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  • 1. PCOS – Obesity The Present Day Menace
  • 2. Epidemiology
    • There is an epidemic of Childhood obesity in the world
    • From 1963-91 -Doubling of the incidence of children with BMI of more than 95th centile
    • Overall scales are going up. Children with the same BMI centiles are now heavier
    • Genetic shift unlikely. Profound environmental effect
  • 3. Definition
    • Weight centile alone is useless as it does not consider height
    • Height for weight is better but does not differentiate between increased muscle or fat
    • BMI reflects the degree of fat content best
    • BMI = Weight in Kgs / Height in m 2
  • 4.
    • Obesity is not overweight.
    • Obesity is excess body fat
    • In adults
      • BMI > 25 is overweight
      • BMI > 30 is obese
    • In children
      • BMI > 85 centile for the age is overweight
      • BMI > 95 centile is obese
    Definition
  • 5.
    • Lab methods
      • Underwater weighing
      • DEXA
      • Air displacement plethysmography
      • Skin fold thickness
      • Bioelectric impedence
      • Not useful in clinical practice
    • Country specific BMI charts
      • Should be prepared and then 85 and 95 centile limits should be used
    Definition
  • 6. BMI Centile Charts
  • 7. Definition and Epidemiology
    • Increased prevalence is now seen in countries where the major problem used to be malnutrition
    • Now obesity is caused by poor food choice and decreased activity
    • Indeed we are seeing this more and more commonly in urban areas in India !
  • 8. Tracking of Obesity
    • Three crucial periods determine the chance of obesity during adulthood
      • Gestational period – Infant’s of Diabetic Mother’s have higher chance of becoming obese at 6-10 years and persist into adulthood
      • Adiposity rebound - Early adiposity rebound was related to parental obesity and persistence of obesity in adulthood
      • Adolescent period
  • 9.
    • Childhood onset obesity
      • Has worse prognosis than adult onset obesity
      • Associated with
        • High BP
        • Increased risk of cardiovascular morbidity
        • Insulin resistance and dyslipidemia
        • Lipid profile reveals
          • High triglyceride levels
          • Low HDL levels
    • Visceral fat is most metabolically active
    Tracking of Obesity
  • 10. Sequel of Obesity
    • Obese children have . . .
    • 2.5 times risk of having high BP
    • 8.5 times risk of being hypertensive adults
    • Increased left ventricular mass
    • Higher chance of being insulin resistant
    • May develop Type 2 diabetes as early as 6 years
  • 11.
    • Functional ovarian hyperandrogenism
    • Restrictive airway disease
    • Obstructive airway disease
    • Snoring, Sleep apnea, Right ventricular hypertrophy
    • Heart failure
    • High incidence of asthma
    Sequel of Obesity
  • 12. Gynaecological Consequenses Of Obesity
    • PCOD- Hair-An syndrome
    • Anovulation
    • Amenorrhoea
    • D.U.B.
    • Fibroid Uterus
    • Fungal Infections
    • Infertility
  • 13. Evaluation of Obese Youth
    • Family history
    • SMR, acanthosis and striae, goitre
    • Blood pressure
    • Cholesterol, Blood sugar and HbA1c
    • Liver function tests
  • 14. Evaluation of Obese Youth - Endocrine tests
    • T3, T4, TSH
    • Cortisol
    • Dexamethasone suppression test - Low dose
      • 1.5 mg/m2 of Dexamethasone given at 10 p.m.
    • If short metacarpal, cataract etc. then Ca, Phosphorus, PTH
    • Bone age
  • 15. Therapy
    • Dietary restriction
    • Increase physical activity and exercise
    • Reduce sedentary behavior
    • Modify behavior
    • Change of life style for the whole family
    • Reduce TV viewing and computer games
  • 16. Intensive Therapies - Indications
    • BMI > 95 Centile and one medical complication ( co morbidity)
    • Co morbid conditions include
      • Dyslipidemia
      • Disorders of glucose metabolism
      • Hepatic enzyme derangement
      • Hypertension ( Systolic or Diastolic)
      • Pseudotumour
      • Sleep apnea
      • Orthopedic problems
  • 17. Intensive Diet
    • Calorie intake 2400 to 2940 KJ per day
    • Aim is to induce a weight loss of 0.5 kg per week
    • Protein sparing modified fast (PSMF)
      • 2520-3360 KJ/day
      • 1.5 -2.5 g/kg of IBW / day of high quality protein
      • Carbohydrate 20-40 gms/day
    • Does not lead to cardiac arrhythmia as was observed earlier
  • 18.
