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Childhood obesityDr Michal AjzensztejnThe Evelina London Children’s Hospital July 2014
Overview
Definition
Size of the problem?
Aetiology
What is the cause for concern?
ManagementpreventionInvestigationTreatment
Definition of obesity
Gold standard is body composition
MRI / Dexa / bioimpedence (proxy)
Waist circumference
BMI = Kg/M²
A child's weight status is determined using an age- and sex-specific percentile for BMI rather than the BMI categories used for adults because children's body composition varies as they age and varies between boys and girls.
DefinitionObesity expert
committee- pediatrics 1998
Overweight: 85-95th Centile
Obese: >95th Centile
International Obesity Task Force
Overweight>91st centile
Obese>99th centile
International obesity task force definition (IOTF) Cole et al BMJ 2000;320:1
Centiles for body mass index for British males and females. Centile curves are spaced two thirds of z score apart. Also shown are body mass index values of 25 and 30 kg/m2 at age 18, with extra centile curves drawn through them
Types of obesity in childhood
Primary
SecondaryEndocrine Hypothyroidism Cushings syndrome pseudohypoparathyroidismHypothalamic MonogenicSyndromes
The scale of the problem WHO- childhood obesity one of the most serious global public health
challenges of 21st century.
The National Child Measurement Program (CCMP) measures the height and weight of ~1M school children in England/yr. Latest figures show: 14.4% of children aged 10-11yrs – obese 18.9% of children aged 10-11yrs- overweight 9.3% of children aged 4-5yrs – obese 13% of children aged 4-5yrs - overweight.
1/3rd of 10-11yrs old + >1/5th of 4-5 yr olds were overweight or obese.
According to the National Audit Office- weight problems costs the Health Service £500million in consultations, drugs and other therapies.
Obesity causes 30,000 deaths a year.
Research from British Heart Foundation suggests children and young people could die from complications of obesity before their parents
By 2030 up to 48% of men and 43% of women in the UK could be obese if current trends in rise of obesity continue
Trends in adult prevalence of obesity (BMI > 30kg/m2)
Trend in childhood obesity US children 1971-2006
Causes of primary obesity Interaction between genetic predisposition (50-
90%)& environment affecting food intake and energy expenditure
Twin studies offer some insight into the genetics of common obesity Data from > 25,000 twin pairs and 50,000
biological and adoptive family members Estimates for mean correlations for BMI are:
0.74 for monozygotic twins, 0.32 for dizygotic twins 0.25 for siblings 0.19 for parent–offspring pairs, 0.06 for adoptive relatives 0.12 for spouses
Environmental factors Increase risk
History of SGA- increased rates of obesity and metabolic syndrome
Poor infant feeding
Reduced energy expenditure
Social concerns- fear to let children play outside
Parental obesity/ eating disorders
Increased high fat / carb food intake
Increased sedentary lifestyle Screen time (TV, computers, phones, ipad)
Protective factors
Family meals
Self esteem
Breastfeeding
Foetal origin hypothesis “Barker Hypothesis”
‘Foetal undernutrition in middle to late gestation leads to disproportionate foetal growth’ programmes later coronary heart disease’
‘The most unfavourable outcome is thinness at birth followed by a rapid increase in body weight’
Foetal programming
The way the mother prepares the foetus for the world in which it will be born
A communication through placental nutrition
Nutrition may alter the expression of maternal genes involved in foetal growth – ‘imprinting’ – gene methylation
The ‘Thrifty Phenotype’ - a mismatch between fetal programming and the environment
Genetics
Polygenic inheritance pattern with 2 subtypes (generalised and abdominal) multiple polymorphic single genes likely involved no genes for common obesity identified very rare monogenic forms of obesity
Gene defects ob/ob mouse – genes mutant – leptin deficient db/db mouse- mutation in leptin receptor POMC/ MC4R / neuronal insulin receptor mutations
Genetics Of Obesity Study (GOOS) Cambridge
Sadaf Farooqi and Stephen O’Rahilly
BMI >4SDs for age /sex
Consanguineous or
FH of early onset < 10 yrs
Over 3000 samples analysed
Monogenic causes of obesity
Leptin deficiency
Leptin receptor deficiency Hypogonadotrophin hypogonadism and other
pituitary hormone abnormalities
Prohormone convertase1 (PC1) defect Abnormal glucose tolerance Hypocortisolism, hypog/hypog.
