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Childhood Obesity in Practice: Childhood Obesity in Practice: A look at the obeseA look at the obese
& the extremely obese& the extremely obese
Robert Murray MD
Marc Michalsky MD
Nationwide Children’s Hospital
Aims of Presentation
• a synopsis national guidelines
• the risk of extreme obesity • bariatric surgery
and resolution of health risk
The Expert Committee
• American Medical Association
• Dept of Health and Human Services
• CDC & Prevention• American Academy of
Pediatrics• American Dietetics
Association• Natl Assoc of Pediatric
Nurse Practitioners • National Medical
Association
• American Heart Association• National Association of
School Nurses• American college of Sports
Medicine• The Obesity Society• The Endocrine Society• American College of
Preventive Medicine• American Academy of Child
& Adolescent Psychiatry• Association of American
Indian Physicians
Pediatrics, December 2007, 120:supplement 4
The Primary Physician’s RoleThe Primary Physician’s Role
Prevention Identification Intervention
Nine Evidence-Based Messages
1. Support exclusive breastfeeding 4-6 months
2. Limit sweetened beverages
3. Eat 5 servings per day of fruits & vegetables
4. Participate in moderate to vigorous physical activity for 60 mins/ day
5. Limit screen time to a maximum of 2hrs/ day
6. Do not allow your child to have a television in his or her bedroom
7. Eat a nutritious breakfast every day
8. Engage in regular family meals 5-6 times/ week
9. Limit portion sizes
For Prevention & Counseling
An OUNCE of PREVENTION:An OUNCE of PREVENTION:Anticipatory Guidance for obesity prevention Anticipatory Guidance for obesity prevention
www.NationwideChildrens.org/HealthyWeight/
Ohio Chapter, American Academy of PediatricsOhio Department of HealthOhio Dietetics AssociationAmerican Dairy Council, Mid-East
Normal at 10 yrs = 10% risk of obesity as adult“At risk” or overweight at 10 yrs = 80% risk
Media Policy
Food IndustryNeighborhood Environment
SchoolsPre-schools
Medical Medical CommunityCommunity
Early Childhood Providers
Out of school time/Faith Based
Societal Level
Community Level
Inter-personal Level
CHILD
Family
The Workplace
Health & Fitness Takes Many TeachersHealth & Fitness Takes Many Teachers
Communityprograms
Parental Perceptions of their Overweight Child
– Only 1/3 recognized it– Only 1/4 worried about it– Only 1/5 recalled MD concern
In most studies In most studies parental recognition parental recognition
of overweight of overweight occurs around age 8-12 yrs -- occurs around age 8-12 yrs --
Even later for boys Even later for boys
Eckstein, Pediatrics 2006; 117:681
At every well-child visit, discuss weightnutrition, activity
and health risk
Pediatric Obesity Management Pocket Guide
Create a Risk ProfilePlace the BMI in Context
• Family health history– Obesity– Diabetes– Cardiovascular disease
• Targeted review of systems
• Targeted physical exam
• Blood pressure
Review of Systems• Abdominal pain• Joint pain• Snoring, apnea, daytime
sleepiness• Polyuria, polydipsia• Irregular menses• Signs of mood disorder
– Depression, anxiety– social or school avoidance
• Exercise tolerance• Diet• Screen time
Physical Exam
• Papilledema on eye exam• Tonsillar hypertrophy• Abdominal pain• Hepatomegaly• Tibial bowing• Hip or knee pain• Signs of precocious puberty • Skin findings
– acne, striae, hirsutism – acanthosis nigricans
insulin resistance hyperinsulinemia skin changes
Fat mass insulin resistance altered metabolismaltered metabolism• diabetes• hypertension• abnormal lipids• inflammation• cardiovascular ds• asthma• liver disease• sleep apnea• orthopedic problems
Identifythis
early
Blood Pressurea critical risk
• Children >3 years of age • Auscultation is preferred • Use appropriate sized cuff• Must be plotted on curves
adjusted for age, sex, and height
• Measurements that exceed the 90th percentile should be repeated
Do I have to check labs?BMI Percentile Labs
85-94%
No risk factors
Fasting Lipid Profile
85-94%
With risk factors
Fasting Lipid Profile
ALT, AST, Fasting glucose
>95% Fasting Lipid Profile
ALT, AST, Fasting glucose
Consider Fasting Lipid Profile age >=2 years, Additional hepatic function and fasting glucose should be considered at age >= 10years. Clinical judgment may dictate additional labs in the younger child with higher risk.
