childhood obesity in practice: a look at the obese & the extremely obese

Childhood Obesity in Practice: Childhood Obesity in Practice: A look at the obeseA look at the obese

& the extremely obese& the extremely obese

Robert Murray MD

Marc Michalsky MD

Nationwide Children’s Hospital

Aims of Presentation

• a synopsis national guidelines

• the risk of extreme obesity • bariatric surgery

and resolution of health risk

The Expert Committee

• American Medical Association

• Dept of Health and Human Services

• CDC & Prevention• American Academy of

Pediatrics• American Dietetics

Association• Natl Assoc of Pediatric

Nurse Practitioners • National Medical

Association

• American Heart Association• National Association of

School Nurses• American college of Sports

Medicine• The Obesity Society• The Endocrine Society• American College of

Preventive Medicine• American Academy of Child

& Adolescent Psychiatry• Association of American

Indian Physicians

Pediatrics, December 2007, 120:supplement 4

The Primary Physician’s RoleThe Primary Physician’s Role

Prevention Identification Intervention

Nine Evidence-Based Messages

1. Support exclusive breastfeeding 4-6 months

2. Limit sweetened beverages

3. Eat 5 servings per day of fruits & vegetables

4. Participate in moderate to vigorous physical activity for 60 mins/ day

5. Limit screen time to a maximum of 2hrs/ day

6. Do not allow your child to have a television in his or her bedroom

7. Eat a nutritious breakfast every day

8. Engage in regular family meals 5-6 times/ week

9. Limit portion sizes

For Prevention & Counseling

An OUNCE of PREVENTION:An OUNCE of PREVENTION:Anticipatory Guidance for obesity prevention Anticipatory Guidance for obesity prevention

www.NationwideChildrens.org/HealthyWeight/

Ohio Chapter, American Academy of PediatricsOhio Department of HealthOhio Dietetics AssociationAmerican Dairy Council, Mid-East

Normal at 10 yrs = 10% risk of obesity as adult“At risk” or overweight at 10 yrs = 80% risk

Media Policy

Food IndustryNeighborhood Environment

SchoolsPre-schools

Medical Medical CommunityCommunity

Early Childhood Providers

Out of school time/Faith Based

Societal Level

Community Level

Inter-personal Level

CHILD

Family

The Workplace

Health & Fitness Takes Many TeachersHealth & Fitness Takes Many Teachers

Communityprograms

Parental Perceptions of their Overweight Child

– Only 1/3 recognized it– Only 1/4 worried about it– Only 1/5 recalled MD concern

In most studies In most studies parental recognition parental recognition

of overweight of overweight occurs around age 8-12 yrs -- occurs around age 8-12 yrs --

Even later for boys Even later for boys

Eckstein, Pediatrics 2006; 117:681

At every well-child visit, discuss weightnutrition, activity

and health risk

Pediatric Obesity Management Pocket Guide

Create a Risk ProfilePlace the BMI in Context

• Family health history– Obesity– Diabetes– Cardiovascular disease

• Targeted review of systems

• Targeted physical exam

• Blood pressure

Review of Systems• Abdominal pain• Joint pain• Snoring, apnea, daytime

sleepiness• Polyuria, polydipsia• Irregular menses• Signs of mood disorder

– Depression, anxiety– social or school avoidance

• Exercise tolerance• Diet• Screen time

Physical Exam

• Papilledema on eye exam• Tonsillar hypertrophy• Abdominal pain• Hepatomegaly• Tibial bowing• Hip or knee pain• Signs of precocious puberty • Skin findings

– acne, striae, hirsutism – acanthosis nigricans

insulin resistance hyperinsulinemia skin changes

Fat mass insulin resistance altered metabolismaltered metabolism• diabetes• hypertension• abnormal lipids• inflammation• cardiovascular ds• asthma• liver disease• sleep apnea• orthopedic problems

Identifythis

early

Blood Pressurea critical risk

• Children >3 years of age • Auscultation is preferred • Use appropriate sized cuff• Must be plotted on curves

adjusted for age, sex, and height

• Measurements that exceed the 90th percentile should be repeated

Do I have to check labs?BMI Percentile Labs

85-94%

No risk factors

Fasting Lipid Profile

85-94%

With risk factors

Fasting Lipid Profile

ALT, AST, Fasting glucose

>95% Fasting Lipid Profile

ALT, AST, Fasting glucose

Consider Fasting Lipid Profile age >=2 years, Additional hepatic function and fasting glucose should be considered at age >= 10years. Clinical judgment may dictate additional labs in the younger child with higher risk.

