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CHILDHOOD CHILDHOOD OBESITYOBESITY
CRITERIA FOR OBESITYCRITERIA FOR OBESITY
Body mass index (BMI) Body mass index (BMI) BMI= Weight (Kg) / Height (m)BMI= Weight (Kg) / Height (m)2 2
BMI more than 85BMI more than 85thth percentile - percentile - Overweight Overweight
BMI more than 95BMI more than 95thth percentile – Obese percentile – Obese BMI is a good indicator of body fatBMI is a good indicator of body fat BMI is unreliable in short muscular BMI is unreliable in short muscular
individualsindividuals
Weight for height Weight for height
Weight for height compares the Weight for height compares the child’s weight to the expected child’s weight to the expected weight for his/her heightweight for his/her height
Weight for height more than 120% - Weight for height more than 120% - Obese Obese
Skin fold thicknessSkin fold thickness
Skin fold thickness (SFT)– indicator Skin fold thickness (SFT)– indicator of subcutaneous fat. of subcutaneous fat.
Measured over subscapular, triceps Measured over subscapular, triceps or biceps region. or biceps region.
Age specific cut-offs should be used.Age specific cut-offs should be used. SFTmore than 85SFTmore than 85thth percentile is percentile is
considered as abnormal. considered as abnormal.
Waist circumferenceWaist circumference
Marker of abdominal adiposity.Marker of abdominal adiposity. Key risk factor for metabolic and Key risk factor for metabolic and
cardiovascular effects of obesity. cardiovascular effects of obesity.
INCIDENCE &PREVALENCE
ETIOLOGYETIOLOGY
CONSTITUTIONAL OBESITYCONSTITUTIONAL OBESITY ENVIRONMENTAL FACTORSENVIRONMENTAL FACTORS ENDOCRINE CAUSES ENDOCRINE CAUSES HYPOTHALAMIC OBESITY HYPOTHALAMIC OBESITY DRUGS DRUGS GENETIC SYNDROMES GENETIC SYNDROMES MONOGENIC DISORDERS MONOGENIC DISORDERS
CONSTITUTIONAL CONSTITUTIONAL OBESITYOBESITY
Over 95% of all casesOver 95% of all cases Imbalance in energy intake and Imbalance in energy intake and
expenditure expenditure Proportional obesity Proportional obesity Tall for age Tall for age Normal developmentNormal development Avoid unnecessary investigations Avoid unnecessary investigations Family historyFamily history
ENVIRONMENTAL ENVIRONMENTAL FACTORSFACTORS
Excessive calorie intake Excessive calorie intake Sedentary lifestyle Sedentary lifestyle Television viewing Television viewing Computer games Computer games Decreased physical Decreased physical
activity activity
ENDOCRINE CAUSESENDOCRINE CAUSES
Cushing syndrome Cushing syndrome Hypothyroidism Hypothyroidism GH DeficiencyGH Deficiency Pseudohypoparathyroidism Pseudohypoparathyroidism
Growth failure in obese child is an Growth failure in obese child is an important indicator important indicator
Cushing syndromeCushing syndrome
Central obesity Central obesity Hypertension Hypertension Striae Striae Retarded skeletal maturation Retarded skeletal maturation Hirsutism Hirsutism Myopathy Myopathy
HypothyroidismHypothyroidism
Rare cause of isolated obesity Rare cause of isolated obesity Developmental delay Developmental delay Coarse skin Coarse skin Retarded skeletal maturation Retarded skeletal maturation Constipation Constipation Cold intolerance etc Cold intolerance etc
GH DeficiencyGH Deficiency
Short statureShort stature Body proportions are normal Body proportions are normal Immature facies “doll like”Immature facies “doll like” Delayed teeth development Delayed teeth development Bone age is delayed Bone age is delayed
Pseudohypoparathyroidism Pseudohypoparathyroidism
