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Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
Associated Comorbidities of Pediatric Obesity
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Associated Comorbidities of Pediatric Obesity

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  • Papilledema is a bilateral swelling or edema of the optic disc secondary to any factor which may increase cerebral spinal fluid pressure. Fundus examination reveals a swollen optic nerve head with elevation, edema and narrowing of the physiological cup, vascular congestion with small areas of flame-shaped hemorrhage and exudates, and possible surrounding retinal edema (#22092).
  • Transcript

    • 1. Associated Comorbidities of Pediatric Obesity Sandra G Hassink, MD, FAAP Director Weight Management Program A I duPont Hospital for Children Wilmington, DE
    • 2. Severe Obesity Related Emergencies <ul><li>Hyperglycemic Hyperosmolar state </li></ul><ul><li>DKA </li></ul><ul><li>Pulmonary emboli </li></ul><ul><li>Cardiomyopathy of obesity </li></ul><ul><li>Complications of Bariatric Surgery </li></ul>
    • 3. Chiasson JL, Aris-Jilwan N, Bélanger R, Bertrand S, et al. CMAJ . 2003 Apr 1;168(7):859-66.
    • 4. Hyperglycemic Hyperosmolar State <ul><li>“ Death caused by hyperglycemic Hyperosmolar state at the onset of type 2 diabetes. &quot; Morales AE, Rosenbloom AL.J Pediatric 2004 Feb 144 (2) 270-3. </li></ul><ul><li>“Seven obese African American youth were considered to have died from diabetic ketoacidosis.” </li></ul>
    • 5. Hyperglycemic Hyperosmolar State <ul><li>“Despite meeting the criteria for Hyperglycemic Hyperosmolar state and not for DKA.” </li></ul><ul><li>“All had previously unrecognized type 2 diabetes, and death may have been prevented with earlier diagnosis or treatment.” </li></ul>
    • 6. Hyperglycemic Hyperosmolar State <ul><li>Patients presented to medical care with symptoms which were not linked to presentation of type 2 diabetes. </li></ul><ul><ul><li>Vomiting. </li></ul></ul><ul><ul><li>Abdominal Pain. </li></ul></ul><ul><ul><li>Dizziness. </li></ul></ul><ul><ul><li>Weakness. </li></ul></ul><ul><ul><li>Polyuria/Polydipsia. </li></ul></ul><ul><ul><li>Weight loss. </li></ul></ul><ul><ul><li>Diarrhea. </li></ul></ul>
    • 7. Hyperglycemic Hyperosmolar State <ul><li>HHS- diagnostic criteria </li></ul><ul><ul><li>plasma glucose > 600mg/dl </li></ul></ul><ul><ul><li>Arterial pH >7.3 </li></ul></ul><ul><ul><li>serum bicarbonate > 15 mmol/l </li></ul></ul><ul><ul><li>Serum ketones none-trace </li></ul></ul><ul><ul><li>Urine ketones none-trace </li></ul></ul><ul><ul><li>effective serum osmolality >320 mOsm/kg </li></ul></ul><ul><ul><li>stupor or coma </li></ul></ul><ul><ul><ul><ul><ul><li>Rubin HM J Pediatr 1969:74:`77-86 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Morales A J Pediatr 2004 Feb, 270-273 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Chiasson JLCMAJ. 2003 Apr 1;168(7):859-66. </li></ul></ul></ul></ul></ul>
    • 8. Pulmonary Embolism <ul><li>Classic Symptoms </li></ul><ul><ul><li>Dyspnea </li></ul></ul><ul><ul><li>Chest pain </li></ul></ul><ul><ul><li>Decreased O 2 </li></ul></ul><ul><ul><li>Hemoptysis </li></ul></ul><ul><li>Other Signs/Symptoms: </li></ul><ul><ul><ul><li>Back, shoulder, upper abdominal pain </li></ul></ul></ul><ul><ul><ul><li>Painful respiration </li></ul></ul></ul><ul><ul><ul><li>Cyanosis </li></ul></ul></ul><ul><ul><ul><li>Syncope </li></ul></ul></ul><ul><ul><ul><li>Cardia Arrhythmia </li></ul></ul></ul><ul><ul><ul><li>New onset of wheezing </li></ul></ul></ul><ul><li>Obstructive Sleep Apnea and Coagulation disorders increase risk </li></ul><ul><li>Most common complication of gastric bypass/banding in adults, has been reported in adolesents after surgery </li></ul><ul><ul><ul><ul><ul><li>Sugerman HJ, Sugerman EL, DeMaria EJ, et al Gastrointest Surg. 2003 Jan: 7(1):102-07 </li></ul></ul></ul></ul></ul>
    • 9. Cardiomyopathy of Obesity <ul><li>Cardiac steatosis </li></ul><ul><li>Left ventricular dysfunction. </li></ul><ul><ul><li>dilation </li></ul></ul><ul><ul><li>increased left ventricular wall stress </li></ul></ul><ul><ul><li>compensatory (eccentric) left ventricular hypertrophy </li></ul></ul><ul><ul><li>left ventricular diastolic dysfunction </li></ul></ul><ul><li>Right Ventricular dysfunction </li></ul><ul><ul><li>Exacerbated by pulmonary hypertension due to UAO </li></ul></ul><ul><ul><ul><ul><ul><li>Alpert, MA Am J Med Sci 2001 Apr, 321(4);225-36. </li></ul></ul></ul></ul></ul>
    • 10.  
