Published on

  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide
  • This slide illustrates the spectrum of care that comes from the Center. The Center is unique because it has a focus on prevention AND treatment. Many of you may be familiar with the Borden Center name. The Borden Center has melded into the prevention piece of the Center. We are very active in the community representing in several community initiatives and projects such as the Healthy and Fit project; Action for Healthy Kids. We are continuously seeking outside funding to support our efforts in this area. To date we have one fund grant and 3 pending proposals. Our superb bariatric program is in the umbrella of the Center. All patients that enter this program come through a thorough assessment clinic and are part of the Center’s family. Dr. Murray and Dr. Ihuoma Eneli are working on several research projects. With some funding from CRI, we are creating a database that is collecting detailed data on our patients that will be necessary for research.
  • Risk

    1. 1. Childhood Obesity in Practice: A look at the obese & the extremely obese Robert Murray MD Marc Michalsky MD Nationwide Children’s Hospital
    2. 2. Aims of Presentation <ul><li>a synopsis national guidelines </li></ul><ul><li>the risk of extreme obesity </li></ul><ul><li>bariatric surgery </li></ul><ul><ul><li>and resolution of health risk </li></ul></ul>
    3. 3. The Expert Committee <ul><li>American Medical Association </li></ul><ul><li>Dept of Health and Human Services </li></ul><ul><li>CDC & Prevention </li></ul><ul><li>American Academy of Pediatrics </li></ul><ul><li>American Dietetics Association </li></ul><ul><li>Natl Assoc of Pediatric Nurse Practitioners </li></ul><ul><li>National Medical Association </li></ul><ul><li>American Heart Association </li></ul><ul><li>National Association of School Nurses </li></ul><ul><li>American college of Sports Medicine </li></ul><ul><li>The Obesity Society </li></ul><ul><li>The Endocrine Society </li></ul><ul><li>American College of Preventive Medicine </li></ul><ul><li>American Academy of Child & Adolescent Psychiatry </li></ul><ul><li>Association of American Indian Physicians </li></ul>Pediatrics , December 2007, 120:supplement 4
    4. 4. The Primary Physician’s Role Prevention Identification Intervention
    5. 5. Nine Evidence-Based Messages <ul><li>Support exclusive breastfeeding 4-6 months </li></ul><ul><li>Limit sweetened beverages </li></ul><ul><li>Eat 5 servings per day of fruits & vegetables </li></ul><ul><li>Participate in moderate to vigorous physical activity for 60 mins/ day </li></ul><ul><li>Limit screen time to a maximum of 2hrs/ day </li></ul><ul><li>Do not allow your child to have a television in his or her bedroom </li></ul><ul><li>Eat a nutritious breakfast every day </li></ul><ul><li>Engage in regular family meals 5-6 times/ week </li></ul><ul><li>Limit portion sizes </li></ul>For Prevention & Counseling
    6. 6. An OUNCE of PREVENTION: Anticipatory Guidance for obesity prevention www.NationwideChildrens.org/HealthyWeight/ Ohio Chapter, American Academy of Pediatrics Ohio Department of Health Ohio Dietetics Association American Dairy Council, Mid-East
    7. 7. Normal at 10 yrs = 10% risk of obesity as adult “ At risk” or overweight at 10 yrs = 80% risk
    8. 8. Media Policy Food Industry Neighborhood Environment Schools Pre-schools Medical Community Early Childhood Providers Out of school time/Faith Based Societal Level Community Level Inter-personal Level CHILD Family The Workplace Health & Fitness Takes Many Teachers Community programs
