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COMORBIDITES OF PEDIATRIC OBESITY

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Title: COMORBIDITES OF PEDIATRIC OBESITY


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

2
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3
WHY WORR ABOUT PEDIDATRIC OBESITY?
4
INTRODUCTION
  • Pediatric obesity is of epidemic proportion
  • Pediatric obesity is the most common chronic
    disease of childhood

5
Figure IV Percent of obese children and
adolescents
6
IS PEDIATRIC OBESITY A REAL HEALTH ISSUE OR JUST
A COSMETIC PROBLEM?
7
ADULT OBESITY
  • Type II Diabetes
  • Coronary Heart Disease
  • Hypertension
  • Cancer
  • Joint Disease
  • Gallbladder Disease
  • Pulmonary Disease

8
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9
RISK OF CHILDHOOD OBESITY PERSISTING INTO
ADULTHOOD
  • Guo 1999
  • 20 at 4 years of age
  • 80 in adolescence

10
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

11
IMPACT OF CHILDHOOD OBESITY ON ADULT HEALTH
  • Mossberg 1989
  • Swedish adolescents studied after 40 years
  • Increased mortality in obese vs. non-obese

12
IMPACT OF CHILDHOOD OBESITY ON ADULT HEALTH
  • Must, 1992Harvard growth study
  • 13-18 year old adolescents
  • 1922-1935, evaluated 1988
  • Obesity BMI 75 on at least two occasions
    during adolescence

13
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

14
IMPACT OF CHILDHOOD OBESITY ON ADULT HEALTH
  • Obesity in childhood was a more powerful
    predictor of these risks than obesity in
    adulthood!

15
CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY
16
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

17
PSYCHOSOCIAL
  • Self
  • Mellbin, 1989
  • Increased rates of behavior and learning problems
    in those gaining weight rapidly
  • Etiology uncertain, ? Sleep apnea

18
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

19
PSYCHOSOCIAL
  • Adult Relationships
  • May have false expectations of child based on
    their size

20
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

21
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

22
ENDOCRINE COMPLICATIONS
  • Insulin resistance
  • Elevated fasting insulin levels with normal Hgb
    A1C
  • Ratio of fasting insulin to glucose
  • Adult female normal
  • Normal for children not established
  • First step towards developing Type II DM

23

Obesity
Insulin Resistance
Metabolic Syndrome Syndrome
Type 2DM
Hypertension
NASH
Dyslipidemia
PCOS
24
ENDOCRINE COMPLICATIONS
  • Geisinger weight management program
  • 60 have insulin resistance
  • 10 have fasting insulin level 100 (Nl

25
ENDOCRINE COMPLICATIONS
  • Acanthosis nigricans
  • Velvety, hyperpigmented, thickened skin
  • Associated with obesity and insulin resistance
  • Not sensitive for insulin resistance
  • Resolves with weight loss

26
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27
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28
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29
ENDOCRINE COMPLICATIONS
  • Increased linear growth initially
  • Growth plates may close earlier
  • Advanced bone age
  • Earlier onset of puberty

30
POLYCYSTIC OVARY SYNDROME
  • Hyperandrogenism
  • Ovarian dysfunction
  • Oligomenorrhea
  • Amenorrhea
  • 55 of adolescent females have polycystic ovaries
    on US
  • Cutaneous manifestations
  • Hirsuitism
  • Acne
  • Acanthosis nigricans

31
POLYCYSTIC OVARY SYNDROME
  • Insulin resistance
  • Hyperlipidemia
  • Infertility
  • Premature adrenarche
  • Bacha F, Arslanian S. Enod Trends 11(1)2004

32
HYPERTENSION
  • Hypertension
  • Primary hypertension uncommon in childhood
  • 60 of children with persistently elevated blood
    pressure had weight 120 IBW
  • Lauer J Pediatr 197586697-706.
  • Use pediatric standards
  • Geisinger weight management program
  • 45 have hypertension

33
HYPERTENSION
  • Risk
  • Overweight adolescents have 8.5 fold risk of
    hypertension as adults.
  • Srinivasan Metab 199645235-240.
  • Cardiac hypertrophy/LVH on ultrasound.
  • Long term risk of CVD and stroke

34
DYLIPIDEMIA
  • The atherosclerotic process beings in childhood
    (Bogalusa Heart Study)
  • Lipid levels tend to track with age

35
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 values27-31 years
  • Srinivasan Metab 199645235-240.

