Transcript OVERWEIGHT AND OBESITY - Zanjan University of Medical …

OVERWEIGHT AND OBESITY
DR.MOEZZI
Overweigth &obesity are terms that are
commonly used interchangably in
children,with overweigth being the preferred
term.
EPIDEMIOLOGY
NHANES documents that 16% of children are
overweight and 31% are at risk for becoming
overweight .
The first predictor of overweight is high
birthweight,probably linked to maternal obesity or
maternal diabetes.
Children who are overweight are more likely to be over
weight as adults.
The Strongest predictor of childhood overweight is
parental obesity.
PATHOGENESIS
OVERWEIGHT RESULTS FROM A
DYSREGULATION OF CALORIC INTAKE
AND ENERGY EXPENDITURE.
Eat too much and
Move too little
PATHOGENESIS
Enviromental changes: the type &cost of food
has dramatically changed over last several
decades .snacking between meals has risen
steadily the last 2 decades ,with many
snacks being high in fat ,sugars, or both.
1/3 children in USA eat fast food daily;
a typical single meal can contain 2000 kcal 84
gr fat &only 12gr fiber.
Decrease in activity &a lack of exersise also
contribute to an increase in the prevalence of
overweight.
Wacth of TV-video games-internet computer
use-telephone use
Continued…
Endogenous weight control mechanisms:
Super Sized Fast Food
Disease associated with childhood
obesity
Alstrom
Bardet-biedl syndrome
Carpenter syndrome
Cohen syndrome
Cushing syndrome
Deletion 9q34
Frohilich syndrome
Hyperinsulinism
Melanocortin 4 receptor gen mutation
Muscular dystrophy
Myelodysplasia
Prader-willi syndrome
Pseudohypoparathyroidism
Turner syndrome
Excessive weight
Gain or BMI in
infant&toddler
Diagnostic criteria for overweight
The calculated BMI can overestimated adiposity in
trained athletes or muscular children ,but it is
generally recognized as the most reliable method to
dtermine healthy&unhealthy adiposity.
Other methods of determining adiposity are usefull .
But are either too expensive to of practical use in a
clinical setting(ulrasound,CT,MRI,DEXA,total body
conductivity,air displcement plethymography),require
specialized training (skinfold thickness),have poor
reproducibility(waist-hip ratio),or lack extensive
normative data in children(bioelectric impedence
analysis)
Continued…
BMI in combination with clinical assement is
sufficient to make the diagnosis .
Children adiposity rises in the 1st year of life,
reaches a nadir around 5-6 yr of age,and
then increases again throughout
chilhood.this is called adiposity rebound.
Continued…
The 95th percentile BMI for a 4 yr old is
approximately 19,but it is 25 in a 13 yr old.
BMI classification of children &adolescents:
<5th percentile
under weight
5th -84th percentile
normal weight
85th -94th percentile
at risk overweight
≥95th percentile
overweight
Evaluation of the overweight child
Evaluation of overweight children & families
requires sensitivity &compasion, because the
general puplic often percieves overweight
individuals as un healthy ,uninteligent,
unhygienic&hazy.
Obesity is chronic medical problem that
requires management in a manner similar to
that of other chronic disorders.
Contineud….
The initial evaluation is focused exploring
dietary practices ,family structures &habits
because alteration of these factors is usually
the basis of successful treatment.
Continued…
cushing syndrome:
1.The onest of relatively rapid weight gain
2.Increase in BMI percentile
3.Centeral obesity
Other symptoms:muscle weaknesseccymoses-unexplained osteoporesishypokalemia
Continued…
Hypothyroidism can be associated with obesity
but usually weight gain is modest ,because
appetite is often reduced and problems of
poor linear growth ,delayed skeletal
development ,delayed puperty are more
prominent feature.
Endocrinologic disease
1.Normal linear growth alone generally
precludes the diagnosis of endocrinologic
disease.
2.A family history of endocrinopathy
3.height/age <50th percentile
4.T4 –TSH evaluation
5.The 24hr urinary free cortisol level.
