1 Associated Comorbidities of Pediatric ObesitySandra G Hassink, MD, FAAP Director Weight Management Program A I duPont Hospital for Children Wilmington, DE

2 Severe Obesity Related EmergenciesHyperglycemic Hyperosmolar state DKA Pulmonary emboli Cardiomyopathy of obesity Complications of Bariatric Surgery

3 Chiasson JL, Aris-Jilwan N, Bélanger R, Bertrand S, et al. CMAJChiasson JL, Aris-Jilwan N, Bélanger R, Bertrand S, et al. CMAJ Apr 1;168(7):

4 Hyperglycemic Hyperosmolar State“Death caused by hyperglycemic Hyperosmolar state at the onset of type 2 diabetes." Morales AE, Rosenbloom AL.J Pediatric 2004 Feb 144 (2) “Seven obese African American youth were considered to have died from diabetic ketoacidosis.”

5 Hyperglycemic Hyperosmolar State“Despite meeting the criteria for Hyperglycemic Hyperosmolar state and not for DKA.” “All had previously unrecognized type 2 diabetes, and death may have been prevented with earlier diagnosis or treatment.”

6 Hyperglycemic Hyperosmolar StatePatients presented to medical care with symptoms which were not linked to presentation of type 2 diabetes. Vomiting. Abdominal Pain. Dizziness. Weakness. Polyuria/Polydipsia. Weight loss. Diarrhea.

7 Hyperglycemic Hyperosmolar StateHHS- diagnostic criteria plasma glucose > 600mg/dl Arterial pH >7.3 serum bicarbonate > 15 mmol/l Serum ketones none-trace Urine ketones none-trace effective serum osmolality >320 mOsm/kg stupor or coma Rubin HM J Pediatr 1969:74:`77-86 Morales A J Pediatr 2004 Feb, Chiasson JLCMAJ Apr 1;168(7):

8 Pulmonary Embolism Other Signs/Symptoms: Classic SymptomsDyspnea Chest pain Decreased O2 Hemoptysis Other Signs/Symptoms: Back, shoulder, upper abdominal pain Painful respiration Cyanosis Syncope Cardia Arrhythmia New onset of wheezing Obstructive Sleep Apnea and Coagulation disorders increase risk Most common complication of gastric bypass/banding in adults, has been reported in adolesents after surgery Sugerman HJ, Sugerman EL, DeMaria EJ, et al Gastrointest Surg Jan: 7(1):102-07

9 Cardiomyopathy of ObesityCardiac steatosis Left ventricular dysfunction. dilation increased left ventricular wall stress compensatory (eccentric) left ventricular hypertrophy left ventricular diastolic dysfunction Right Ventricular dysfunction Exacerbated by pulmonary hypertension due to UAO Alpert, MA Am J Med Sci 2001 Apr, 321(4);

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11 Roux-en-Y Gastric Bypass-Early ComplicationsBleeding Bowel Perforation DVT/PE Dehydration Dysphagia Nausea/Vomiting Small Bowel Obstruction Anastomotic Leak Peritonitis

12 Roux-en-Y Gastric Bypass-Late ComplicationsCholecystitis Dysphagia GERD Incisional Hernia Malnutrition Pancreatitis Ulcers Renal Calculi Strictures Internal Hernia Small Bowel Obstruction

13 Lap-Band Adverse EventsIntra operative Iatrogenic gastrostomy Early Post-operative Hemorrhage Port infection Stomal obstruction Perforation Late complications Mechanical dysfunction Erosion Slippages Ponce, et al., 2005

14 Post Bariatric Surgery Mediation ConsiderationsNo aspirin or aspirin containing products No non steroidal anti inflammatory agents All medications should be crushed (no extended release or enteric coated products)

15 Potential Metabolic Complications from Bariatric SurgeryAnemia Fe, B12, copper, vitamins A and E, deficiency or an imbalance in zinc intake Neurologic Complications - Related to Vitamin B12 deficiency Ophthalmoplegia Nystagmus Ataxia Peripheral Neuropathy Impaired memory Gallstone Formation von Drygalski A, Andris DA. Nutr Clin Pract Apr-May;24(2):217-26

