Transcript Obesity Related Comorbidities - American Academy of Pediatrics

Associated Comorbidities of
Pediatric Obesity
Sandra G Hassink, MD, FAAP
Director Weight Management Program
A I duPont Hospital for Children
Wilmington, DE
Severe Obesity Related
Emergencies
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Hyperglycemic
Hyperosmolar state
DKA
Pulmonary emboli
Cardiomyopathy of
obesity
Complications of
Bariatric Surgery
Chiasson JL, Aris-Jilwan N, Bélanger R, Bertrand S, et al. CMAJ. 2003 Apr
1;168(7):859-66.
Hyperglycemic Hyperosmolar State
“Death caused by hyperglycemic Hyperosmolar
state at the onset of type 2 diabetes."
Morales AE, Rosenbloom AL.J Pediatric 2004 Feb 144 (2)
270-3.
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“Seven obese African American
youth were considered to have died
from diabetic ketoacidosis.”
Hyperglycemic Hyperosmolar State
“Despite meeting the criteria for
Hyperglycemic Hyperosmolar state
and not for DKA.”
 “All had previously unrecognized
type 2 diabetes, and death may have
been prevented with earlier
diagnosis or treatment.”
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Hyperglycemic Hyperosmolar State
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Patients presented to medical care with
symptoms which were not linked to
presentation of type 2 diabetes.
– Vomiting.
– Abdominal Pain.
– Dizziness.
– Weakness.
– Polyuria/Polydipsia.
– Weight loss.
– Diarrhea.
Hyperglycemic Hyperosmolar State
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HHS- diagnostic criteria
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plasma glucose > 600mg/dl
Arterial pH >7.3
serum bicarbonate > 15 mmol/l
Serum ketones none-trace
Urine ketones none-trace
effective serum osmolality >320 mOsm/kg
stupor or coma
• Rubin HM J Pediatr 1969:74:`77-86
• Morales A J Pediatr 2004 Feb, 270-273
• Chiasson JLCMAJ. 2003 Apr 1;168(7):859-66.
Pulmonary Embolism
Classic Symptoms
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Dyspnea
Chest pain
Decreased O2
Hemoptysis
Other Signs/Symptoms:
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Back, shoulder, upper abdominal pain
Painful respiration
Cyanosis
Syncope
Cardia Arrhythmia
New onset of wheezing
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Obstructive Sleep Apnea and Coagulation disorders
increase risk
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Most common complication of gastric bypass/banding in adults, has been
reported in adolesents after surgery
•
Sugerman HJ, Sugerman EL, DeMaria EJ, et al Gastrointest Surg. 2003 Jan: 7(1):102-07
Cardiomyopathy of Obesity
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Cardiac steatosis
 Left ventricular dysfunction.
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dilation
increased left ventricular wall stress
compensatory (eccentric) left ventricular hypertrophy
left ventricular diastolic dysfunction
Right Ventricular dysfunction
– Exacerbated by pulmonary hypertension due to UAO
• Alpert, MA Am J Med Sci 2001 Apr, 321(4);225-36.
Roux-en-Y Gastric Bypass-Early
Complications
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Bleeding
Bowel Perforation
DVT/PE
Dehydration
Dysphagia
Nausea/Vomiting
Small Bowel
Obstruction
Anastomotic Leak
Peritonitis
Roux-en-Y Gastric Bypass-Late
Complications
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Cholecystitis
Dysphagia
GERD
Incisional Hernia
Malnutrition
Pancreatitis
Ulcers
Renal Calculi
Strictures
Internal Hernia
Small Bowel Obstruction
Lap-Band Adverse Events
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Intra operative
– Iatrogenic gastrostomy
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Early Post-operative
– Hemorrhage
– Port infection
– Stomal obstruction
– Perforation
 Late complications
– Mechanical dysfunction
– Erosion
– Slippages
Ponce, et al., 2005
Post Bariatric Surgery Mediation
Considerations
No aspirin or aspirin containing
products
 No non steroidal anti inflammatory
agents
 All medications should be crushed
(no extended release or enteric
coated products)
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Potential Metabolic Complications
from Bariatric Surgery
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Anemia
– Fe, B12, copper, vitamins A and E, deficiency or an
imbalance in zinc intake
– Neurologic Complications - Related to Vitamin B12
deficiency
– Ophthalmoplegia
– Nystagmus
– Ataxia
– Peripheral Neuropathy
– Impaired memory
Gallstone Formation