    9. 9. Parental Perceptions of their Overweight Child <ul><ul><li>Only 1/3 recognized it </li></ul></ul><ul><ul><li>Only 1/4 worried about it </li></ul></ul><ul><ul><li>Only 1/5 recalled MD concern </li></ul></ul>In most studies parental recognition of overweight occurs around age 8-12 yrs -- Even later for boys Eckstein, Pediatrics 2006; 117:681
    10. 10. know the number! BMI %-ile At every well-child visit, discuss weight nutrition, activity and health risk
    11. 11. Pediatric Obesity Management Pocket Guide
    12. 12. Create a Risk Profile Place the BMI in Context <ul><li>Family health history </li></ul><ul><ul><li>Obesity </li></ul></ul><ul><ul><li>Diabetes </li></ul></ul><ul><ul><li>Cardiovascular disease </li></ul></ul><ul><li>Targeted review of systems </li></ul><ul><li>Targeted physical exam </li></ul><ul><li>Blood pressure </li></ul>
    13. 13. Review of Systems <ul><li>Abdominal pain </li></ul><ul><li>Joint pain </li></ul><ul><li>Snoring, apnea, daytime sleepiness </li></ul><ul><li>Polyuria, polydipsia </li></ul><ul><li>Irregular menses </li></ul><ul><li>Signs of mood disorder </li></ul><ul><ul><li>Depression, anxiety </li></ul></ul><ul><ul><li>social or school avoidance </li></ul></ul><ul><li>Exercise tolerance </li></ul><ul><li>Diet </li></ul><ul><li>Screen time </li></ul>
    14. 14. Physical Exam <ul><li>Papilledema on eye exam </li></ul><ul><li>Tonsillar hypertrophy </li></ul><ul><li>Abdominal pain </li></ul><ul><li>Hepatomegaly </li></ul><ul><li>Tibial bowing </li></ul><ul><li>Hip or knee pain </li></ul><ul><li>Signs of precocious puberty </li></ul><ul><li>Skin findings </li></ul><ul><ul><li>acne, striae, hirsutism </li></ul></ul><ul><ul><li>acanthosis nigricans </li></ul></ul>
    15. 15. acanthosis nigricans insulin resistance hyperinsulinemia skin changes
    16. 16. acanthosis nigricans = metabolic changes are already underway Fat mass insulin resistance altered metabolism <ul><li>diabetes </li></ul><ul><li>hypertension </li></ul><ul><li>abnormal lipids </li></ul><ul><li>inflammation </li></ul><ul><li>cardiovascular ds </li></ul><ul><li>asthma </li></ul><ul><li>liver disease </li></ul><ul><li>sleep apnea </li></ul><ul><li>orthopedic problems </li></ul>Identify this early
    17. 17. Blood Pressure a critical risk <ul><li>Children >3 years of age </li></ul><ul><li>Auscultation is preferred </li></ul><ul><li>Use appropriate sized cuff </li></ul><ul><li>Must be plotted on curves adjusted for age, sex, and height </li></ul><ul><li>Measurements that exceed the 90th percentile should be repeated </li></ul>
    18. 20. Do I have to check labs? 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. Fasting Lipid Profile ALT, AST, Fasting glucose > 95% Fasting Lipid Profile ALT, AST, Fasting glucose 85-94% With risk factors Fasting Lipid Profile 85-94% No risk factors Labs BMI Percentile
    19. 21. Motivation/Attitude
    20. 22. Nine Evidence-Based Messages <ul><li>Support exclusive breastfeeding 4-6 months </li></ul><ul><li>Limit sweetened beverages </li></ul><ul><li>Eat 5 servings per day of fruits & vegetables </li></ul><ul><li>Participate in moderate to vigorous physical activity for 60 mins/ day </li></ul><ul><li>Limit screen time to a maximum of 2hrs/ day </li></ul><ul><li>Do not allow your child to have a television in his or her bedroom </li></ul><ul><li>Eat a nutritious breakfast every day </li></ul><ul><li>Engage in regular family meals 5-6 times/ week </li></ul><ul><li>Limit portion sizes </li></ul>Prevention & Counseling
