Childhood obesity and metabolic syndrome

Risk Factor Definitions for Dyslipidemia Algorithms Moderate level RFs

- HTN that does not require drug tx - BMI ≥95th percentile, <97th percentile - HDL cholesterol <40 mg/dL - presence of mod risk conditions

Risk Factor Definitions for Dyslipidemia Algorithms Positive FHx

- MI - angina - coronary artery bypass graft/stent/angioplasty - sudden cardiac death in parent, grandparent, aunt or uncle at < 55 for males and < 65 for females

Complications Orthopedic problems

- Slipped Capital femoral epiphysis (SCFE) --> socket falls off the bond in hip due to wt - tibia vara- bowing of lower legs

Dyslipidemia risk conditions High risk

- T1DM or T2DM - CKD/end stage renal dz - post-othotopic heart transplant - kawasaki dz with current aneurysms

Fruit juice Infants

- by 1 year of age, 90% consume juice - mean 2oz/d

Complications social and psychological stress

- negative social attitudes toward obesity as early as age 7 years - underlying emotional problems

CV diagnostic evaluation Echocardiography

- only if tx is being considered, obtain to detect target organ damage - if no injury, repeat annually if stage 2, secondary or chronic stage 1 hen

Pharmacotherapy for wt loss

- orlistat (denial) - metformin (glucophage) - exenatide (byetta)

HTN management BP goal for children <13

- reduce BP <90th percentile for children

Polycystic ovarian disease

- state of chronic oligo-ovulation or anovulation culminating in oligomenorrhea/amenorrhea due to increased insulin sensitivity

Childhood T2DM Tx options

1. metformin 2. insulin

Dyslipidemia screening

universal screening at *9-11 yo and 17-21* - no routine screening 12-16 years**

Very low calorie diets

*ADOLESCENTS ONLY* protein-sprain modified fast - 600-800 kcal/d - 1.5-2.5 G protein/kg of IBW - 20-40 g CHO/d daily vitamin and mineral supplementation *NTE 12 WEEK*

Pharmacotherapy for Weight loss Orlistat AEs

*GI effects* --> lead to 50% DC rate in first month and only 10% retention after 6 months - malabsorption ± vitamin D & E deficiency

Childhood T2DM Metformin Tx when insulin was initially required

*Transition from insulin to metformin over 2-6 weeks usually starting metformin **1-2 wks after diagnosis* - *decrease insulin by 10-20% each time metformin dose is increased* with goal of eliminating insulin tx

After 6 months of CHILD-2- LDL + lifestyle change FLP with LDL ≥ 190 mg/dL

*initiate statin tx*

AAP statment Snacks, sweetened beverages, added sugars in schools Beverage Portion size limitations

- 8 oz elementary schools - 12oz middle and high schools

Pharmacotherapy for Weight loss Metformin: place in Tx

- >10 yo for T2DM - *NOT a wt loss tx but may consider in obese pediatric pts receiving atypical antipsychotics or with PCOS*

Risk Factor Definitions for Dyslipidemia Algorithms High level risk factors

- HTN that requires drug tx (BP ≥99th percentile + 5 mm Hg) - current cigarette smoker - BMI ≥97th percentile - presence of high-risk conditions

Pharmacotherapy for Weight loss Exanatide AEs

- N/V - abdominal - HA - injection site bruising

Complications Hepatic steatosis

- NAFLD - gallstones

Childhood T2DM Insulin tx

- T2DM pts who are ketotic or in diabetic ketoacidosis - for pediatric pts in whome distinction between T1DM and T2DM is unclear - for those who have random venous or plasma *BG ≥250 mg/dL* - for those whose *A1c >9%*

CV diagnostic evaluation Labs

- UA, Chem 7, lipid profile - renal US <6 yo with abnormal UA/renal fx - if BMI >95th percentile, HA1c, AST/ALT, fasting lipids

