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COMORBIDITES OF PEDIATRIC OBESITY

COMORBIDITES OF PEDIATRIC OBESITY. William J. Cochran, MD, FAAP Geisinger Clinic. WHY WORR ABOUT PEDIDATRIC OBESITY?. INTRODUCTION. Pediatric obesity is of epidemic proportion Pediatric obesity is the most common chronic disease of childhood.

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COMORBIDITES OF PEDIATRIC OBESITY

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  1. COMORBIDITES OF PEDIATRIC OBESITY William J. Cochran, MD, FAAP Geisinger Clinic

  2. WHY WORR ABOUT PEDIDATRIC OBESITY?

  3. INTRODUCTION • Pediatric obesity is of epidemic proportion • Pediatric obesity is the most common chronic disease of childhood

  4. Figure IV: Percent of obese children and adolescents

  5. IS PEDIATRIC OBESITY A REAL HEALTH ISSUE OR JUST A COSMETIC PROBLEM?

  6. ADULT OBESITY • Type II Diabetes • Coronary Heart Disease • Hypertension • Cancer • Joint Disease • Gallbladder Disease • Pulmonary Disease

  7. RISK OF CHILDHOOD OBESITY PERSISTING INTO ADULTHOOD • Guo 1999 • 20% at 4 years of age • 80% in adolescence

  8. IMPACT OF CHILDHOOD OBESITY ON ADULT HEALTH • Childhood obesity has significant impact on health in adulthood • Hoffmans 1998 • Dutch adolescent males followed for 32 years • Increased mortality in obese vs. lean

  9. IMPACT OF CHILDHOOD OBESITY ON ADULT HEALTH • Mossberg 1989 • Swedish adolescents studied after 40 years • Increased mortality in obese vs. non-obese

  10. IMPACT OF CHILDHOOD OBESITY ON ADULT HEALTH • Must, 1992:Harvard growth study • 13-18 year old adolescents • 1922-1935, evaluated 1988 • Obesity: BMI >75% on at least two occasions during adolescence

  11. IMPACT OF CHILDHOOD OBESITY ON ADULT HEALTH • Increased all cause mortality in males and females • Increased mortality from CAD in males • Increased morbidity from CAD in males and females • Increased risk of colon cancer in males • Increased risk of arthritis in females

  12. IMPACT OF CHILDHOOD OBESITY ON ADULT HEALTH • Obesity in childhood was a more powerful predictor of these risks than obesity in adulthood!

  13. CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY

  14. PSYCHOSOCIAL • Most common complication of childhood obesity • Self • Increased rates of depression • Poor self esteem • May carry over into adulthood • Children are sensitized to obesity at young age

  15. PSYCHOSOCIAL • Self • Mellbin, 1989 • Increased rates of behavior and learning problems in those gaining weight rapidly • Etiology uncertain, ? Sleep apnea

  16. PEER RELATIONSHIPS • Richardson, 1961 • 10-11 year old children prefer friends with various handicaps vs. obese • Staffieri, 1967 • Children 6-10 years of age associate obesity with laziness • Obese children may choose younger friends, less judgmental

  17. PSYCHOSOCIAL • Adult Relationships • May have false expectations of child based on their size

  18. SOCIETAL DISCRIMINATION Canning, 1966 • Acceptance rates at college lower for obese than non-obese females with the same credentials National Longitudinal Survey of Youth 1993 • Obese adolescent females as young adults had less education, less income, higher poverty rate, and decreased rates of marriage

  19. ENDOCRINE COMPLICATIONS • Non-insulin-dependent diabetes mellitus • Pinhas-Hamiel 1994 • The incidence of NIDDM has increased 10 fold • One third of new diabetic children 10-19 years of age had Type II DM • 92% of these had a BMI >90% • Geisinger weight management program • 1-2% have type II DM

  20. ENDOCRINE COMPLICATIONS • Insulin resistance • Elevated fasting insulin levels with normal Hgb A1C • Ratio of fasting insulin to glucose • Adult female: normal <1:4 • Normal for children not established • First step towards developing Type II DM

  21. Obesity Insulin Resistance Metabolic Syndrome Syndrome Type 2DM Hypertension NASH Dyslipidemia PCOS

  22. ENDOCRINE COMPLICATIONS • Geisinger weight management program • 60% have insulin resistance • 10% have fasting insulin level > 100 (Nl <17)

  23. ENDOCRINE COMPLICATIONS • Acanthosis nigricans • Velvety, hyperpigmented, thickened skin • Associated with obesity and insulin resistance • Not sensitive for insulin resistance • Resolves with weight loss

  24. ENDOCRINE COMPLICATIONS • Increased linear growth initially • Growth plates may close earlier • Advanced bone age • Earlier onset of puberty

  25. POLYCYSTIC OVARY SYNDROME Hyperandrogenism • Ovarian dysfunction • Oligomenorrhea • Amenorrhea • 55% of adolescent females have polycystic ovaries on US • Cutaneous manifestations • Hirsuitism • Acne • Acanthosis nigricans

  26. POLYCYSTIC OVARY SYNDROME • Insulin resistance • Hyperlipidemia • Infertility • Premature adrenarche • Bacha F, Arslanian S. Enod Trends 11(1)2004

  27. HYPERTENSION • Hypertension • Primary hypertension uncommon in childhood • 60% of children with persistently elevated blood pressure had weight >120% IBW • Lauer J Pediatr 1975;86:697-706. • Use pediatric standards • Geisinger weight management program • 45% have hypertension

  28. HYPERTENSION • Risk • Overweight adolescents have 8.5 fold risk of hypertension as adults. • Srinivasan Metab 1996;45:235-240. • Cardiac hypertrophy/LVH on ultrasound. • Long term risk of CVD and stroke

  29. DYLIPIDEMIA • The atherosclerotic process beings in childhood (Bogalusa Heart Study) • Lipid levels tend to track with age

  30. DYLIPIDEMIA • Overweight during adolescence associated with • 2.4 fold increase in prevalence of cholesterol >240mg/dl • 3 fold increase in LDL values >160mg/dl • 8 fold increase in HDL values<35 mg/dl in adults 27-31 years • Srinivasan Metab 1996;45:235-240.

