CHILDHOOD OBESITY. CRITERIA FOR OBESITY Body mass index (BMI) Body mass index (BMI) BMI= Weight (Kg) / Height (m) 2 BMI= Weight (Kg) / Height (m) 2 BMI

CHILDHOOD CHILDHOOD OBESITYOBESITY

CRITERIA FOR OBESITYCRITERIA FOR OBESITY

Body mass index (BMI) Body mass index (BMI) BMI= Weight (Kg) / Height (m)BMI= Weight (Kg) / Height (m)2 2

BMI more than 85BMI more than 85thth percentile - percentile - Overweight Overweight

BMI more than 95BMI more than 95thth percentile – Obese percentile – Obese BMI is a good indicator of body fatBMI is a good indicator of body fat BMI is unreliable in short muscular BMI is unreliable in short muscular

individualsindividuals

Weight for height Weight for height

Weight for height compares the Weight for height compares the child’s weight to the expected child’s weight to the expected weight for his/her heightweight for his/her height

Weight for height more than 120% - Weight for height more than 120% - Obese Obese

Skin fold thicknessSkin fold thickness

Skin fold thickness (SFT)– indicator Skin fold thickness (SFT)– indicator of subcutaneous fat. of subcutaneous fat.

Measured over subscapular, triceps Measured over subscapular, triceps or biceps region. or biceps region.

Age specific cut-offs should be used.Age specific cut-offs should be used. SFTmore than 85SFTmore than 85thth percentile is percentile is

considered as abnormal. considered as abnormal.

Waist circumferenceWaist circumference

Marker of abdominal adiposity.Marker of abdominal adiposity. Key risk factor for metabolic and Key risk factor for metabolic and

cardiovascular effects of obesity. cardiovascular effects of obesity.

INCIDENCE &PREVALENCE

ETIOLOGYETIOLOGY

CONSTITUTIONAL OBESITYCONSTITUTIONAL OBESITY ENVIRONMENTAL FACTORSENVIRONMENTAL FACTORS ENDOCRINE CAUSES ENDOCRINE CAUSES HYPOTHALAMIC OBESITY HYPOTHALAMIC OBESITY DRUGS DRUGS GENETIC SYNDROMES GENETIC SYNDROMES MONOGENIC DISORDERS MONOGENIC DISORDERS

CONSTITUTIONAL CONSTITUTIONAL OBESITYOBESITY

Over 95% of all casesOver 95% of all cases Imbalance in energy intake and Imbalance in energy intake and

expenditure expenditure Proportional obesity Proportional obesity Tall for age Tall for age Normal developmentNormal development Avoid unnecessary investigations Avoid unnecessary investigations Family historyFamily history

ENVIRONMENTAL ENVIRONMENTAL FACTORSFACTORS

Excessive calorie intake Excessive calorie intake Sedentary lifestyle Sedentary lifestyle Television viewing Television viewing Computer games Computer games Decreased physical Decreased physical

activity activity

ENDOCRINE CAUSESENDOCRINE CAUSES

Cushing syndrome Cushing syndrome Hypothyroidism Hypothyroidism GH DeficiencyGH Deficiency Pseudohypoparathyroidism Pseudohypoparathyroidism

Growth failure in obese child is an Growth failure in obese child is an important indicator important indicator

Cushing syndromeCushing syndrome

Central obesity Central obesity Hypertension Hypertension Striae Striae Retarded skeletal maturation Retarded skeletal maturation Hirsutism Hirsutism Myopathy Myopathy

HypothyroidismHypothyroidism

Rare cause of isolated obesity Rare cause of isolated obesity Developmental delay Developmental delay Coarse skin Coarse skin Retarded skeletal maturation Retarded skeletal maturation Constipation Constipation Cold intolerance etc Cold intolerance etc

GH DeficiencyGH Deficiency

Short statureShort stature Body proportions are normal Body proportions are normal Immature facies “doll like”Immature facies “doll like” Delayed teeth development Delayed teeth development Bone age is delayed Bone age is delayed