Growth retardation Growth retardation Hypocalcemia Hypocalcemia Round facies Round facies BrachydactylyBrachydactyly Brachymetacarpia Brachymetacarpia Subcutaneous calcifications Subcutaneous calcifications Bony deformities Bony deformities
DRUGSDRUGS Antiepileptic drugsAntiepileptic drugs Steroids Steroids Estrogen Estrogen Glucocorticoids, Glucocorticoids, sulfonylureas, sulfonylureas, MAOIs MAOIs oral contraceptives, oral contraceptives, risperidone, risperidone, clozapineclozapine
HYPOTHALAMIC HYPOTHALAMIC OBESITYOBESITY
Head injury Head injury Infection Infection Brain tumors Brain tumors Radiation Radiation Post-neurosurgeryPost-neurosurgery
HYPOTHALAMIC HYPOTHALAMIC OBESITYOBESITY
Excessive appetite Excessive appetite Signs & symptoms of CNS Signs & symptoms of CNS
involvementinvolvement Hypothalamic pituitary defects Hypothalamic pituitary defects
GENETIC SYNDROMESGENETIC SYNDROMES
Prader willi syndrome Prader willi syndrome Laurence Moon Biedle Bardet Laurence Moon Biedle Bardet
syndrome syndrome Beckwith weidmann syndrome Beckwith weidmann syndrome Carpenter syndrome Carpenter syndrome
Prader willi syndromePrader willi syndrome
Infantile hypotonia Infantile hypotonia Hyperphagia Hyperphagia Almond like eyes Almond like eyes Behavioural abnormalityBehavioural abnormality Hypogonadism Hypogonadism
Laurence Moon Biedle Laurence Moon Biedle Bardet syndromeBardet syndrome
Hypogonadism Hypogonadism Retinitis pigmentosa Retinitis pigmentosa Polydactyly mental retardation Polydactyly mental retardation Type 2 diabetes mellitusType 2 diabetes mellitus Renal abnormalities Renal abnormalities
Beckwith weidmann Beckwith weidmann syndromesyndrome
OrganomegalyOrganomegaly Earlobe creasesEarlobe creases hemihypertrophyhemihypertrophy
MONOGENIC MONOGENIC DISORDERSDISORDERS
Leptin deficiency Leptin deficiency Leptin resistance Leptin resistance Abnormalities of MC4R & Abnormalities of MC4R &
proconvertaseproconvertase
EVALUATIONEVALUATION
HistoryHistory Age of onset – use of growth charts Age of onset – use of growth charts
and family photographs. Early onset and family photographs. Early onset (_5 years of age) suggests a genetic (_5 years of age) suggests a genetic causecause
Duration of obesity – short history Duration of obesity – short history suggests endocrine or central causesuggests endocrine or central cause
History(cont….)History(cont….)
A history of damage to the CNS A history of damage to the CNS (e.g. infection, trauma, hemorrhage, (e.g. infection, trauma, hemorrhage, radiation therapy, seizures) suggests radiation therapy, seizures) suggests hypothalamic obesity with or without hypothalamic obesity with or without pituitary GH deficiency or pituitary pituitary GH deficiency or pituitary hypothyroidism. hypothyroidism.
History(cont….)History(cont….)
A history of morning headaches, A history of morning headaches, vomiting, visual disturbances and vomiting, visual disturbances and excessive urination or drinking also excessive urination or drinking also suggests that the obesity may be suggests that the obesity may be caused by a tumor or mass in the caused by a tumor or mass in the hypothalamushypothalamus
History(cont….)History(cont….)
A history of dry skin, constipation, A history of dry skin, constipation, intolerance to cold or fatigue intolerance to cold or fatigue suggests hypothyroidism.suggests hypothyroidism.
Mood disturbance and central Mood disturbance and central obesity suggest Cushing syndrome.obesity suggest Cushing syndrome.
Frequent infections and fatigue may Frequent infections and fatigue may suggest ACTH deficiency due to suggest ACTH deficiency due to POMC mutationsPOMC mutations
History(cont….)History(cont….)