AHA Pediatric Dietary Strategies for Individuals Aged > 2 Years

- balance dietary calories with physical activity - *60 minutes of mod-vigorous physical activity daily* - eat vegetables and fruits daily, limit juice intake - use vegetable oils and soft margarines low in saturate fat and trans fat - eat whole grain breads and cereals rather than refined-grains - reduce intake of sugar sweetened beverages/foods - use nonfat skim or low-fat milk and dairy products - eat more fish, especially oily fish broiled or baked - reduce salt intake, especially in processed foods

Obesity Dietary risk factors: Intrauterine malnutrition

- central adiposity - metabolic syndrome - DM - CV disease

Statistics

- children with obesity in US has triples since 1970s - 1/5 children of school aged children (6-19) has obesity - >1/3 of children and adolescents are overweight or obese -

Parent responsibilities for children nutrition

- choose breastfeeding for first nutrition--> try to maintain 12 months - respond to satiety clues and do not overfeed - control when food is available and when it can be eaten - provide social context for eating behavior - teach about food and nutrition at grocery store and when cooking - counteract inaccurate information - teach other care providers about Childs diet - serve as role model - disband the "clean plate" club - offer structured meals and snacks - never use food as a reward or punishment - remember the rules

CV risk

- dyslipidemia - tobacco exposure - FHx of early CAD - kidney disease - chronic inflammatory disease - diabetes - congenital heart disease - previous cancer treatment

Obesity Risk factors: Positive energy balance

- excessive intake of high-energy foods - inadequate exercise in relation to age and activity and more sedentary lifestyle

Obesity Risk factors: Disease state

- hypothyroidism - growth hormone deficiency - prader-Willi, Bardet-Biedl, Alstrom, Smith-Magenis syndromes

Family risk factors Parenteral obesity

- if 1 parent obese, odds ratio of 3 for adulthood obesity - if both parents obese, odds ratio increases to more than 10 - before 3 years of age, parenteral obesity is a stronger predictor of obesity in adulthood than the child's wt status

Association of fast food consumption with poor dietary outcomes and obesity among children

- if consuming fast food, you may gravitate toward bad food choices also when eating other things

HTN magement General tx goals

- initiate single medication at low end of dosing range - can titrate tx every 2-4 wks until BP controlled or max dose reached or ADE - pt *MUST be seen every 4-6 weeks until BP normalizes* - once BP normalizes, pt should be seen every 3-6 months ==> monitor adherence, ADE, labs

Dyslipidemia risk conditions Moderate risks

- kawasaki dz with regressed coronary aneurysms - chronic inflammatory dz (SLE, juvenile arthritis) - HIV - nephrotic syndrome

Obesity Dietary risk factors: Overcontrol of parenteral behavior

- lack of child self-regulation - expect/seek food when frustrated

Obesity Risk factors: Metabolic disorders

- low metabolic rate relative to body composition - increased insulin sensitivity

Other goals

- maintenance of wt during growth spurt - size acceptance - eating should be pleasurable - sleep duration 8-11 hrs for school age children and adolescents - *lose no more than 1/2-1 lb/wk*

Fruit juice Toddlers

- mean 6oz/d --> 12 oz/d

Childhood T2DM

- overwt or obese - strong FHx of T2DM - substantial residual insulin secretory capacity - *normal or elevated insulin or C-peptide* - insidious onset - insulin resistance - lacks evidence of diabetic autoimmunity

Dyslipidemia screening Measure fasting lipid panel (FLP) twice if new knowledge of:

- parent/grandparent with MI, angina, stroke, coronary artery bypass graft/stent/angioplasty, sudden death at <55 yo in male or <65 yo in female - parent with TC ≥240 mg/dL or known dyslipidemia - pt has DM, HTN, BMI ≥85th percentile or smokes - pt has moderate-high risk medical condition

AAP statment Snacks, sweetened beverages, added sugars in schools Beverage requirements

- schools may sell plain carbonated water, unflavored low-fat or unflavored/flavored fat free milk - 100% fruit or vegetable juice

Bariatric surgery Recommended ONLY IF:

- tanner 4 or 5 pubertal development and final or near-final adult ht - *BMI > 40 kg/m2 or BMI>35 kg/m2 and significant comorbidities* - extreme obesity and comorbidites persist despite lifestyle mod - psych evaluation confirms stability and competence of family - demonstrates adherence to health and dietary activity - access to experienced pediatric surgeon

