, fasting glucose and Liver function tests. Presence of acanthosis, impaired fasting glucose, family history of diabetes or maternal gestational diabetes warrant further testing

such as HgA1C and 2 hour glucose tolerance test and fasting insulin Screening test for comorbidities Comorbidity Abnormal test results Prediabetes Diabetes Dyslipidemia Fasting serum glucose >100mg/dl or 2 hours OGTT serum glucose

>140mg/dl But less then 200mg/dl Fasting serum glucose >126mg/dl Random serum BG >200mg/dl x2 (or 1 time with symptoms) Or >200mg/dl based on 2 hour OGTT test Fasting (>12hours) lipids TG>110mg/dl (TG>160mg/dl to start pharmaceutical agent) LDL >110mg/dl (>130mg/dl to start statin therapy Total cholesterol>180mg/dl HDL <=35mg/dl

Other useful tests in assessment of obesity comorbidities Female patients with acanthosis, and BMI>85% as well as irregular periods or excessive acne or hirsutism should be screened for PCOS Pediatric patient with obesity should

be screened for obstructive sleep apnea. Obese children with HTN should be also screened for LVH and CVD Cardiovascular risks and HTN Excessive adipose accumulation induces increased blood volume and cardiac output.

Childhood obesity increases risk for endothelial dysfunction, carotid intimal medial thickening, and the development of early aortic and coronary arterial fatty streaks and fibrous plaques. Childhood obesity is the leading cause of pediatric hypertension. PCOS

In adolescent girls and young women, excess central or abdominal body fat is associated with hyperandrogenemia. Hyperinsulinism affects ovaries and causes increase in testosterone and decrease in SHBP. PCOS is associate with menstrual abnormalities,

an-ovulatory cycles. Physical Exam Focus of body proportions Dysmorphic features Acanthosis In female patients (acne, body hair distribution and amount) Weight, height, BMI, waist

circumference should be recorded at each visit Acanthosis Each age group needs to be approached in different way 0-5 year old are most fast growing group of obese kids and focus should be on identifying patients at future risk and

focusing on prevention, screening, counseling 6-10 year olds focus on early identification, looking at secondary factors (early puberty) and early screening, counseling, diagnosis and treatment 10-15 year olds early screening diagnosis of obesity, metabolic syndrome, PCOS, Medications and obesity

Chronic glucocorticoid treatment is well known to be associated weight gain, with visceral fat accumulation predisposing to cardiovascular risk and diabetes. Other drugs such as cyproheptadine, valproate, and progestins also implicated. treatment with some newer antipsychotic drugs can cause a rapid increase in body weight. The prevalence of both diabetes and hyperlipidemia among individuals with schizophrenia and affective disorders is 1.52 times higher than the general population. Respiradol, Abilify and other antipsychotic are

linked to insulin resistance, weight gain, and increase in diabetes incidence. Nature vs. Nurture There is a lot of evidence that combination of genetic predisposition and environment ( energy sur plus) are involved in pediatric obesity. There are studies linking LGA as well

as SGA babies to impaired glucose tolerance and insulin resistance. Thus, the effect of fetal hyperinsulinemia on body composition and size at birth may set Special history to focus on Therefore focus on LGA and SGA babies and prevention of obesity

Provide nutritional information early at every well child visit, focusing on breastfeeding, limiting milk after one, no juice at all, no flavored milk. Monitor SGA babies carefully dont miss excessive weight gain (happens very frequently in ages from 2 to 10) Role of Life style and diet

Studies using motion sensors have shown that children who spend less time in moderately vigorous activity are at higher risk to become obese during childhood and adolescence There is a positive correlation between hours of television viewing and overweight, especially in older children and adolescents . Eating pattern of children and adolescents have changed dramatically in the past few decades. Dietary factors that place children at risk for obesity include high fat and excess calorie intake. Obese children tend to skip breakfast but

consume a large amount of food at dinner Treatment Best treatment of obesity is prevention There are several studies focusing on impact of improving nutrition and decreasing weight gain in at risk pregnant women and impact on glucose tolerance and insulin