Melanocortin – 4-receptor defect
POMC deficiency Red hair, adrenal insufficiency
PPARγ defect
GhrelinHunger-stimulating peptide
produced by P/D1 cells in lining of the fundus of stomach
Ghrelin receptors are expressed in the pituitary, stomach, intestine + pancreas.
Gherlin levels increase before meals and decrease post meals
When a person loses weight- ghrelin levels , which causes food consumption and weight gain
When a person gains weight ghrelin levels, causing a in food consumption and weight loss
Leptin "satiety hormone"Leptin is made by adipose tissue, it acts via
receptors in the brain (LRb) to regulate energy balance and satiety.
Leptin stimulates the hypothalamus to give us the sensation of satiety resulting in decreased appetite and increases metabolism to aid wt loss.
The less fat you have, the less leptin you produce, resulting in increased appetite and decreased metabolism to enables wt gain.
However if you have increased fat stores there is increased leptin, which can lead to leptin resistance. So despite lots of leptin, appetite is not suppressed, metabolism is slowed down resulting in increased appetite and wt gain.
Medical causes of obesityEndocrine
HypothyroidCushing syndromePseudohypoparathyroidismPCOS
MonogenicLeptin deficiencyPOMC deficiencyMC4R mutation 5% BMI>3 or 4SD
Hypothalamic Eg tumours/craniopharyngioma
SyndromesPrader-WilliBardel-BiedlCohenCarpenter
Why is childhood obesity getting so much attention!
Tracking into adult life( 60%)
Metabolic syndrome (IRS)
Secondary effects
Implications of childhood obesity
Obese children become obese adults
Comorbidities: Hypertension Metabolic syndrome: hyperlipidaemia PCOS Non-alcoholic fatty liver Insulin resistance/ impaired fasting and glucose tolerance Type
2 DM Slipped femoral capital epiphysis/ joint pain Sleep apnea Asthma Benign raised intracranial pressure
Emotional + psychological effects of being overweight Teasing/ bullying Low self esteem Anxiety Depression
Insulin resistance SyndromeMetabolic syndrome (syndrome X)
Central obesity (apple shape)
Hypertension
Raised triglycerides
Low HDL
Insulin resistance PCOS
Steatohepatitis
Glomerulonephritis
Atherosclerosis
Impaired glucose tolerance
Insulin resistance syndrome
A velvety brown change to the skin
Mostly in neck, axilla, groin
Looks like dirt but doesn’t wash off!
Usually obese
Almost always have insulin resistance
Leads to Type 2 diabetes
Local problem
In 2000, the first cases of Type 2 diabetes in children were diagnosed in overweight girls aged 9 to 16 of Pakistani, Indian or Arabic origin in the UK.
Nationally incidence of type 2 diabetes amongst children is 1.5%
In Lambeth and Southwark the incidence of type 2 is closer to 5%.