Obesity Risk factors: Low socioeconomic status

-urbanization - play space

Obesity Risk factors

1, metabolic disorders 2. positive energy balance 3. behavioral 4. low socioeconomic status 5. shortened sleep duration 6. disease state 7. medications

BP management Eleavted BP

1. *lifestyle intervention* --> consider nutrition or wt management referral, f/u in 6 mo 2. still high at 6 mo -->check upper and lower extremity BP; repeat lifestyle counseling, re-check in after another 6 mo 3. still high after 12 mo - order ambulatory BP monitoring 4. if BP normalizes at any pt, return to check at well-child visits only

Pharmacotherapy for management of BP

1. ACE 2. ARB 3. Thiazides 4. CCB

BP management Stage 2 HTN

1. Check upper and lower extremity BP - lifestyle counseling - recheck in 1 week - refer to pediatric cardiologist within 1 wk 2. at follow up - if BP still high, diagnostic evaluation including ABPM - *initiate tx* - refer to pediatric cardiologist 3. if pt is symptomatic OR > 30 mm Hg above 95th percentile or >180/20 mm Hg - REFER TO ER

BP management Non-pharm

1. DASH diet 2. physical activity 3. sleep recommendations 4. stress reducgtion 5. wt management: if indicated

Five Areas of health risk

1. FHx --> (+) hx CVD, DM, parenteral elevated total cholesterol' 2. BP 3. cholesterol 4. large annual incremental increase in BMI 5. Concern about wt

Complications

1. HTN 2. dyslipidemia 3. T2DM 4. polycystic ovarian disease 5. pubertal advancement 6. orthopedic problems 7. hepatic steatosis 8. hidradenitis suppurative 9. atherosclerosis 10. LV hypertrophy 11. sleep apnea 12. adult obesity 13. social and psychological stress

BP management Stage 1 HTN

1. Lifestyle counseling - f/u in 1-2 weeks 2. Follow up - if BP still high, check upper and lower extremity BP - repeat lifestyle cousneling - recheck BP in 3 mo 3. High at 3rd visit: *initiate tx*

Obesity Risk factors: Neurotransmitters types

1. Neurotransmitters 2. Leptin 3. Neuropeptide Y 4. Galanin

Obesity Risk factors: Medications

1. antipsychotics - atypicals - lithium 2. anti:depressants: - TCA - paroxetine 3. anti epileptic drugs - VPA - CBZ 4. glucocorticoids: - prednisone - prednisolone 5. Protease inhibitors - LPV/r - SQV - TPV 6. insulin - regular - glargine - aspart 7. antihistamine - diphenhydramine - cyproheptadine 8. antihypertensives - clonidine - propranolol - nifedipine

Dyslipidemia Non-pharmacologic Tx

1. child 1 Diet - age-appropriate reduced calorie training for child and family - specific diet/wt f/u every 2-4 wks for 6 months, BMI calculation at 6 mo - activity counseling 2. CHILD 2 DIET - wt loss program referral plus exercise training program - basically trainer + nutritionist

Childhood T2DM Diagnosis

1. fasting plasma glucose ≥126 mg/dL OR 2. 2 hr postprandial glucose ≥200 mg/dl during OGTT OR 3. HbA1c ≥6.5% 4. s'sx of hyperglycemia with random glucose ≥200 mg/dL

Age-appropriate recommendations for physical activity

1. free play - I/T - PS - ES 2. organized sports - ES - MS - A 3. competitive sports - MS - A 4. Free wts - MS - A

Childhood T2DM Non-pharm

1. hypocaloric diet 2. better food choices - low fat, sugar, increase fiber, fruits, and veggies 3. spread food intake across day 4. physical exercise

Obesity Risk factors: Neurotransmitters

1. increase food intake - 5-HT1A noradrneergic a2 receptor stimulation 2. decrease food intake - 5-HT2C and noradrenergic a1 or B2 receptor - histamine receptor subtypes 1 and 3 - dopamine receptor subtypes 1 and 2

