Childhood Obesity in Practice: A look at the obese

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Childhood Obesity in Practice A look at the
obese the extremely obese

• Robert Murray MD
• Marc Michalsky MD
• Nationwide Childrens Hospital

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Aims of Presentation

• a synopsis national guidelines
• the risk of extreme obesity
• bariatric surgery
• and resolution of health risk

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The Expert Committee

• American Heart Association
• National Association of School Nurses
• American college of Sports Medicine
• The Obesity Society
• The Endocrine Society
• American College of Preventive Medicine
• American Academy of Child Adolescent Psychiatry
• Association of American Indian Physicians

• American Medical Association
• Dept of Health and Human Services
• CDC Prevention
• American Academy of Pediatrics
• American Dietetics Association
• Natl Assoc of Pediatric Nurse Practitioners
• National Medical Association

Pediatrics, December 2007, 120supplement 4
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The Primary Physicians Role
Prevention Identification Intervention
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Nine Evidence-Based Messages

• Support exclusive breastfeeding 4-6 months
• Limit sweetened beverages
• Eat 5 servings per day of fruits vegetables
• Participate in moderate to vigorous physical
  activity for 60 mins/ day

• Limit screen time to a maximum of 2hrs/ day
• Do not allow your child to have a television in
  his or her bedroom
• Eat a nutritious breakfast every day
• Engage in regular family meals 5-6 times/ week
• Limit portion sizes

For Prevention Counseling
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An OUNCE of PREVENTION Anticipatory Guidance for
obesity prevention
Ohio Chapter, American Academy of
Pediatrics Ohio Department of Health Ohio
Dietetics Association American Dairy Council,
Mid-East
www.NationwideChildrens.org/HealthyWeight/
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Normal at 10 yrs 10 risk of obesity as
adult At risk or overweight at 10 yrs 80
risk
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Media
Societal Level
Policy
Community Level
The Workplace
Neighborhood Environment
Food Industry
Medical Community
Family
Schools Pre-schools
Community programs
CHILD
Early Childhood Providers
Out of school time/Faith Based
Inter-personal Level
Health Fitness Takes Many Teachers
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Parental Perceptions of their Overweight Child

• Only 1/3 recognized it
• Only 1/4 worried about it
• Only 1/5 recalled MD concern

In most studies parental recognition of
overweight occurs around age 8-12 yrs -- Even
later for boys
Eckstein, Pediatrics 2006 117681
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know the number!
BMI -ile
At every well-child visit, discuss
weight nutrition, activity and health risk
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Pediatric Obesity Management Pocket Guide
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Create a Risk ProfilePlace the BMI in Context

• Family health history
• Obesity
• Diabetes
• Cardiovascular disease
• Targeted review of systems
• Targeted physical exam
• Blood pressure

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Review of Systems

• Abdominal pain
• Joint pain
• Snoring, apnea, daytime sleepiness
• Polyuria, polydipsia
• Irregular menses
• Signs of mood disorder
• Depression, anxiety
• social or school avoidance
• Exercise tolerance
• Diet
• Screen time

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Physical Exam

• Papilledema on eye exam
• Tonsillar hypertrophy
• Abdominal pain
• Hepatomegaly
• Tibial bowing
• Hip or knee pain
• Signs of precocious puberty
• Skin findings
• acne, striae, hirsutism
• acanthosis nigricans

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acanthosis nigricans
insulin resistance hyperinsulinemia skin
changes
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acanthosis nigricans metabolic changes are
already underway
altered metabolism
Fat mass insulin resistance
Identify this early

• diabetes
• hypertension
• abnormal lipids
• inflammation
• cardiovascular ds
• asthma
• liver disease
• sleep apnea
• orthopedic problems

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Blood Pressurea critical risk

• Children gt3 years of age
• Auscultation is preferred
• Use appropriate sized cuff
• Must be plotted on curves adjusted for age, sex,
  and height
• Measurements that exceed the 90th percentile
  should be repeated

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Do I have to check labs?
Consider Fasting Lipid Profile age gt2 years,
Additional hepatic function and fasting glucose
should be considered at age gt 10years. Clinical
judgment may dictate additional labs in the
younger child with higher risk.
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Motivation/Attitude
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Nine Evidence-Based Messages