    21. 23. Algorithm For Intervention
    22. 24. Resources to Help You <ul><li>Ounce of Prevention </li></ul><ul><ul><li>Birth to 5 years </li></ul></ul><ul><ul><li>6 to 19 yrs NEW! </li></ul></ul><ul><ul><li>Parent handouts </li></ul></ul><ul><li>BMI wheels and tables </li></ul><ul><li>Parent Tip Sheets </li></ul><ul><li>Pocket management book </li></ul><ul><li>Coding sheet </li></ul><ul><li>Acanthosis training NEW! </li></ul>www.NationwideChildrens.org/HealthyWeight
    23. 25. Extreme Obesity What to do with
    24. 26. Medical Sequelae of Obesity <ul><li>Hypertension </li></ul><ul><li>Lipid disorders </li></ul><ul><li>Diabetes </li></ul><ul><li>Ischaemic heart disease </li></ul><ul><li>Cardiomyopathy </li></ul><ul><li>Pulmonary hypertension </li></ul><ul><li>Asthma </li></ul><ul><li>Hypoventilation syndromes </li></ul><ul><li>Obstructive sleep apnea </li></ul><ul><li>Gallstones </li></ul><ul><li>NASH (Non-alcoholic steatohepatitis) </li></ul><ul><li>Urinary incontinence </li></ul><ul><li>Gastroesophageal reflux </li></ul><ul><li>Arthritis – weight bearing </li></ul><ul><li>Low back pain </li></ul><ul><li>Infertility and menstrual problems </li></ul><ul><li>Obstetric complications </li></ul><ul><li>DVT and thromboembolism </li></ul><ul><li>Depression </li></ul><ul><li>Immobility </li></ul><ul><li>Cancer </li></ul><ul><li>Venous/stasis ulcers </li></ul><ul><li>Intertrigo </li></ul><ul><li>Accident prone </li></ul>
    25. 27. Adipocytes are Endocrine Cells <ul><li>Secretion of > 50 Adipokines </li></ul><ul><li>Leptin </li></ul><ul><li>Adiponectin </li></ul><ul><li>Resistin </li></ul><ul><li>TNF- alpha </li></ul><ul><li>Adipose Actions </li></ul><ul><li>stimulate inflammation </li></ul><ul><ul><li>increase insulin resistance (block receptor signaling) </li></ul></ul><ul><ul><li>attract macrophages into fat & vessels (foam cells) </li></ul></ul><ul><li>alter metabolism </li></ul><ul><ul><li>lower sensitivity to insulin’s actions </li></ul></ul><ul><ul><li>shift glucose-based to FFA-based metabolism </li></ul></ul><ul><ul><li>fat storage in non-adipose tissues </li></ul></ul>
    26. 28. Obesity & Endothelial Dysfunction Adipose Tissue Nitric Oxide Adhesion Molecules Macrophage Chemoattractives Vascular Endothelial Cell leptin IL-6 FFA fibrinogen Angiotensin II TNF- alpha <ul><li>inflammation </li></ul><ul><li>thrombus formation </li></ul><ul><li>plaque destabilization </li></ul><ul><li>lipid accumulation </li></ul><ul><li>poor distensibility </li></ul>Pharmacol Reports 2006; 58: s81
    27. 29. Extreme Obesity in Children <ul><li>BMI > 99th percentile or BMI > 35 </li></ul><ul><li>2-6% of all kids </li></ul><ul><li>> 50% have metabolic syndrome </li></ul><ul><li>Significant cardiovascular changes </li></ul><ul><li>Multi-organ complications </li></ul>
    28. 30. Weight Loss - Pediatric Programs <ul><li>NACHRI identified 80 pediatric centers with weight management programs </li></ul><ul><li>Only 15 had an associated surgical weight loss program </li></ul><ul><li>6 to 8 “high” volume programs </li></ul><ul><li>August, 2008 – NACHRI formed Obesity Steering Committee </li></ul>
    29. 31. The Bariatric Program at Nationwide Children’s <ul><li>Surgeons: </li></ul><ul><ul><li>Marc Michalsky, MD </li></ul></ul><ul><ul><li>Steve Teich, MD </li></ul></ul><ul><ul><li>Allen Browne, MD </li></ul></ul><ul><ul><li>Bradley Needleman, MD (OSUMC) </li></ul></ul><ul><ul><li>Scott Melvin, MD (OSUMC) </li></ul></ul><ul><li>Medical Director </li></ul><ul><ul><li>Robert Murray, MD </li></ul></ul>