von Drygalski A, Andris DA.
Nutr Clin Pract. 2009 Apr-May;24(2):217-26
Potential Metabolic Complications
from Bariatric Surgery
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Hyperparathyroidism –Ca and vitamin D def
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Aches/pains
Depression
Abdominal pain, Nausea/Vomiting
Excessive urination
Confusion
Muscle Weakness, Fatigue
Protein deficiency
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Hair loss
Edema
Hypoalbuminemia
Anemia
Extreme Fatigue
Inability to walk
Co-morbidity's Requiring
Immediate Attention
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Pseudotumor
Cerebri
Slipped Capital
Femoral Epiphysis
Blount’s Disease
Sleep Apnea
Non alcoholic
hepatosteatosis
Cholelithiasis
John A Moran Eye Center, Salt Lake City UT
Pseudotumor Cerebri
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Definition.
– Raised intracranial pressure with papilledema
and a normal cerebrospinal fluid in the
absence of ventricular enlargement.
 Risk
– Obesity occurs in 30%-80% of affected children.
• Scott Am J Opth 1997; 124:253-255
– In a series of case-controlled studies in adolescents and
adults, obesity and recent weight gain were the only
factors found significantly more often in pseudotumor
cerebri patients than control patients.
• Lessell S. Surg Ophthalmol 1992;37(3):155-66.
Pseudotumor Cerebri
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Diagnosis
– May present with headaches, vomiting, blurred vision or
diplopia.
– Neck, shoulder, and back pain have also been reported.
• Lessell S. Surv Ophthalmol 1992;37(3):155-66.
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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
1985;103(11):1681-6.
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Increased intracranial pressure may lead to visual
impairment or blindness.
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Treatment
– Acetazolamide
– Lumboperitoneal shunt (in severe cases),
– Weight loss
• Newborg B. Arch Intern Med 1974;133(5):802-7.
Pseudotumor Cerebri Associated Conditions
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Mastoiditis and lateral sinus thrombosis
Hypoparathyroidism, Pseudohypoparathyroidism
Steroid treatment and withdrawal
Thyroid replacement
SLE
•
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Green M. Pediatr Clin North Am 1967;14(4):819-30.Palmer RF, Searles HH, Boldrey EB.. J
Neurosurg 1959;16(4):378-84.Baker RS, Baumann RJ, Buncic JR. Pediatr Neurol
1989;5(1):5-11.Walker AE, Adamkiewicz JJ. JAMA 1964;188:779-84.Neville BG, Wilson J.. Br
Med J 1970;3(722):554-6.Huseman CA, Torkelson RD.. Am J Dis Child 1984;138(10):92731.DelGiudice GC, Scher CA, Athreya BH, Diamond GR.. J Rheumatol 1986;13(4):748-52.
Medication associated with no clear does-response
relationship
– Nalidixic acid
– Ciprofloxacin
– Tetracycline
• Lessell S. Surv Ophthalmol 1992;37(3):155-66.
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Vitamin A and isoretinoin therapy are established causes
of pseudotumor cerebri.
•
Morrice G Jr, Havener WH, Kapetansky F. JAMA 1960;173:1802-5.
Points to Remember
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A fundiscopic examination should be a
routine part of the examination of the obese
child
 Children may not complain of visual field
disturbances. When suspicious – test
 Pseudotumor cerebri is essentially a
diagnosis of exclusion after other causes of
increased intracranial pressure are
eliminated.
Slipped Capital Femoral Epiphysis
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Diagnosis
– Suspect and immediately evaluate in an
obese patient who presents with limp.
– 50%-70% patients with SCFE are obese.
• Wilcox J Pediatr Orthop 1988:8:196-200.
– Can also present with complaints of groin,
thigh, or knee pain referred by obturator
nerve
Slipped Capital Femoral Epiphysis
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Diagnosis
– Motion of the hip in abduction and internal rotation
is limited on examination.
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X- ray
– Anteroposterior view of the pelvis and frog leg that
includes both hips.
– Comparison of the hips
– Bilateral disease occurs in up to 20% of patients.
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Intervention
– Requires surgical correction and weight loss.
SCFE-Pathology
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Medial and posterior displacement of the
