Obesity in Childhood and AdolescenceM.Nazir HZ Departement of Child Health Faculty of Medicine, Sriwijaya University

Nutrition Problems in IndonesiaIron DeficiencyVitamin A DeficiencyIodine DeficiencyMalnutrition

Malnutrition:

1. Undernutrition2. OvernutritionObesity

Indonesia Double Burden

Obesity:Increased of body weight caused by an excess accumulation of body fatOver weightIncreased of body weight caused by an increase of lean body mass without excess accumulation of fat

16 Weeks:Diffrentiation of embryonic cell which contain lipoprotein lipase 30 WeeksFat deposition doesnt commence 3th trimesterRapid accumulation of fatTotal body fat in full term infant 400 gr (16% BW)- 80% synthezise- 20% FFA transplacentally - hypertrophy/ hyperplasia Pre adipocyte diffrentiation

Etiology of Obesity Multi Factorial and complex

Environment Genetic

Obesity

Taitz LS, Obesity in Mc.Laren DS, Burman D, Belton NR and Williams AF. Textbook of Paediatric Nutrition, third ed. Churchil Livingstone UK, 1991

Metabolic programming

Enviroment

Positif energy balanced stored as adipose tissue

Excessive energy intakeInadequate exercise (sedentary life style)low metabolic rate to body composition and massincreased insulin sensitivity

Obesity and Television Viewing in Children and AdolescentDietz WH, Jr and Gortmaker SL, Pediatrics 1985;75;807-812

Timing of Solid Food Introduction and Risk of Obesityin Preschool-Aged Children847 infants67% breastfed, 33% formula-fed. 3 years, 75 children (9%) were obese. 3.1. BF , OR 1,1 (95% CI 0,3 4,4)3.2. Formula infant introduction of solid foods < 4 months 6 times than BF, OR 6.3 (95% CI 2.3 6.9)Huh SY , Rifas-Shiman SL, Taveras EM, Oken E and Matthew PEDIATRICS Volume 127, Number 3, March 2011

The Role of maternal Obesity in Early Pregnancy prevalence of childhood obesity:

2 years9,5%3 years14,8%4 years14,8%30,3% if the children had obese mother.

Whitaker RC, Pediatrics Vol. 114 No. 1 July 2004

- gen mutation: leptin2 propiomelanocortin (POMC), prohormone convertase (PCSK1) reseptor melanocortin 4 (MC4R) (130 obese 42 mutasi,2003)

90 gen lain (2003): ghrelin, peroxisome proliferation-activated receptor gamma, uncoupling protein beta3-adrenoreceptor

2Montague CT, Farooqi IS, Whitehead JP, et al. Congenital leptin deficiency is associated with severe early-onset obesity in humans. Nature. 1997;387:903-908. Genetic

ObesitySyndrome (-)Non endocrine tall statureSyndrome (+)EndocrineShort staturePrimarySecondary

Obesity and syndromePrader-Willi short stature, small hands and feet, almond-shaped eye, round face, hypogonadism, devop. delay

Albright hereditary round face, short 4th , 5th metacarpals , dev.delay, osteodystrophy hypocalcemia (pseudoparahypothyroidism)

Laurence-Moon/ retinitis pigmentosa, polydactily, short stature, dev.Barder-Bliedl delaySyndromeSigns

Jakarta 1: 6 18 years: 6,7% Boy: 3,1% Girl : 10,2 %

Palembang2: 3 Elementery Schools:Middle High economic level >10%Low economic level 3 5%1Syamsuddin, Gizi lebih pada anak dan masalahnya: Risalah Widya Pangan & Gizi V LIPPI Jakarta 1994;396-4082 Nazir, Unpublished

Rapidly Increase

Age Over Weight

0 5 8,7

6 12 4,9 141

13 24 4,9 19,12

24 35 3,9

36 47 3,6

48 60 3,7 RisKesDas 2007, Profile Kesehatan Indonesi a 2008 RisKesDas 2010, 1, Childhood Overweight, 2, Adolsc obesity Over Weight (BW/A)according to Age Riskesdas 20101