sensitivity in the infants . Healthy nutrition starts from infancy and before. Goals of the treatment Stabilization of weight gain. Increase in energy expenditure and decrease in energy intake (caloric restriction) to restrict calories while increasing energy expenditure. The long-term objectives of

treatment of childhood obesity are to reduce BMI and reverse and prevent short- and long-term comorbidities. Life style modification USPSTF concluded (2010, 2017) that the only treatment of childhood obesity that has proven to result in weight loss has been comprehensive intensive behavioral intervention programs of >26 contact hours. Successful program includes

individual session for child, parents separately and together as well as group of parents and children Life style modification programs Program must include information and demonstration on healthy eating, meal preparation, food label reading. Program must encourage and demonstrate use of physical exercise during supervises activity sessions. Program must educate about reduction of screen time . Programs usually include medical provider, nutritionist, exercise specialist

and social worker. Most programs require referral outside of Activity is a key Pictures taken in weight camp. 1 week at this camp Dietary Consideration Mild caloric restriction is safe and can be effective when obese children and their families are motivated and encouraged to change longstanding feeding behaviors .

Example is to eliminate and decrease unhealthy excesses (pop, juice, excess snacking, junk food). The role of specific dietary macronutrients in the pathogenesis and treatment of obesity is controversial. Low fat vs. low carbs?? Extreme diets dont seem to work well. (Atkins, south beach) However reduction of specific nutrient groups (carbs, sugars, fat, calories works well when provided specific goals).

Resource to families looking for life style modification program Healthy way is a free program at Kroc (Salvation army Dayton center in collaboration with Dayton childrens) which is available to overweight and obese patients and their families is offered for age specific groups for limited number of sessions. Program focuses on

healthy nutrition and exercise. Resource to families looking for life style modification program Type 2 diabetes camp is reduce cost 3 day

resident camp at YMCA camp Wilson. This camp is called camp Tiponi. It is collaboration between Dayton Diabetes (non profit organization) and Dayton children's. This program offers very lost cost program ($200 and less with scholarships) in the summer for children with type 2 diabetes or prediabetes or obesity that focuses on healthy nutrition and exercise. More information is found on www.diabetesdaytoncamp.com Obesity and Eating Disorders

In last few years there has been focus on recognizing obesity as a cause or and result of eating disorders. Research shows that most children with ED were not previously overweight. However some children especially adolescents develop ED as result of attempts of weight loss and dieting. Obesity and Eating Disorder

Studies show that overweight teens are more likely to engage in disorganized eating, meal skipping, food avoidance, starvation, binge eating, as well as self induced vomiting, use of laxatives and diet pills. One study showed that 36% of teenagers seeking treatment for ED were previously overweight with AAP recommendation on role of Primary care provider in

prevention of obesity and eating disorders Discourage dieting, skipping of meals, or the use of diet pills; instead, encourage and support the implementation of healthy eating and physical activity behaviors that can be maintained on an ongoing basis. The focus should be on healthy living and healthy habits rather than on weight. Promote a positive body image

AAP Recommendation for prevention of obesity and ED Encourage more frequent family meals. Studies show that children who participate regularly in family meals are less likely to develop ED. Encourage families not to talk about

weight but rather to talk about healthy eating and being active to stay healthy. Inquire about a history of mistreatment or bullying in overweight and obese teenagers. Carefully monitor weight loss in an Pediatric Obesity and Depression There is link between pediatric obesity and depression. In a prospective study of over 9,000

youth, depressed mood significantly predicted obesity at one year follow up, Pediatrics. 2002;110(3):497504. [ PubMed] Another prospective study showed significant increase in depression and anxiety in females age 12 to 19 with obesity but did not show the same in males. (Analysis of a prospective community-based cohort originally Pediatric obesity and Mental health disorders

It is important to screen children and adolescents with overweight and obesity for depression. Many obese children have depression and anxiety as result of social family issues and family conflict as well as bulling at home and at school and use food as therapeutic agent of coping. Provider can use simple questionnaire such as modified for teens (age 13 to 19) PHQ-9 during routine health visit for all teens including teens with obesity Obesity and food

insecurities Food insecurity is a critical child health issue that impacts children and families in all communities. In 2015, 13.1 million U.S. children lived in households without consistent access to adequate food for resource-related reasons. The U.S. Department of Agricultures (USDA) official definition of a foodinsecure household is one

in which access to adequate food is limited by a lack of money and other Screening for food insecurities Screening can be one question included on healthy child visits questionnaire form used in your practice.