•Hyperphagia – often denied but Hyperphagia – often denied but sympathetic approach needed sympathetic approach needed and specific questions, such as and specific questions, such as waking at night to eat and/or waking at night to eat and/or demanding food very soon after a demanding food very soon after a meal, suggest hyperphagia. If meal, suggest hyperphagia. If severe, especially in children, severe, especially in children, suggests a genetic cause for suggests a genetic cause for obesityobesity
History(cont….)History(cont….)
• Developmental delay – milestones, Developmental delay – milestones, educational history, behavioral educational history, behavioral disorders. disorders.
• Consider craniopharyngioma or Consider craniopharyngioma or structural causes(often relatively structural causes(often relatively short history) and genetic causesshort history) and genetic causes
History(cont….)History(cont….)
Visual impairment and deafness can Visual impairment and deafness can suggest genetic causessuggest genetic causes
Onset and tempo of pubertal Onset and tempo of pubertal development – onset can be early or development – onset can be early or delayed in children and adolescents. delayed in children and adolescents.
Primary hypogonadotropic Primary hypogonadotropic hypogonadism or hypogenitalism hypogonadism or hypogenitalism associated with some genetic disordersassociated with some genetic disorders
History(cont….)History(cont….)
Family history – consanguineous Family history – consanguineous relationships, other children affected, relationships, other children affected, family photographs useful. family photographs useful.
Severity may differ due to Severity may differ due to environmental effectsenvironmental effects
Treatment with certain drugs or Treatment with certain drugs or medications. Glucocorticoids, medications. Glucocorticoids, sulfonylureas, MAOIs oral sulfonylureas, MAOIs oral contraceptives, risperidone, clozapinecontraceptives, risperidone, clozapine
ExaminationExamination
Document weight and height Document weight and height compared with normal centiles. compared with normal centiles.
Calculate BMI and WHR (in adults). Calculate BMI and WHR (in adults). In children, obtain parentalheights In children, obtain parentalheights and weights where possibleand weights where possible
Head circumference if clinically Head circumference if clinically suggestivesuggestive
Examination(cont…)Examination(cont…)
Short stature or a reduced rate of Short stature or a reduced rate of linear growth in a child with obesity linear growth in a child with obesity suggests the possibility of GH suggests the possibility of GH deficiency, hypothyroidism, cortisol deficiency, hypothyroidism, cortisol excess, pseudohypoparathyroidism excess, pseudohypoparathyroidism or a genetic syndrome such as or a genetic syndrome such as Prader–Willi syndromePrader–Willi syndrome
Examination(cont…)Examination(cont…)
Obese children and adolescents are often Obese children and adolescents are often tall (on the upper centiles), however, tall (on the upper centiles), however, accelerated linear growth (height SDS accelerated linear growth (height SDS >2) is a feature of MC4R deficiency>2) is a feature of MC4R deficiency
Body fat distribution – central Body fat distribution – central distribution with purple striae suggests distribution with purple striae suggests Cushing syndrome. Cushing syndrome.
Selective fat deposition (60%) is a feature Selective fat deposition (60%) is a feature of leptin and leptin receptor deficiencyof leptin and leptin receptor deficiency
Dysmorphic features or skeletal Dysmorphic features or skeletal dysplasiadysplasia
Examination(cont…)Examination(cont…)
Pubertal development/secondary sexual Pubertal development/secondary sexual characteristics.characteristics.
Most obese adolescents grow at a normal or Most obese adolescents grow at a normal or excessive rate and enter puberty at the appropriate excessive rate and enter puberty at the appropriate age; many mature more quickly than children with age; many mature more quickly than children with normal weight, and bone age is commonlynormal weight, and bone age is commonly
advanced.advanced. In contrast, growth rate and pubertal development In contrast, growth rate and pubertal development
are diminished or delayed in GH deficiency, are diminished or delayed in GH deficiency, hypothyroidism, cortisol excess and a variety of hypothyroidism, cortisol excess and a variety of genetic syndrome. genetic syndrome.