Motivation/Attitude
Nine Evidence-Based Messages
1. Support exclusive breastfeeding 4-6 months
2. Limit sweetened beverages
3. Eat 5 servings per day of fruits & vegetables
4. Participate in moderate to vigorous physical activity for 60 mins/ day
5. Limit screen time to a maximum of 2hrs/ day
6. Do not allow your child to have a television in his or her bedroom
7. Eat a nutritious breakfast every day
8. Engage in regular family meals 5-6 times/ week
9. Limit portion sizes
Prevention & Counseling
Algorithm For Intervention
Resources to Help You• Ounce of Prevention
– Birth to 5 years– 6 to 19 yrs NEW!– Parent handouts
• BMI wheels and tables• Parent Tip Sheets• Pocket management book • Coding sheet• Acanthosis training NEW!
www.NationwideChildrens.org/HealthyWeight
Extreme ObesityExtreme Obesity
What to do with
Medical Sequelae of ObesityMedical Sequelae of Obesity Hypertension Lipid disorders Diabetes Ischaemic heart disease Cardiomyopathy Pulmonary hypertension Asthma Hypoventilation syndromes Obstructive sleep apnea Gallstones NASH (Non-alcoholic
steatohepatitis) Urinary incontinence
Gastroesophageal reflux Arthritis – weight bearing Low back pain Infertility and menstrual
problems Obstetric complications DVT and thromboembolism Depression Immobility Cancer Venous/stasis ulcers Intertrigo Accident prone
Adipocytes are Endocrine Cells
Secretion of > 50 Adipokines• Leptin•Adiponectin•Resistin•TNF- alpha
Adipose Actions• stimulate inflammation
• increase insulin resistance (block receptor signaling)• attract macrophages into fat & vessels (foam cells)
• alter metabolism• lower sensitivity to insulin’s actions • shift glucose-based to FFA-based metabolism• fat storage in non-adipose tissues
Obesity & Endothelial Dysfunction
Adipose Tissue
Nitric Oxide
Adhesion Molecules
MacrophageChemoattractives
Vascular Endothelial Cell
leptin IL-6 FFA fibrinogen Angiotensin II TNF- alpha
• inflammation• thrombus formation• plaque destabilization• lipid accumulation • poor distensibility
Pharmacol Reports 2006; 58: s81
• BMI > 99th percentile or BMI > 35• 2-6% of all kids• > 50% have metabolic syndrome• Significant cardiovascular changes• Multi-organ complications
Extreme Obesity in Children
Weight Loss - Weight Loss - Pediatric ProgramsPediatric Programs
• NACHRI identified 80 pediatric centers NACHRI identified 80 pediatric centers with weight management programs with weight management programs
• Only 15 had an associated surgical Only 15 had an associated surgical weight loss programweight loss program
• 6 to 8 “high” volume programs6 to 8 “high” volume programs
• August, 2008 – NACHRI formed August, 2008 – NACHRI formed Obesity Steering CommitteeObesity Steering Committee
The Bariatric ProgramThe Bariatric Programat Nationwide Children’sat Nationwide Children’s
• Surgeons: Surgeons: – Marc Michalsky, MDMarc Michalsky, MD
– Steve Teich, MDSteve Teich, MD
