Childhood and Adolescent Obesity

1. Childhood and Adolescent Obesity JILL HAMILTON, MD, FRCPC THE HOSPITAL FOR SICK CHILDREN UNIVERSITY OF TORONTO

2. Objectives 1) Definition of childhood overweight and obesity 2) Common comorbidities 3) Unique aspects of obesity management in children and adolescents

3. BMI %iles • Downloadable:http://www.cdc.gov/growthcharts/ • based on 5 NHES/NHANES surveys (weight not changed after 1980 – NHANES II) • Overweight = BMI ≥ 85th %ile • Obese = BMI ≥95th%ile for age and gender

4. WHO 2007 BMI Charts • http://www.dietitians.ca • Separate charts for age 2-19 yrs and 0-2 yrs • Definition (age 2-19): • Overweight ≥ 85th%ile • Obese ≥ 97th%ile

5. Canadian Community Health Survey 2004 Child Overweight and obese = 26% !!!

6. % children BMI ≥ 99th%ile 1.3% ADOLESCENTS BMI ≥ 40 kg/m2 NHANES 1970’s-2004 (II, III, 1999-2004) Skelton et al. Acad Pediatr. 2009;9(5):322-329.

7. Vandenbroeck et al. http://www.bis.gov.uk/foresight

8. We will aggressively take on the challenge to reduce childhood obesity by 20 per cent over five years. Ontario’s Action Plan For Health Care ontario.ca/health Jan 30, 2012 Health Minister Deb Matthews creates panel to tackle childhood obesity May 18, 2012

9. Why childhood obesity? • 90% obese children become obese adults • Prevention must begin early • Treatment outcomes poorer as children get older • Comorbidities appear in childhood • Economic effects of earlier chronic diseases • Socieconomic effects on individual: NLSY: obese adults who were obese as adolescents were more likely to experience household poverty, had lower incomes, less education

10. Risks Associated with Childhood Obesity obesityhelp.com

11. Type 2 Diabetes – Pediatric Issues • 90+% obese • OGTT more sensitive to diagnose pre-diabetes/ T2D in very obese • 25% T2D may have ketones at presentation • Rapid progression from IGT to T2D • Rapid need for intensification of therapy

13. Type 2 Diabetes – Sensitivity Analysis minimum conservative maximum 113 new cases/year 822 new cases/year 2958 new cases/year Amed S et al, Diabetes Care, 2010

14. Clinical Presentation T2D 10.1 % 25.1 % 10.1 % 44.1 %

15. NAFLD • Chronic elevation in ALT • Fat deposition in liver, inflammation fibrosis • May be progressive and lead to cirrhosis • Autopsy study : prevalence 38% in obese children Schwimmer et al. Pediatrics 2006

16. Dyslipidemia NHANES 1999-2004 Obese youth had 2-4X prevalence of adverse lipid profiles Lamb et al. Amer J Clin Nut 2011

17. Baker et al. NEJM 2007

18. Orthopedic Issues Blount’s disease (CoxaVara) SCFE • All ages • Abnormal growth of postmedial portion of proximal tibial physis • Increased with BMI and esp BMI > 40 • May be asymptomatic • Nontraumatic slip of the femoral epipysis • 80% of children with SCFE are obese • Peak age 12-15 yrs • Present limp, knee, hip pain Chan et al. Curr Opinion Pediatrics 2009

19. Mental Health • Bullying and obesity: 58 % of boys and 63 % of girls experiencing daily teasing, bullying or rejection because of their size (www.obesityaction.org) • Obese teens report lower QOL (Varni et al. JAMA 2003) • Adolescent obesity predicts depression • (Laitenen et al. IJO 2006; • Boutelle et al. Health Psych 2010)

20. Edmonton Obesity Staging System EOSS Stage 0-4 • Obesity-related risk factors • Physical symptoms • Psychological symptoms • Functional limitations EOSS-P Stage 0-3 • Metabolic • Mental: psychological function • Mechanical: functional limitations • Family: parental, familial, or social environment concerns

21. Obesity Management CMAJ April 10, 2007 • 2006 Canadian Clinical Practice Guidelines on the management and prevention of obesity in adults and children • Cochrane Review Oude et al. Evid.-Based Child Health 4: 2009; 1571–1729 • Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity Barlow et al. Pediatrics 2007;120;S164-S192

22. Approach to Treatment • Multi-D approach to Tx • Assess Readiness to Change – behaviour change focus • Frequent small changes • Frequent follow up • Goal-oriented • Healthy lifestyle versus ‘diet’ • Logging of activity / diet • Consideration of medication/surgery in select cases

23. Unique Pediatric Aspects • Growth and development • Dietary recommendations must take this into account • Sensitivity to approach depending on age of child • Attention to development or presence of disordered eating

24. Family-based approach

25. Surgical Criteria Inclusion Exclusion • BMI > 35 with serious co-morbidity or BMI > 40 • Tanner IV • Psychology evaluation • Family assessments/support • Assessment of compliance in program- attendance, physical results, wt. stabilization. • Anesthesia risk • Acute psychosis, acute mental health issues • Pregnancy or planned in 2 years • Structural GI Abnormality • Eating disorder (binge eating uncontrolled, bulimia, NOS) • Development delay • ETOH abuse or dependence

26. Outcomes from the Pediatric Literature • Behavioural intervention alone: 5-15% overweight reduction • + Pharmacotherapy (orlistat, sibutramine, metformin) : additional 2-5 kg weight loss • + Bariatric surgery: reduce BMI by 30% Ref: Latzer et al. Obesity (2008) 17, 411–423

28. www.obesityinyouth.org