• Support exclusive breastfeeding 4-6 months
• Limit sweetened beverages
• Eat 5 servings per day of fruits vegetables
• Participate in moderate to vigorous physical
  activity for 60 mins/ day

• Limit screen time to a maximum of 2hrs/ day
• Do not allow your child to have a television in
  his or her bedroom
• Eat a nutritious breakfast every day
• Engage in regular family meals 5-6 times/ week
• Limit portion sizes

Prevention Counseling
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Algorithm For Intervention
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Resources to Help You

• Ounce of Prevention
• Birth to 5 years
• 6 to 19 yrs NEW!
• Parent handouts
• BMI wheels and tables
• Parent Tip Sheets
• Pocket management book
• Coding sheet
• Acanthosis training NEW!

www.NationwideChildrens.org/HealthyWeight
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Extreme Obesity
What to do with
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Medical Sequelae of Obesity

• Hypertension
• Lipid disorders
• Diabetes
• Ischaemic heart disease
• Cardiomyopathy
• Pulmonary hypertension
• Asthma
• Hypoventilation syndromes
• Obstructive sleep apnea
• Gallstones
• NASH (Non-alcoholic steatohepatitis)
• Urinary incontinence

• Gastroesophageal reflux
• Arthritis weight bearing
• Low back pain
• Infertility and menstrual problems
• Obstetric complications
• DVT and thromboembolism
• Depression
• Immobility
• Cancer
• Venous/stasis ulcers
• Intertrigo
• Accident prone

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Adipocytes are Endocrine Cells

• Secretion of gt 50 Adipokines
• Leptin
• Adiponectin
• Resistin
• TNF- alpha

• Adipose Actions
• stimulate inflammation
• increase insulin resistance (block receptor
  signaling)
• attract macrophages into fat vessels (foam
  cells)
• alter metabolism
• lower sensitivity to insulins actions
• shift glucose-based to FFA-based metabolism
• fat storage in non-adipose tissues

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Obesity Endothelial Dysfunction
Adipose Tissue
leptin IL-6 FFA fibrinogen Angiotensin II
TNF- alpha
Adhesion Molecules
Nitric Oxide
Macrophage Chemoattractives

• inflammation
• thrombus formation
• plaque destabilization
• lipid accumulation
• poor distensibility

Vascular Endothelial Cell
Pharmacol Reports 2006 58 s81
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Extreme Obesity in Children

• BMI gt 99th percentile or BMI gt 35
• 2-6 of all kids
• gt 50 have metabolic syndrome
• Significant cardiovascular changes
• Multi-organ complications

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Weight Loss - Pediatric Programs

• NACHRI identified 80 pediatric centers with
  weight management programs
• Only 15 had an associated surgical weight loss
  program
• 6 to 8 high volume programs
• August, 2008 NACHRI formed Obesity Steering
  Committee

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The Bariatric Programat Nationwide Childrens

• Surgeons
• Marc Michalsky, MD
• Steve Teich, MD
• Allen Browne, MD
• Bradley Needleman, MD (OSUMC)
• Scott Melvin, MD (OSUMC)
• Medical Director
• Robert Murray, MD

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First 50 Patients
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Co-Morbidities in Bariatric PatientsNCH and OSU
Experience
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Resolution of Co-morbid Conditions 5 months
post-pediatric bypass
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Gastric Bypass Effect on HOMA
Insulin Resistance
Body Mass Index
4 wk 8wk 12wk 20wk 32wk
52wk
4 wk 8wk 12wk 20wk 32wk
52wk
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Homeostatic Model Assessment (HOMA)ß Cell
Activity vs. Insulin Sensitivity
4 wk 8wk 12wk
20wk 32wk 52wk
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Quality of Life Measures 6 months post- bypass
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Washington State Healthcare Authority
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Health Technology Clinical Committee

• Evaluated healthcare coverage for adolescent
  bariatric surgery
• Assessment of the strength of current
  peer-reviewed evidence
• Determine safety, efficacy and cost
• Guide decisions regarding state program coverage

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Health Technology Clinical Committee

• 2004 Estimate 2000 bariatric procedures were
  performed in patients under 21 years
• 75 of bariatric surgeons surveyed report
  planning to perform a procedure on an adolescent
  in the near future