36
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

37
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 199786238-241

38
INSULIN RESISTANCE AND FAT DEPOSITION
Muscle
Insulin resistance
insulin
Insulin resistance
Liver
Insulin resistance
Free Fatty Acids
39
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 199930(6)1356-62

40
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

41
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42
CHOLELITHIASIS
  • Uncommon in children
  • Increased risk in those with hemolytic disorders
  • Obesity accounts for 8-33 of gallstones in
    children
  • Friesen Clin Pediatr 1989.7294
  • May be associated with weight loss
  • Crichlow Dig Dis. 19721768-72

43
CHOLELITHIASIS
  • Relative risk of gallstones in adolescent girls
    with obesity is 4.2
  • Honore Arch Surg 198011562-64
  • 50 of cholecystitis in adolescents associated
    with obesity
  • Crichlow Dig Dis. 19721768-72

44
SLIPPED CAPITAL FEMORAL EPIPHYSIS
  • 50-70 patients with SCFE are obese.
  • Wilcox J Pediatr Orthop 19888196-200
  • Suspect and immediately evaluate in an obese
    patient who presents with limp.
  • Can also present with complaints of groin, thigh,
    or knee pain

45
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 198718(4)637-47

46
BLOUNTS 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 Blounts disease are obese
  • Dietz J Pediatr 1982101735-737
  • Treatment
  • Surgery associated with weight loss

47
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 2002109(4)e69-79.

48
OBSTRUCTIVE SLEEP APNEA
  • 40 of severely obese children demonstrated
    central hypoventilation
  • Silvesti Pediatr Pulmonol 199316124-139
  • 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 198912(5)430-8.

49
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 1998102(3 Pt
    1)616-20.

50
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
    199316(2)124-9

51
OSAS-DIAGNOSIS
  • History, audio and video taping, and overnight
    oximetry are poor predictors
  • The definitive diagnosis of OSAS is made by
    nighttime polysomnography
  • Clinical practice guideline diagnosis and
    management of childhood obstructive sleep apnea
    syndrome. No authors listed. Pediatrics
    2002109(4)704-12
  • Severity of obstruction may not correlate with
    either degree of obesity or severity of sleep
    symptoms

52
OBSTRUCTIVE SLEEP APNEA
  • Children with sleep apnea demonstrate significant
    decreases in learning, attention span and memory
  • Rhodes J Pediatr 1995127741-744.
  • Greenberg GD, Watson RK, Deptula D.. Sleep
    198710(3)254-62.

53
OBSTRUCTIVE SLEEP APNEA
  • Pulmonary hypertension,systemic hypertension,
    right heart failure
  • .Tal A, Leiberman A, Margulis G, Sofer S. Pediatr
    Pulmonol 19884(3)139-43
  • Marcus CL, Greene MG, Carroll JL. Am J Respir
    Crit Care Med 1998157(4 Pt 1)1098-103
  • Massumi RA, Sarin RK, Pooya M, Reichelderfer Dis
    Chest 196955(2)110-4

54
OSAS - TREATMENT
  • Weight loss
  • Willi SM, Oexmann MJ, Wright NM, Collop NA, Key
    LL Jr. Pediatrics 1998101(1 Pt 1)61-7
  • Continuous positive airway pressure (CPAP) or
    bilevel positive airway pressure (BPAP)
  • Tonsilladenoidectomy