– Allen Browne, MDAllen Browne, MD
– Bradley Needleman, MD (OSUMC)Bradley Needleman, MD (OSUMC)
– Scott Melvin, MD (OSUMC)Scott Melvin, MD (OSUMC)
• Medical DirectorMedical Director– Robert Murray, MDRobert Murray, MD
“First 50 Patients”Co-morbidity Overall (%) New Dx (%)
Hypothyroidism 7 33Insulin Resistance
28 54
Hypertension 24 10Depression 42 5.5GERD 26 13Type II DM 19 25Asthma 21 22
OSA 26 42
Co-Morbidities in Bariatric PatientsCo-Morbidities in Bariatric PatientsNCH and OSU ExperienceNCH and OSU Experience
0
5
10
15
20
25
30
35
40
45
50
OSA DM HTN
Adults%
0
5
10
15
20
25
30
35
40
45
50
OSA DM HTN
Peds %
0
10
20
30
40
50
60
70
80
% Patients
OSA HTN DM
Pre-Op
20 Weeks
Resolution of Co-morbid Conditions Resolution of Co-morbid Conditions 5 months post-pediatric bypass5 months post-pediatric bypass
Gastric Bypass: Effect on HOMA
0
1
2
3
4
5
6
7
IR25
30
35
40
45
50
55
BM
I
4 wk 8wk 12wk 20wk 32wk 52wk 4 wk 8wk 12wk 20wk 32wk 52wk
Insulin ResistanceBody Mass Index
Homeostatic Model Assessment (HOMA)β Cell Activity vs. Insulin Sensitivity
0
50
100
150
200
250
300
350
400
Per
cent
%B
%S
4 wk 8wk 12wk 20wk 32wk 52wk4 wk 8wk 12wk 20wk 32wk 52wk
Quality of Life Measures 6 months post- bypass
Healthy
Mean (SD)
Pre-Op
Mean (SD)
Post-Op
(6 month)
Mean (SD)
Total Score 83.8 (12.6) 55.7 (15.4) 77.3 (12.3)
Physical Score 87.5 (13.5) 54.2 (18.5) 78.0 (14.0)
Psychosocial 81.8 (14.1) 56.6 (16.6) 77.0 (14.0)
Emotional
Function
79.3 (18.1) 57.2 (21.0) 80.8 (19.3)
Social
Function
85.1 (16.8) 56.6 (23.7) 80.0 (18.3)
School
Function
81.1 (16.5) 55.1 (18.2) 69.5 (21.3)
Washington State Healthcare Washington State Healthcare AuthorityAuthority
Health Technology Clinical Health Technology Clinical CommitteeCommittee
• Evaluated healthcare coverage for Evaluated healthcare coverage for adolescent bariatric surgeryadolescent bariatric surgery
• Assessment of the strength of current Assessment of the strength of current peer-reviewed evidence peer-reviewed evidence
• Determine safety, efficacy and cost Determine safety, efficacy and cost
• Guide decisions regarding state Guide decisions regarding state program coverageprogram coverage
Health Technology Clinical Health Technology Clinical CommitteeCommittee
• 2004: Estimate 2000 bariatric 2004: Estimate 2000 bariatric procedures were performed in patients procedures were performed in patients under 21 yearsunder 21 years
• 75% of bariatric surgeons surveyed 75% of bariatric surgeons surveyed report planning to perform a procedure report planning to perform a procedure on an adolescent in the near futureon an adolescent in the near future
Health Technology Clinical Health Technology Clinical CommitteeCommittee
• Review 17 peer-reviewed studiesReview 17 peer-reviewed studies
• 553 pediatric patients553 pediatric patients
• Studies were assessed for Studies were assessed for validity/qualityvalidity/quality