    • 11. Roux-en-Y Gastric Bypass-Early Complications <ul><li>Bleeding </li></ul><ul><li>Bowel Perforation </li></ul><ul><li>DVT/PE </li></ul><ul><li>Dehydration </li></ul><ul><li>Dysphagia </li></ul><ul><li>Nausea/Vomiting </li></ul><ul><li>Small Bowel Obstruction </li></ul><ul><li>Anastomotic Leak </li></ul><ul><li>Peritonitis </li></ul>
    • 12. Roux-en-Y Gastric Bypass-Late Complications <ul><li>Cholecystitis </li></ul><ul><li>Dysphagia </li></ul><ul><li>GERD </li></ul><ul><li>Incisional Hernia </li></ul><ul><li>Malnutrition </li></ul><ul><li>Pancreatitis </li></ul><ul><li>Ulcers </li></ul><ul><li>Renal Calculi </li></ul><ul><li>Strictures </li></ul><ul><li>Internal Hernia </li></ul><ul><li>Small Bowel Obstruction </li></ul>
    • 13. Lap-Band Adverse Events <ul><li>Intra operative </li></ul><ul><ul><li>Iatrogenic gastrostomy </li></ul></ul><ul><li>Early Post-operative </li></ul><ul><ul><li>Hemorrhage </li></ul></ul><ul><ul><li>Port infection </li></ul></ul><ul><ul><li>Stomal obstruction </li></ul></ul><ul><ul><li>Perforation </li></ul></ul><ul><li>Late complications </li></ul><ul><ul><li>Mechanical dysfunction </li></ul></ul><ul><ul><li>Erosion </li></ul></ul><ul><ul><li>Slippages </li></ul></ul><ul><ul><li>Ponce, et al., 2005 </li></ul></ul>
    • 14. Post Bariatric Surgery Mediation Considerations <ul><li>No aspirin or aspirin containing products </li></ul><ul><li>No non steroidal anti inflammatory agents </li></ul><ul><li>All medications should be crushed (no extended release or enteric coated products) </li></ul>
    • 15. Potential Metabolic Complications from Bariatric Surgery <ul><li>Anemia </li></ul><ul><ul><li>Fe, B12, copper, vitamins A and E, deficiency or an imbalance in zinc intake </li></ul></ul><ul><ul><li>Neurologic Complications - Related to Vitamin B12 deficiency </li></ul></ul><ul><ul><ul><ul><li>Ophthalmoplegia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Nystagmus </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Ataxia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Peripheral Neuropathy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Impaired memory </li></ul></ul></ul></ul><ul><li>Gallstone Formation </li></ul>von Drygalski A, Andris DA. Nutr Clin Pract . 2009 Apr-May;24(2):217-26
    • 16. Potential Metabolic Complications from Bariatric Surgery <ul><li>Hyperparathyroidism –Ca and vitamin D def </li></ul><ul><ul><ul><ul><li>Aches/pains </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Depression </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Abdominal pain, Nausea/Vomiting </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Excessive urination </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Confusion </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Muscle Weakness, Fatigue </li></ul></ul></ul></ul><ul><li>Protein deficiency </li></ul><ul><ul><ul><ul><li>Hair loss </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Edema </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hypoalbuminemia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Anemia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Extreme Fatigue </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Inability to walk </li></ul></ul></ul></ul>
    • 17. Co-morbidity's Requiring Immediate Attention <ul><li>Pseudotumor Cerebri </li></ul><ul><li>Slipped Capital Femoral Epiphysis </li></ul><ul><li>Blount’s Disease </li></ul><ul><li>Sleep Apnea </li></ul><ul><li>Non alcoholic hepatosteatosis </li></ul><ul><li>Cholelithiasis </li></ul>
    • 18. John A Moran Eye Center, Salt Lake City UT
    • 19. Pseudotumor Cerebri <ul><li>Definition. </li></ul><ul><ul><li>Raised intracranial pressure with papilledema and a normal cerebrospinal fluid in the absence of ventricular enlargement. </li></ul></ul><ul><li>Risk </li></ul><ul><ul><li>Obesity occurs in 30%-80% of affected children. </li></ul></ul><ul><ul><ul><ul><ul><li>Scott Am J Opth 1997; 124:253-255 </li></ul></ul></ul></ul></ul><ul><ul><li>In a series of case-controlled studies in adolescents and adults, obesity and recent weight gain were the only factors found significantly more often in pseudotumor cerebri patients than control patients. </li></ul></ul><ul><ul><ul><ul><ul><li>Lessell S. Surg Ophthalmol 1992;37(3):155-66. </li></ul></ul></ul></ul></ul>
    • 20. Pseudotumor Cerebri <ul><li>Diagnosis </li></ul><ul><ul><li>May present with headaches, vomiting, blurred vision or diplopia. </li></ul></ul><ul><ul><li>Neck, shoulder, and back pain have also been reported. </li></ul></ul><ul><ul><ul><ul><ul><li>Lessell S. Surv Ophthalmol 1992;37(3):155-66. </li></ul></ul></ul></ul></ul><ul><li>Loss of peripheral visual fields and reduction in visual acuity may be present at diagnosis </li></ul><ul><ul><ul><ul><ul><li>Baker RS, Carter D, Hendrick EB, Buncic JR. Arch Ophthalmol 1985;103(11):1681-6. </li></ul></ul></ul></ul></ul><ul><li>Increased intracranial pressure may lead to visual impairment or blindness. </li></ul><ul><li>Treatment </li></ul><ul><ul><li>Acetazolamide </li></ul></ul><ul><ul><li>Lumboperitoneal shunt (in severe cases), </li></ul></ul><ul><ul><li>Weight loss </li></ul></ul><ul><ul><ul><ul><ul><li>Newborg B. Arch Intern Med 1974;133(5):802-7. </li></ul></ul></ul></ul></ul>
    • 21. Pseudotumor Cerebri - Associated Conditions <ul><li>Mastoiditis and lateral sinus thrombosis </li></ul><ul><li>Hypoparathyroidism, Pseudohypoparathyroidism </li></ul><ul><li>Steroid treatment and withdrawal </li></ul><ul><li>Thyroid replacement </li></ul><ul><li>SLE </li></ul><ul><ul><ul><ul><ul><li>Green M. Pediatr Clin North Am 1967;14(4):819-30.Palmer RF, Searles HH, Boldrey EB.. J Neurosurg 1959;16(4):378-84.Baker RS, Baumann RJ, Buncic JR. Pediatr Neurol 1989;5(1):5-11.Walker AE, Adamkiewicz JJ. JAMA 1964;188:779-84.Neville BG, Wilson J.. Br Med J 1970;3(722):554-6.Huseman CA, Torkelson RD.. Am J Dis Child 1984;138(10):927-31.DelGiudice GC, Scher CA, Athreya BH, Diamond GR.. J Rheumatol 1986;13(4):748-52. </li></ul></ul></ul></ul></ul><ul><li>Medication associated with no clear does-response relationship </li></ul><ul><ul><li>Nalidixic acid </li></ul></ul><ul><ul><li>Ciprofloxacin </li></ul></ul><ul><ul><li>Tetracycline </li></ul></ul><ul><ul><ul><ul><ul><li>Lessell S. Surv Ophthalmol 1992;37(3):155-66 . </li></ul></ul></ul></ul></ul><ul><li>Vitamin A and isoretinoin therapy are established causes of pseudotumor cerebri . </li></ul><ul><ul><ul><ul><ul><li>Morrice G Jr, Havener WH, Kapetansky F. JAMA 1960;173:1802-5. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Roytman M, Frumkin A, Bohn TG. Cutis 1988;42(5):399-400. </li></ul></ul></ul></ul></ul>
    • 22. Points to Remember <ul><li>A fundiscopic examination should be a routine part of the examination of the obese child </li></ul><ul><li>Children may not complain of visual field disturbances. When suspicious – test </li></ul><ul><li>Pseudotumor cerebri is essentially a diagnosis of exclusion after other causes of increased intracranial pressure are eliminated. </li></ul>
    • 23. Slipped Capital Femoral Epiphysis <ul><li>Diagnosis </li></ul><ul><ul><li>Suspect and immediately evaluate in an obese patient who presents with limp. </li></ul></ul><ul><ul><li>50%-70% patients with SCFE are obese. </li></ul></ul><ul><ul><ul><ul><ul><li>Wilcox J Pediatr Orthop 1988:8:196-200. </li></ul></ul></ul></ul></ul><ul><ul><li>Can also present with complaints of groin, thigh, or knee pain referred by obturator nerve </li></ul></ul>
    • 24.  
