COMORBIDITES OF PEDIATRIC OBESITY

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COMORBIDITES OF PEDIATRIC OBESITY

• William J. Cochran, MD, FAAP
• Geisinger Clinic

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WHY WORR ABOUT PEDIDATRIC OBESITY?
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INTRODUCTION

• Pediatric obesity is of epidemic proportion
• Pediatric obesity is the most common chronic
  disease of childhood

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Figure IV Percent of obese children and
adolescents
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IS PEDIATRIC OBESITY A REAL HEALTH ISSUE OR JUST
A COSMETIC PROBLEM?
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ADULT OBESITY

• Type II Diabetes
• Coronary Heart Disease
• Hypertension
• Cancer
• Joint Disease
• Gallbladder Disease
• Pulmonary Disease

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RISK OF CHILDHOOD OBESITY PERSISTING INTO
ADULTHOOD

• Guo 1999
• 20 at 4 years of age
• 80 in adolescence

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IMPACT OF CHILDHOOD OBESITY ON ADULT HEALTH

• Childhood obesity has significant impact on
  health in adulthood
• Hoffmans 1998
• Dutch adolescent males followed for 32 years
• Increased mortality in obese vs. lean

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IMPACT OF CHILDHOOD OBESITY ON ADULT HEALTH

• Mossberg 1989
• Swedish adolescents studied after 40 years
• Increased mortality in obese vs. non-obese

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IMPACT OF CHILDHOOD OBESITY ON ADULT HEALTH

• Must, 1992Harvard growth study
• 13-18 year old adolescents
• 1922-1935, evaluated 1988
• Obesity BMI 75 on at least two occasions
  during adolescence

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IMPACT OF CHILDHOOD OBESITY ON ADULT HEALTH

• Increased all cause mortality in males and
  females
• Increased mortality from CAD in males
• Increased morbidity from CAD in males and females
• Increased risk of colon cancer in males
• Increased risk of arthritis in females

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IMPACT OF CHILDHOOD OBESITY ON ADULT HEALTH

• Obesity in childhood was a more powerful
  predictor of these risks than obesity in
  adulthood!

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CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY
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PSYCHOSOCIAL

• Most common complication of childhood obesity
• Self
• Increased rates of depression
• Poor self esteem
• May carry over into adulthood
• Children are sensitized to obesity at young age

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PSYCHOSOCIAL

• Self
• Mellbin, 1989
• Increased rates of behavior and learning problems
  in those gaining weight rapidly
• Etiology uncertain, ? Sleep apnea

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PEER RELATIONSHIPS

• Richardson, 1961
• 10-11 year old children prefer friends with
  various handicaps vs. obese
• Staffieri, 1967
• Children 6-10 years of age associate obesity with
  laziness
• Obese children may choose younger friends, less
  judgmental

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PSYCHOSOCIAL

• Adult Relationships
• May have false expectations of child based on
  their size

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SOCIETAL DISCRIMINATION

• Canning, 1966
• Acceptance rates at college lower for obese than
  non-obese females with the same credentials
• National Longitudinal Survey of Youth 1993
• Obese adolescent females as young adults had less
  education, less income, higher poverty rate, and
  decreased rates of marriage

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ENDOCRINE COMPLICATIONS

• Non-insulin-dependent diabetes mellitus
• Pinhas-Hamiel 1994
• The incidence of NIDDM has increased 10 fold
• One third of new diabetic children 10-19 years of
  age had Type II DM
• 92 of these had a BMI 90
• Geisinger weight management program
• 1-2 have type II DM

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ENDOCRINE COMPLICATIONS

• Insulin resistance
• Elevated fasting insulin levels with normal Hgb
  A1C
• Ratio of fasting insulin to glucose
• Adult female normal
• Normal for children not established
• First step towards developing Type II DM

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Obesity
Insulin Resistance
Metabolic Syndrome Syndrome
Type 2DM
Hypertension
NASH
Dyslipidemia
PCOS
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ENDOCRINE COMPLICATIONS

• Geisinger weight management program
• 60 have insulin resistance
• 10 have fasting insulin level 100 (Nl