femoral epiphysis through the growth plate
relative to the femoral neck
• Busch MT, Morrissy RT. Orthop Clin North Am 1987;18(4):637-47.
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The preferential site of slipping within the
epiphysis is a zone of hypertrophic cartilage
cells under the influence of both gonadal
hormones and growth hormone
• Kempers MJ, Noordam C, Rouwe CW, Otten BJ. CanJ Pediatr
Endocrinol Metab 2001;14(6):729-34.
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SCFE - Associated Causes
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Continued weight gain.
 Renal failure
 History of radiation therapy
 Primary hypothyroidism.
• Loder RT, Greenfield ML.. J Pediatr Orthop . 2001;21(4):481-7.
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Gonadotropin-releasing hormone agonists
 Growth hormone therapy
• Kempers MJ, Noordam C, Rouwe CW, Otten BJ. J Pediatr
Endocrinol Metab 2001;14(6):729-34.
• Grumbach MM, Bin-Abbas BS, Kaplan SL. Horm Res
1998;49(Suppl 2);41-57.
Blount’s disease
Bowing of tibia and femur
either unilateral or bilateral.
2/3 of patients with Blount’s
disease may be obese.
Dietz J Pediatr 1982:101:735-737
.
•Blounts Disease
Blount’s Disease - Obesity Related
Orthopedic Morbidity
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Etiology
– Injury to the growth plate, fissuring and clefts
in the physis as well as fibrovascular
and cartilaginous repair tissue at the physealmetaphyseal junction.
– .Wenger DR, Mickelson M, Maynard JA.J Pediatr Orthop.
1984 Jan;4(1):78-88.
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– Results from overgrowth of the medial aspect
of the proximal tibial metaphysis.
Treatment
– Requires evaluation and correction by
orthopedic surgeon.
– Weight loss
Blount’s disease
Points to Remember
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A careful hip and knee examination should be a
routine part of the evaluation and follow-up of every
obese child.
An obese child complaining of or presenting with hip,
knee, groin, or thigh pain should have a complete
and thorough examination of his/her hips, including
radiological studies.
In an obese child, an unusual or abnormal gait should
not be attributed to “excess weight” but should be
thoroughly investigated with a careful hip and knee
examination.
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/www.airecoremedicalservices.com/pic02.jpg
Upper Airway Obstructive Sleep
Apnea Syndrome
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Structure
– Adipose tissue in upper airway contributes to
Upper Airway Obstruction
•
Shelton KE, et al Pharyngeal fat in obstructive sleep apnea. Am Rev Respir
Dis. 1993;148(2):462–466
– Abdominal adiposity may compromise
respiratory excursion
•
Kessler R et al The obesity-hypoventilation syndrome revisited: a prospective study of 34
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consecutive cases. Chest. 2001;120(2):369–376
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Function
– Infiltration of adipocytes into diaphragmatic
muscles may alter respiratory mechanics
• Fadell E et al. Fatty infiltration of the respiratory muscles in the
Pickwickian syndrome. N Engl J Med. 1962;266(17):861–863.
Obstructive Sleep Apnea
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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
2002;109(4):e69-79.
Airway Mechanics:
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Dynamic relationship:
– Negative intra-thoracic
pressure during
inspiration:
• Always a closing
pressure
– Airway size and shape:
• This may favor airway
opening or closure
– Airway tone:
• Tissue rigidity
• Neuromuscular:
– Too much: Airway
constriction
– Too little: Airway Fricke, BL et al: Korean J Radiol 8(6), December 2007
collapse
Obstructive Sleep Apnea Effects
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Cognitive
– Decreases in learning and memory.
• Rhodes J Pediatr 1995;127:741-744.
– Deficits in attention, motor efficiency and graphomotor ability.
• Greenberg GD, Watson RK, Deptula D.. Sleep 1987;10(3):254-62.
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Cardiopulmonary
– Pulmonary hypertension,systemic hypertension, right heart
failure.
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Tal A, Leiberman A, Margulis G, Sofer S. Pediatr Pulmonol 1988;4(3):139-43.
Marcus CL, Greene MG, Carroll JL. Am J Respir Crit Care Med 1998;157(4 Pt 1):1098-103.
• Massumi RA, Sarin RK, Pooya M, Reichelderfer Dis Chest 1969;55(2):110-4.