Conversely, growth rate and pubertal development Conversely, growth rate and pubertal development are accelerated in precocious puberty and in some are accelerated in precocious puberty and in some girls with PCOSgirls with PCOS
Examination(cont…)Examination(cont…)
Acanthosis nigricansAcanthosis nigricans Valgus deformities - in severe Valgus deformities - in severe
childhood obesitychildhood obesity Hair color – red hair (if not familial) Hair color – red hair (if not familial)
may suggest mutations in may suggest mutations in POMC (pro-POMC (pro-opiomelanocortin) in white opiomelanocortin) in white CaucasiansCaucasians
InvestigationsInvestigations
Fasting and 2-h post glucose and Fasting and 2-h post glucose and insulin levels. Proinsulin if insulin levels. Proinsulin if PC1( prohormone convertase 1) PC1( prohormone convertase 1) deficiency considereddeficiency considered
Fasting lipid panel for detection of Fasting lipid panel for detection of dyslipidemiadyslipidemia
Thyroid function testsThyroid function tests Serum leptin if indicatedSerum leptin if indicated
Investigations(cont…)Investigations(cont…)
KaryotypeKaryotype DNA for molecular diagnosisDNA for molecular diagnosis Bone ageBone age GH secretion and function tests, GH secretion and function tests,
when indicatedwhen indicated Assessment of reproductive Assessment of reproductive
hormones, when indicatedhormones, when indicated
Investigations(cont…)Investigations(cont…)
Serum calcium, phosphorus and Serum calcium, phosphorus and parathyroid hormone levels to parathyroid hormone levels to evaluate for suspected evaluate for suspected pseudohypoparathyroidismpseudohypoparathyroidism
MRI scan of the brain with focus on MRI scan of the brain with focus on the hypothalamus and pituitary, the hypothalamus and pituitary, when clinically indicatedwhen clinically indicated
Screening for glucose intolerance and Screening for glucose intolerance and thethe
metabolic syndrome in children and metabolic syndrome in children and adolescents.adolescents.
High-risk populationsHigh-risk populations Obese (BMI Obese (BMI zz-score >95th percentile) -score >95th percentile)
children or adolescent, pluschildren or adolescent, plus High-risk ethnic group and/orHigh-risk ethnic group and/or Family history of type 2 diabetes or GDM Family history of type 2 diabetes or GDM
and/orand/or Acanthosis nigricans and/orAcanthosis nigricans and/or Prominent abdominal fat depositionProminent abdominal fat deposition Ovarian hyperandrogenismOvarian hyperandrogenism
Screening for glucose intolerance and Screening for glucose intolerance and thethe
metabolic syndrome in children and metabolic syndrome in children and adolescentsadolescents
Screening proceduresScreening procedures Blood pressureBlood pressure Fasting glucose and insulin levelsFasting glucose and insulin levels Fasting lipid panel (_FFA if possible)Fasting lipid panel (_FFA if possible) 2-h glucose level (_insulin if 2-h glucose level (_insulin if
possible)possible) HbA1c (less useful)HbA1c (less useful)
COMPLICATIONSCOMPLICATIONS
CNS – Benign intracranial hypertensionCNS – Benign intracranial hypertension Respiratory – Obstructive sleep apneaRespiratory – Obstructive sleep apnea Cardiovascular – Atherosclerosis, Cardiovascular – Atherosclerosis,
HypertensionHypertension Hepatobiliary – Nonalcoholic steatohepatitis,Hepatobiliary – Nonalcoholic steatohepatitis,
gall stonesgall stones Endocrine – PCOD, Type 2 DM, DislipidemiaEndocrine – PCOD, Type 2 DM, Dislipidemia Orthopedic – Osteoarthritis, slipped capital Orthopedic – Osteoarthritis, slipped capital
femoral epiphyses femoral epiphyses
ManagementManagement
Treatment of obesity aims to:Treatment of obesity aims to: Reduce BMI and visceral fat mass;Reduce BMI and visceral fat mass; Decrease circulating insulin Decrease circulating insulin