    • 25. Slipped Capital Femoral Epiphysis <ul><li>Diagnosis </li></ul><ul><ul><li>Motion of the hip in abduction and internal rotation is limited on examination. </li></ul></ul><ul><li>X- ray </li></ul><ul><ul><li>Anteroposterior view of the pelvis and frog leg that includes both hips. </li></ul></ul><ul><ul><li>Comparison of the hips </li></ul></ul><ul><ul><li>Bilateral disease occurs in up to 20% of patients. </li></ul></ul><ul><li>Intervention </li></ul><ul><ul><li>Requires surgical correction and weight loss. </li></ul></ul>
    • 26. SCFE-Pathology <ul><li>Medial and posterior displacement of the femoral epiphysis through the growth plate relative to the femoral neck </li></ul><ul><ul><ul><ul><ul><li>Busch MT, Morrissy RT. Orthop Clin North Am 1987;18(4):637-47. </li></ul></ul></ul></ul></ul><ul><li>The preferential site of slipping within the epiphysis is a zone of hypertrophic cartilage cells under the influence of both gonadal hormones and growth hormone </li></ul><ul><ul><ul><ul><ul><li>Kempers MJ, Noordam C, Rouwe CW, Otten BJ. CanJ Pediatr Endocrinol Metab 2001;14(6):729-34 . </li></ul></ul></ul></ul></ul><ul><li>. </li></ul>
    • 27. SCFE - Associated Causes <ul><li>Continued weight gain. </li></ul><ul><li>Renal failure </li></ul><ul><li>History of radiation therapy </li></ul><ul><li>Primary hypothyroidism. </li></ul><ul><ul><ul><ul><ul><li>Loder RT, Greenfield ML.. J Pediatr Orthop . 2001;21(4):481-7. </li></ul></ul></ul></ul></ul><ul><li>Gonadotropin-releasing hormone agonists </li></ul><ul><li>Growth hormone therapy </li></ul><ul><ul><ul><ul><ul><li>Kempers MJ, Noordam C, Rouwe CW, Otten BJ. J Pediatr Endocrinol Metab 2001;14(6):729-34. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Grumbach MM, Bin-Abbas BS, Kaplan SL. Horm Res 1998;49(Suppl 2);41-57. </li></ul></ul></ul></ul></ul>
    • 28.  
    • 29. Bowing of tibia and femur either unilateral or bilateral. Blount’s disease <ul><ul><li>2/3 of patients with Blount’s </li></ul></ul><ul><ul><li>disease may be obese . </li></ul></ul><ul><ul><ul><ul><li>Dietz J Pediatr 1982:101:735-737 . </li></ul></ul></ul></ul>
    • 30. <ul><li>Blounts Disease </li></ul>
    • 31. Blount’s Disease - Obesity Related Orthopedic Morbidity <ul><li>Etiology </li></ul><ul><ul><li>Injury to the growth plate, fissuring and clefts in the physis as well as fibrovascular </li></ul></ul><ul><ul><li>and cartilaginous repair tissue at the physeal-metaphyseal junction. </li></ul></ul><ul><ul><ul><ul><li>. Wenger DR, Mickelson M, Maynard JA.J Pediatr Orthop . 1984 Jan;4(1):78-88. </li></ul></ul></ul></ul><ul><ul><li>Results from overgrowth of the medial aspect of the proximal tibial metaphysis. </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>Requires evaluation and correction by orthopedic surgeon. </li></ul></ul><ul><ul><li>Weight loss </li></ul></ul>
    • 32. Blount’s disease
    • 33. Points to Remember <ul><li>A careful hip and knee examination should be a routine part of the evaluation and follow-up of every obese child. </li></ul><ul><li>An obese child complaining of or presenting with hip, knee, groin, or thigh pain should have a complete and thorough examination of his/her hips, including radiological studies. </li></ul><ul><li>In an obese child, an unusual or abnormal gait should not be attributed to “excess weight” but should be thoroughly investigated with a careful hip and knee examination. </li></ul>
    • 34. 2.bp.blogspot.com/.../GCODtaW6Av4/s320/bipap.jpg /www.airecoremedicalservices.com/pic02.jpg
    • 35. Upper Airway Obstructive Sleep Apnea Syndrome <ul><li>Structure </li></ul><ul><ul><li>Adipose tissue in upper airway contributes to Upper Airway Obstruction </li></ul></ul><ul><ul><ul><ul><ul><li>Shelton KE, et al Pharyngeal fat in obstructive sleep apnea. Am Rev Respir Dis. 1993;148(2):462–466 </li></ul></ul></ul></ul></ul><ul><ul><li>Abdominal adiposity may compromise respiratory excursion </li></ul></ul><ul><ul><ul><ul><ul><li>Kessler R et al The obesity-hypoventilation syndrome revisited: a prospective study of 34 consecutive cases. Chest. 2001;120(2):369–376 . </li></ul></ul></ul></ul></ul><ul><li>Function </li></ul><ul><ul><li>Infiltration of adipocytes into diaphragmatic muscles may alter respiratory mechanics </li></ul></ul><ul><ul><ul><ul><ul><li>Fadell E et al. Fatty infiltration of the respiratory muscles in the Pickwickian syndrome. N Engl J Med. 1962;266(17):861–863 . </li></ul></ul></ul></ul></ul>
    • 36. Obstructive Sleep Apnea <ul><li>OSAS in children is defined as a disorder of breathing during sleep characterized by. </li></ul><ul><ul><li>prolonged partial upper airway obstruction. </li></ul></ul><ul><ul><li>and/or intermittent complete obstruction (obstructive apnea). </li></ul></ul><ul><ul><li>that disrupts normal ventilation during sleep and normal sleep patterns. </li></ul></ul><ul><ul><ul><ul><ul><li>Schechter MS. Technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2002;109(4):e69-79. </li></ul></ul></ul></ul></ul>