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Sleep disturbance
– Weight >200% above ideal had oxygen saturation <90% for half to total sleep time.
– 40% of severely obese children demonstrated central hypoventilation.
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Silvesti Pediar Pulmonol 1993;16:124-139
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Evaluation- History
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Nighttime symptoms
symptoms
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Snoring
Restless sleeping
Heavy or noisy breathing
Orthopnea
Frequent night awakening
Enuresis
Observed apnea
Diaphoresis
Cyanosis
Daytime
Morning headache
Daytime tiredness
Napping
Poor school function
Inattentiveness
Short term memory
deficit
Irritability
Elevated blood pressure
OSAS-diagnosis
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Symptom checklists in research settings
• Chervin RD et Sleep Med. 2000;1(1):21–32
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History, audio and video taping, and overnight
oximetry and daytime nap polysomnography are
poor predictors of OSAS.
The definitive diagnosis of OSAS is made by
nighttime polysomnography.
• Clinical practice guideline: Pediatrics 2002;109(4):70412.
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Severity of obstruction may not correlate with
either degree of obesity or severity of sleep
symptoms.
Treatment
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Definitive treatment is weight loss
• Willi SM et al Pediatrics. 1998;101(1 Pt 1):61–67.
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Tonsil/Adenoidectomy-temporizing
CPAP/BIPAP-Titrated in sleep lab
• Marcus CL et al.J Pediatr. 1995;127(1)(((3):88–94.
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Extreme cases unresponsive to weight
loss/BiPap/CPAP uvulopharyngopalatoplasty,
craniofacial surgery, and, in severe cases,
tracheostomy
• Section on Pediatric Pulmonology, Pediatrics. 2002;109(4):704–
712.
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Gastric Bypass/Banding in adults
Points to Remember
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Ask specifically about sleep disturbances, snoring,
and sleep position. Families will often disregard these
symptoms.
Obstructive sleep apnea syndrome should be
especially considered in obese children with poor
school performance and concentration difficulties.
Sleep symptoms can evolve over time. Keep asking
about sleep disturbance as you follow these children.
Weight gain, intercurrent upper respiratory infections,
and Tonsillar enlargement can provoke symptoms.
Asthma Prevalence in Children
Is at an All-time High
Asthma Prevalence Among Children ≤17 Years of Age
Survey Redesign
14
12
% of Children
10
8
Asthma Period Prevalence
Lifetime Asthma Diagnosis
Current Asthma Prevalence
Asthma Attack Prevalence
6
4
2
0
1980
1985
1990
1995
2000
Adapted from Akinbami LJ. Advance data from vital and health statistics; no 381. National Center for Health Statistics. 2006.
2005
Asthma and obesity:
Respiratory physiology
Obesity
Asthma
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Classic example of an
obstructive lung disorder
Airway obstruction:
– Inflammation
– Bronchospasm
– Mucus plugging
Airway reactivity:
– Response to triggers
– Reversible airflow
obstruction
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Classic example of a
restrictive lung disorder
Chest wall restriction:
– Body mass
– Abdominal fat
– Decreased breathing
movements
– Lung compression
Tissue deposition of fat:
– Airway narrowing
– Fixed airflow
obstruction
Courtesy of Dr. Aaron Chidikel
Pulmonary - Asthma
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Pulmonary mechanics change with obesity
– Decreased lung volumes and thoracic distensibility
• Fung KP, et al. Arch Dis Child. 1990;65(5):512–515.
– Breathing pattern: Higher frequency, lower tidal
volume.
• Weiss S, et al.Obesity and Asthma Direction for Research NHLBI
Workshop. Am J Respir Crit Care Med. 2004;169;963–968
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Obesity may contribute to severity of asthma
– Obese asthmatic children have more missed school
days, receive more medication and have lower peak
expiratory flow rates than non obese asthmatic children.
• Luder E, et al. J Pediatr. 1998;132(4):699–703.
– Increase cough, wheeze and dyspnea.
• del Rio-Navaro B, et al. Allergol Immunopathol (Madr).
2000;28(1):5–11.
•