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ENDOCRINE COMPLICATIONS

• Acanthosis nigricans
• Velvety, hyperpigmented, thickened skin
• Associated with obesity and insulin resistance
• Not sensitive for insulin resistance
• Resolves with weight loss

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ENDOCRINE COMPLICATIONS

• Increased linear growth initially
• Growth plates may close earlier
• Advanced bone age
• Earlier onset of puberty

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POLYCYSTIC OVARY SYNDROME

• Hyperandrogenism
• Ovarian dysfunction
• Oligomenorrhea
• Amenorrhea
• 55 of adolescent females have polycystic ovaries
  on US
• Cutaneous manifestations
• Hirsuitism
• Acne
• Acanthosis nigricans

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POLYCYSTIC OVARY SYNDROME

• Insulin resistance
• Hyperlipidemia
• Infertility
• Premature adrenarche
• Bacha F, Arslanian S. Enod Trends 11(1)2004

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HYPERTENSION

• Hypertension
• Primary hypertension uncommon in childhood
• 60 of children with persistently elevated blood
  pressure had weight 120 IBW
• Lauer J Pediatr 197586697-706.
• Use pediatric standards
• Geisinger weight management program
• 45 have hypertension

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HYPERTENSION

• Risk
• Overweight adolescents have 8.5 fold risk of
  hypertension as adults.
• Srinivasan Metab 199645235-240.
• Cardiac hypertrophy/LVH on ultrasound.
• Long term risk of CVD and stroke

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DYLIPIDEMIA

• The atherosclerotic process beings in childhood
  (Bogalusa Heart Study)
• Lipid levels tend to track with age

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DYLIPIDEMIA

• Overweight during adolescence associated with
• 2.4 fold increase in prevalence of cholesterol
  240mg/dl
• 3 fold increase in LDL values 160mg/dl
• 8 fold increase in HDL values27-31 years
• Srinivasan Metab 199645235-240.

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DYLIPIDEMIA

• Geisinger weight management program
• 45 have hypercholesterolemia
• Range of abnormal cholesterol 175-338
• Freeman 1999
• 65 of obese 5-10 year old children have at least
  one cardiovascular disease risk factor
• 25 of obese 5-10 year old children have 2 or
  more risk factors

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NON-ALCOHOLIC FATTY LIVER DISEASE

• Hepatic steatosis
• Increased fat in the liver
• Steatohepatitis associated with liver
  inflammation and elevated liver enzymes
• 20-25 obese children have evidence of
  steatohepatitis
• Tazawa Acta Paeditr 199786238-241

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INSULIN RESISTANCE AND FAT DEPOSITION
Muscle
Insulin resistance
insulin
Insulin resistance
Liver
Insulin resistance
Free Fatty Acids
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NON-ALCOHOLIC FATTY LIVER DISEASE

• Liver disease can progress to fibrosis or frank
  cirrhosis
• Obesity and type 2 diabetes are the strongest
  predictors of progression of fibrosis
• Age is also a risk factor for cirrhosis which may
  reflect increased duration of risk for the
  second hit thought to initiate fibrosis.
• Angulo P, Keach JC, Batts KP, Lindor KD.
  Hepatology 199930(6)1356-62

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NON-ALCOHOLIC FATTY LIVER DISEASE

• Rashid
• 83 of children with steatohepatitis were obese
• 75 had fibrosis-cirrhosis
• Geisinger weight management program
• 50 have hepatomegaly
• 15 have elevated liver enzymes

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CHOLELITHIASIS

• Uncommon in children
• Increased risk in those with hemolytic disorders
• Obesity accounts for 8-33 of gallstones in
  children
• Friesen Clin Pediatr 1989.7294
• May be associated with weight loss
• Crichlow Dig Dis. 19721768-72

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CHOLELITHIASIS

• Relative risk of gallstones in adolescent girls
  with obesity is 4.2
• Honore Arch Surg 198011562-64
• 50 of cholecystitis in adolescents associated
  with obesity
• Crichlow Dig Dis. 19721768-72

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SLIPPED CAPITAL FEMORAL EPIPHYSIS