US expert comminittee recommendations

1. interventions begin early 2. family must be ready for change 3. treatment programs should make permanent changes - no short-term diets or exercise programs aimed at rapid wt loss 4. tx program should help family make small, gradual changes 5. clinicians should encourage and empathize and NOT criticize

Obesity Dietary risk factors

1. lack of breastfeeding 2. intrauterine malnutrition 3. over control of parenteral behavior 4. early introduction of high-caloric solids, fruit juices, soft drinks 5. lack of consistent access to healthful food choices

Childhood T2DM Goals of Tx

1. normalize blood glucose and HbA1c - FBG <126 - HbA1c ≤7% 2. normalize lipids and BP 3. achieve and maintain desirable wt 4. promote physical/psychologial well being 5. prevent acne and chronic complications

Family risk factors

1. parenteral obesity 2. adipose tissue distribution 3. gestational and infancy nutrition 4. gestational diabetes 5. small family size 6. family patterns of inactivity and food choices 7. ethnicity 8. geographic location

CV diagnostic evaluation

1. pt hx 2. FHx 3. PE 4. Labs 5. echocardiography

BP management indications for pharmacotherapy

1. symptomatic HTN 2. chronic stage 1 or stage 2 HTN 3. CKD 4. T1DM or T2DM 5. persistent HTN despite non-pharm measures

Lose no more than _______ per week

1/2-1lb

Target goal for childhood and adolescence obesity

2005-2008: 16.2% By 2020: want 14.6%

BP management Non-pharm: physical activity

3-5 days/wk 30-60 minutes - sports recreation from high static sports ==> wt lifting, boxing, wrestling

Percentrage of children and adolescents afed 2-19 who consumed fast food on a given day

65.7% do not consume fast-food

BMI between ______ percentile should be considered overwt

85-95th

BMI ≥_____ percentile should be considered obese

95th

HTN children aged ≥13 yrs Normal BP

<120/80 mm Hg

BP management Non-pharm: sleep recommendations

>7 hrs/night

Medication therapy for wt loss recommendation

AFTER lifestyle modification has FAILED to limit wt gain or minimize comorbidities - medication *NOT recommended <16 rs old who are overwt but not obese* - medication should be *D/C if pts does not want to achieve >4% BMI reduction after 12 seeks on full dose*

Physical activity suggestions

Accumulate 2 hr of physical activity per day - *at least 3 days per week, vigorous intensity muscle and bone strengthening* - aim for sustainable lifestyle activity for child and family - encourage active play - communities invest in extracurricular activities

Childhood T2DM Screening

Age initiation *≥10 yo or at onset of puberty, if puberty occurs at younger age* overwt or obese PLUS ≥1 of following: 1. first or second degree relative with T2DM 2. race/ethnicity - native american - african american - latino - asian-american - pacific islander 3. maternal history of DM or GDM 4. s's or conditions associated with insulin ressistance - polycystic ovarian syndrome (PCOS) - acanthuses nigricans - HTN - dyslipidemia - small for gestational age birth wt

Obesity Secondary risk factors

Amount of time spent: - watching TV - playing video games - surfing the internet - avrg child watches 3 hrs TV/d

Complications HTN

Annual screening should begin at *3 years* - BP should be checked AT EVERY healthcare encounter if obese, taking med that can elevate BP, diabetic or history of renal disease, aortic arch obstruction/co-araction - normal BP determined by ht percentile, age, and sex

Pharmacotherapy for Weight loss Orlistat: outcomes

BMI decease 0.7-1.7 kg/m2

Pharmacotherapy for Weight loss Metformin: outcomes

BMI decrease 1.16 kg/m2

HTN children aged ≥13 yrs: elevated BP

BP 120/<80 to 129/<80

HTN children aged ≥13 yrs: stage 1 HTN

BP 130/80 to 139/89 mm Hg

HTN children aged ≥13 yrs: Stage 2 HTN

BP ≥ 140/90 mm Hg

Dyslipidemia Pharmacological Tx: 2nd line

Bile acid sequestrant or exetimibe

Family risk factors Ethnicity

Blacks/African Americans and hispanics typically have lower metabolic rate

Extreme obesity

Definition not standardized in childhood obesity - BMI ≥99% percentile was defined in large population study - BMI ≥120% of 95th percentile or BMI ≥35 kg/m2 - represents 5.8% of children and adolescents