Pseudohypoparathyroidism Pseudohypoparathyroidism

Growth retardation Growth retardation Hypocalcemia Hypocalcemia Round facies Round facies BrachydactylyBrachydactyly Brachymetacarpia Brachymetacarpia Subcutaneous calcifications Subcutaneous calcifications Bony deformities Bony deformities

DRUGSDRUGS Antiepileptic drugsAntiepileptic drugs Steroids Steroids Estrogen Estrogen Glucocorticoids, Glucocorticoids, sulfonylureas, sulfonylureas, MAOIs MAOIs oral contraceptives, oral contraceptives, risperidone, risperidone, clozapineclozapine

HYPOTHALAMIC HYPOTHALAMIC OBESITYOBESITY

Head injury Head injury Infection Infection Brain tumors Brain tumors Radiation Radiation Post-neurosurgeryPost-neurosurgery

HYPOTHALAMIC HYPOTHALAMIC OBESITYOBESITY

Excessive appetite Excessive appetite Signs & symptoms of CNS Signs & symptoms of CNS

involvementinvolvement Hypothalamic pituitary defects Hypothalamic pituitary defects

GENETIC SYNDROMESGENETIC SYNDROMES

Prader willi syndrome Prader willi syndrome Laurence Moon Biedle Bardet Laurence Moon Biedle Bardet

syndrome syndrome Beckwith weidmann syndrome Beckwith weidmann syndrome Carpenter syndrome Carpenter syndrome

Prader willi syndromePrader willi syndrome

Infantile hypotonia Infantile hypotonia Hyperphagia Hyperphagia Almond like eyes Almond like eyes Behavioural abnormalityBehavioural abnormality Hypogonadism Hypogonadism

Laurence Moon Biedle Laurence Moon Biedle Bardet syndromeBardet syndrome

Hypogonadism Hypogonadism Retinitis pigmentosa Retinitis pigmentosa Polydactyly mental retardation Polydactyly mental retardation Type 2 diabetes mellitusType 2 diabetes mellitus Renal abnormalities Renal abnormalities

Beckwith weidmann Beckwith weidmann syndromesyndrome

OrganomegalyOrganomegaly Earlobe creasesEarlobe creases hemihypertrophyhemihypertrophy

MONOGENIC MONOGENIC DISORDERSDISORDERS

Leptin deficiency Leptin deficiency Leptin resistance Leptin resistance Abnormalities of MC4R & Abnormalities of MC4R &

proconvertaseproconvertase

EVALUATIONEVALUATION

HistoryHistory Age of onset – use of growth charts Age of onset – use of growth charts

and family photographs. Early onset and family photographs. Early onset (_5 years of age) suggests a genetic (_5 years of age) suggests a genetic causecause

Duration of obesity – short history Duration of obesity – short history suggests endocrine or central causesuggests endocrine or central cause

History(cont….)History(cont….)

A history of damage to the CNS A history of damage to the CNS (e.g. infection, trauma, hemorrhage, (e.g. infection, trauma, hemorrhage, radiation therapy, seizures) suggests radiation therapy, seizures) suggests hypothalamic obesity with or without hypothalamic obesity with or without pituitary GH deficiency or pituitary pituitary GH deficiency or pituitary hypothyroidism. hypothyroidism.


A history of morning headaches, A history of morning headaches, vomiting, visual disturbances and vomiting, visual disturbances and excessive urination or drinking also excessive urination or drinking also suggests that the obesity may be suggests that the obesity may be caused by a tumor or mass in the caused by a tumor or mass in the hypothalamushypothalamus


A history of dry skin, constipation, A history of dry skin, constipation, intolerance to cold or fatigue intolerance to cold or fatigue suggests hypothyroidism.suggests hypothyroidism.

Mood disturbance and central Mood disturbance and central obesity suggest Cushing syndrome.obesity suggest Cushing syndrome.