    • 37. Airway Mechanics: <ul><li>Dynamic relationship: </li></ul><ul><ul><li>Negative intra-thoracic pressure during inspiration: </li></ul></ul><ul><ul><ul><li>Always a closing pressure </li></ul></ul></ul><ul><ul><li>Airway size and shape: </li></ul></ul><ul><ul><ul><li>This may favor airway opening or closure </li></ul></ul></ul><ul><ul><li>Airway tone: </li></ul></ul><ul><ul><ul><li>Tissue rigidity </li></ul></ul></ul><ul><ul><ul><li>Neuromuscular: </li></ul></ul></ul><ul><ul><ul><ul><li>Too much: Airway constriction </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Too little: Airway collapse </li></ul></ul></ul></ul>Fricke, BL et al: Korean J Radiol 8(6), December 2007 Courtesy of Dr. Aaron Chidikel
    • 38. Obstructive Sleep Apnea Effects <ul><li>Cognitive </li></ul><ul><ul><li>Decreases in learning and memory . </li></ul></ul><ul><ul><ul><ul><ul><li>Rhodes J Pediatr 1995;127:741-744 . </li></ul></ul></ul></ul></ul><ul><ul><li>Deficits in attention, motor efficiency and graphomotor ability. </li></ul></ul><ul><ul><ul><ul><ul><li>Greenberg GD, Watson RK, Deptula D.. Sleep 1987;10(3):254-62. </li></ul></ul></ul></ul></ul><ul><li>Cardiopulmonary </li></ul><ul><ul><li>Pulmonary hypertension,systemic hypertension, right heart failure . </li></ul></ul><ul><ul><ul><ul><ul><li>Tal A, Leiberman A, Margulis G, Sofer S. Pediatr Pulmonol 1988;4(3):139-43. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Marcus CL, Greene MG, Carroll JL. Am J Respir Crit Care Med 1998;157(4 Pt 1):1098-103. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Massumi RA, Sarin RK, Pooya M, Reichelderfer Dis Chest 1969;55(2):110-4. </li></ul></ul></ul></ul></ul><ul><li>Sleep disturbance </li></ul><ul><ul><li>Weight >200% above ideal had oxygen saturation <90% for half to total sleep time. </li></ul></ul><ul><ul><li>40% of severely obese children demonstrated central hypoventilation. </li></ul></ul><ul><ul><ul><ul><ul><li>Silvesti Pediar Pulmonol 1993;16:124-139 . </li></ul></ul></ul></ul></ul>
    • 39. Evaluation- History <ul><li>Nighttime symptoms Daytime symptoms </li></ul><ul><ul><li>Snoring Morning headache </li></ul></ul><ul><ul><li>Restless sleeping Daytime tiredness </li></ul></ul><ul><ul><li>Heavy or noisy breathing Napping </li></ul></ul><ul><ul><li>Orthopnea Poor school function </li></ul></ul><ul><ul><li>Frequent night awakening Inattentiveness </li></ul></ul><ul><ul><li>Enuresis Short term memory </li></ul></ul><ul><ul><li>Observed apnea deficit </li></ul></ul><ul><ul><li>Diaphoresis Irritability </li></ul></ul><ul><ul><li>Cyanosis Elevated blood pressure </li></ul></ul>
    • 40. OSAS-diagnosis <ul><li>Symptom checklists in research settings </li></ul><ul><ul><ul><ul><ul><li>Chervin RD et Sleep Med. 2000;1(1):21–32 </li></ul></ul></ul></ul></ul><ul><li>History, audio and video taping, and overnight oximetry and daytime nap polysomnography are poor predictors of OSAS. </li></ul><ul><li>The definitive diagnosis of OSAS is made by nighttime polysomnography. </li></ul><ul><ul><ul><ul><ul><li>Clinical practice guideline: Pediatrics 2002;109(4):704-12. </li></ul></ul></ul></ul></ul><ul><li>Severity of obstruction may not correlate with either degree of obesity or severity of sleep symptoms. </li></ul>
    • 41. Treatment <ul><li>Definitive treatment is weight loss </li></ul><ul><ul><ul><ul><ul><li>Willi SM et al Pediatrics. 1998;101(1 Pt 1):61–67 . </li></ul></ul></ul></ul></ul><ul><li>Tonsil/Adenoidectomy-temporizing </li></ul><ul><li>CPAP/BIPAP-Titrated in sleep lab </li></ul><ul><ul><ul><ul><ul><li>Marcus CL et al.J Pediatr. 1995;127(1)(((3):88–94. </li></ul></ul></ul></ul></ul><ul><li>Extreme cases unresponsive to weight loss/BiPap/CPAP uvulopharyngopalatoplasty, craniofacial surgery, and, in severe cases, tracheostomy </li></ul><ul><ul><ul><ul><ul><li>Section on Pediatric Pulmonology, Pediatrics. 2002;109(4):704–712. </li></ul></ul></ul></ul></ul><ul><li>Gastric Bypass/Banding in adults </li></ul>
    • 42. Points to Remember <ul><li>Ask specifically about sleep disturbances, snoring, and sleep position. Families will often disregard these symptoms. </li></ul><ul><li>Obstructive sleep apnea syndrome should be especially considered in obese children with poor school performance and concentration difficulties. </li></ul><ul><li>Sleep symptoms can evolve over time. Keep asking about sleep disturbance as you follow these children. Weight gain, intercurrent upper respiratory infections, and Tonsillar enlargement can provoke symptoms. </li></ul>
    • 43.  