    30. 32. “ First 50 Patients” 42 26 OSA 22 21 Asthma 25 19 Type II DM 13 26 GERD 5.5 42 Depression 10 24 Hypertension 54 28 Insulin Resistance 33 7 Hypothyroidism New Dx (%) Overall (%) Co-morbidity
    31. 33. Co-Morbidities in Bariatric Patients NCH and OSU Experience
    32. 34. Resolution of Co-morbid Conditions 5 months post-pediatric bypass
    33. 35. Gastric Bypass: Effect on HOMA 4 wk 8wk 12wk 20wk 32wk 52wk 4 wk 8wk 12wk 20wk 32wk 52wk Insulin Resistance Body Mass Index
    34. 36. Homeostatic Model Assessment (HOMA) β Cell Activity vs. Insulin Sensitivity 4 wk 8wk 12wk 20wk 32wk 52wk
    35. 37. Quality of Life Measures 6 months post- bypass 80.8 (19.3) 57.2 (21.0) 79.3 (18.1) Emotional Function 80.0 (18.3) 56.6 (23.7) 85.1 (16.8) Social Function 77.0 (14.0) 56.6 (16.6) 81.8 (14.1) Psychosocial 69.5 (21.3) 55.1 (18.2) 81.1 (16.5) School Function 78.0 (14.0) 54.2 (18.5) 87.5 (13.5) Physical Score 77.3 (12.3) 55.7 (15.4) 83.8 (12.6) Total Score Post-Op (6 month) Mean (SD) Pre-Op Mean (SD) Healthy Mean (SD)
    36. 38. Washington State Healthcare Authority
    37. 39. Health Technology Clinical Committee <ul><li>Evaluated healthcare coverage for adolescent bariatric surgery </li></ul><ul><li>Assessment of the strength of current peer-reviewed evidence </li></ul><ul><li>Determine safety, efficacy and cost </li></ul><ul><li>Guide decisions regarding state program coverage </li></ul>
    38. 40. Health Technology Clinical Committee <ul><li>2004: Estimate 2000 bariatric procedures were performed in patients under 21 years </li></ul><ul><li>75% of bariatric surgeons surveyed report planning to perform a procedure on an adolescent in the near future </li></ul>
    39. 41. Health Technology Clinical Committee <ul><li>Review 17 peer-reviewed studies </li></ul><ul><li>553 pediatric patients </li></ul><ul><li>Studies were assessed for validity/quality </li></ul>
    40. 42. Meta-analysis Results <ul><li>Majority: academic medical centers </li></ul><ul><li>Mean age 15.6 to 18.1 years </li></ul><ul><li>Average BMI </li></ul><ul><ul><li>RYGB 51.8 kg/m 2 </li></ul></ul><ul><ul><li>LAGB 45.8 kg/m 2 </li></ul></ul>
    41. 43. Questions <ul><li>Does PBS lead to significant (> 7%EBWL) and durable weight loss? </li></ul><ul><li>Does PBS improve co-morbidities, QOL and survival compared to medical therapy? </li></ul><ul><li>Safety Profile (surgical v. medical) </li></ul><ul><li>Cost Profile (surgical v medical) </li></ul><ul><li>Does efficacy, safety and cost vary according to demographics (age, sex, BMI) </li></ul>
    42. 44. Conclusion
    43. 45. Clinical Research NIH Sponsored <ul><li>TeenLABS (Longitudinal Assessme nt of Bariatric Surgery) </li></ul><ul><ul><li>NIH-sponsored, </li></ul></ul><ul><ul><li>Mu lti-centered observational study </li></ul></ul><ul><ul><li>2 year follow-up </li></ul></ul><ul><ul><li>5 centers </li></ul></ul><ul><ul><li>N = 200 teens </li></ul></ul>
    44. 46. Clinical Research NIH Sponsored <ul><li>Teen-Intake (Nutritional Assessme nt of Bariatric Surgery) </li></ul><ul><ul><li>NIH-sponsored, </li></ul></ul><ul><ul><li>Mu lti-centered observational study </li></ul></ul><ul><ul><li>2 year follow-up </li></ul></ul><ul><ul><li>N = 200 teens </li></ul></ul><ul><li>TeenVIEW (Controlled Longitudinal o f Psycho-social Development) </li></ul><ul><ul><li>NIH-sponsored, </li></ul></ul><ul><ul><li>Mu lti-centered observational study </li></ul></ul><ul><ul><li>2 year follow-up </li></ul></ul><ul><ul><li>N = 200 teens </li></ul></ul>