COMORBITIES OF OVERWEIGHT
1.Asthma
shothness of breath,wheezing,couqh
pulmonary function test
2.Gallstone
abdominal pain ,vomiting, jaundice
ultrasound
3.Obstructive sleep apnea
snoring,daytime somnolence,enuresis
polysomnography,hypoxia,electrolyte
4.Blount disease
knee pain,limp,bowing of legs
knee x-ray
5.Slipped capital femoral epiphysis
hip pain,limp
hip x-ray
6.Pseudotumor cerebri
headache,dizziness,diplopia,papilledema
CT,MRI,cerebrospinal fluid opening pressure
7.Behavioral complication
disordered eating,sign of depression ,social isolation , low self
–steem,worsening school performance
Behavioral survey
8.Nonalcoholic fatty liver disease
hepatomegaly,abdominal pain,dependent edema
AST,ALT,ultrasound,CT,MRI
9.Hypertension
elevated BP>95th percentile for age,sex,height
serial testing,U/A,electrolyte,BUN,creatinine
10.insuline resistance
family history,polyuria,polydypsia,unintentional↓weight
Fasting glucose,Hb A1c ,insuline level,oral GL tolerance
test
11.Dyslipidemia
family history(high cholesterol,early onset heart
disease)
fasting total cholestrol,HDL,LDL,TG
Make Your Own Lunch From
These Choices
Physical finding
Hypertension
Acantosis nigricans-insulin resistance
Tanner staging -premature adrenarche
Hirsutism,male pattern baldness,severe acne( polycystic ovary syndrome)
Simplified laboratory norms for
assessing overwieght children
Glucose
Insulin
Hemoglobin A1c
AST 2-8yr
9-15yr
15-18yr
ALT
Total cholestrol
LDL
HDL
Triglycerides
2-15yr
15-19yr
<110mg/dl
<15mu/l
<6.0%
<58u/l
<46u/l
<35u/l
<35u/l
<170mg/dl
<110mg/dl
<35mg/dl
<100mg/dl
<125mg/dl
TREATMENT
Successful treatment of obesity is challenging and
trearment goals vary ,depending on the age and
severity complication.
Children of still growing ,so severe caloric restriction
and weight loss maybe detrimental.
Weight loss should be slow (0.5kg or less per
week),because more rapid weight loss requires
overly restrictive dieting.
Initial goal of a 10% reduction in weight is reasonable
because this amount of weight loss has been shown
to significant improve overal health.
Continued….
The new weight should be maintained for 6month
before furture weight loss is attemptemed.
The most successful approach to weight maitenance or
weight loss requires substatial lifestyle changes that
include increased physical activity and altered eating
habits.
Therapies often combine diet ,exercise ,behavior
modification,medication,and rarely ,surgery.
Office-Based Managment
Anticipatory guidance:establishing healthy eating habits
in children
Do not punish a child during mealtimeswith regard to eating.
Do not use foods for reward.
Parents,sibling should model healthy eating.
Children should be exposed to a wide range of foods,tastes,and
textures.
Foods should be offered multiple time.
Offering a range of foods with low energy density helps children
balance energy intake.
Continued…
Rectricting access to foods will increase than
decrease a child preference for that food.
Forcing a child to eat a certain food will
decrease his or her preference for that food.
Children tend to be more aware of satiety than
adult.
Do not force children to clean their plate.
Multidisiplinary and community-based
managment
Severely overweight children and adolescents
with complication from obesity are best
managed with multidisiplinary team.
Teams may include a physician,a
psychologist,a dietian,exercise espcialist,a
nurse, and counselors.
Management consists of dietary
counseling,exercise therapy,and behavioral
mangement.
Dietary counseling
Recommendations for healthy eating should be agespecific and flexible enough to accommodate family
and ethnic food preferences.
In toddlers ,limiting sweetened beverages is usually the
most useful initial strategy.the American Academy Of
Pediatrics(AAP) recomeds a maximum intake of 4-6
oz of fruit juice/day for children 1-6 yr and 8-12 oz for
7-18 yr olds.
Continued….
Other simple intervention include changing to skim milk in children
older than the age of 2 yr and assuring exposure to a wide
variety of foods;including less caloric dense food choices and
limitation of between –meal snacking.