    • 44. Asthma and obesity: Respiratory physiology <ul><li>Asthma </li></ul><ul><li>Classic example of an obstructive lung disorder </li></ul><ul><li>Airway obstruction: </li></ul><ul><ul><li>Inflammation </li></ul></ul><ul><ul><li>Bronchospasm </li></ul></ul><ul><ul><li>Mucus plugging </li></ul></ul><ul><li>Airway reactivity: </li></ul><ul><ul><li>Response to triggers </li></ul></ul><ul><ul><li>Reversible airflow obstruction </li></ul></ul><ul><li>Obesity </li></ul><ul><li>Classic example of a restrictive lung disorder </li></ul><ul><li>Chest wall restriction: </li></ul><ul><ul><li>Body mass </li></ul></ul><ul><ul><li>Abdominal fat </li></ul></ul><ul><ul><li>Decreased breathing movements </li></ul></ul><ul><ul><li>Lung compression </li></ul></ul><ul><li>Tissue deposition of fat: </li></ul><ul><ul><li>Airway narrowing </li></ul></ul><ul><ul><li>Fixed airflow obstruction </li></ul></ul>Courtesy of Dr. Aaron Chidikel
    • 45. Pulmonary - Asthma <ul><li>Pulmonary mechanics change with obesity </li></ul><ul><ul><li>Decreased lung volumes and thoracic distensibility </li></ul></ul><ul><ul><ul><ul><ul><li>Fung KP, et al. Arch Dis Child. 1990;65(5):512–515. </li></ul></ul></ul></ul></ul><ul><ul><li>Breathing pattern: Higher frequency, lower tidal volume . </li></ul></ul><ul><ul><ul><ul><ul><li>Weiss S, et al.Obesity and Asthma Direction for Research NHLBI Workshop. Am J Respir Crit Care Med. 2004;169;963–968 </li></ul></ul></ul></ul></ul><ul><li>Obesity may contribute to severity of asthma </li></ul><ul><ul><li>Obese asthmatic children have more missed school days, receive more medication and have lower peak expiratory flow rates than non obese asthmatic children. </li></ul></ul><ul><ul><ul><ul><ul><li>Luder E, et al. J Pediatr. 1998;132(4):699–703. </li></ul></ul></ul></ul></ul><ul><ul><li>Increase cough, wheeze and dyspnea. </li></ul></ul><ul><ul><ul><ul><ul><li>del Rio-Navaro B, et al. Allergol Immunopathol (Madr). 2000;28(1):5–11. </li></ul></ul></ul></ul></ul>
    • 46. Pulmonary- Asthma <ul><li>Bronchial hyperreponsiveness increases in obesity </li></ul><ul><ul><ul><ul><ul><li>Szilagyi PG et al. Pediatr Ann. 1999;28(1):43–52 </li></ul></ul></ul></ul></ul><ul><li>Weight reduction in obese patients reduces asthma symptoms. </li></ul><ul><ul><ul><ul><ul><li>Weiss S, Shore S. Am J Respir Crit Care Med. 2004;169;963–968 </li></ul></ul></ul></ul></ul><ul><li>Gastroesophageal reflux is increased in obesity </li></ul><ul><li>Leptin is increased in obese children and in normal weight asthmatic boys vs. non asthmatic boys. </li></ul><ul><ul><li>Inflammatory cytokines may exacerbate asthma . </li></ul></ul><ul><ul><ul><ul><ul><li>Guler N et al. J Allergy Clin Immunol. 2004;114(2):254–259. </li></ul></ul></ul></ul></ul>
    • 47. Asthma- Evaluation and Treatment <ul><li>Obese children, if inactive may not report symptoms unless specifically asked. </li></ul><ul><ul><li>Altered activity patterns </li></ul></ul><ul><ul><li>Dropping out of sports </li></ul></ul><ul><ul><li>Slowing down </li></ul></ul><ul><ul><li>Losing interest </li></ul></ul><ul><li>As exercise increases during treatment of obesity, symptoms of exercise induced asthma may emerge </li></ul><ul><li>It is important to optimize asthma treatment in every obese, asthmatic child </li></ul>
    • 48. NAFLD to NASH Obesity Fatty Liver/Steatosis Inflammation Fibrosis Cirrhosis 2 nd “Hit” Genetic Predisposition <ul><ul><ul><ul><ul><li>Day CP, James OF. Gastroenterology 1998;114(4):842-5. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Harrison SA, Diehl AM. Semin Gastrointest Dis 2002;13(1): 3-16. </li></ul></ul></ul></ul></ul>
    • 49.  
    • 50. Non Alcoholic Steatohepatitis - Obesity <ul><li>Diagnosis </li></ul><ul><ul><li>Increased liver enzymes and fatty liver on ultrasound in the absence of other causes of liver disease. </li></ul></ul><ul><ul><li>Rule out other causes of fatty liver </li></ul></ul><ul><ul><li>Liver Biopsy </li></ul></ul><ul><li>Etiology </li></ul><ul><ul><li>20%-25% obese children have evidence of steatohepatitis. </li></ul></ul><ul><ul><ul><ul><li>Tazawa Acta Paeditr 1997;86:238-241. </li></ul></ul></ul></ul><ul><ul><li>Obesity and type 2 diabetes are the strongest predictors of progression of fibrosis </li></ul></ul><ul><ul><li>Age is also a risk factor for cirrhosis which may reflect increased duration of risk for the “second hit” thought to initiate fibrosis. </li></ul></ul><ul><ul><ul><ul><ul><li>Angulo P, Keach JC, Batts KP, Lindor KD. Hepatology 1999;30(6):1356-62. </li></ul></ul></ul></ul></ul>
    • 51. NASH risk <ul><li>Predictors of elevated serum ALT in obese children </li></ul><ul><ul><li>Male gender </li></ul></ul><ul><ul><li>Hispanic ethnicity </li></ul></ul><ul><ul><li>Elevated BMI </li></ul></ul><ul><ul><ul><ul><ul><li>Schwimmer JB, McGreal N,Deutsch R, Finegold MJ, Lavine JE. Influence of gender, race, and ethnicity on suspected fatty liver in obese adolescents. Pediatrics. 115(5):e561-5, 2005 May. </li></ul></ul></ul></ul></ul><ul><li>Predictors of fibrosis </li></ul><ul><ul><li>Obesity (BMI z score) </li></ul></ul><ul><ul><li>Insulin resistance </li></ul></ul><ul><ul><li>Leptin (?) </li></ul></ul><ul><ul><ul><ul><ul><li>Schwimmer, J B et al Pediatr 2003 143(4), 500-505 </li></ul></ul></ul></ul></ul><ul><li>“ A liver NAFLD runs a higher risk of being damaged by other factors, from viruses to endotoxins, from alcohol to industrial toxic compounds” </li></ul><ul><ul><ul><ul><ul><li>Yang SO, Lin HZ, Lane MD, Clemens M, Diehl AM. Proc Natl Acd Sci USA 1997; 94 : 25572562 </li></ul></ul></ul></ul></ul>
