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,