Obesogenic Environement
Family• Excess weight in parents• Breast feeding practices
• Parent’s health• Much Sedentary activity e.g
TV, computers etc.• Knowledge
• Budgeting, shopping and cooking skills• Genetic predisposition
Education & information• School lessons
• Lifestyles• Nutrition• Cooking
• Media messages• Fashions
• Body image• Cultural beliefs
• Conflicting information
Sports & Leisure• Lack of school facilities• Few local playing areas• Widely available indoor-
passive entertainment• Unsafe streets
• Few cycle routes
Social + economic inequalities in diet and physical activity
ManagementPrimary Prevention
Community based weight management service
Tertiary obesity serviceSevere obesityObesity with co-morbidities
Primary Prevention
Ante-natal care of the obese mother
Use of appropriate standardsWHO-UK Growth charts
Focus on early intervention (under 5s)Education of midwives and HVsBetter infant feeding advicePromotion of breast feedingBetter management of SGA/IUGR
infants
Community based services
Not just an issue for health workers-
community-wide approach
Input from education, LAs, sports bodies and voluntary groups
Specialised school nurse An Information Resource Educators Give basic dietary advice Risk assessment for referral
MEND- Mind, Exercise, Nutrition, Do it / Ready Steady Go
Planning permission- locality of sweet shops / fast food shops to schools
Media + Advertising companies- also have a duty
Tertiary level
Severe ‘morbid’ obesity
Pre-diabetic, insulin resistance, Type 2 diabetes
Adverse FH diabetes, ↑BP, ↑cholesterol, Ischaemic heart disease
Health co-morbidities CardiacRenalNeurological/muscular disordersSteroids induced
Monogenic / syndrome
Tertiary serviceMulti-disciplinary team
Psychologist / Family therapyDieticianSports trainerPaediatrician?Social worker
An initial team assessmentMotivational Interviewing skillsUnderstanding eating behavioursFuller family analysis
Classification for Investigation
Primary obesity with no family risk
Primary obesity with adverse family risk or signs/ suspicion of hyperinsulinism/ type II diabetes
Suspicion of secondary obesity/ genetic cause
InvestigationsSimple obesity with no adverse family
risk
If well grown in height and normal on examination: liver & renal function +/- liver USSTFTFasting lipidsFasting glucose/insulin blood pressure (ambulatory if possible)
Simple obesity with family risk history or clinical suspicion of hyperinsulinismAs above plusOGTT with insulins
Secondary / genetic cause Investigate cause Eg UFC for cushings. Overnight
Dex suppression test Genetics for GOOS study
Who to treat?Those with BMI > IOTF 30
Those with BMI >IOTF 25 with strong family history diabetes/early CVD impaired glucose tolerance
Age:Rx should focus on >8 yrsThose obese < 8yrs with obese parents
IOTF- international obesity task force
Treatment
Treatment of obesityDietDrugsExercise programsPsychological approachesMulti-disciplinary approachesSurgery- Bariatric surgery /
intragastric balloon
Treatment of obesity complications
Treatment targets
5% loss is standard adult weight loss target10% is doing very well!but losses are maintained better in children
than adults
Weight maintenance in growing children
Imperative to start Rx before growth ceases
Treatment of Choicecomprehensive treatments
including:behavioral modification proceduresdietary interventionan exercise programreduction of sedentary behavioursfamily centred
motivational enhancement
Drugs
Drug trials for obesity in children & adolescents
Extremely few published
Drugs not licensed
We cannot assume risks and benefits same as in adult
What’s availableOrlistat – binds intestinal and pancreatic
lipase and reduces dietary fat absorption by 30%
2.5 kg to 3.0 kg over 3-4 yrs. Compared with placebo
Reduces absorption of fat soluble vitamins
Metformin – useful in diabetes, impaired glucose intolerance and possibly insulin resistance
May improve cardiovascular outcome and reduce risk of PCOS/ metabolic syndrome
Surgery
UK: NICE guidelines recommend consideration of surgery for young people in exceptional circumstances
“Surgery...has the best chance of significant weight loss, reversal or improvement of current co-morbidities, and reduction of risk for future co-morbidities” Brown &Inge 2009
Criteria for Bariatric Surgery in children BMI of 40 (kg/m2) or more - OR
BMI >30 + other significant disease
All non-surgical measures have failed for at least 6 months
Receiving intensive management in a specialist service
Generally fit for anaesthesia and surgery
Commitment to long-term follow-up
Physiological and psychological maturity
Bariatric Surgery
Types Gastric banding Gastric bypass Gastric sleeve surgery
No surgery without risk- High risk group
Post surgical complications
Long term follow up
Long term supplement therapy
Intragastric balloon Rx?
Less invasive
No long term complications
However are the results as sustainable?
The Evelina London Children’s Hospital obesity service Still in the job planning phase
Will integrate community to tertiary level care
Bridge between medical and surgical intervention
Provide intragastric balloons
Multidisciplinary team: Psychological/ family approach Dietician Sport/ activity Nurse Doctor Speciality care: sleep study, orthopaedic, referral to King’s for
liver and bariatric surgery
Thank youQUESTIONS?