Pulmonary- Asthma
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Bronchial hyperreponsiveness increases in
obesity
• Szilagyi PG et al. Pediatr Ann. 1999;28(1):43–52
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Weight reduction in obese patients reduces
asthma symptoms.
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Weiss S, Shore S. Am J Respir Crit Care Med. 2004;169;963–968
Gastroesophageal reflux is increased in obesity
Leptin is increased in obese children and in
normal weight asthmatic boys vs. non asthmatic
boys.
– Inflammatory cytokines may exacerbate asthma.
• Guler N et al. J Allergy Clin Immunol. 2004;114(2):254–259.
Asthma- Evaluation and Treatment
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Obese children, if inactive may not report
symptoms unless specifically asked.
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Altered activity patterns
Dropping out of sports
Slowing down
Losing interest
As exercise increases during treatment of
obesity, symptoms of exercise induced
asthma may emerge
 It is important to optimize asthma
treatment in every obese, asthmatic child
NAFLD to NASH
Obesity
Genetic Predisposition Fatty Liver/Steatosis
2nd “Hit”
Inflammation
Fibrosis
Cirrhosis
Day
CP, James OF. Gastroenterology
1998;114(4):842-5.
Harrison
SA, Diehl AM. Semin Gastrointest Dis
2002;13(1): 3-16.
Non Alcoholic Steatohepatitis - Obesity
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Diagnosis
– Increased liver enzymes and fatty liver on ultrasound in
the absence of other causes of liver disease.
– Rule out other causes of fatty liver
– Liver Biopsy
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Etiology
– 20%-25% obese children have evidence of
steatohepatitis.
– Tazawa Acta Paeditr 1997;86:238-241.
– 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
1999;30(6):1356-62.
NASH risk
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Predictors of elevated serum ALT in obese
children
– Male gender
– Hispanic ethnicity
– Elevated BMI
•
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Schwimmer JB, McGreal N,Deutsch R, Finegold MJ, Lavine JE. Influence of
gender, race, and ethnicity on suspected fatty liver in obese adolescents.
Pediatrics. 115(5):e561-5, 2005 May.
Predictors of fibrosis
– Obesity (BMI z score)
– Insulin resistance
– Leptin (?)
•
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Schwimmer, J B et al Pediatr 2003 143(4), 500-505
“A liver NAFLD runs a higher risk of being damaged by
other factors, from viruses to endotoxins, from alcohol to
industrial toxic compounds”
•
Yang SO, Lin HZ, Lane MD, Clemens M, Diehl AM. Proc Natl Acd Sci USA 1997; 94: 25572562
NASH - Treatment
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Loss of at least 10% of their excess weight
normalized ALT and AST values and decreased
ultrasound evidence of fatty infiltration
• Vajro P, Fontanella A, Perna C, Orso G, Tedesco M, De Vincenzo
A. J Pediatr 1994;125(2):239-41.
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Clinical trial (TONIC)
– Metformin normalizes liver enzymes in 40%-50% of
children with Reduction in heapatosteatosis by 23%30%biopsy proven NASH.
– Improved insulin sensitivity
•
Schwimmer JB, et al Alimentary Pharmacology & Therapeutics. 2005
21(7):871-9,
Cholelithiasis- Obesity Related
Gastrointestinal Morbidity
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Diagnosis
– Abdominal pain, tenderness .
– Ultrasound, laboratory studies.
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Etiology
– Obesity accounts for 8%-33% of
gallstones in children.
• Friesen Clin Pediatr 1989.7:294.
– May be associated with weight loss.
• Crichlow Dig Dis. 1972;17:68-72.
Cholelithiasis- Obesity
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Risk
– 50% of cholecystitis in adolescents associated
with obesity
• Crichlow Dig Dis. 1972;17:68-72.
– Relative risk of gallstones in adolescent girls with
obesity is 4.2
• Honore Arch Surg 1980;115:62-64.
– Hormonal contraception increases risk
• Schweizer P, Lenz MP, Kirschner HJ.
• Dig Surg. 2000;17(5):459-67.
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Surgical Intervention
Chronic - Obesity Related Co
Morbid Conditions
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Insulin Resistance
Pre diabetes
Type II Diabetes
Polycystic Ovary
Syndrome
Hypertension
Hyperlipidemia
Psychological
Acanthosis Nigricans
Courtesy Dr. G Datto
https://online.epocrates.com/data_
Acanthosis Nigricans