• 50-70 patients with SCFE are obese.
• Wilcox J Pediatr Orthop 19888196-200
• Suspect and immediately evaluate in an obese
  patient who presents with limp.
• Can also present with complaints of groin, thigh,
  or knee pain

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SLIPPED CAPITAL FEMORAL EPIPHYSIS

• Diagnosis
• Physical examination
• Motion of the hip in abduction and internal
  rotation is limited on examination.
• Xray
• AP view of pelvis to include both hips
• Bilateral disease occurs in up to 20 of patients
• Medial and posterior displacement of the femoral
  epiphysis through the growth plate relative to
  the femoral neck
• Busch MT. Orthop Clin North Am 198718(4)637-47

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BLOUNTS DISEASE

• Diagnosis
• Bowing of tibia and femur either unilateral or
  bilateral.
• Etiology
• Results from overgrowth of the medial aspect of
  the proximal tibial metaphysis
• 2/3 of patients with Blounts disease are obese
• Dietz J Pediatr 1982101735-737
• Treatment
• Surgery associated with weight loss

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OBSTRUCTIVE SLEEP APNEA

• OSAS in children is defined as a disorder of
  breathing during sleep characterized by
• prolonged partial upper airway obstruction
• and/or intermittent complete obstruction
  (obstructive apnea)
• that disrupts normal ventilation during sleep and
  normal sleep patterns
• Schechter MS. Technical report diagnosis and
  management of childhood obstructive sleep apnea
  syndrome. Pediatrics 2002109(4)e69-79.

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OBSTRUCTIVE SLEEP APNEA

• 40 of severely obese children demonstrated
  central hypoventilation
• Silvesti Pediatr Pulmonol 199316124-139
• Abnormal sleep patterns reported in 94 of obese
  children studied
• Kahn A, Mozin MJ, Rebuffat E, Sottiaux M, Burniat
  W, Shepherd S, et al. Sleep 198912(5)430-8.

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OBSTRUCTIVE SLEEP APNEA

• Symptoms of sleep apnea
• Nighttime awakening / restless sleep
• Excessive snoring / apnea
• Difficulty awaking in the morning
• Daytime somnolence
• Nocturnal enuresis
• Decreased ability to concentrate
• Poor school performance.
• Gozal D. Sleep-disordered breathing and school
  performance in children. Pediatrics 1998102(3 Pt
  1)616-20.

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OSAS - ETIOLOGY

• Increased fat mass in pharynx, neck, chest and
  diaphragm
• Increased muscle relaxation during sleep
• Enlarged tonsils and adenoids
• Silvestri JM, Weese-Mayer DE, Bass MT, Kenny AS,
  Hauptman SA, Pearsall SM. Pediatr Pulmonol
  199316(2)124-9

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OSAS-DIAGNOSIS

• History, audio and video taping, and overnight
  oximetry are poor predictors
• The definitive diagnosis of OSAS is made by
  nighttime polysomnography
• Clinical practice guideline diagnosis and
  management of childhood obstructive sleep apnea
  syndrome. No authors listed. Pediatrics
  2002109(4)704-12
• Severity of obstruction may not correlate with
  either degree of obesity or severity of sleep
  symptoms

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OBSTRUCTIVE SLEEP APNEA

• Children with sleep apnea demonstrate significant
  decreases in learning, attention span and memory
• Rhodes J Pediatr 1995127741-744.
• Greenberg GD, Watson RK, Deptula D.. Sleep
  198710(3)254-62.

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OBSTRUCTIVE SLEEP APNEA

• Pulmonary hypertension,systemic hypertension,
  right heart failure
• .Tal A, Leiberman A, Margulis G, Sofer S. Pediatr
  Pulmonol 19884(3)139-43
• Marcus CL, Greene MG, Carroll JL. Am J Respir
  Crit Care Med 1998157(4 Pt 1)1098-103
• Massumi RA, Sarin RK, Pooya M, Reichelderfer Dis
  Chest 196955(2)110-4

