JILL HAMILTON, MD, FRCPC

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Childhood and Adolescent Obesity

• JILL HAMILTON, MD, FRCPC
• THE HOSPITAL FOR SICK CHILDREN
• UNIVERSITY OF TORONTO

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Objectives

• 1) Definition of childhood overweight and
  obesity
•  
• 2) Common comorbidities
•  
• 3) Unique aspects of obesity management in
  children and adolescents

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BMI iles

• Downloadable http//www.cdc.gov/growthcharts/
• based on 5 NHES/NHANES surveys (weight not
  changed after 1980 NHANES II)
• Overweight BMI 85th ile
• Obese BMI 95thile for age and gender

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WHO 2007 BMI Charts

• http//www.dietitians.ca
• Separate charts for age 2-19 yrs and 0-2 yrs
• Definition (age 2-19)
• Overweight 85thile
• Obese 97thile

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Canadian Community Health Survey 2004
Child Overweight and obese 26 !!!
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children BMI 99thile
1.3 ADOLESCENTS BMI 40 kg/m2
NHANES 1970s-2004 (II, III, 1999-2004) Skelton
et al. Acad Pediatr. 20099(5)322-329.
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Vandenbroeck et al. http//www.bis.gov.uk/foresigh
t
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We will aggressively take on the challenge to
reduce childhood obesity by 20 per cent over five
years. Ontarios Action Plan For Health Care
ontario.ca/health Jan 30, 2012
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Why childhood obesity?

• 90 obese children become obese adults
• Prevention must begin early
• Treatment outcomes poorer as children get older
• Comorbidities appear in childhood
• Economic effects of earlier chronic diseases
• Socieconomic effects on individual NLSY obese
  adults who were obese as adolescents were more
  likely to experience household poverty, had lower
  incomes, less education

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Risks Associated with Childhood Obesity
obesityhelp.com
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Type 2 Diabetes Pediatric Issues

• 90 obese
• OGTT more sensitive to diagnose pre-diabetes/ T2D
  in very obese
• 25 T2D may have ketones at presentation
• Rapid progression from IGT to T2D
• Rapid need for intensification of therapy

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Type 2 Diabetes Sensitivity Analysis
SENSITIVITY ANALYSIS SENSITIVITY ANALYSIS SENSITIVITY ANALYSIS
Incidence Rate No. of cases/100,000 children/year No. of cases/100,000 children/year
MINIMUM -MAXIMUM CONSERVATIVE
Type 2 diabetes 1.54 - 40.5 11.25
Amed S et al, Diabetes Care, 2010
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Clinical Presentation T2D
Co-morbidity of cases of T2DM
Polycystic ovarian syndrome 8.4 (16/191)
Dyslipidemia 44.8 (78/174)
Hypertension 28.3 (58/205)
Alanine transferase gt90 or fatty liver on ultrasound 22.2 (39/176)
Micro or Macroalbuminuria 14.2 (21/148)
10.1
25.1
10.1
44.1
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NAFLD

• Chronic elevation in ALT
• Fat deposition in liver, inflammation fibrosis
• May be progressive and lead to cirrhosis
• Autopsy study prevalence 38 in obese children
• Schwimmer et al. Pediatrics 2006

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Dyslipidemia
NHANES 1999-2004
Obese youth had 2-4X prevalence of adverse lipid
profiles Lamb et al. Amer J Clin Nut 2011
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Baker et al. NEJM 2007
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Orthopedic Issues

• Blounts disease
• (Coxa Vara)

• SCFE

• All ages
• Abnormal growth of postmedial portion of proximal
  tibial physis
• Increased with BMI and esp BMI gt 40
• May be asymptomatic

• Nontraumatic slip of the femoral epipysis
• 80 of children with SCFE are obese
• Peak age 12-15 yrs
• Present limp, knee, hip pain

Chan et al. Curr Opinion Pediatrics 2009
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Mental Health

• Bullying and obesity 58 of boys and 63 of
  girls experiencing daily teasing, bullying or
  rejection because of their size
  (www.obesityaction.org)
• Obese teens report lower QOL
• (Varni et al. JAMA 2003)
• Adolescent obesity predicts depression
• 
  (Laitenen et al. IJO
  2006
• 
  Boutelle et al.
  Health Psych 2010)

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 Edmonton Obesity Staging System

• EOSS
• Stage 0-4
• Obesity-related risk factors
• Physical symptoms
• Psychological symptoms
• Functional limitations

• EOSS-P
• Stage 0-3
• Metabolic
• Mental psychological function
• Mechanical functional limitations
• Family parental, familial, or social environment
  concerns

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Obesity Management

• CMAJ April 10, 2007
• 2006 Canadian Clinical Practice Guidelines on the
  management and prevention of obesity in adults
  and children
• Cochrane Review Oude et al. Evid.-Based Child
  Health 4 2009 15711729
• Expert Committee Recommendations Regarding the
  Prevention, Assessment, and Treatment of Child
  and Adolescent Overweight and Obesity Barlow et
  al. Pediatrics 2007120S164-S192

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Approach to Treatment

• Multi-D approach to Tx
• Assess Readiness to Change behaviour change
  focus
• Frequent small changes
• Frequent follow up
• Goal-oriented
• Healthy lifestyle versus diet
• Logging of activity / diet
• Consideration of medication/surgery in select
  cases

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Unique Pediatric Aspects

• Growth and development
• Dietary recommendations must take this into
  account
• Sensitivity to approach depending on age of child
• Attention to development or presence of
  disordered eating

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• Family-based approach

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Surgical Criteria

• Inclusion

• Exclusion

• BMI gt 35 with serious co-morbidity or BMI gt 40
• Tanner IV
• Psychology evaluation
• Family assessments/support
• Assessment of compliance in program- attendance,
  physical results, wt. stabilization.

• Anesthesia risk
• Acute psychosis, acute mental health issues
• Pregnancy or planned in 2 years
• Structural GI Abnormality
• Eating disorder (binge eating uncontrolled,
  bulimia, NOS)
• Development delay
• ETOH abuse or dependence

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Outcomes from the Pediatric Literature

• Behavioural intervention alone 5-15 overweight
  reduction
• Pharmacotherapy (orlistat, sibutramine,
  metformin) additional 2-5 kg weight loss
• Bariatric surgery reduce BMI by 30
• Ref Latzer et al. Obesity (2008) 17, 411423

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www.obesityinyouth.org