No diffrence :economic and educational level, rural municipallow (13.7%) and high economic (14.0%) level 1. Endang Rahayu Sedyaningsih,, HGN, Jakarta 25/1-2011

The probabilities of obesity in adulthood BMI 95 th 3 to 5 years20% to 39.9% 6 to 11 years40% to 59.9%12 to 20 years 60% 3 to 4 years20% 5 to 11.5 years20% to 39.9% 11.5 to 16 years40% to 59.9% 17 to 20 years60%

Guo SS, Wu W, Chumlea WC, Roche AF. Predicting overweight and obesity in adulthood from body mass index values in childhood and adolescence. Am J Clin Nutr. 2002;76: 653658) GirlsObese BoysObese

Persistence of obesity: preschool to elementary school

85th percentile at ages 24, 36, or 54 months

5 times to be overweight at age 12 years Nader PR, OBrien M, Houts R, Pediatrics, Volume 118, Number 3, September 2006

Persistence of obesity: childhood into adulthoodBMI in childhood obesity in adulthood 1.Whitlock EP, Williams SB, Gold R, Smith PR, Shipman SA. Screening and interventions for childhood Overweight and obesity in childhood and adolescence1,2,3- associated with adverse socioeconomic outcomes- increased health risks and morbidities- increased mortality rates in adulthood

1.Must A, Strauss RS. Risks and consequences of childhood and adolescent obesity. Int J Obes Relat Metab Disord. 1999;23(suppl 2):S2S112.Reilly JJ, Methven E, McDowell ZC, et al. Health consequences of obesity. Arch Dis Child. 2003;88:7487523.Whitlock EP, Williams SB, Gold R, Smith PR, Shipman SA.Screening and interventions for childhood overweight: a summary of evidence for the US Preventive Services Task Force. Pediatrics. 2005;116(1).

Obesity in childhood and adolescent is important

In the future the next generationof every nation

1. Kiess W, Galler A, Reich A, et al. Clinical aspects of obesity in childhood and adolescence. Obes Rev. 2001;2(1):29 362. Clinton Smith J. The current epidemic of childhood obesity and its implications for future coronary heart disease. Pediatr ClinNorth Am. 2004;51(6):1679 16953. Snitker S, Le KY, Hager E, Caballero B, Black MM. Association of physical activity and body composition with insulin sensitivity in a community sample of adolescents. Arch Pediatr Adolesc Med. 2007;161(7):677 683Immediate and longterm health problems123Obstructive sleep disordersAsthmaElevated Blood Lipids/ insulin Hypertension, Heart diseaseType 2 diabeticMusculosceletal (Orthopedic) problemsMenstrual IrregularityDepression and social stigmatization.

Diabetes Prevalence Parallels Obesity Diabesity

Insulin Resistence and Adolsc. T2DM in USAObstructive sleep apnea in USA adult and children

Obesity and the metabolic syndrome in childhood and adolescentWeists R, Dziura J, Burgert TS et al. Obesity and the metabolic syndrome children and adolescents .N. Eng J Med 2004;350:2362-74 Severely obese 50 %

Increasing of each half unit on BMI

the risk of metab syndr ( OR 1,55 95 CI 1,16 2,08)

What we have to doIdentificationAssessmentPrevention ( No health risk): 4.Intervention for Treatment (Health Risk)

Barlow SE and the Expert Committee. Expert Committee Recommendations Regarding the Prevention, Assessment and Treatmentof Child and Adolsecent Overweight and Obesity : Summary Report Pediatrics 2007;120; S164 S 192

underwater weight measurementsdual energy x-ray absorptiometrymagneting resonance imagingcomputed tomographystable isotop methods