HTN children aged 1-13 yrs: elevated BP

Elevated BP: - BP ≥90th percentile to <95th percentile OR - 120/80 mmHg to <95th percentile

Health report card

Evaluation of family awareness of weight and fitness for elementary school children - child's wt status - planned medical help - dieting activities - physical activities ==> increases %age of awareness of pareents

Childhood T2DM Metoformin alone

FIRST LINE *WITH* close monitoring - BG checks 2-4 times daily

Childhood T2DM Metformin Tx

FIRST LINE at time of diagnosis of T2DM IF METABOLICALLY STABLE 250 mg QD for 3-4 days, titrate to BID - continue over 3-4 wks to 1g BID

Dyslipidemia Pharmacological Tx: adjunctive tx

Fish oil vibrate niacin IF: - TG ≥200-499 mg/dL - LDL-C target achieved and non-HDL ≥145 mg/dL

AAP statment Snacks, sweetened beverages, added sugars in schools

Food sold In school mUST have - fruit, veggie, dairy product or protein as first ingredient - be a whole grain rich products, or have whole grain as first ingredient - combination food containing 1/4 cup or more of fruit/veg or contain 10% RDA of K, Ca, Vit D, or fiber

Pharmacotherapy for Weight loss Metformin: AEs

GI distress

Pharmacotherapy for Weight loss Exanatide MOA

Glucagon-like peptide (GLP)-1 agonis - includes targets in GI tract and CNS for T2DM adults - Leptin secretion is increased as a result of signaling from the GI tract ==> appetite suppression, decreased energy intake, and delayed gastric emptying

After 6 months of CHILD-2- LDL + lifestyle change FLP with LDL ≥ 130-159 mg/dL + 2 high level RFs or 1 high level + ≥2 moderate level RFs OR clinical cvd

INITIATE STATIN TX

Pharmacotherapy for Weight loss Exanatide: place in tx

INVESTIGATIONAL dont use this lol

Obesity Risk factors: Galanin

Increase concentration ==> increase food intake

Obesity Risk factors: Neuropeptide Y

Increase concentration ==> increase foot intake

Dyslipidemia goals Borderline

LDL: 110-129 tx: CHILD 1 DIET F/U: 1 year

Dyslipidemia goals Acceptable

LDL: <110 Tx: education F/U: <5 yrs

Dyslipidemia goals HIGH

LDL: ≥130 Tx: CHILD 1 DIET F/U ≥3 months

AAP Media time

LIMIT to *no more than 1-2 hrs per day* - remove TV from bedrooms - children younger than 2 -> discourage TV watching - encourage interactive activities

_______________ is present in 40% of children with HTN

Left ventricular hypertrophy

HTN children aged 1-13 yrs normal BP

Normal BP: <90th percentile

Healthy people 2020

Nutrition 1. parental influence 2. school curriculum - health eating behaviors - food safety - obesity risk factors

Pediatric HTN Secondary

Renal/renovascular disease --> most common cause of secondary - coarctation of aorta - endocrine - environmental exposures --> lead, mercury, cadmium, phthalates - neurofibromatosis - medication related

Healthy people 2020 In schools

School curriculum for education of inadequate physical activity Public and private schools requiring PE for all students - 3.8% elementary - 7.9% middle - 2.1% high

HTN children aged 1-13 yrs: stage 1 HTN

Stage 1 - BP ≥95th percentile to <95th percentile + 12 mm Hg OR - 130/80 to 139/89 mn Hg

HTN children aged 1-13 yrs: Stage 2 HTN

Stage 2 - Bp≥95th percentile + 12 mm Hg OR - ≥140/90 mm Hg

Dyslipidemia Pharmacological Tx: 1st line

Statin tx - choice of statin is a matter of preference - *start with lowest available dose QD* - *measure baseline CK, ALT, AST* - advise females pts about concerns with pregnancy and need for contraception - advise about potential DDIs