Hyperpigmentation and velvety thickening that
occurs in neck, axilla, groin, can occur over
knuckles
 Also seen in malignancies and other insulin
resistant syndromes.
 Obese pediatric pts with acanthosis have higher
fasting insulin and lower insulin sensitivity than
acanthosis negative obese patients
 Insulin resistant pts were more likely to be obese
(88%) than have acanthosis (65%)
– Yanovski et al, Journal of Peds 2001
Progression from Normoglycemia to Type 2 Diabetes
DIABETES
199
140
Impaired Glucose Tolerance
Normal Glucose
Tolerance
Impaired
Fasting
Glucose
Courtesy Dr. J Silverstein
Note: HgbA1C is not a diagnostic criteria for pre-diabetes
Progression from Pre-Diabetes to
Diabetes in Adolescents
117 obese children and adolescents
At T=0: 33 (28%) had IGT
At 2 years:
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8 IGT subjects developed T2D (24.2%)
15 IGT subjects reverted to NGT (45.5%)
10 IGT subjects remained IGT (30.3%)
Best predictors of development of T2D:
– Severe obesity (BMI ≥ 97th percentile) and persistent
weight gain
– Relative with T2DM
– Increased insulin resistance (puberty, ethnicity,
inactivity, visceral fat distribution, PCOS
Weiss R. et al. Diabetes Care 2005; 28:902-909American Diabetes Association Diabetes
Care 2000;23(3) 381-389.
Incidence of Type 2 Diabetes
Ethnicity
10-14 yrs
15-19 yrs
Native American 25.3/100,000per
son yrs
49.4
African
American
Asian/Pacific
Islander
22.3
19.4
11.8
22.7
Hispanic
8.9
17.0
Non Hispanic
White
3.0
5.6
Diabetes - Diagnosis
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Hemoglobin A1C >6.5%
Symptoms of diabetes plus random
plasma glucose >200mg/dl (11.1mmol/l)
or
Fasting plasma glucose >126 mg/dl (7.0
mmol/l) or
2 hour plasma glucose >200 mg/dl
during an oral glucose tolerance test
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•
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American Diabetes Association Diabetes Care 2000;23(3) 381-389.
Diabetes Care July 2009 vol. 32 no. 7 1327-1334
Associated findings
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Polycystic ovarian syndrome, Acanthosis nigricans
Dyslipidemia, Hypertension
Goals of Treatment T2DM
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Physical well being, Psychological well being
Weight loss or no further weight gain/Continued normal linear
growth
Long term glycemic control
Control hypertension and hyperlipidemia
•
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Hassink SG, Pediatric Weight Mgmt and Obesity, 2007 Lippincott Phila, Pa
Family involvement
Education including a basic knowledge of pathophysiology and
short and long term complication
Nutrition and meal planning
Exercise
Pharmacologic management
Self monitoring.
Ongoing monitoring of glucose, HgbA1C, Bun/Crt, LFT’’s,
microalbuminuria, lipids, dilated eye examination, neurologic and
foot
Pharmacologic Management Metformin