Frequent infections and fatigue may Frequent infections and fatigue may suggest ACTH deficiency due to suggest ACTH deficiency due to POMC mutationsPOMC mutations


•Hyperphagia – often denied but Hyperphagia – often denied but sympathetic approach needed sympathetic approach needed and specific questions, such as and specific questions, such as waking at night to eat and/or waking at night to eat and/or demanding food very soon after a demanding food very soon after a meal, suggest hyperphagia. If meal, suggest hyperphagia. If severe, especially in children, severe, especially in children, suggests a genetic cause for suggests a genetic cause for obesityobesity


• Developmental delay – milestones, Developmental delay – milestones, educational history, behavioral educational history, behavioral disorders. disorders.

• Consider craniopharyngioma or Consider craniopharyngioma or structural causes(often relatively structural causes(often relatively short history) and genetic causesshort history) and genetic causes


Visual impairment and deafness can Visual impairment and deafness can suggest genetic causessuggest genetic causes

Onset and tempo of pubertal Onset and tempo of pubertal development – onset can be early or development – onset can be early or delayed in children and adolescents. delayed in children and adolescents.

Primary hypogonadotropic Primary hypogonadotropic hypogonadism or hypogenitalism hypogonadism or hypogenitalism associated with some genetic disordersassociated with some genetic disorders


Family history – consanguineous Family history – consanguineous relationships, other children affected, relationships, other children affected, family photographs useful. family photographs useful.

Severity may differ due to Severity may differ due to environmental effectsenvironmental effects

Treatment with certain drugs or Treatment with certain drugs or medications. Glucocorticoids, medications. Glucocorticoids, sulfonylureas, MAOIs oral sulfonylureas, MAOIs oral contraceptives, risperidone, clozapinecontraceptives, risperidone, clozapine

ExaminationExamination

Document weight and height Document weight and height compared with normal centiles. compared with normal centiles.

Calculate BMI and WHR (in adults). Calculate BMI and WHR (in adults). In children, obtain parentalheights In children, obtain parentalheights and weights where possibleand weights where possible

Head circumference if clinically Head circumference if clinically suggestivesuggestive

Examination(cont…)Examination(cont…)

Short stature or a reduced rate of Short stature or a reduced rate of linear growth in a child with obesity linear growth in a child with obesity suggests the possibility of GH suggests the possibility of GH deficiency, hypothyroidism, cortisol deficiency, hypothyroidism, cortisol excess, pseudohypoparathyroidism excess, pseudohypoparathyroidism or a genetic syndrome such as or a genetic syndrome such as Prader–Willi syndromePrader–Willi syndrome


Obese children and adolescents are often Obese children and adolescents are often tall (on the upper centiles), however, tall (on the upper centiles), however, accelerated linear growth (height SDS accelerated linear growth (height SDS >2) is a feature of MC4R deficiency>2) is a feature of MC4R deficiency

Body fat distribution – central Body fat distribution – central distribution with purple striae suggests distribution with purple striae suggests Cushing syndrome. Cushing syndrome.

Selective fat deposition (60%) is a feature Selective fat deposition (60%) is a feature of leptin and leptin receptor deficiencyof leptin and leptin receptor deficiency

Dysmorphic features or skeletal Dysmorphic features or skeletal dysplasiadysplasia


Pubertal development/secondary sexual Pubertal development/secondary sexual characteristics.characteristics.

Most obese adolescents grow at a normal or Most obese adolescents grow at a normal or excessive rate and enter puberty at the appropriate excessive rate and enter puberty at the appropriate age; many mature more quickly than children with age; many mature more quickly than children with normal weight, and bone age is commonlynormal weight, and bone age is commonly

advanced.advanced. In contrast, growth rate and pubertal development In contrast, growth rate and pubertal development

are diminished or delayed in GH deficiency, are diminished or delayed in GH deficiency, hypothyroidism, cortisol excess and a variety of hypothyroidism, cortisol excess and a variety of genetic syndrome. genetic syndrome.