  31. DYLIPIDEMIA • Geisinger weight management program • 45% have hypercholesterolemia • Range of abnormal cholesterol: 175-338 • Freeman 1999 • 65% of obese 5-10 year old children have at least one cardiovascular disease risk factor • 25% of obese 5-10 year old children have 2 or more risk factors

  32. NON-ALCOHOLIC FATTY LIVER DISEASE • Hepatic steatosis • Increased fat in the liver • Steatohepatitis associated with liver inflammation and elevated liver enzymes • 20%-25% obese children have evidence of steatohepatitis • Tazawa Acta Paeditr 1997;86:238-241

  33. INSULIN RESISTANCE AND FAT DEPOSITION Muscle Insulin resistance insulin Insulin resistance Liver Insulin resistance Free Fatty Acids

  34. NON-ALCOHOLIC FATTY LIVER DISEASE • Liver disease can progress to fibrosis or frank cirrhosis • Obesity and type 2 diabetes are the strongest predictors of progression of fibrosis • Age is also a risk factor for cirrhosis which may reflect increased duration of risk for the “second hit” thought to initiate fibrosis. • Angulo P, Keach JC, Batts KP, Lindor KD. Hepatology 1999;30(6):1356-62

  35. NON-ALCOHOLIC FATTY LIVER DISEASE • Rashid • 83% of children with steatohepatitis were obese • 75% had fibrosis-cirrhosis • Geisinger weight management program • 50 % have hepatomegaly • 15% have elevated liver enzymes

  36. CHOLELITHIASIS • Uncommon in children • Increased risk in those with hemolytic disorders • Obesity accounts for 8%-33% of gallstones in children • Friesen Clin Pediatr 1989.7:294 • May be associated with weight loss • Crichlow Dig Dis. 1972;17:68-72

  37. CHOLELITHIASIS • Relative risk of gallstones in adolescent girls with obesity is 4.2 • Honore Arch Surg 1980;115:62-64 • 50% of cholecystitis in adolescents associated with obesity • Crichlow Dig Dis. 1972;17:68-72

  38. SLIPPED CAPITAL FEMORAL EPIPHYSIS • 50%-70% patients with SCFE are obese. • Wilcox J Pediatr Orthop 1988:8:196-200 • Suspect and immediately evaluate in an obese patient who presents with limp. • Can also present with complaints of groin, thigh, or knee pain

  39. SLIPPED CAPITAL FEMORAL EPIPHYSIS • Diagnosis • Physical examination • Motion of the hip in abduction and internal rotation is limited on examination. • Xray • AP view of pelvis to include both hips • Bilateral disease occurs in up to 20% of patients • Medial and posterior displacement of the femoral epiphysis through the growth plate relative to the femoral neck • Busch MT. Orthop Clin North Am 1987;18(4):637-47

  40. BLOUNT’S DISEASE • Diagnosis • Bowing of tibia and femur either unilateral or bilateral. • Etiology • Results from overgrowth of the medial aspect of the proximal tibial metaphysis • 2/3 of patients with Blount’s disease are obese • Dietz J Pediatr 1982:101:735-737 • Treatment • Surgery associated with weight loss

  41. OBSTRUCTIVE SLEEP APNEA • OSAS in children is defined as a disorder of breathing during sleep characterized by: • prolonged partial upper airway obstruction • and/or intermittent complete obstruction (obstructive apnea) • that disrupts normal ventilation during sleep and normal sleep patterns • Schechter MS. Technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2002;109(4):e69-79.

  42. OBSTRUCTIVE SLEEP APNEA • 40% of severely obese children demonstrated central hypoventilation • Silvesti Pediatr Pulmonol 1993;16:124-139 • Abnormal sleep patterns reported in 94% of obese children studied • Kahn A, Mozin MJ, Rebuffat E, Sottiaux M, Burniat W, Shepherd S, et al. Sleep 1989;12(5):430-8.

  43. OBSTRUCTIVE SLEEP APNEA • Symptoms of sleep apnea • Nighttime awakening / restless sleep • Excessive snoring / apnea • Difficulty awaking in the morning • Daytime somnolence • Nocturnal enuresis • Decreased ability to concentrate • Poor school performance. • Gozal D. Sleep-disordered breathing and school performance in children. Pediatrics 1998;102(3 Pt 1):616-20.

  44. OSAS - ETIOLOGY • Increased fat mass in pharynx, neck, chest and diaphragm • Increased muscle relaxation during sleep • Enlarged tonsils and adenoids • Silvestri JM, Weese-Mayer DE, Bass MT, Kenny AS, Hauptman SA, Pearsall SM. Pediatr Pulmonol 1993;16(2):124-9

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