In patients with both IFG and IGT + 1 of the following:

• <60 yo
• BMI >35 kg.m2
• FH DM in first degree relatives
• High TG
• Low HDL-C
• HTN
• A1c >6%
Metformin approved in children >10 years
• Decreases hepatic gluconeogenesis, increases insulin
sensitivity, and lower triglycerides and LDL cholesterol
• Nausea, vomiting, fullness, constipation, heartburn
• Lactic acidosis
Nathan DM, et al. Diabetes Care. 2007;30:753-759
Pharmacologic Management- Insulin
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If metformin contraindicated
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Renal insufficiency, Liver disease
Alcohol abuse,
Hypoxemia
Hypoperfusion
Sepsis
Discontinue with contrast dye, serious illness
Vitamin B12 deficiency reported in adults with long term
use.
If metabolic control cannot be achieved with lifestyle and
metformin
If beta cell failure ( in adults 6-8 yrs after diagnosis)
Polycystic Ovarian Syndrome

Polycystic Ovary Syndrome.
– Hyperandrogenism
– Oligomenorrhea/amenorrhea.
– Hirsuitism
– Acne
– Polycystic ovaries and eventual infertility.

Increased risk
– Girls with premature adrenarche
• Bacha F, Arslanian S. Enod Trends 11(1)2004
Hypertension

Use tables to classify
 Classification on three occasions
– Prehypertension 90%-95% or BP >120/80.
– Stage 1 hypertension 95%-99% plus 5 mm Hg
– Stage 2 hypertension >99% plus 5 mmHg.

Goal Blood pressure <90% for age and
gender
• Fourth Report on the Diagnosis, Evaluation and
Treatment of High Blood Pressure in Children and
Adolescents Pediatrics 2004;114(2 Suppl)555-576
Hypertension Treatment

Prehypertension
– Recheck in 6 months
– Weight management counseling
– Pharmacologic therapy not indicated
unless chronic kidney disease, diabetes
heart failure of LVH
• Fourth Report on the Diagnosis, Evaluation and
Treatment of High Blood Pressure in Children and
Adolescents Pediatrics 2004;114(2 Suppl)555-576
Stage 1 Hypertension Treatment
– Recheck in 1-2 weeks or sooner if
symptomatic
– Evaluate or refer within 1 month if elevated on
2 additional occasions
– Weight management
– Pharmacologic therapy if;
•
•
•
•
•
Symptomatic hypertension
Secondary hypertension
Hypertensive target organ damage
Diabetes (1 or 2)
Persistent hypertension despite non pharmacologic
measures.
• Fourth Report on the Diagnosis, Evaluation and Treatment of
High Blood Pressure in Children and Adolescents Pediatrics
2004;114(2 Suppl)555-576
Stage 2 Hypertension Treatment
– Evaluate or refer within 1 week or immediately
if patient is symptomatic
– Weight management
– Pharmacologic therapy
•
•
•
•
•
Angiotensin converting enzyme inhibitors
Angiotensin receptor blockers
Beta blocker
Calcium Channel blockers
Diuretics
• Fourth Report on the Diagnosis, Evaluation and Treatment of
High Blood Pressure in Children and Adolescents Pediatrics
2004;114(2 Suppl)555-576
Hyperlipidemia

Diagnosis
– Elevated LDL cholesterol, triglycerides
and lowered HDL cholesterol .
– Component of the metabolic syndrome

Etiology
– Increased central fat distribution
– Hyperinsulinemia
Lipid Levels
Low
Normal
High
TChol
<170mg/dl
170-199
mg/dl
>200mgdl
HDLChol
>40mg/dl
LDLChol
<100mg/dl
Trig
<200mg/dl
<40mg/dl
100129mg/dl
>130mg/dl
>200mg/dl
Hyperlipidemia
 Risk
– Overweight adolescents
• 2.4 fold increase in prevalence of
cholesterol >240mg/dl
• 3 fold increase in LDL values
>160mg/dl
• 8 fold increase in HDL values<35
mg/dl as adults 27-31 years.
• Srinivasan Metab 1996;45:235-240
BMI>99% Cardiovascular Risk