For preschool-aged children ,sweetend beverages should be
limited and parents should continue to offer healthy foods.
As children reach shool age ,busy schedules and exposure to food
advertisements often increase fast food intake.education
regarding meal planning and the value of family mealtimes in
maintaining family structures can decrease the number of
meals eaten away from home.
Continued….
Encouraging children to eat breakfast
decreasing their intake of sweetend
beverage ,and teaching them the principles
of balanced nutrition are useful strategies for
the overweight adolescent.
continued
More severe dietary restriction should be used only in
supervised program.
An extremely low-caloric diet(800kcal/24hr) is used for
children with severe obesity needing rapid weight
loss.
Low carbohydrate or controlled-carbohydrate diets
show superior weight loss compared with low fat diet
in adolescent.
Nutrition plans based on the glycemic index of foods
has shown great promise in overweight children.
continued
Glycemic index is based on the insulin
response to a carbohydrate,with simple
carbohydrates having a higher ,and therefore
less desirable,glycemic index compared with
complex carbohydrates.
Complex carbohydrates such as non-starchy
vegetables and whole grains.
Continued….
A successful approach used preschool and
preadolescent children is the traffic light or
stoplight.it is designed to limit calories ,yet
achieve good nutrient balance and is easily
adaptable to fit particular ethnicities and
nutrition plans,such as low carbohydrate or
glycemic index diets.
Stoplight Diet Plan
Color
Quality
Types of
foods
green light food
low calorie
high fiber
low fat
fruits
vegetables
Quantity unlimited
yellow light food
nutreint dense
but higher in
calories&fat
lean,meats,dairy
starches,grain
limited
red light food
high in calorie
suger&fat
fatty meats
suger,fried
foods
infrequent or
avoided
Physical Activity
Increased activity not only increases calorie
use bul also appears to decrease appetite.
In children younger than 2 yr of age ,AAP recommends
avoiding TV computers.
children 2-18yr of age should have <2hr/day of “screen
time”(TV,video games,computer)and TVshould be
removed from children bedrooms.
Continued…
Prescribed exercise regimens can be useful.
Simple measures such as daily walks can be
useful.
Medication
Pharmacologic treatment is sometimes
indicated as an adjunct to diet and physical
activity in overweight adult with obesity –
related complication.
Medication of overweight children &adolescent
is reserved for those with sever medical
complication.
The use of sibutramine isnot recommended in
children younger than 16 yr of age.
Continued…
Olistat has been effective in adolescents older
than 12 yr of age,but GI side effects of
diarrhea and abdominal pain are
common,and the potential effects on fatsoluble vitamin and mineral absorption in
growing adolescent are a concern.
Topiramat an antiepileptic ,has marked
anorectic effects.
Metformin is being studied in adult patients and
appears to promote weight loss and prevent
development of metabolic
syndrome.although metformin does appear
to have some efficacy in promoting weight
loss and lifestyle changes .
Octreotide has shown promise for weight
control in children with hypothalamic obesity.
Continued….
Rimonabant a cannabinoid type 1 receptor
antagonist ,has been effective in obese adult
in reducing weight and ameliorating
abnormal metabolic parameters.
At this time,the use of pharmacologic agents
for the treatment of overweight children and
adolescents is of marginal value ,with
unclear risk.
Bariatric surgery
There is some efficacy of bariatric surgery in
adolescents,the long term safety has not been
adequately studied.
In USA roux-en-y gastric bypass is one approach for
weight control surgery.weight loss that approaches
60-70% of excess body weight is often
achieved.monitoring for nutritional complications is
mandatory because deficiencies of iron,vit B12,folate
,thiamine,vit D and calcium has been reported.
Continued…
Cases of wernicke encephalopathy have
occurred in some patients who have not
complied with the recommended dietary
supplement after surgery.
The American Pediatric Surgical
Association Guideline recommend
that surgery be considered only in
children with a BMI>40 and
medical complication of obesity
after they have failed 6 mo of
multidisiplinary weight
management program.
Less invasive procedure than the Roux-en-y
gastric bypass are available and include the
adjustable gastric band that functions only by
extrinsic gastric restriction.
One benefit is the band canbe removed.