    • Not prescribed for more than 12 weeks
    • Risks:
      • Cholelithiasis, hyperuricemia, hypoproteinemia, orhthostatic hypotension, halitosis, diarrhea
    • PSMF produce rapid weight loss in the short term
    • In the long term does not seem to be superior to restrictive diet programmes
    Intensive Diet
  • 19. Pharmacotherapy
    • Limited data available in children and adolescents
    • Medications reducing energy intake
      • Fenfuramine
      • Phenteramine
      • Diethylpropion
      • Sibutramine
  • 20. Leptin
    • A hormone secreted by adipocytes in relation to lipid content
    • It is a peripheral signal to the hypothalamus of inadequate food intake but NOT of Satiety
    • Leptin deficiency causing obesity is VERY VERY RARE
    • Leptin therapy to Leptin sufficient adults is not very impressive in terms of weight loss
    • No studies in children are available
  • 21. Metformin
    • Stops hepatic glucose production
    • Reduces insulin resistance
    • Several studies have shown impressive weight reduction in dosages varying from 500 mg to 2 gm per day in children of 8 - 14 years
    • Side effects
      • Nausea, flatulence, bloating
      • Diarrhea, Vitamin B12 deficiency
      • Lactic Acidosis - Rare
  • 22.
    • Contraindications
      • Renal failure, creatinine > 1.4 mg/dl
      • CCF, cardiac and pulmonary insufficiency
      • Liver disease
    Metformin
  • 23. No medications are approved for use in children in routine clinical practice except Leptin in Leptin deficiency children
  • 24. Bariatric Surgery
    • Limited experience in children and adolescents
    • Balloons placed in the stomach are shown to be ineffective
    • Jejunoileal bypass is not done now due to high complication rate
    • Roux-en-Y gastric bypass (RYGB) is performed now
  • 25. RYGB
    • Post op complications are many (8.5%)
    • Post op mortality is 1.5%
    • In a recent study by Strauss - Adolescents were treated with bariatric surgery
      • 90% lost > 30 kgs and co morbid conditions improved
    • Complications include iron deficiency, folate deficiency, small bowel obstruction
  • 26.
    • This is the only treatment with evidence that it can induce sustained significant weight reduction in adolescents who have severe obesity
    • Can only be recommended to those with highest morbidity
    • As Strauss concluded: “Gastric bypass remains a last resort option for severely obese adolescents”
    Bariatric Surgery
  • 27.
    • Education and awareness programs for parents are required to prevent adolescent obesity
    • At risk individuals can be identified with BMI curve
    • The mainstay of treatment is diet, exercise and behaviour modification
    • At present no medicine is routinely used in clinical practice to prevent or treat obesity
    Take Home Message
  • 28. Concept – Dr. Duru Shah
    • Contributors
    • Dr. Suvarna Khadilkar
    • Dr. Vaman Khadilkar
    • Editors
    • Dr. Sangeeta Agrawal
    • Dr. Reena Wani
  • 29. We acknowledge the efforts of our :
    • Coordinators :
      • Dr. Sangeeta Agrawal - Central
      • Dr. Narendra Malhotra - North
      • Dr. Hema Divakar - South
      • Dr. P. C. Mahapatra - East
      • Dr. Uday Thanawala - West
    • In bringing the FOGSI YOUTH EXPRESS to your city.
  • 30. This Youth Express has been possible through an educational grant from
    • Charak Pharma Pvt. Ltd
    • CIPLA Ltd.
    • Emcure Pharmaceuticals Ltd
    • GlaxoSmithKline Pharmaceuticals Limited
    • Glenmark Pharmaceuticals Ltd.
    • Metropolis Health Services (India) Pvt.Ltd.
    • Organon India Ltd
    • Roche Pharmaceuticals Ltd.
    • Sandoz Private Limited
    • USV Limited
    • Wyeth Limited