Motivation/Attitude

Nine Evidence-Based Messages

1. Support exclusive breastfeeding 4-6 months

2. Limit sweetened beverages

3. Eat 5 servings per day of fruits & vegetables

4. Participate in moderate to vigorous physical activity for 60 mins/ day

5. Limit screen time to a maximum of 2hrs/ day

6. Do not allow your child to have a television in his or her bedroom

7. Eat a nutritious breakfast every day

8. Engage in regular family meals 5-6 times/ week

9. Limit portion sizes

Prevention & Counseling

Algorithm For Intervention

Resources to Help You• Ounce of Prevention

– Birth to 5 years– 6 to 19 yrs NEW!– Parent handouts

• BMI wheels and tables• Parent Tip Sheets• Pocket management book • Coding sheet• Acanthosis training NEW!

www.NationwideChildrens.org/HealthyWeight

Extreme ObesityExtreme Obesity

What to do with

Medical Sequelae of ObesityMedical Sequelae of Obesity Hypertension Lipid disorders Diabetes Ischaemic heart disease Cardiomyopathy Pulmonary hypertension Asthma Hypoventilation syndromes Obstructive sleep apnea Gallstones NASH (Non-alcoholic

steatohepatitis) Urinary incontinence

Gastroesophageal reflux Arthritis – weight bearing Low back pain Infertility and menstrual

problems Obstetric complications DVT and thromboembolism Depression Immobility Cancer Venous/stasis ulcers Intertrigo Accident prone

Adipocytes are Endocrine Cells

Secretion of > 50 Adipokines• Leptin•Adiponectin•Resistin•TNF- alpha

Adipose Actions• stimulate inflammation

• increase insulin resistance (block receptor signaling)• attract macrophages into fat & vessels (foam cells)

• alter metabolism• lower sensitivity to insulin’s actions • shift glucose-based to FFA-based metabolism• fat storage in non-adipose tissues

Obesity & Endothelial Dysfunction

Adipose Tissue

Nitric Oxide

Adhesion Molecules

MacrophageChemoattractives

Vascular Endothelial Cell

leptin IL-6 FFA fibrinogen Angiotensin II TNF- alpha

• inflammation• thrombus formation• plaque destabilization• lipid accumulation • poor distensibility

Pharmacol Reports 2006; 58: s81

• BMI > 99th percentile or BMI > 35• 2-6% of all kids• > 50% have metabolic syndrome• Significant cardiovascular changes• Multi-organ complications

Extreme Obesity in Children

Weight Loss - Weight Loss - Pediatric ProgramsPediatric Programs

• NACHRI identified 80 pediatric centers NACHRI identified 80 pediatric centers with weight management programs with weight management programs

• Only 15 had an associated surgical Only 15 had an associated surgical weight loss programweight loss program

• 6 to 8 “high” volume programs6 to 8 “high” volume programs

• August, 2008 – NACHRI formed August, 2008 – NACHRI formed Obesity Steering CommitteeObesity Steering Committee

The Bariatric ProgramThe Bariatric Programat Nationwide Children’sat Nationwide Children’s

• Surgeons: Surgeons: – Marc Michalsky, MDMarc Michalsky, MD

– Steve Teich, MDSteve Teich, MD

– Allen Browne, MDAllen Browne, MD

– Bradley Needleman, MD (OSUMC)Bradley Needleman, MD (OSUMC)

– Scott Melvin, MD (OSUMC)Scott Melvin, MD (OSUMC)

• Medical DirectorMedical Director– Robert Murray, MDRobert Murray, MD

“First 50 Patients”Co-morbidity Overall (%) New Dx (%)