BMI >95%
– 39% two cardiovascular risk factors
– 65% had adult BMI >35%

BMI >99%
– 59% two cardiovascular risk factors
– 88% adults BMI >35

4% US children BMI >99%
• Freedman DS et al Cardiovascular risk factors and
excess adiposity among overweight children and
adolescents; the Bogalusa Heart Study J Pediatric
2007 150(1) 3-5.
Treatment

Nutritional
– Lower fat, cholesterol intake, Increase fiber

Weight loss
 Pharmacologic Therapy (after trial of
dietary therapy for 6 months)
– Children >10 yr
– LDL cholesterol>190mg/dl or LDL>160mg/dl
with 2 major risk factors.
• AAP Cholesterol in Childhood 1998 101;141-147.
Treatment- Hypercholesterolemia

Cholestyramine
– Approved for use in children
• Absorption of medications affected
• Worsening of bleeding problems,
constipation, gallstones, hemorrhoids,
ulcers, hypothyroidism, renal disease and
PKU.
• Gastrointestinal side effects, constipation,
flatulence and bloating
• Contraindicated when TG>400mg/dl
Studies Hypercholesterolemia

Lovastatin, Pravastatin, Simvastatin,
Atorvastatin, HMG CoA reductase
inhibitors
– Have been studied for up to 48 weeks in
children, no long term studies, not
approved in pregnancy
Treatment - Hypertriglyceridemia
Decrease simple sugars
 Weight loss
 If persistent evaluate for diabetes,
thyroid disease, renal disease,
alcohol abuse
 Fish oil (omega-3 fatty acids) 2 gm/d
if TG>500-700mg/dl. Restrict contact
sports (risk of bleeding)

• Gidding. Cardiovascular risk factor in
adolescents Curr Treat Options
Cardiovascular Med 2006 8
Psychological Morbidity
 Obesity Associated
Psychological Conditions
– Depression
– Anxiety
– Low self esteem
– Teasing/Bullying
– Binge eating disorder
Psychological Morbidity
 Additional
psychological
conditions with may impact
treatment
– ADHD/ADD
– Bipolar Illness
– Adjustment Disorder
– Oppositional Defiant Disorder
Depression and Obesity

In adolescents 7-12 grade depressed
mood predicted follow-up obesity
 Baseline obesity did not predict follow-up
depression
– Data from the National Longitudinal Study of
Adolescent Health (Add Health), a nationally
representative, comprehensive, school-based
study of youth in grades 7 to 12
• Goodman E, Whitaker RC Prospective Study of the
Role of Depression in the Development and
Persistence of Adolescent Obesity Pediatr2002
110(3)497-504
Obesity Trajectory and Depression/ODD



Chronically obese children had significantly
higher rates of oppositional defiant disorder, and
(for boys) depression.
No difference among groups in gender, family
structure, parenting style, family history of mental
illness, drug abuse, crime, or traumatic events.
Chronic and childhood obesity were associated
with having uneducated parents and low family
income.
– Study of children over a 4 year period in Appalachia
• Mustillo S et al.Obesity and Psychiatric Disorder:
Developmental Trajectories Pediatr 2003 111(4)4
851-859
Health related quality of life

Obese children and adolescents 5.5 times
more likely to have impaired health related
quality of life than normal weight child
 Reported lower pediatric health related
quality of life cores in all domains,
physical, psychosocial, emotional, social, and
school functioning than healthy children
and adolescents
 Parents scores were even lower than
children's
• Schwimmer JB, et al JAMA. 2003;289:1813-1819.
Health related quality of life

Obese children and adolescents with OSA
reported lower quality of life scores than
other obese children
 Health-related QOL did not vary by age,
sex, SES, or race
 BMI z score among obese children and
adolescents was inversely correlated with
physical functioning.
• Schwimmer JB, et alHealth-Related Quality of Life of
Severely Obese Children and Adolescents
JAMA. 2003;289:1813-1819.
Comorbidities of Obesity
Complete evaluation of an obese
child includes history, review of
systems and physical which includes
obesity related comorbidities.
 Treatment of obesity reduces
morbidity
 Modest weight loss is effective in
ameliorating effects of obesity
related comorbidities.