Meta-analysis Results
• Majority: academic medical centers
• Mean age 15.6 to 18.1 years
• Average BMI– RYGB 51.8 kg/m2
– LAGB 45.8 kg/m2
Questions
1. Does PBS lead to significant (> 7%EBWL) and durable weight loss?
2. Does PBS improve co-morbidities, QOL and survival compared to medical therapy?
3. Safety Profile (surgical v. medical)
4. Cost Profile (surgical v medical)
5. Does efficacy, safety and cost vary according to demographics (age, sex, BMI)
Conclusion
Clinical Clinical ResearchResearchNIH Sponsored
• TeenLABS (Longitudinal AssessmeTeenLABS (Longitudinal Assessment of Bariatric Surgery)– NIH-sponsored, NIH-sponsored, – Multi-centered observational studylti-centered observational study– 2 year follow-up2 year follow-up– 5 centers5 centers– N = 200 teens
Clinical Clinical ResearchResearchNIH Sponsored
• Teen-Intake (Nutritional AssessmeTeen-Intake (Nutritional Assessment of Bariatric Surgery)– NIH-sponsored, NIH-sponsored, – Multi-centered observational studylti-centered observational study– 2 year follow-up2 year follow-up– N = 200 teens
• TeenVIEW (Controlled Longitudinal oTeenVIEW (Controlled Longitudinal of Psycho-social Development)– NIH-sponsored, NIH-sponsored, – Multi-centered observational studylti-centered observational study– 2 year follow-up2 year follow-up– N = 200 teens
Clinical ResearchClinical ResearchIndustry Sponsored
• LBA 001 (Allergan)LBA 001 (Allergan)– Industry-sponsored IDE, 5 year follow-upIndustry-sponsored IDE, 5 year follow-up– Multi-institutional safety/efficacy trialMulti-institutional safety/efficacy trial
• n = 150 subjects (14 to 17 years)n = 150 subjects (14 to 17 years)– Local: n = 26, enrollment closed Dec, 2007Local: n = 26, enrollment closed Dec, 2007
Reversal of Type II Diabetes• 11 teens > 1 year after Roux-en-Y bypass• Mean BMI 50 + 5.9; 50% metabolic synd• Post-op
– BMI fell by 34% to 33 + 7 kg/m2– Improvement of fasting glucose, insulin,
HOMA-IR, Hb A1C, AST, ALT, LDL, triglycerides, total cholesterol, blood pressure
– Remission of diabetes in 10 of 11 cases– Removal of oral hypoglycemics in 10 cases
Inge et al, Pediatrics 2008; 123:214
Cardiovascular Risk &Extreme Obesity in Teens
• BMI > 99th %ile or BMI > 40
• N=38 13-19 yrs old
• Pre- and post- gastric bypass surgery
• Echocardiogram, doppler studies– Adequate studies in only 38 of 67 cases– LV geometry (size, ventricular shape, mass, wall thickness)
– LV systolic function (contractility, wall thickness)
– Diastolic function (atrial size, pulsed doppler assessment)
Ippisch et al, J Am Coll Cardiol 2008; 51:1342
Weight Loss & Cardiovascular Risk
• ¼ showed high risk concentric LVH– Adults: with concentric LVH, 53% had a cardiovascular event– Teens: 28% had concentric LVH pre-op, only 3% post-op
• LV mass increased – Adults: > 51 g/m2.7 had 4-fold higher CV mortality– Teens studied: averaged > 54 g/m2.7, max 86 g/m2.7
• LV dimensions, systolic function: abnormal– Normal LV geometry: only 36% pre-, up to 79% post-op
• Elevated cardiac workload, BP– Decreased HR and systolic BP, rate-pressure product
• Abnormal diastolic function– Improved mitral valve and filling dynamics post-op
Ippisch et al, J Am Coll Cardiol 2008; 51:1342
Comparison of CMR results from obese (OB) adolescents to published normal weight (NW) normative reference values. (A) Left ventricular (LV) mass, (B) LV end diastolic volume, (C) LV ejection fraction, (D) Myocardial Perfusion Reserve Index (MPRI). * p<0.01
A B C D
Cardiovascular Status Pre-surgeryCMR Results
10 patients pre-bariatric surgery show strikingcardiovascular abnormalities and risk
ConclusionsConclusions
• Extremely Obese Teens– Have many serious co-morbidities– High risk of type II diabetes– Extreme cardiovascular risk
• Bariatric Surgery– Shows effective metabolic resolution– Resolution of co-morbid conditions– Resolution of cardiovascular abnormalities– Minimal risk
Center for Healthy Weight & NutritionCenter for Healthy Weight & Nutrition
PreventionPrevention TreatmentTreatment
Public Health
HealthcareProviderSupport
Medical Weight Loss Programs
ResearchResearchChild &FamilyEducation
Bariatric Bariatric SurgerySurgery
www.NationwideChildrens.org/HealthyWeight