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OSAS - TREATMENT

• Weight loss
• Willi SM, Oexmann MJ, Wright NM, Collop NA, Key
  LL Jr. Pediatrics 1998101(1 Pt 1)61-7
• Continuous positive airway pressure (CPAP) or
  bilevel positive airway pressure (BPAP)
• Tonsilladenoidectomy

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PSUEDOTUMOR CEREBRI

• Definition
• Raised intracranial pressure with papilledema and
  a normal cerebrospinal fluid in the absence of
  ventricular enlargement
• Obesity occurs in 30-80 of children with
  psuedotumor cerebri
• Scott Am J Opth 1997 124253-255

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PSUEDOTUMOR CEREBRI

• May present with headaches, vomiting, blurred
  vision or diplopia
• Neck, shoulder, and back pain have also been
  reported
• Lessell S. Surv Ophthalmol 199237(3)155-66
• Papilledema is part of pathology but may not
  occur at presentation

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John A Moran Eye Center, Salt Lake City UT
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PSUEDOTUMOR CEREBRI

• Loss of peripheral visual fields and reduction in
  visual acuity may be present at diagnosis
• Baker RS, Carter D, Hendrick EB, Buncic JR. Arch
  Ophthalmol 1985103(11)1681-6.
• Increased intracranial pressure may lead to
  visual impairment or blindness.

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PSUEDOTUMOR CEREBRI

• Weight loss
• Newborg B. Arch Intern Med 1974133(5)802-7
• Acetazolamide
• Lumboperitoneal shunt in severe cases

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CONCLUSIONS REGARDING PEDIATRIC OBESITY
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• PEDIATRIC OBESITY IS NOT JUST A COSMETIC PROBLEM!

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COMPLICATIONS ARE COMMON IN PEDITRIC OBESITY

• All children with BMI 95 should be evaluated
  for associated co-morbidities
• Physical examination
• BP
• Fundiscopic exam
• Hip and knee examination
• Acanthosis nigricans
• Hirsutism / acne
• Hepatomegaly

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COMPLICATIONS ARE COMMON IN PEDITRIC OBESITY

• Laboratory evaluation
• Fasting lipid profile
• Liver panel
• Fasting insulin and glucose
• Hgb A1C
• To be considered
• Polysomnogram
• Abdominal US

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THANK YOU!
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SCFE ASSOCIATED CAUSES

• Continued weight gain
• Renal failure
• History of radiation therapy
• Primary hypothyroidism
• Loder RT, Greenfield ML.. J Pediatr Orthop .
  200121(4)481-7
• Gonadotropin-releasing hormone agonists
• Growth hormone therapy
• Kempers MJ, Noordam C, Rouwe CW, Otten BJ. J
  Pediatr Endocrinol Metab 200114(6)729-34

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Pseudotumor Cerebri - Associated Conditions

• Mastoiditis.
• Lateral sinus thrombosis.
• Hypoparathyroidism,
• Steroid treatment and withdrawal.
• Thyroid replacement,
• SLE.
• Green M. Pediatr Clin North Am 196714(4)819-30.
• Palmer RF, Searles HH, Boldrey EB.. J Neurosurg
  195916(4)378-84.
• Baker RS, Baumann RJ, Buncic JR. Pediatr Neurol
  19895(1)5-11.
• Walker AE, Adamkiewicz JJ. JAMA 1964188779-84.
• Neville BG, Wilson J.. Br Med J
  19703(722)554-6.
• Huseman CA, Torkelson RD.. Am J Dis Child
  1984138(10)927-31.
• DelGiudice GC, Scher CA, Athreya BH, Diamond GR..
  J Rheumatol 198613(4)748-52.

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Drugs Associated With Pseudotumor Cerebri

• Growth hormone therapy
• Nalidixic acid,Ciprofloxacin,Tetracycline therapy
  
• No clear dose-response relationship
• Lessell S. Surv Ophthalmol 199237(3)155-66.
• Vitamin A and isoretinoin therapy are
  established causes of pseudotumor cerebri.
• Morrice G Jr, Havener WH, Kapetansky F. JAMA
  19601731802-5.
• Roytman M, Frumkin A, Bohn TG. Cutis
  198842(5)399-400.