    • 52. NASH - Treatment <ul><li>Loss of at least 10% of their excess weight normalized ALT and AST values and decreased ultrasound evidence of fatty infiltration </li></ul><ul><ul><ul><ul><ul><li>Vajro P, Fontanella A, Perna C, Orso G, Tedesco M, De Vincenzo A. J Pediatr 1994;125(2):239-41. </li></ul></ul></ul></ul></ul><ul><li>Clinical trial (TONIC) </li></ul><ul><ul><li>Metformin normalizes liver enzymes in 40%-50% of children with Reduction in heapatosteatosis by 23%-30%biopsy proven NASH. </li></ul></ul><ul><ul><li>Improved insulin sensitivity </li></ul></ul><ul><ul><ul><ul><ul><li>Schwimmer JB, et al Alimentary Pharmacology & Therapeutics. 2005 21(7):871-9, </li></ul></ul></ul></ul></ul>
    • 53. Cholelithiasis- Obesity Related Gastrointestinal Morbidity <ul><li>Diagnosis </li></ul><ul><ul><li>Abdominal pain, tenderness . </li></ul></ul><ul><ul><li>Ultrasound, laboratory studies. </li></ul></ul><ul><li>Etiology </li></ul><ul><ul><li>Obesity accounts for 8%-33% of gallstones in children. </li></ul></ul><ul><ul><ul><ul><ul><li>Friesen Clin Pediatr 1989.7:294. </li></ul></ul></ul></ul></ul><ul><ul><li>May be associated with weight loss. </li></ul></ul><ul><ul><ul><ul><ul><li>Crichlow Dig Dis. 1972;17:68-72. </li></ul></ul></ul></ul></ul>
    • 54. Cholelithiasis- Obesity <ul><li>Risk </li></ul><ul><ul><li>50% of cholecystitis in adolescents associated with obesity </li></ul></ul><ul><ul><ul><ul><ul><li>Crichlow Dig Dis. 1972;17:68-72. </li></ul></ul></ul></ul></ul><ul><ul><li>Relative risk of gallstones in adolescent girls with obesity is 4.2 </li></ul></ul><ul><ul><ul><ul><ul><li>Honore Arch Surg 1980;115:62-64. </li></ul></ul></ul></ul></ul><ul><ul><li>Hormonal contraception increases risk </li></ul></ul><ul><ul><ul><ul><ul><li>Schweizer P, Lenz MP, Kirschner HJ. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Dig Surg . 2000;17(5):459-67. </li></ul></ul></ul></ul></ul><ul><li>Surgical Intervention </li></ul>
    • 55. Chronic - Obesity Related Co Morbid Conditions <ul><li>Insulin Resistance </li></ul><ul><li>Pre diabetes </li></ul><ul><li>Type II Diabetes </li></ul><ul><li>Polycystic Ovary Syndrome </li></ul><ul><li>Hypertension </li></ul><ul><li>Hyperlipidemia </li></ul><ul><li>Psychological </li></ul>
    • 56. Acanthosis Nigricans Courtesy Dr. G Datto https://online.epocrates.com/data_
    • 57. Acanthosis Nigricans <ul><li>Hyperpigmentation and velvety thickening that occurs in neck, axilla, groin, can occur over knuckles </li></ul><ul><li>Also seen in malignancies and other insulin resistant syndromes. </li></ul><ul><li>Obese pediatric pts with acanthosis have higher fasting insulin and lower insulin sensitivity than acanthosis negative obese patients </li></ul><ul><li>Insulin resistant pts were more likely to be obese (88%) than have acanthosis (65%) </li></ul><ul><ul><li>Yanovski et al, Journal of Peds 2001 </li></ul></ul>
    • 58. Normal Glucose Tolerance Fasting Glucose (mg/dL) 2 Hr P P Glucose (mg/dL ) Impaired Glucose Tolerance Impaired Fasting Glucose 125 100 199 140 DIABETES Note: HgbA1C is not a diagnostic criteria for pre-diabetes Progression from Normoglycemia to Type 2 Diabetes Courtesy Dr. J Silverstein
    • 59. Progression from Pre-Diabetes to Diabetes in Adolescents <ul><li>117 obese children and adolescents </li></ul><ul><li>At T=0: 33 (28%) had IGT </li></ul><ul><li>At 2 years: </li></ul><ul><li>8 IGT subjects developed T2D (24.2%) </li></ul><ul><li>15 IGT subjects reverted to NGT (45.5%) </li></ul><ul><li>10 IGT subjects remained IGT (30.3%) </li></ul><ul><li>Best predictors of development of T2D: </li></ul><ul><ul><li>Severe obesity (BMI ≥ 97 th percentile) and persistent weight gain </li></ul></ul><ul><ul><li>Relative with T2DM </li></ul></ul><ul><ul><li>Increased insulin resistance (puberty, ethnicity, inactivity, visceral fat distribution, PCOS </li></ul></ul>Weiss R. et al. Diabetes Care 2005; 28:902-909 American Diabetes Association Diabetes Care 2000;23(3) 381-389. Courtesy Dr. J Silverstein
    • 60. Incidence of Type 2 Diabetes Dabelea D, et al “JAMA 2007;297:2716-2724 5.6 3.0 Non Hispanic White 17.0 8.9 Hispanic 22.7 11.8 Asian/Pacific Islander 19.4 22.3 African American 49.4 25.3/100,000person yrs Native American 15-19 yrs 10-14 yrs Ethnicity
    • 61. Diabetes - Diagnosis <ul><li>Hemoglobin A1C >6.5% </li></ul><ul><li>Symptoms of diabetes plus random plasma glucose >200mg/dl (11.1mmol/l) or </li></ul><ul><li>Fasting plasma glucose >126 mg/dl (7.0 mmol/l) or </li></ul><ul><li>2 hour plasma glucose >200 mg/dl during an oral glucose tolerance test </li></ul><ul><ul><ul><ul><ul><li>American Diabetes Association Diabetes Care 2000;23(3) 381-389. </li></ul></ul></ul></ul></ul><ul><li> Diabetes Care July 2009 vol. 32 no. 7 1327-1334 </li></ul><ul><li>Associated findings </li></ul><ul><ul><li>Polycystic ovarian syndrome, Acanthosis nigricans </li></ul></ul><ul><ul><li>Dyslipidemia, Hypertension </li></ul></ul>
    • 62. Goals of Treatment T2DM <ul><li>Physical well being, Psychological well being </li></ul><ul><li>Weight loss or no further weight gain/Continued normal linear growth </li></ul><ul><li>Long term glycemic control </li></ul><ul><li>Control hypertension and hyperlipidemia </li></ul><ul><ul><ul><ul><ul><li>Hassink SG, Pediatric Weight Mgmt and Obesity, 2007 Lippincott Phila, Pa </li></ul></ul></ul></ul></ul><ul><li>Family involvement </li></ul><ul><li>Education including a basic knowledge of pathophysiology and short and long term complication </li></ul><ul><li>Nutrition and meal planning </li></ul><ul><li>Exercise </li></ul><ul><li>Pharmacologic management </li></ul><ul><li>Self monitoring. </li></ul><ul><li>Ongoing monitoring of glucose, HgbA1C, Bun/Crt, LFT’’s, microalbuminuria, lipids, dilated eye examination, neurologic and foot </li></ul>