concentrations;concentrations; Increase insulin sensitivityIncrease insulin sensitivity Decrease hepatic glucose production Decrease hepatic glucose production
and fasting and post-prandial and fasting and post-prandial glucose concentrations;glucose concentrations;
Management( cont…)Management( cont…)
Reduce circulating FFA and TG Reduce circulating FFA and TG concentrations;concentrations;
Decrease blood pressure;Decrease blood pressure; Reduce the expression of Reduce the expression of
inflammatory cytokines;inflammatory cytokines; Normalize vascular and endothelial Normalize vascular and endothelial
function function
Management( cont…)Management( cont…)
Dietary measuresDietary measures 30-40% caloric restriction 30-40% caloric restriction Improve nutritive value of dietImprove nutritive value of diet Reduction in consumption of junk Reduction in consumption of junk
food, carbonated drink , saturated food, carbonated drink , saturated fatfat
Increase in fiber, fruits, vegetables.Increase in fiber, fruits, vegetables.
Management( cont…)Management( cont…)
Lifestyle modificationLifestyle modification Increase in physical activities- 30-45 Increase in physical activities- 30-45
min/daymin/day Swimming Swimming Running Running Playing outdoors Playing outdoors
Management( cont…)Management( cont…)
DrugsDrugs Orlistat – gastric lipase inhibitor Orlistat – gastric lipase inhibitor Sibutramine – neurotransmitter Sibutramine – neurotransmitter
modulator modulator Metformin – in children with insulin Metformin – in children with insulin
resistance resistance Leptin – for leptin deficiency Leptin – for leptin deficiency Octreotide – for hypothalamic obesityOctreotide – for hypothalamic obesity
SurgerySurgery
Indicated for morbid obesity Indicated for morbid obesity BMI>40 kg/mBMI>40 kg/m22
Last resort in treatmentLast resort in treatment Laparoscopic gastric banding- Laparoscopic gastric banding-
procedure of choice procedure of choice
directed at reducing gastric directed at reducing gastric capacity capacity
Learning PointsLearning Points
There is a global epidemic of obesityThere is a global epidemic of obesity A very few obese children have a monogenic A very few obese children have a monogenic
cause of their conditioncause of their condition Consequences of obesity include insulin Consequences of obesity include insulin
resistance and type 2 diabetes, dyslipidemia, resistance and type 2 diabetes, dyslipidemia, hepatic steatosis/steatohepatitis (fatty liver), hepatic steatosis/steatohepatitis (fatty liver), hypertension, focal glomerulosclerosis, hypertension, focal glomerulosclerosis, accelerated growth and bone maturation, accelerated growth and bone maturation, ovarian hyperandrogenism, gynecomastia,ovarian hyperandrogenism, gynecomastia,
cholecystitis, pancreatitis and cholecystitis, pancreatitis and pseudotumorcerebripseudotumorcerebri
Learning PointsLearning Points Non-metabolic complications include sleep Non-metabolic complications include sleep
apnea,apnea,orthopedic disorders and stress incontinenceorthopedic disorders and stress incontinence Long-standing obesity and insulin resistanceLong-standing obesity and insulin resistanceincrease the risk of cardiovascular disease, stroke,increase the risk of cardiovascular disease, stroke,orthopedic complications, sleep apnea, someorthopedic complications, sleep apnea, somemalignancies and psychosocial disorders in adultsmalignancies and psychosocial disorders in adults Treatment is by lifestyle intervention (includingTreatment is by lifestyle intervention (includingbehavior therapy), pharmacotherapy andbehavior therapy), pharmacotherapy andsurgery but success is very limitedsurgery but success is very limited Prevention is better than curePrevention is better than cure
Thank youThank you