Conversely, growth rate and pubertal development Conversely, growth rate and pubertal development are accelerated in precocious puberty and in some are accelerated in precocious puberty and in some girls with PCOSgirls with PCOS


Acanthosis nigricansAcanthosis nigricans Valgus deformities - in severe Valgus deformities - in severe

childhood obesitychildhood obesity Hair color – red hair (if not familial) Hair color – red hair (if not familial)

may suggest mutations in may suggest mutations in POMC (pro-POMC (pro-opiomelanocortin) in white opiomelanocortin) in white CaucasiansCaucasians

InvestigationsInvestigations

Fasting and 2-h post glucose and Fasting and 2-h post glucose and insulin levels. Proinsulin if insulin levels. Proinsulin if PC1( prohormone convertase 1) PC1( prohormone convertase 1) deficiency considereddeficiency considered

Fasting lipid panel for detection of Fasting lipid panel for detection of dyslipidemiadyslipidemia

Thyroid function testsThyroid function tests Serum leptin if indicatedSerum leptin if indicated

Investigations(cont…)Investigations(cont…)

KaryotypeKaryotype DNA for molecular diagnosisDNA for molecular diagnosis Bone ageBone age GH secretion and function tests, GH secretion and function tests,

when indicatedwhen indicated Assessment of reproductive Assessment of reproductive

hormones, when indicatedhormones, when indicated

Investigations(cont…)Investigations(cont…)

Serum calcium, phosphorus and Serum calcium, phosphorus and parathyroid hormone levels to parathyroid hormone levels to evaluate for suspected evaluate for suspected pseudohypoparathyroidismpseudohypoparathyroidism

MRI scan of the brain with focus on MRI scan of the brain with focus on the hypothalamus and pituitary, the hypothalamus and pituitary, when clinically indicatedwhen clinically indicated

Screening for glucose intolerance and Screening for glucose intolerance and thethe

metabolic syndrome in children and metabolic syndrome in children and adolescents.adolescents.

High-risk populationsHigh-risk populations Obese (BMI Obese (BMI zz-score >95th percentile) -score >95th percentile)

children or adolescent, pluschildren or adolescent, plus High-risk ethnic group and/orHigh-risk ethnic group and/or Family history of type 2 diabetes or GDM Family history of type 2 diabetes or GDM

and/orand/or Acanthosis nigricans and/orAcanthosis nigricans and/or Prominent abdominal fat depositionProminent abdominal fat deposition Ovarian hyperandrogenismOvarian hyperandrogenism

Screening for glucose intolerance and Screening for glucose intolerance and thethe

metabolic syndrome in children and metabolic syndrome in children and adolescentsadolescents

Screening proceduresScreening procedures Blood pressureBlood pressure Fasting glucose and insulin levelsFasting glucose and insulin levels Fasting lipid panel (_FFA if possible)Fasting lipid panel (_FFA if possible) 2-h glucose level (_insulin if 2-h glucose level (_insulin if

possible)possible) HbA1c (less useful)HbA1c (less useful)

COMPLICATIONSCOMPLICATIONS

CNS – Benign intracranial hypertensionCNS – Benign intracranial hypertension Respiratory – Obstructive sleep apneaRespiratory – Obstructive sleep apnea Cardiovascular – Atherosclerosis, Cardiovascular – Atherosclerosis,

HypertensionHypertension Hepatobiliary – Nonalcoholic steatohepatitis,Hepatobiliary – Nonalcoholic steatohepatitis,

gall stonesgall stones Endocrine – PCOD, Type 2 DM, DislipidemiaEndocrine – PCOD, Type 2 DM, Dislipidemia Orthopedic – Osteoarthritis, slipped capital Orthopedic – Osteoarthritis, slipped capital

femoral epiphyses femoral epiphyses

ManagementManagement

Treatment of obesity aims to:Treatment of obesity aims to: Reduce BMI and visceral fat mass;Reduce BMI and visceral fat mass; Decrease circulating insulin Decrease circulating insulin

concentrations;concentrations; Increase insulin sensitivityIncrease insulin sensitivity Decrease hepatic glucose production Decrease hepatic glucose production

and fasting and post-prandial and fasting and post-prandial glucose concentrations;glucose concentrations;