    • 63. Pharmacologic Management -Metformin <ul><li>In patients with both IFG and IGT + 1 of the following: </li></ul><ul><ul><ul><li><60 yo </li></ul></ul></ul><ul><ul><ul><li>BMI >35 kg.m2 </li></ul></ul></ul><ul><ul><ul><li>FH DM in first degree relatives </li></ul></ul></ul><ul><ul><ul><li>High TG </li></ul></ul></ul><ul><ul><ul><li>Low HDL-C </li></ul></ul></ul><ul><ul><ul><li>HTN </li></ul></ul></ul><ul><ul><ul><li>A1c >6% </li></ul></ul></ul><ul><li>Metformin approved in children >10 years </li></ul><ul><ul><ul><li>Decreases hepatic gluconeogenesis, increases insulin sensitivity, and lower triglycerides and LDL cholesterol </li></ul></ul></ul><ul><ul><ul><li>Nausea, vomiting, fullness, constipation, heartburn </li></ul></ul></ul><ul><ul><ul><li>Lactic acidosis </li></ul></ul></ul>Nathan DM, et al. Diabetes Care . 2007;30:753-759
    • 64. Pharmacologic Management- Insulin <ul><li>If metformin contraindicated </li></ul><ul><ul><li>Renal insufficiency, Liver disease </li></ul></ul><ul><ul><li>Alcohol abuse, </li></ul></ul><ul><ul><li>Hypoxemia </li></ul></ul><ul><ul><li>Hypoperfusion </li></ul></ul><ul><ul><li>Sepsis </li></ul></ul><ul><ul><li>Discontinue with contrast dye, serious illness </li></ul></ul><ul><ul><li>Vitamin B12 deficiency reported in adults with long term use. </li></ul></ul><ul><li>If metabolic control cannot be achieved with lifestyle and metformin </li></ul><ul><li>If beta cell failure ( in adults 6-8 yrs after diagnosis) </li></ul>
    • 65. Polycystic Ovarian Syndrome <ul><li>Polycystic Ovary Syndrome. </li></ul><ul><ul><li>Hyperandrogenism </li></ul></ul><ul><ul><li>Oligomenorrhea/amenorrhea. </li></ul></ul><ul><ul><li>Hirsuitism </li></ul></ul><ul><ul><li>Acne </li></ul></ul><ul><ul><li>Polycystic ovaries and eventual infertility . </li></ul></ul><ul><li>Increased risk </li></ul><ul><ul><li>Girls with premature adrenarche </li></ul></ul><ul><ul><ul><ul><ul><li>Bacha F, Arslanian S. Enod Trends 11(1)2004 </li></ul></ul></ul></ul></ul>
    • 66. Hypertension <ul><li>Use tables to classify </li></ul><ul><li>Classification on three occasions </li></ul><ul><ul><li>Prehypertension 90%-95% or BP >120/80. </li></ul></ul><ul><ul><li>Stage 1 hypertension 95%-99% plus 5 mm Hg </li></ul></ul><ul><ul><li>Stage 2 hypertension >99% plus 5 mmHg. </li></ul></ul><ul><li>Goal Blood pressure <90% for age and gender </li></ul><ul><ul><ul><ul><ul><li>Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood Pressure in Children and Adolescents Pediatrics 2004;114(2 Suppl)555-576 </li></ul></ul></ul></ul></ul>
    • 67. Hypertension Treatment <ul><li>Prehypertension </li></ul><ul><ul><li>Recheck in 6 months </li></ul></ul><ul><ul><li>Weight management counseling </li></ul></ul><ul><ul><li>Pharmacologic therapy not indicated unless chronic kidney disease, diabetes heart failure of LVH </li></ul></ul><ul><ul><ul><ul><ul><li>Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood Pressure in Children and Adolescents Pediatrics 2004;114(2 Suppl)555-576 </li></ul></ul></ul></ul></ul>
    • 68. Stage 1 Hypertension Treatment <ul><ul><li>Recheck in 1-2 weeks or sooner if symptomatic </li></ul></ul><ul><ul><li>Evaluate or refer within 1 month if elevated on 2 additional occasions </li></ul></ul><ul><ul><li>Weight management </li></ul></ul><ul><ul><li>Pharmacologic therapy if; </li></ul></ul><ul><ul><ul><li>Symptomatic hypertension </li></ul></ul></ul><ul><ul><ul><li>Secondary hypertension </li></ul></ul></ul><ul><ul><ul><li>Hypertensive target organ damage </li></ul></ul></ul><ul><ul><ul><li>Diabetes (1 or 2) </li></ul></ul></ul><ul><ul><ul><li>Persistent hypertension despite non pharmacologic measures. </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood Pressure in Children and Adolescents Pediatrics 2004;114(2 Suppl)555-576 </li></ul></ul></ul></ul></ul>
    • 69. Stage 2 Hypertension Treatment <ul><ul><li>Evaluate or refer within 1 week or immediately if patient is symptomatic </li></ul></ul><ul><ul><li>Weight management </li></ul></ul><ul><ul><li>Pharmacologic therapy </li></ul></ul><ul><ul><ul><li>Angiotensin converting enzyme inhibitors </li></ul></ul></ul><ul><ul><ul><li>Angiotensin receptor blockers </li></ul></ul></ul><ul><ul><ul><li>Beta blocker </li></ul></ul></ul><ul><ul><ul><li>Calcium Channel blockers </li></ul></ul></ul><ul><ul><ul><li>Diuretics </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood Pressure in Children and Adolescents Pediatrics 2004;114(2 Suppl)555-576 </li></ul></ul></ul></ul></ul>
    • 70. Hyperlipidemia <ul><li>Diagnosis </li></ul><ul><ul><li>Elevated LDL cholesterol, triglycerides and lowered HDL cholesterol . </li></ul></ul><ul><ul><li>Component of the metabolic syndrome </li></ul></ul><ul><li>Etiology </li></ul><ul><ul><li>Increased central fat distribution </li></ul></ul><ul><ul><li>Hyperinsulinemia </li></ul></ul>
    • 71. Lipid Levels >200mg/dl <200mg/dl Trig >130mg/dl 100-129mg/dl <100mg/dl LDLChol <40mg/dl >40mg/dl HDLChol >200mgdl 170-199 mg/dl <170mg/dl TChol High Normal Low
    • 72. Hyperlipidemia <ul><li>Risk </li></ul><ul><ul><li>Overweight adolescents </li></ul></ul><ul><ul><ul><li>2.4 fold increase in prevalence of cholesterol >240mg/dl </li></ul></ul></ul><ul><ul><ul><li>3 fold increase in LDL values >160mg/dl </li></ul></ul></ul><ul><ul><ul><li>8 fold increase in HDL values<35 mg/dl as adults 27-31 years. </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Srinivasan Metab 1996;45:235-240 </li></ul></ul></ul></ul></ul>
