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1: PCOS – Obesity The Present Day Menace
2: Epidemiology There is an epidemic of Childhood obesity in the world
From 1963-91 -Doubling of the incidence of children with BMI of more than 95th centile
Overall scales are going up. Children with the same BMI centiles are now heavier
Genetic shift unlikely. Profound environmental effect
3: Definition Weight centile alone is useless as it does not consider height
Height for weight is better but does not differentiate between increased muscle or fat
BMI reflects the degree of fat content best
BMI = Weight in Kgs / Height in m 2
4: Obesity is not overweight.
Obesity is excess body fat
In adults
BMI > 25 is overweight
BMI > 30 is obese
In children
BMI > 85 centile for the age is overweight
BMI > 95 centile is obese Definition
5: Lab methods
Underwater weighing
DEXA
Air displacement plethysmography
Skin fold thickness
Bioelectric impedence
Not useful in clinical practice
Country specific BMI charts
Should be prepared and then 85 and 95 centile limits should be used Definition
6: BMI Centile Charts
7: Definition and Epidemiology Increased prevalence is now seen in countries where the major problem used to be malnutrition
Now obesity is caused by poor food choice and decreased activity
Indeed we are seeing this more and more commonly in urban areas in India !
8: Tracking of Obesity Three crucial periods determine the chance of obesity during adulthood
Gestational period – Infant’s of Diabetic Mother’s have higher chance of becoming obese at 6-10 years and persist into adulthood
Adiposity rebound - Early adiposity rebound was related to parental obesity and persistence of obesity in adulthood
Adolescent period
9: Childhood onset obesity
Has worse prognosis than adult onset obesity
Associated with
High BP
Increased risk of cardiovascular morbidity
Insulin resistance and dyslipidemia
Lipid profile reveals
High triglyceride levels
Low HDL levels
Visceral fat is most metabolically active Tracking of Obesity
10: Sequel of Obesity Obese children have . . .
2.5 times risk of having high BP
8.5 times risk of being hypertensive adults
Increased left ventricular mass
Higher chance of being insulin resistant
May develop Type 2 diabetes as early as 6 years
11: Functional ovarian hyperandrogenism
Restrictive airway disease
Obstructive airway disease
Snoring, Sleep apnea, Right ventricular hypertrophy
Heart failure
High incidence of asthma Sequel of Obesity
12: Gynaecological Consequenses Of Obesity PCOD- Hair-An syndrome
Anovulation
Amenorrhoea
D.U.B.
Fibroid Uterus
Fungal Infections
Infertility
13: Evaluation of Obese Youth Family history
SMR, acanthosis and striae, goitre
Blood pressure
Cholesterol, Blood sugar and HbA1c
Liver function tests
14: Evaluation of Obese Youth - Endocrine tests T3, T4, TSH
Cortisol
Dexamethasone suppression test - Low dose
1.5 mg/m2 of Dexamethasone given at 10 p.m.
If short metacarpal, cataract etc. then Ca, Phosphorus, PTH
Bone age
15: Therapy Dietary restriction
Increase physical activity and exercise
Reduce sedentary behavior
Modify behavior
Change of life style for the whole family
Reduce TV viewing and computer games
16: Intensive Therapies - Indications BMI > 95 Centile and one medical complication ( co morbidity)
Co morbid conditions include
Dyslipidemia
Disorders of glucose metabolism
Hepatic enzyme derangement
Hypertension ( Systolic or Diastolic)
Pseudotumour
Sleep apnea
Orthopedic problems
17: Intensive Diet Calorie intake 2400 to 2940 KJ per day
Aim is to induce a weight loss of 0.5 kg per week
Protein sparing modified fast (PSMF)
2520-3360 KJ/day
1.5 -2.5 g/kg of IBW / day of high quality protein
Carbohydrate 20-40 gms/day
Does not lead to cardiac arrhythmia as was observed earlier
18: Not prescribed for more than 12 weeks
Risks:
Cholelithiasis, hyperuricemia, hypoproteinemia, orhthostatic hypotension, halitosis, diarrhea
PSMF produce rapid weight loss in the short term
In the long term does not seem to be superior to restrictive diet programmes Intensive Diet
19: Pharmacotherapy Limited data available in children and adolescents
Medications reducing energy intake
Fenfuramine
Phenteramine
Diethylpropion
Sibutramine
20: Leptin A hormone secreted by adipocytes in relation to lipid content
It is a peripheral signal to the hypothalamus of inadequate food intake but NOT of Satiety
Leptin deficiency causing obesity is VERY VERY RARE
Leptin therapy to Leptin sufficient adults is not very impressive in terms of weight loss
No studies in children are available
21: Metformin Stops hepatic glucose production
Reduces insulin resistance
Several studies have shown impressive weight reduction in dosages varying from 500 mg to 2 gm per day in children of 8 - 14 years
Side effects
Nausea, flatulence, bloating
Diarrhea, Vitamin B12 deficiency
Lactic Acidosis - Rare
22: Contraindications
Renal failure, creatinine > 1.4 mg/dl
CCF, cardiac and pulmonary insufficiency
Liver disease Metformin
23: No medications are approved for use in children in routine clinical practice except Leptin in Leptin deficiency children
24: Bariatric Surgery Limited experience in children and adolescents
Balloons placed in the stomach are shown to be ineffective
Jejunoileal bypass is not done now due to high complication rate
Roux-en-Y gastric bypass (RYGB) is performed now
25: RYGB Post op complications are many (8.5%)
Post op mortality is 1.5%
In a recent study by Strauss - Adolescents were treated with bariatric surgery
90% lost > 30 kgs and co morbid conditions improved
Complications include iron deficiency, folate deficiency, small bowel obstruction
26: This is the only treatment with evidence that it can induce sustained significant weight reduction in adolescents who have severe obesity
Can only be recommended to those with highest morbidity
As Strauss concluded: “Gastric bypass remains a last resort option for severely obese adolescents” Bariatric Surgery
27: Education and awareness programs for parents are required to prevent adolescent obesity
At risk individuals can be identified with BMI curve
The mainstay of treatment is diet, exercise and behaviour modification
At present no medicine is routinely used in clinical practice to prevent or treat obesity Take Home Message
28: Concept – Dr. Duru Shah Contributors
Dr. Suvarna Khadilkar
Dr. Vaman Khadilkar
29: We acknowledge the efforts of our : Coordinators :
Dr. Sangeeta Agrawal - Central
Dr. Narendra Malhotra - North
Dr. Hema Divakar - South
Dr. P. C. Mahapatra - East
Dr. Uday Thanawala - West
In bringing the FOGSI YOUTH EXPRESS to your city.
30: This Youth Express has been possible through an educational grant from Charak Pharma Pvt. Ltd
CIPLA Ltd.
Emcure Pharmaceuticals Ltd
GlaxoSmithKline Pharmaceuticals Limited
Glenmark Pharmaceuticals Ltd.
Metropolis Health Services (India) Pvt.Ltd.
Organon India Ltd
Roche Pharmaceuticals Ltd.
Sandoz Private Limited
USV Limited
Wyeth Limited