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Health Technology Clinical Committee

• Review 17 peer-reviewed studies
• 553 pediatric patients
• Studies were assessed for validity/quality

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Meta-analysis Results

• Majority academic medical centers
• Mean age 15.6 to 18.1 years
• Average BMI
• RYGB 51.8 kg/m2
• LAGB 45.8 kg/m2

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Questions

• Does PBS lead to significant (gt 7EBWL) and
  durable weight loss?
• Does PBS improve co-morbidities, QOL and survival
  compared to medical therapy?
• Safety Profile (surgical v. medical)
• Cost Profile (surgical v medical)
• Does efficacy, safety and cost vary according to
  demographics (age, sex, BMI)

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Conclusion
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Clinical ResearchNIH Sponsored

• TeenLABS (Longitudinal Assessment of Bariatric
  Surgery)
• NIH-sponsored,
• Multi-centered observational study
• 2 year follow-up
• 5 centers
• N 200 teens

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Clinical ResearchNIH Sponsored

• Teen-Intake (Nutritional Assessment of Bariatric
  Surgery)
• NIH-sponsored,
• Multi-centered observational study
• 2 year follow-up
• N 200 teens
• TeenVIEW (Controlled Longitudinal of
  Psycho-social Development)
• NIH-sponsored,
• Multi-centered observational study
• 2 year follow-up
• N 200 teens

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Clinical ResearchIndustry Sponsored

• LBA 001 (Allergan)
• Industry-sponsored IDE, 5 year follow-up
• Multi-institutional safety/efficacy trial
• n 150 subjects (14 to 17 years)
• Local n 26, enrollment closed Dec, 2007

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Reversal of Type II Diabetes

• 11 teens gt 1 year after Roux-en-Y bypass
• Mean BMI 50 5.9 50 metabolic synd
• Post-op
• BMI fell by 34 to 33 7 kg/m2
• Improvement of fasting glucose, insulin, HOMA-IR,
  Hb A1C, AST, ALT, LDL, triglycerides, total
  cholesterol, blood pressure
• Remission of diabetes in 10 of 11 cases
• Removal of oral hypoglycemics in 10 cases

Inge et al, Pediatrics 2008 123214
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Cardiovascular Risk Extreme Obesity in Teens

• BMI gt 99th ile or BMI gt 40
• N38 13-19 yrs old
• Pre- and post- gastric bypass surgery
• Echocardiogram, doppler studies
• Adequate studies in only 38 of 67 cases
• LV geometry (size, ventricular shape, mass, wall
  thickness)
• LV systolic function (contractility, wall
  thickness)
• Diastolic function (atrial size, pulsed doppler
  assessment)

Ippisch et al, J Am Coll Cardiol 2008 511342
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Weight Loss Cardiovascular Risk

• ¼ showed high risk concentric LVH
• Adults with concentric LVH, 53 had a
  cardiovascular event
• Teens 28 had concentric LVH pre-op, only 3
  post-op
• LV mass increased
• Adults gt 51 g/m2.7 had 4-fold higher CV
  mortality
• Teens studied averaged gt 54 g/m2.7, max 86
  g/m2.7
• LV dimensions, systolic function abnormal
• Normal LV geometry only 36 pre-, up to 79
  post-op
• Elevated cardiac workload, BP
• Decreased HR and systolic BP, rate-pressure
  product
• Abnormal diastolic function
• Improved mitral valve and filling dynamics
  post-op

Ippisch et al, J Am Coll Cardiol 2008 511342
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Cardiovascular Status Pre-surgery CMR Results
10 patients pre-bariatric surgery show
striking cardiovascular abnormalities and risk
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Conclusions

• Extremely Obese Teens
• Have many serious co-morbidities
• High risk of type II diabetes
• Extreme cardiovascular risk
• Bariatric Surgery
• Shows effective metabolic resolution
• Resolution of co-morbid conditions
• Resolution of cardiovascular abnormalities
• Minimal risk

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Center for Healthy Weight Nutrition
Prevention
Treatment
Medical Weight Loss Programs
Child Family Education
Public Health
Healthcare Provider Support
Research
Bariatric Surgery

www.NationwideChildrens.org/HealthyWeight