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Childhood Obesity


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Childhood Obesity

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