Pharmacotherapy for Weight loss Orlistat: place in tx

Xenical: approved for ≥12 years Alli: approved > 18 yrs

BMI

accept3ed standard measure of obesity and overweight children 2 years of age and older - BMI ≥95th percentile should be considered obese - BMI between 85-95th percentile should be considered overwt

Obesity Risk factors: Behavioral

adolescents who engage in high-risk behaviors - smoking - alcohol use - early sexual experimentation have GREATER risk of poor dietary and exercise habits

Pharmacotherapy for management of BP CCB

amlodipine felodipine isradipine nifedipine ER may be better 1st Lin tx in African American pts

Pharmacotherapy for management of BP ACE

benazepril captopril enalapril fosinopril lisinopril ramipril quinapril Initial tx: - DM - CKD - proteinuria - renal transplant

Pharmacotherapy for Weight loss Metformin: MOA

biguanide - decreases glucose production - decreases intestinal absorption of glucose - improves insulin sensitivity

Pharmacotherapy for management of BP ARB

candesartan irbesartan losartan olmesartan valsartan Initial tx - DM - CKD - proteinuria - renal transplant

Fruit juice Consumption in children <12

children <12 consume nearly 30% of all juice and juice drinks

Pharmacotherapy for management of BP Thiazide diuretics

chlorthalidone chlorthiazide HCTZ *preferred 2nd line agent* - may be better first lien tx in African American pts

soft drinks

consumption of sugar-sweetened beverages is associated with childhood obesity - *for every additional serving of sugar-sweetened drink consumed, the odds of becoming obese increase by 60%*

After 6 months of CHILD-2- LDL + lifestyle change FLP with LDL ≥130-189 mg/dL no other RF

continue child-2-LDL - f/u every 6 mo with FLP - FHx/RF update

Obesity Dietary risk factors: Lack of breastfeeding

extent and duration of breastfeeding have been found to be inversely associated with obesity risk later in childhood

Obesity Risk factors: Leptin

increase concentration ==> decrease food intake

Family risk factors Gestational DM

increased glucose concentration in utero, baby produces more insulin, baby hyperinsulinemia --> increased body fat

Family risk factors Geographic location

increased in south, in mississippi

Pharmacotherapy for Weight loss Orlistat MOA

inhibits intestinal lipases and reduces GI absorption of dietary fat by 30%

After 6 months of CHILD-2- LDL + lifestyle change FLP with LDL ≥ 160-189 mg/dL + FHx or high-level RF or ≥2 mod level RFs

initiate statin tx

AAP statement Fruit Juice

juice should *NOT be introduced into the diet before 12 months of age* Intake of juice should be limited - 4oz/d for children 1-3 - 4-6oz/d for children 4-6 - 8oz/d for children 7-18 ENCOURAGE children to eat whole fruits to meet recommended daily fruit intake

Mean percentage of calories from fast food amount children and adolescents aged 2-19 by poverty status

majority 130-350% poverty level

Mean percentage of calories from fast food amount children and adolescents aged 2-19 by race

majority non-hispanic black

Childhood T2DM Screening with HbA1c, FPG, OGTT

may be used - data validation for HbA1c lacking in children - FBG or OGTT are most sensitive and are better choice amount ethnic minorities or those showing signs of insulin resistance - if normal, repeat q 3 yrs, earlier if risk changes

Obesity Etiology

may result from increase in the number or in the size of fat cells - increase in number of fat cells when caloric intake is increased - during gestational months and 1st year, adipocytes increase rapidly - *decrease in size but NOT in number during adolescent/adult wt reduction*

Childhood T2DM incidence/prevalence

more common T1DM

Pediatric HTN primary

more common cause than secondary HTN in children Characteristics: - age ≥6 yo - FHx - overwt/obese

Mean percentage of calories from fast food amount children and adolescents aged 2-19

most ages 12-19, majority males

HTN management BP goal for children ≥13

reduce BP <130/80 mm Hg for adolescants

BP management Non-pharm: DASH DIET

sodium intake 2300 mg/d

HTN management BP goal for children with CKD, T1DM or T2DM

treat to 24 hr MAP <50th percentile by ABP,