    45. 47. Clinical Research Industry Sponsored <ul><li>LBA 001 (Allergan) </li></ul><ul><ul><li>Industry-sponsored IDE, 5 year follow-up </li></ul></ul><ul><ul><li>Multi-institutional safety/efficacy trial </li></ul></ul><ul><ul><ul><li>n = 150 subjects (14 to 17 years) </li></ul></ul></ul><ul><ul><li>Local: n = 26, enrollment closed Dec, 2007 </li></ul></ul>
    46. 48. Reversal of Type II Diabetes <ul><li>11 teens > 1 year after Roux-en-Y bypass </li></ul><ul><li>Mean BMI 50 + 5.9; 50% metabolic synd </li></ul><ul><li>Post-op </li></ul><ul><ul><li>BMI fell by 34% to 33 + 7 kg/m2 </li></ul></ul><ul><ul><li>Improvement of fasting glucose, insulin, HOMA-IR, Hb A1C, AST, ALT, LDL, triglycerides, total cholesterol, blood pressure </li></ul></ul><ul><ul><li>Remission of diabetes in 10 of 11 cases </li></ul></ul><ul><ul><li>Removal of oral hypoglycemics in 10 cases </li></ul></ul>Inge et al, Pediatrics 2008; 123:214
    47. 49. Cardiovascular Risk & Extreme Obesity in Teens <ul><li>BMI > 99 th %ile or BMI > 40 </li></ul><ul><li>N=38 13-19 yrs old </li></ul><ul><li>Pre- and post- gastric bypass surgery </li></ul><ul><li>Echocardiogram, doppler studies </li></ul><ul><ul><li>Adequate studies in only 38 of 67 cases </li></ul></ul><ul><ul><li>LV geometry (size, ventricular shape, mass, wall thickness) </li></ul></ul><ul><ul><li>LV systolic function (contractility, wall thickness) </li></ul></ul><ul><ul><li>Diastolic function (atrial size, pulsed doppler assessment) </li></ul></ul>Ippisch et al, J Am Coll Cardiol 2008; 51:1342
    48. 50. Weight Loss & Cardiovascular Risk <ul><li>¼ showed high risk concentric LVH </li></ul><ul><ul><li>Adults: with concentric LVH, 53% had a cardiovascular event </li></ul></ul><ul><ul><li>Teens: 28% had concentric LVH pre-op, only 3% post-op </li></ul></ul><ul><li>LV mass increased </li></ul><ul><ul><li>Adults: > 51 g/m 2.7 had 4-fold higher CV mortality </li></ul></ul><ul><ul><li>Teens studied: averaged > 54 g/m 2.7 , max 86 g/m 2.7 </li></ul></ul><ul><li>LV dimensions, systolic function: abnormal </li></ul><ul><ul><li>Normal LV geometry: only 36% pre-, up to 79% post-op </li></ul></ul><ul><li>Elevated cardiac workload, BP </li></ul><ul><ul><li>Decreased HR and systolic BP, rate-pressure product </li></ul></ul><ul><li>Abnormal diastolic function </li></ul><ul><ul><li>Improved mitral valve and filling dynamics post-op </li></ul></ul>Ippisch et al, J Am Coll Cardiol 2008; 51:1342
    49. 51. Cardiovascular Status Pre-surgery CMR Results 10 patients pre-bariatric surgery show striking cardiovascular abnormalities and risk 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
    50. 52. Conclusions <ul><li>Extremely Obese Teens </li></ul><ul><ul><li>Have many serious co-morbidities </li></ul></ul><ul><ul><li>High risk of type II diabetes </li></ul></ul><ul><ul><li>Extreme cardiovascular risk </li></ul></ul><ul><li>Bariatric Surgery </li></ul><ul><ul><li>Shows effective metabolic resolution </li></ul></ul><ul><ul><li>Resolution of co-morbid conditions </li></ul></ul><ul><ul><li>Resolution of cardiovascular abnormalities </li></ul></ul><ul><ul><li>Minimal risk </li></ul></ul>
    51. 53. Center for Healthy Weight & Nutrition Prevention Treatment Public Health Healthcare Provider Support Medical Weight Loss Programs Research Child & Family Education Bariatric Surgery www.NationwideChildrens.org/HealthyWeight