Hypothyroidism 7 33Insulin Resistance

28 54

Hypertension 24 10Depression 42 5.5GERD 26 13Type II DM 19 25Asthma 21 22

OSA 26 42

Co-Morbidities in Bariatric PatientsCo-Morbidities in Bariatric PatientsNCH and OSU ExperienceNCH and OSU Experience

0

5

10

15

20

25

30

35

40

45

50

OSA DM HTN

Adults%

0

5

10

15

20

25

30

35

40

45

50

OSA DM HTN

Peds %

0

10

20

30

40

50

60

70

80

% Patients

OSA HTN DM

Pre-Op

20 Weeks

Resolution of Co-morbid Conditions Resolution of Co-morbid Conditions 5 months post-pediatric bypass5 months post-pediatric bypass

Gastric Bypass: Effect on HOMA

0

1

2

3

4

5

6

7

IR25

30

35

40

45

50

55

BM

I

4 wk 8wk 12wk 20wk 32wk 52wk 4 wk 8wk 12wk 20wk 32wk 52wk

Insulin ResistanceBody Mass Index

Homeostatic Model Assessment (HOMA)β Cell Activity vs. Insulin Sensitivity

0

50

100

150

200

250

300

350

400

Per

cent

%B

%S

4 wk 8wk 12wk 20wk 32wk 52wk4 wk 8wk 12wk 20wk 32wk 52wk

Quality of Life Measures 6 months post- bypass

Healthy

Mean (SD)

Pre-Op

Mean (SD)

Post-Op

(6 month)

Mean (SD)

Total Score 83.8 (12.6) 55.7 (15.4) 77.3 (12.3)

Physical Score 87.5 (13.5) 54.2 (18.5) 78.0 (14.0)

Psychosocial 81.8 (14.1) 56.6 (16.6) 77.0 (14.0)

Emotional

Function

79.3 (18.1) 57.2 (21.0) 80.8 (19.3)

Social

Function

85.1 (16.8) 56.6 (23.7) 80.0 (18.3)

School

Function

81.1 (16.5) 55.1 (18.2) 69.5 (21.3)

Washington State Healthcare Washington State Healthcare AuthorityAuthority

Health Technology Clinical Health Technology Clinical CommitteeCommittee

• Evaluated healthcare coverage for Evaluated healthcare coverage for adolescent bariatric surgeryadolescent bariatric surgery

• Assessment of the strength of current Assessment of the strength of current peer-reviewed evidence peer-reviewed evidence

• Determine safety, efficacy and cost Determine safety, efficacy and cost

• Guide decisions regarding state Guide decisions regarding state program coverageprogram coverage

Health Technology Clinical Health Technology Clinical CommitteeCommittee

• 2004: Estimate 2000 bariatric 2004: Estimate 2000 bariatric procedures were performed in patients procedures were performed in patients under 21 yearsunder 21 years

• 75% of bariatric surgeons surveyed 75% of bariatric surgeons surveyed report planning to perform a procedure report planning to perform a procedure on an adolescent in the near futureon an adolescent in the near future

Health Technology Clinical Health Technology Clinical CommitteeCommittee

• Review 17 peer-reviewed studiesReview 17 peer-reviewed studies

• 553 pediatric patients553 pediatric patients

• Studies were assessed for Studies were assessed for validity/qualityvalidity/quality

Meta-analysis Results

• Majority: academic medical centers

• Mean age 15.6 to 18.1 years

• Average BMI– RYGB 51.8 kg/m2

– LAGB 45.8 kg/m2

Questions

1. Does PBS lead to significant (> 7%EBWL) and durable weight loss?

2. Does PBS improve co-morbidities, QOL and survival compared to medical therapy?

3. Safety Profile (surgical v. medical)

4. Cost Profile (surgical v medical)

5. Does efficacy, safety and cost vary according to demographics (age, sex, BMI)

Conclusion

Clinical Clinical ResearchResearchNIH Sponsored

• TeenLABS (Longitudinal AssessmeTeenLABS (Longitudinal Assessment of Bariatric Surgery)– NIH-sponsored, NIH-sponsored, – Multi-centered observational studylti-centered observational study– 2 year follow-up2 year follow-up– 5 centers5 centers– N = 200 teens

