Obesity: A Pediatric Epidemic

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  • 1. Obesity in Children: Obesity in Africa A worldwide epidemic Jerrold Lerman, BASc, MD, FRCPC, FANZCA Clinical Professor of Anesthesiology Women and Children’s Hospital of Buffalo SUNY at Buffalo and Strong Memorial Hospital, University of Rochester, Rochester, NY Obesity Epidemic Childhood Obesity Current statistics: Fiscal implications: • >60% of US adults are overweight • OB-related costs ↑ from $35 M in 1980 to $127 M in • >30% of US adults are obese 1998 (Institute of Medicine, 2005) • Prevalence of both have ↑ both genders, all ages, • Teens with no insurance or Medicaid more likely to races and education be OW than those with insurance, 2003. (Am J Public Health, 2003) • 33 B$ spent annually for weight loss/reduction • As SES decreases: • teen girls ↑ prevalence of overweight Childhood Obesity Childhood Obesity Definitions: Essentials: • BMI is the body/mass index: • Weight (kg)/Height2 (m) • Epidemiology • Weight status > 2yr BMI: • Factoids behind the epidemic • Healthy is 5-85%ile • Overweight is 85%-95%ile • Physiologic manifestations • Obesity is ≥ 95%ile • Perioperative Management • These are specific for age and gender up to adolescents • Long-term outcome • Ideal weight: • < 8 yr, 2 x Age (yr) + 9 • > 8 yr, 3 x Age 1
  • 2. Epidemiology Immigration & Obesity Roshania R, et al. Obesity 2008:16;2669 Childhood Obesity Childhood Obesity Genetics Environmental Calories Exercise Family l lo g ic a Socio cho e Statu conomic NHANES: National Health and Nutrition Examination Survey P s y rs s to Ogden CL, et al JAMA 2000:288;728 Fac Childhood Obesity Childhood Obesity Etiology: Essentials: • 5% due to underlying disorders: • Epidemiology • Cerebral damage • Factoids behind the epidemic • Endocrine dysfunction or hereditary syndromes • Physiologic manifestations • These are 1%: Prader-Willi, Cushing's, Frohlich's, Laurence-Moon-Biedl • Perioperative Management • 95% have no clear cause • Long-term outcome • Rare genetic mutations 2
  • 3. Childhood Obesity Breastfeeding & Obesity Related to pregnancy? Is there a relationship? • 29% Amer women 20-39 yr Obese & 8% • 2043 Dutch children 1996-7 in asthma study morbidly obese (BMI > 40 kg/m2) • Breastfeeding, other data collected up to 7 yr • 29% have C-section at all time high • ↑ in obese women • Breastfed (> 16 wk) kids: • ↑ wound infection • consumed more fruit and vegetables; less white • ↓ likely to breast-feed bread, meat, fried snacks, chocolate bars, carbonated • ↑ macroscopic babies (>90%ile weight) drinks than non-breastfed • 17% incidence of obese kids • 3 x increase in past 2 decades Ramussen K, et al. Scholtens S, B et al. Obesity 2008:16, 929 Obesity 2008:16;2498 Childhood Obesity Eating Behavior and Obesity at Diet ↑s the risk of obesity: Chinese Buffets • Reduced dietary intake of Ca++ and fewer dairy food servings in first 2 years of life, children and adolescents Moore LL et al. DeJong ED et al. Obesity 2006:10:1010 Am J Clin Nutr 2006:84;1123 • Few intake occasions and greater contribution of Wansink B, Payne CR main meals Lioret S, et al Obesity 2008:16;2518 Obesity 2008:16;1957 • In 2001, 80% of school age children did not eat 5 fruits/vegetables daily (esp. AA kids) (213 patrons in Chinese buffets) Ogden CL, et al JAMA 2000:288;728 Chinese Buffet Study Childhood Obesity Those with increased BMI: Factoids: • Used larger plates • Between 1990 & 1995, the • Faced the buffet % of high-school kids who • Less likely to use chopsticks engaged in 20 min of activity daily decreased • Less likely to browse the buffet before eating from 81% to 70% Less likely to have a napkin on their lap • In 1996, 50% of kids 12-21 • Left less food on their plates yr reported doing daily vigorous PA and 25% did • Chewed less per bite of food none Ogden CL, et al Wansink B, Payne CR, JAMA 2000:288;728 Obesity 2008:16;1957 3