Role of primary care in addressing food insecurities AAP recommends screening at scheduled health maintenance visits or sooner, if indicated. Remember food insecurities is sensitive

matter. Address food insecurities in the office by providing information to families about resources available. Encourage families to apply for SNAP (food stamps). Find out and provide information about Example of Resources for families with food insecurity Dayton children hospital encourages their providers in specialty clinics, health

clinics and ED to screen for food insecurities and then if positive to refer patients to family resource center located in Dayton childrens main campus. Family resource center helps families to apply for SNAP or WIC if available and provides locations of food pantries or food banks local to family. Resources at Dayton Childrens hospital FRC refers families to pick up box of

food from Dayton food bank. Dayton children's is opening Food Pharmacy at main campus soon. Families identified as having food insecurities during visits to DCH will be given prescription to Food Pharmacy at Childrens Health Pavilion to pick up box of food directly. Pharmacotherapy

Pharmacotherapy in obesity is controversial especially in pediatrics and lack of safe well studied options predominates. No magic weight loss pill exists at this time. As of today there is only one FDA approved medication exists for treatment of pediatric obesity for adolescent >= 12 years of age. That medication is Orlistat. Orlistat is available by prescription as Xenical ($640 if paying cash). It is available OTC as Alli (60mg capsules). Dose of Alli is 2 capsules tid with meals

Orlistat Orlistat dose is 120mg capsules tid with meals. Orlistat acts by decreasing hydrolysis of ingested triglycerides and reducing gastrointestinal absorption of fat by approximately 30% via inhibition of intestinal lipases. Side effects caused by unabsorbed fat

excretion in feces include diarrhea, abdominal discomfort, and flatulence and limit use of orlistat in adolescents. Orlistat Large multicenter, randomized, double-blind study with 539 obese adolescents aged 12 to 16 years at 32 centers in the United States and Canada was done. A 120-mg dose of orlistat (n = 357) or placebo (n = 182) was given 3 times daily for 1 year, along with a mildly hypocaloric diet, exercise, and behavioral therapy. (Jama 2005)

Body mass index decreased in both groups up to week 12, thereafter increasing with placebo beyond the baseline. At the end of the study, BMI had decreased by 0.55 kg/m2 with orlistat but increased by 0.31 kg/m2 with placebo (P = .001). Mild to moderate gastrointestinal adverse events occurred in 9% to 50% of patients in the orlistat Metformin Its major site of action is the liver: the drug increases hepatic glucose uptake, decreases gluconeogenesis,

and reduces hepatic glucose production. Major advantages of the drug include decreased food intake, weight loss, decreased fat stores (sc more than visceral), improved lipid profiles, and a reduction in conversion to T2DM among adults Metformin

There have been two randomized, double-blind, placebo-controlled studies of metformin in obese adolescents with insulin resistance, normal glucose tolerance, and a positive family history of type 2 diabetes. Both showed modest reduction in weight and BMI and decreased plasma leptin, insulin, glucose, cholesterol, and triglyceride concentration. However this is still controversial as side effects include GI upset, Nausea, abdominal pain, and lactic acidosis. At this time Metformin is not approved by FDA for treatment of pediatric obesity and approved for use in children with type 2 diabetes.

Bariatric surgery The long-term success of lifestyle intervention and pharmacotherapy in subjects with severe obesity has in general been disappointing. More aggressive approaches such as bariatric surgery may be indicated in selected subjects with extreme obesity and serious co morbidities. The surgical approaches now used most

commonly are the laparoscopic gastric banding procedure, gastric sleeve, and the Roux-en-Y gastric bypass (RYGB). Bariatric surgery Trials of bariatric surgery in adolescents were conducted in major tertiary pediatric centers. Trials have shown great potential for treatment