How to assess obesity to measure body fat1 :1. Identification:Goran ML, Treuth MS.Energy expenditure, physical activity, and obesity in children. Pediatr Clin North Am 2001;48:931-53expensive/ not routinely

1. Skinfold thickness 2. Bioelectric impedance analysis:- acceptable for clinical/ public health purposes appropriate standards and available ??3. W/L-H : - > 90th percentile on NCHS growth chart - or W > 120% of the median (A,H,Sex)4. BMI : W (kg)/ H2 (m2) useful standard measure of adiposityEasily in clinical/ epidemiological setting

Barlow SE, Dietz WH. Obesity evaluation and treatment: expert committee recommendations: The Maternal and Child Health Bureau, Health Resources and Services Administration and The Departement of Health and human Services. Pediatrics.1998;102(3). Skinfold thickness Overgrowth Fatty (obesity)Triceps, Subscapular Supra iliacNot recommended for routine clinical use: lack of available data reff.

Waist Circumferencea better estimate for adipose tissuemore efficient for predicting insulin resistence, blood pressure serum cholesterolfor adolescentLee S, Bacha F, Gungor N et al. Wist circumference is an independent predictor of insulin resintence in black and whiteYouths. J Pediatr 2001;90:387-92 Not reccommended for routine clinical use- incomplete information- lack spesific guidelines for clinical use

1. Gutin B, Basch C, Shea S et al.Blood pressure, fitness, and fatness in 5 and 6 year old children.JAMA 1990;264:1123-72. Laskarzewesky P, Morrison JA, Mellies MJ et al. The relationships of measurements of body mass to plasma lipoproteins in school children and adults. AmJ Epidemiol 1980;111:395-4063. Ronnema T, Knip M, Lautal P et al. Serum insulin and other cardiovascular risk indicators in children and adults. Ann Med 1991;23:67-72.

BMI1. doesnt directly measured body fat 2. evaluate as predictor adiposity in child, adoles, adult3. predicts risks : present/ future medical complication Children- blood pressure1- lipids2 and insulin3 levels

BMI Calculation - example

BMI = Wt (kg) / Ht2 (m2)

EX: Boy A/ 3 yearsWt = 20 kg; Ht = 90 cm BMI = 20 / (0,9)2 = 19,99

Boy A, 38 monts, W 20 kg, Ht 90 cm

BMI for age ( for children & teens)BMI-for-age percentile shows how your childs weight compares to that of other children of the same age and sex. For example, a BMI-for-age percentile of >95% means that the childs weight is greater than that of >95% of other children of the same age and sex.

From the CDC:http://apps.nccd.cdc.gov/dnpabmi/Result.aspx?&dob=1/1/2003&dom=1/1/2006&age=36&ht=36&wt=40&gender=2&method=0&inchtext=0&wttext=0

Underweight95th percentile

UKK NPM : =< 2 yearsWHO 2005 CDC No reff data 2 years CDC 2000 WHO No reff data >2 yearsBMI WHO 2005

3. Prevention ( No health risk): Target Behavior: problem behaviors, current practicesParent/ Family counseling2. Assessment:Medical Risk : Child growth, Family historyBehavior Risk: sedentary, physical activityAttitudes : concern to motivation

Barlow SE and the Expert Committee. Expert Committee Recommendations Regarding the Prevention, Assessment and Treatmentof Child and Adolsecent Overweight and Obesity : Summary Report Pediatrics 2007;120; S164 S 192

Pediatrics 2003;112:424-30Obese child 2 7 years >= 7 years85 =95 thBMI85 =95 thWeightmaintenanceComorbidityComorbidityYes NoYes NoWeightmaintenanceWeightlossWeightmaintenanceWeightlossWeightloss3.Intervention for Treatment (Health Risk)

Dietary Intervention1. Balanced macronutrient/ Low energy dietsAcute treatment phase 6 12 yNot less than 1200 kcal/day

mixed, effective for weight management2. Traffic light dietgreen, low density energy, free consumptionyellow, moderate density energy, moderate consumptionred, high density energy, very limited consumption (