55
PSUEDOTUMOR CEREBRI
  • Definition
  • Raised intracranial pressure with papilledema and
    a normal cerebrospinal fluid in the absence of
    ventricular enlargement
  • Obesity occurs in 30-80 of children with
    psuedotumor cerebri
  • Scott Am J Opth 1997 124253-255

56
PSUEDOTUMOR CEREBRI
  • May present with headaches, vomiting, blurred
    vision or diplopia
  • Neck, shoulder, and back pain have also been
    reported
  • Lessell S. Surv Ophthalmol 199237(3)155-66
  • Papilledema is part of pathology but may not
    occur at presentation

57
John A Moran Eye Center, Salt Lake City UT
58
PSUEDOTUMOR CEREBRI
  • Loss of peripheral visual fields and reduction in
    visual acuity may be present at diagnosis
  • Baker RS, Carter D, Hendrick EB, Buncic JR. Arch
    Ophthalmol 1985103(11)1681-6.
  • Increased intracranial pressure may lead to
    visual impairment or blindness.

59
PSUEDOTUMOR CEREBRI
  • Weight loss
  • Newborg B. Arch Intern Med 1974133(5)802-7
  • Acetazolamide
  • Lumboperitoneal shunt in severe cases

60
CONCLUSIONS REGARDING PEDIATRIC OBESITY
61
  • PEDIATRIC OBESITY IS NOT JUST A COSMETIC PROBLEM!

62
COMPLICATIONS ARE COMMON IN PEDITRIC OBESITY
  • All children with BMI 95 should be evaluated
    for associated co-morbidities
  • Physical examination
  • BP
  • Fundiscopic exam
  • Hip and knee examination
  • Acanthosis nigricans
  • Hirsutism / acne
  • Hepatomegaly

63
COMPLICATIONS ARE COMMON IN PEDITRIC OBESITY
  • Laboratory evaluation
  • Fasting lipid profile
  • Liver panel
  • Fasting insulin and glucose
  • Hgb A1C
  • To be considered
  • Polysomnogram
  • Abdominal US

64
THANK YOU!
65
SCFE ASSOCIATED CAUSES
  • Continued weight gain
  • Renal failure
  • History of radiation therapy
  • Primary hypothyroidism
  • Loder RT, Greenfield ML.. J Pediatr Orthop .
    200121(4)481-7
  • Gonadotropin-releasing hormone agonists
  • Growth hormone therapy
  • Kempers MJ, Noordam C, Rouwe CW, Otten BJ. J
    Pediatr Endocrinol Metab 200114(6)729-34

66
Pseudotumor Cerebri - Associated Conditions
  • Mastoiditis.
  • Lateral sinus thrombosis.
  • Hypoparathyroidism,
  • Steroid treatment and withdrawal.
  • Thyroid replacement,
  • SLE.
  • Green M. Pediatr Clin North Am 196714(4)819-30.
  • Palmer RF, Searles HH, Boldrey EB.. J Neurosurg
    195916(4)378-84.
  • Baker RS, Baumann RJ, Buncic JR. Pediatr Neurol
    19895(1)5-11.
  • Walker AE, Adamkiewicz JJ. JAMA 1964188779-84.
  • Neville BG, Wilson J.. Br Med J
    19703(722)554-6.
  • Huseman CA, Torkelson RD.. Am J Dis Child
    1984138(10)927-31.
  • DelGiudice GC, Scher CA, Athreya BH, Diamond GR..
    J Rheumatol 198613(4)748-52.

67
Drugs Associated With Pseudotumor Cerebri
  • Growth hormone therapy
  • Nalidixic acid,Ciprofloxacin,Tetracycline therapy
  • No clear dose-response relationship
  • Lessell S. Surv Ophthalmol 199237(3)155-66.
  • Vitamin A and isoretinoin therapy are
    established causes of pseudotumor cerebri.
  • Morrice G Jr, Havener WH, Kapetansky F. JAMA
    19601731802-5.
  • Roytman M, Frumkin A, Bohn TG. Cutis
    198842(5)399-400.
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