of morbid obesity with 2nary conditions in adolescents >14 years of age Bariatric surgery should be reserved for treatment of adolescents with extreme obesity (usually defined as BMI > 40-50 or > 35-40 ( with established co morbidities) who have failed other treatment approaches. Surgery should be performed only under the rubric of clinical trials in large medical centers that have expertise in bariatric surgical techniques. Contraindications to bariatric surgery include substance abuse or psychiatric disabilities (including severe eating disorders) that prevent Approaching obesity in

the office summary Child with BMI >85% Age depended physical exam 0-5 year olds normal exam , exclude genetic obesity, syndromes, hypothyroid, Screen for lifestyle, nutrition, provide support, information, counseling 6-10 year olds detailed physical exam , looks for premature adrenarche, early

central puberty, acanthosis, hypothyroidism , Normal exam Screen for lifestyle, nutrition, provide support, information, counseling Reassess in 6 month if BMI is increasing consider referral to nutritionist , lipid clinic , >10 year olds detailed history and physical exam , looking for acanthosis, HTN, hypothyroidism, PCOS,

type II diabetes gynocomastia, etc as well as risk factors (family history, ethnicity ) Abnormal exam Blood work (puberty, lipids, fasting insulin, glucose, A1C ) or and referral Endocrinology, lipid clinic Abnormal exam or risk

factors Fasting blood work (insulin, A1C, glucose, lipids, and PCOS, UA, urinary creatinine), TFT Any abnormalities, early referral lipid clinic , hypeinsulinism clinic , type II clinic,

Screening, prevention and treatment during office visits Once you identified these with BMI >85%, do detailed physical exam plus or minus blood work Decide if you need to start with prevention and counseling done in your office or do you need to refer. If referring where? (nutritionist, lipid clinic, intense life style modification program)

Counseling about weight during office visits Start with screening tools (life style questionnaires, to identify, nutrition, activity and family life pattern to identify and target risk behavior). Focus on 5,2,1,0 (see below) rules. Use patient handouts and materials. https://www.nichq.org/resource/healthy-care-healthy-kids-obe

sity-toolkit http://ohioaap.org/Projects/PMP/Dashboard (handouts for parenting at the mealtime program) https://www.nutrition.gov/ (handouts such as my plate, food pyramid) 5,2,1,0 example of simple advise When to refer patient

with obesity to subspecialist Children with criteria for prediabetes or diabetes should be seen by endocrinologist (if there is evidence for endocrine origin of obesity) Patients with dyslipidemia should be seen by Lipid disorder clinic or center. HTN patients should be seeing by nephrologist or cardiologist if also at Conclusion

Pediatric obesity is very real and rapidly emerging risk to general population and will affect health, wealth and well being of the future generations of children as well as pediatricians. Obesity is multi-factorial. Much is not known about origin of obesity as well as treatment. Best treatment is a prevention and we

must focus our treatment in that direction. Treatment and prevention must start at primary care providers office. References Childhood Obesity (Consensus) (Phyllis W. Speiser, Mary C. J. Rudolf, Henry Anhalt, Cecilia Camacho-Hubner, Francesco Chiarelli, Alon Eliakim, Michael Freemark, Annette Gruters, Eli Hershkovitz, Lorenzo Iughetti, Heiko Krude, Yael Latzer, Robert H. Lustig, Ora Hirsch Pescovitz, Orit Pinhas-Hamiel, Alan D. Rogol, Shlomit Shalitin, Charles Sultan, Daniel Stein, Pnina Vardi, George A. Werther, Zvi Zadik, Nehama Zuckerman-Levin, Zeev

Hochberg) Obesity Consensus Working Group (Endocrine Society) JCEM Journal of Clinical Endocrinology & Metabolism, doi:10.1210/jc.2004-1389 CLINICAL PRACTICE GUIDELINE. Prevention and Treatment of Pediatric Obesity: An Endocrine Society Clinical Practice Guideline Based on Expert Opinion. Gilbert P. August, Sonia Caprio, Ilene Fennoy, Michael Freemark, Francine R. Kaufman, Robert H. Lustig, Janet H. Silverstein, Phyllis W. Speiser, Dennis M. Styne and Victor M. Montori. Journal of Clinical Endocrinology & Metabolism, doi:10.1210/jc.2007-2458 The Journal of Clinical Endocrinology & Metabolism Vol. 93, No. 12 4576-4599

Thank you

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