Management( cont…)Management( cont…)

Reduce circulating FFA and TG Reduce circulating FFA and TG concentrations;concentrations;

Decrease blood pressure;Decrease blood pressure; Reduce the expression of Reduce the expression of

inflammatory cytokines;inflammatory cytokines; Normalize vascular and endothelial Normalize vascular and endothelial

function function


Dietary measuresDietary measures 30-40% caloric restriction 30-40% caloric restriction Improve nutritive value of dietImprove nutritive value of diet Reduction in consumption of junk Reduction in consumption of junk

food, carbonated drink , saturated food, carbonated drink , saturated fatfat

Increase in fiber, fruits, vegetables.Increase in fiber, fruits, vegetables.


Lifestyle modificationLifestyle modification Increase in physical activities- 30-45 Increase in physical activities- 30-45

min/daymin/day Swimming Swimming Running Running Playing outdoors Playing outdoors


DrugsDrugs Orlistat – gastric lipase inhibitor Orlistat – gastric lipase inhibitor Sibutramine – neurotransmitter Sibutramine – neurotransmitter

modulator modulator Metformin – in children with insulin Metformin – in children with insulin

resistance resistance Leptin – for leptin deficiency Leptin – for leptin deficiency Octreotide – for hypothalamic obesityOctreotide – for hypothalamic obesity

SurgerySurgery

Indicated for morbid obesity Indicated for morbid obesity BMI>40 kg/mBMI>40 kg/m22

Last resort in treatmentLast resort in treatment Laparoscopic gastric banding- Laparoscopic gastric banding-

procedure of choice procedure of choice

directed at reducing gastric directed at reducing gastric capacity capacity

Learning PointsLearning Points

There is a global epidemic of obesityThere is a global epidemic of obesity A very few obese children have a monogenic A very few obese children have a monogenic

cause of their conditioncause of their condition Consequences of obesity include insulin Consequences of obesity include insulin

resistance and type 2 diabetes, dyslipidemia, resistance and type 2 diabetes, dyslipidemia, hepatic steatosis/steatohepatitis (fatty liver), hepatic steatosis/steatohepatitis (fatty liver), hypertension, focal glomerulosclerosis, hypertension, focal glomerulosclerosis, accelerated growth and bone maturation, accelerated growth and bone maturation, ovarian hyperandrogenism, gynecomastia,ovarian hyperandrogenism, gynecomastia,

cholecystitis, pancreatitis and cholecystitis, pancreatitis and pseudotumorcerebripseudotumorcerebri

Learning PointsLearning Points Non-metabolic complications include sleep Non-metabolic complications include sleep

apnea,apnea,orthopedic disorders and stress incontinenceorthopedic disorders and stress incontinence Long-standing obesity and insulin resistanceLong-standing obesity and insulin resistanceincrease the risk of cardiovascular disease, stroke,increase the risk of cardiovascular disease, stroke,orthopedic complications, sleep apnea, someorthopedic complications, sleep apnea, somemalignancies and psychosocial disorders in adultsmalignancies and psychosocial disorders in adults Treatment is by lifestyle intervention (includingTreatment is by lifestyle intervention (includingbehavior therapy), pharmacotherapy andbehavior therapy), pharmacotherapy andsurgery but success is very limitedsurgery but success is very limited Prevention is better than curePrevention is better than cure

Thank youThank you

Documents

CHILDHOOD OBESITY. CRITERIA FOR OBESITY Body mass index (BMI) Body mass index (BMI) BMI= Weight (Kg) / Height (m) 2 BMI= Weight (Kg) / Height (m) 2 BMI