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

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

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

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

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

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

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
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