  • 4. Childhood Obesity Childhood Obesity Factoids re: exercise Essentials: • 251 children 8-10 years; 18% OW, 11.6% OB • Epidemiology • Comparing kids < 5min vs > 15min VPA were: • Factoids behind the epidemic • 4-fold more likely to have ≥20% body fat • 2.9-fold more likely to have ≥25% body fat • Pathophysiologic manifestations • 5.2-fold more likely to be OW • Perioperative Management • Comparing kids ≤ 15min vs > 45min MPA were: • Long-term outcome • 4.2-fold more likely to have ≥20% body fat • 3-fold more likely to have ≥25% body fat Where: VPA is vigorous physical activity or run/jog & Whittmeier KDM, et al. MPA is moderate physical activity or brisk walk Obesity 2008:16;415 Childhood Obesity Childhood Obesity Cognitive Dysfunction? • 2519 children 8-16 years NHANES 1988-94 • Tested cognitive function vs. BMI • ↑ body weight independently associated with decreased visuospatial organization and general mental ability • Consistent with data from adults with ↓ memory, cognition and response times in overweight children Li Y, et al. Obesity 2008:16;1809 Childhood Obesity Childhood Obesity Pharmacology: Essentials: • Few studies in OB children • Epidemiology • What is the child's weight? • Factoids behind the epidemic • 30% of weight above ideal weight is lean • Physiologic manifestations • ?increase Vd for lipid drugs • Perioperative Management • No change in plasma protein binding (↑ lipids?) • Long-term outcome • No change in regional blood flow (fat has ↓flow) • No change in hepatic function • Renal clearance is increased due to ↑GFR Smith HL, et al. Pediatr Anesth 2002:12;750 4
  • 5. Childhood Obesity Childhood Obesity Perioperative Implications: • Database review 6171 children at Mott's Hospital • Mean age 12 yr, BMI 21.6 • Prevalence of overweight: 14% ⇑ 35% ⇑ 5X • Prevalence of obesity: 17% ⇑ 3X • Obese children had greater ASA P/S Nafiu OO, et al. Nafiu OO, et al. Pediatr Anesth 2007:17;426 Pediatr Anesth 2007:17;426 Preoperative Fasting Childhood Obesity Preoperative Assessment: • Appear older, but are not…may be immature • Respiratory problems • Asthma, OSA, URTIs • GERD: 0/50,000 acid aspiration (Borland, 1990) • Assess airway • IV access • Use ideal body weight + 30% of excess for weight (kg) for drug dose Cook-Sather SD, et al. Anesth Analg 2009:109;727 Childhood Obesity Childhood Obesity Induction: • Appropriate size monitors • Mask induction may be difficult with an intermittent obstructed airway, rapid 3.5 X desaturation & distended stomach 3X • Difficult IV access may require assistance, U/S or transillumination • Laryngoscopy may be challenging with adiposity Nafiu OO, et al. Pediatr Anesth 2007:17;426 5
  • 6. Childhood Obesity Childhood Obesity Intraoperative care: • Secure the airway Postoperative Care: • Insoluble inhalational anesthetics • Extubate awake • TIVA is more expensive, caution re: infusion rates • Avoid excessive opioids: OSA • Short-acting opioids: fentanyl • If OSA, assess sensitivity to opioid • Nurse in the head-up position • Regional block (to ⇑ FRC) • NMB: cautious dosing • Admit overnight with OSA or • Always antagonize discharge home? • Secure IV access • DVT prophylaxis? Childhood Obesity Childhood Obesity 10 X 2X 10 X 20 X 2X 2X 2X Nafiu OO, et al. Setzer N, Saade E. Pediatr Anesth 2007:17;426 Pediatr Anesth 2007:17;321 Periop. Respiratory Events Childhood Obesity Essentials: Sequelae: • Epidemiology • Diff. mask vent. • Factoids behind the epidemic • Airway obstructn • Physiologic manifestations • Maj. Desaturation • Overall critical resp. • Perioperative Management adverse events • Long-term outcome Tait AR, et al. Anesthesiology 2008:108;375 6
  • 7. OSA & Types I & II Childhood Obesity Hospital Cost for T&A: • Retrospective review 1643 children, 3-18 yr, AT • 75% d/c on day of surgery • BMI correlated with LOS; obese/overweight more likely to be admitted • Obese and overweight children incur ↑ hospital and perioperative charges than non-OB Nafiu OO, et al. Dayyat E, et al. Obesity 2008:16;1667 Sleep medicine Clinics 2007:2;433 OSA & Outcome Long-term Outcome Preoperative Postoperative Mitchell RB, Kelly J. Otolaryngol Head Neck Surgery 2007:137;43 OBESITY KILLS “Obesity is a “Killer” lifestyle that is the 2nd leading cause of preventable deaths” “300,000 people die unnecessarily each year as a direct result of obesity" benefitsbuzz.net Surgeon General Report 2002; CDC 7