Clinical Clinical ResearchResearchNIH Sponsored

• Teen-Intake (Nutritional AssessmeTeen-Intake (Nutritional Assessment of Bariatric Surgery)– NIH-sponsored, NIH-sponsored, – Multi-centered observational studylti-centered observational study– 2 year follow-up2 year follow-up– N = 200 teens

• TeenVIEW (Controlled Longitudinal oTeenVIEW (Controlled Longitudinal of Psycho-social Development)– NIH-sponsored, NIH-sponsored, – Multi-centered observational studylti-centered observational study– 2 year follow-up2 year follow-up– N = 200 teens

Clinical ResearchClinical ResearchIndustry Sponsored

• LBA 001 (Allergan)LBA 001 (Allergan)– Industry-sponsored IDE, 5 year follow-upIndustry-sponsored IDE, 5 year follow-up– Multi-institutional safety/efficacy trialMulti-institutional safety/efficacy trial

• n = 150 subjects (14 to 17 years)n = 150 subjects (14 to 17 years)– Local: n = 26, enrollment closed Dec, 2007Local: n = 26, enrollment closed Dec, 2007

Reversal of Type II Diabetes• 11 teens > 1 year after Roux-en-Y bypass• Mean BMI 50 + 5.9; 50% metabolic synd• Post-op

– BMI fell by 34% to 33 + 7 kg/m2– Improvement of fasting glucose, insulin,

HOMA-IR, Hb A1C, AST, ALT, LDL, triglycerides, total cholesterol, blood pressure

– Remission of diabetes in 10 of 11 cases– Removal of oral hypoglycemics in 10 cases

Inge et al, Pediatrics 2008; 123:214

Cardiovascular Risk &Extreme Obesity in Teens

• BMI > 99th %ile or BMI > 40

• N=38 13-19 yrs old

• Pre- and post- gastric bypass surgery

• Echocardiogram, doppler studies– Adequate studies in only 38 of 67 cases– LV geometry (size, ventricular shape, mass, wall thickness)

– LV systolic function (contractility, wall thickness)

– Diastolic function (atrial size, pulsed doppler assessment)

Ippisch et al, J Am Coll Cardiol 2008; 51:1342

Weight Loss & Cardiovascular Risk

• ¼ showed high risk concentric LVH– Adults: with concentric LVH, 53% had a cardiovascular event– Teens: 28% had concentric LVH pre-op, only 3% post-op

• LV mass increased – Adults: > 51 g/m2.7 had 4-fold higher CV mortality– Teens studied: averaged > 54 g/m2.7, max 86 g/m2.7

• LV dimensions, systolic function: abnormal– Normal LV geometry: only 36% pre-, up to 79% post-op

• Elevated cardiac workload, BP– Decreased HR and systolic BP, rate-pressure product

• Abnormal diastolic function– Improved mitral valve and filling dynamics post-op

Ippisch et al, J Am Coll Cardiol 2008; 51:1342

Comparison of CMR results from obese (OB) adolescents to published normal weight (NW) normative reference values. (A) Left ventricular (LV) mass, (B) LV end diastolic volume, (C) LV ejection fraction, (D) Myocardial Perfusion Reserve Index (MPRI). * p<0.01

A B C D

Cardiovascular Status Pre-surgeryCMR Results

10 patients pre-bariatric surgery show strikingcardiovascular abnormalities and risk

ConclusionsConclusions

• Extremely Obese Teens– Have many serious co-morbidities– High risk of type II diabetes– Extreme cardiovascular risk

• Bariatric Surgery– Shows effective metabolic resolution– Resolution of co-morbid conditions– Resolution of cardiovascular abnormalities– Minimal risk

Center for Healthy Weight & NutritionCenter for Healthy Weight & Nutrition

PreventionPrevention TreatmentTreatment

Public Health

HealthcareProviderSupport

Medical Weight Loss Programs

ResearchResearchChild &FamilyEducation

Bariatric Bariatric SurgerySurgery

www.NationwideChildrens.org/HealthyWeight