    • 73. BMI>99% Cardiovascular Risk <ul><li>BMI >95% </li></ul><ul><ul><li>39% two cardiovascular risk factors </li></ul></ul><ul><ul><li>65% had adult BMI >35% </li></ul></ul><ul><li>BMI >99% </li></ul><ul><ul><li>59% two cardiovascular risk factors </li></ul></ul><ul><ul><li>88% adults BMI >35 </li></ul></ul><ul><li>4% US children BMI >99% </li></ul><ul><ul><ul><ul><ul><li>Freedman DS et al Cardiovascular risk factors and excess adiposity among overweight children and adolescents; the Bogalusa Heart Study J Pediatric 2007 150(1) 3-5. </li></ul></ul></ul></ul></ul>
    • 74. Treatment <ul><li>Nutritional </li></ul><ul><ul><li>Lower fat, cholesterol intake, Increase fiber </li></ul></ul><ul><li>Weight loss </li></ul><ul><li>Pharmacologic Therapy (after trial of dietary therapy for 6 months) </li></ul><ul><ul><li>Children >10 yr </li></ul></ul><ul><ul><li>LDL cholesterol>190mg/dl or LDL>160mg/dl with 2 major risk factors. </li></ul></ul><ul><ul><ul><ul><ul><li>AAP Cholesterol in Childhood 1998 101;141-147. </li></ul></ul></ul></ul></ul>
    • 75. Treatment- Hypercholesterolemia <ul><li>Cholestyramine </li></ul><ul><ul><li>Approved for use in children </li></ul></ul><ul><ul><ul><li>Absorption of medications affected </li></ul></ul></ul><ul><ul><ul><li>Worsening of bleeding problems, constipation, gallstones, hemorrhoids, ulcers, hypothyroidism, renal disease and PKU. </li></ul></ul></ul><ul><ul><ul><li>Gastrointestinal side effects, constipation, flatulence and bloating </li></ul></ul></ul><ul><ul><ul><li>Contraindicated when TG>400mg/dl </li></ul></ul></ul>
    • 76. Studies Hypercholesterolemia <ul><li>Lovastatin, Pravastatin, Simvastatin, Atorvastatin, HMG CoA reductase inhibitors </li></ul><ul><ul><li>Have been studied for up to 48 weeks in children, no long term studies, not approved in pregnancy </li></ul></ul>
    • 77. Treatment - Hypertriglyceridemia <ul><li>Decrease simple sugars </li></ul><ul><li>Weight loss </li></ul><ul><li>If persistent evaluate for diabetes, thyroid disease, renal disease, alcohol abuse </li></ul><ul><li>Fish oil (omega-3 fatty acids) 2 gm/d if TG>500-700mg/dl. Restrict contact sports (risk of bleeding) </li></ul><ul><ul><ul><ul><ul><li>Gidding. Cardiovascular risk factor in adolescents Curr Treat Options Cardiovascular Med 2006 8 </li></ul></ul></ul></ul></ul>
    • 78. Psychological Morbidity <ul><li>Obesity Associated Psychological Conditions </li></ul><ul><ul><li>Depression </li></ul></ul><ul><ul><li>Anxiety </li></ul></ul><ul><ul><li>Low self esteem </li></ul></ul><ul><ul><li>Teasing/Bullying </li></ul></ul><ul><ul><li>Binge eating disorder </li></ul></ul>
    • 79. Psychological Morbidity <ul><li>Additional psychological conditions with may impact treatment </li></ul><ul><ul><li>ADHD/ADD </li></ul></ul><ul><ul><li>Bipolar Illness </li></ul></ul><ul><ul><li>Adjustment Disorder </li></ul></ul><ul><ul><li>Oppositional Defiant Disorder </li></ul></ul>
    • 80. Depression and Obesity <ul><li>In adolescents 7-12 grade depressed mood predicted follow-up obesity </li></ul><ul><li>Baseline obesity did not predict follow-up depression </li></ul><ul><ul><li>Data from the National Longitudinal Study of Adolescent Health (Add Health), a nationally representative, comprehensive, school-based study of youth in grades 7 to 12 </li></ul></ul><ul><ul><ul><ul><ul><li>Goodman E, Whitaker RC Prospective Study of the Role of Depression in the Development and Persistence of Adolescent Obesity Pediatr2002 110(3)497-504 </li></ul></ul></ul></ul></ul>
    • 81. Obesity Trajectory and Depression/ODD <ul><li>Chronically obese children had significantly higher rates of oppositional defiant disorder, and (for boys) depression. </li></ul><ul><li>No difference among groups in gender, family structure, parenting style, family history of mental illness, drug abuse, crime, or traumatic events. </li></ul><ul><li>Chronic and childhood obesity were associated with having uneducated parents and low family income. </li></ul><ul><ul><li>Study of children over a 4 year period in Appalachia </li></ul></ul><ul><ul><ul><ul><ul><li>Mustillo S et al.Obesity and Psychiatric Disorder: Developmental Trajectories Pediatr 2003 111(4)4 851-859 </li></ul></ul></ul></ul></ul>
    • 82. Health related quality of life <ul><li>Obese children and adolescents 5.5 times more likely to have impaired health related quality of life than normal weight child </li></ul><ul><li>Reported lower pediatric health related quality of life cores in all domains, physical, psychosocial, emotional, social, and school functioning than healthy children and adolescents </li></ul><ul><li>Parents scores were even lower than children's </li></ul><ul><ul><ul><ul><ul><li>Schwimmer JB, et al J AMA.  2003;289:1813-1819. </li></ul></ul></ul></ul></ul>
    • 83. Health related quality of life <ul><li>Obese children and adolescents with OSA reported lower quality of life scores than other obese children </li></ul><ul><li>Health-related QOL did not vary by age, sex, SES, or race </li></ul><ul><li>BMI z score among obese children and adolescents was inversely correlated with physical functioning. </li></ul><ul><ul><ul><ul><ul><li>Schwimmer JB, et alHealth-Related Quality of Life of Severely Obese Children and Adolescents J AMA.  2003;289:1813-1819. </li></ul></ul></ul></ul></ul>
    • 84. Comorbidities of Obesity <ul><li>Complete evaluation of an obese child includes history, review of systems and physical which includes obesity related comorbidities. </li></ul><ul><li>Treatment of obesity reduces morbidity </li></ul><ul><li>Modest weight loss is effective in ameliorating effects of obesity related comorbidities. </li></ul>

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