Energy proportionInfants 2 years child >2 yearsCarbohydrate35 55%55 60%Protein10 20%10 20%Fat35 50%< 30%

RDAAge (Y)Energy (Cal/Kg)0 1110 1201 31004 690boysgirls7 980-9060-8010 1450 -7040-6514 1840-5040Calorie = ideal body weight (Kg) X RDA

Mead Jhonson seminar and workshop, March 20,2011, Horison Hotel,Palembang

Medical Sibutramine- >= 16 y- Behavioral Weight side effectlong-term safety ??

2. Orlistateffective side effect: abd. cramp flatus + discharge

Morbid ObesityMalabsorptive, Restrictive and combination

Recommended1Physical matureBMI >= 50 / >40 kg/m2 + signicant comorbidityFailure to 6 mo conventional treat. (weight loss program)Be capable of life style changes after surgery Experience and capable to long term follow up care

Limited data (risks and benefits)Conservative approach

Bariatric Surgery1.Inge TH, Krebs NF, Garcia WF et al.Bariatric surgery for severely overweight adolescents: concerns and recommendations.Pediatrics.2004;114:217-23

Summary1. Obesity is chronic dis. Metabolic syndrome

2. Early prevention/ treatment best response

3. Management: 3.1. Diet modification3.2. Increase of physical activity3.3. Behavioral changes3.4. Medications3.5. Surgery

4. Involving all family members

THANK YOU

Staged Treatment of Pediatrics Obesity According to Age and BMI PercentileAge2 5 y 6 11 y 12 18 y TreatmentPrevention PlusStructured Weight Management (SWM)Comprehensive Multidiciplinary Intervention (CMI)Tertiary Care Intervention (CTI)BMI Percentile5 th 84 th85 th 94 th95 th 99 th>99 th1. Spear AB, Barlow SE, Ervin C et al. Recommended for Treatment of Child and AdolelescentOverweightand Obesity. Pediatrics 2007;120;S254-88 Recommended for Treatment of Child and Adolelescent Overweight and Obesity1

SuggestedStaged treatment2 5 yearsPediatrics 2007;120:S254-288Prevention PlusSWM :Structured Weight Management CMI: Comprehensive Multidiciplinary Intervention CTI: Tertiary Care Intervention

Mead Jhonson seminar and workshop, March 20,2011, Horison Hotel,Palembang

SuggestedStaged treatment6 11 yearsPediatrics 2007;120:S254-288

Mead Jhonson seminar and workshop, March 20,2011, Horison Hotel,Palembang

SuggestedStaged treatment12 18 yearsPediatrics 2007;120:S254-288

Stage 1. Prevention Plus1. 5 servings of fruit and vegetables/ day

2. 2 h of screen times/ day

3. NO TV in bedroom, NO TV for child

Stage 2. Structured Weight Management (SWM)1. Balance macronutrient diet, small energy dense food (high quality protein)

2. Reduce screen time 1h/ day, increase physical activity 1 h/d

3. Monitor patient/ parent activities (screen time, physical activity, diet etc)

4. Perform medical screening

Stage 3. Comprehensive Multidiciplinary Intervention (CMI)1. As stage 2, more frequent patient/ parent contact with provider

2. Child

Stage 4. Tertiary Care Intervention (CTI)1. Continue diet and activity counseling of meal replacement,

2. Very low energy diet

3. Medication

4. Surgery

Weight Recommendation according to age and BMI PercentileAgeBMITarget

2 5 85 94Weight maintenance until =95 Weight maintenance until 99weight loss 2 lb/Wk cause of exessive weight loss12 1885 94 Weight maintenance until 95 98 Weight loss99weight loss 2 lb/wk cause of exessive weight loss

Pediatrics 2007;120:S254-288

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