16 Potential Metabolic Complications from Bariatric SurgeryHyperparathyroidism –Ca and vitamin D def Aches/pains Depression Abdominal pain, Nausea/Vomiting Excessive urination Confusion Muscle Weakness, Fatigue Protein deficiency Hair loss Edema Hypoalbuminemia Anemia Extreme Fatigue Inability to walk

17 Co-morbidity's Requiring Immediate AttentionPseudotumor Cerebri Slipped Capital Femoral Epiphysis Blount’s Disease Sleep Apnea Non alcoholic hepatosteatosis Cholelithiasis

18 John A Moran Eye Center, Salt Lake City UTPapilledema is a bilateral swelling or edema of the optic disc secondary to any factor which may increase cerebral spinal fluid pressure. Fundus examination reveals a swollen optic nerve head with elevation, edema and narrowing of the physiological cup, vascular congestion with small areas of flame-shaped hemorrhage and exudates, and possible surrounding retinal edema (#22092). John A Moran Eye Center, Salt Lake City UT

19 Pseudotumor Cerebri Definition.Raised intracranial pressure with papilledema and a normal cerebrospinal fluid in the absence of ventricular enlargement. Risk Obesity occurs in 30%-80% of affected children. Scott Am J Opth 1997; 124: In a series of case-controlled studies in adolescents and adults, obesity and recent weight gain were the only factors found significantly more often in pseudotumor cerebri patients than control patients. Lessell S. Surg Ophthalmol 1992;37(3):

20 Pseudotumor Cerebri Diagnosis TreatmentMay present with headaches, vomiting, blurred vision or diplopia. Neck, shoulder, and back pain have also been reported. Lessell S. Surv Ophthalmol 1992;37(3): 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 1985;103(11): Increased intracranial pressure may lead to visual impairment or blindness. Treatment Acetazolamide Lumboperitoneal shunt (in severe cases), Weight loss Newborg B. Arch Intern Med 1974;133(5):802-7.

21 Pseudotumor Cerebri - Associated ConditionsMastoiditis and lateral sinus thrombosis Hypoparathyroidism, Pseudohypoparathyroidism Steroid treatment and withdrawal Thyroid replacement SLE Green M. Pediatr Clin North Am 1967;14(4): Palmer RF, Searles HH, Boldrey EB.. J Neurosurg 1959;16(4): Baker RS, Baumann RJ, Buncic JR. Pediatr Neurol 1989;5(1):5-11.Walker AE, Adamkiewicz JJ. JAMA 1964;188: Neville BG, Wilson J.. Br Med J 1970;3(722):554-6.Huseman CA, Torkelson RD.. Am J Dis Child 1984;138(10): DelGiudice GC, Scher CA, Athreya BH, Diamond GR.. J Rheumatol 1986;13(4): Medication associated with no clear does-response relationship Nalidixic acid Ciprofloxacin Tetracycline Lessell S. Surv Ophthalmol 1992;37(3): Vitamin A and isoretinoin therapy are established causes of pseudotumor cerebri. Morrice G Jr, Havener WH, Kapetansky F. JAMA 1960;173: Roytman M, Frumkin A, Bohn TG. Cutis 1988;42(5):

22 Points to Remember A fundiscopic examination should be a routine part of the examination of the obese child Children may not complain of visual field disturbances. When suspicious – test Pseudotumor cerebri is essentially a diagnosis of exclusion after other causes of increased intracranial pressure are eliminated.

23 Slipped Capital Femoral EpiphysisDiagnosis Suspect and immediately evaluate in an obese patient who presents with limp. 50%-70% patients with SCFE are obese. Wilcox J Pediatr Orthop 1988:8: Can also present with complaints of groin, thigh, or knee pain referred by obturator nerve

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25 Slipped Capital Femoral EpiphysisDiagnosis Motion of the hip in abduction and internal rotation is limited on examination. X- ray Anteroposterior view of the pelvis and frog leg that includes both hips. Comparison of the hips Bilateral disease occurs in up to 20% of patients. Intervention Requires surgical correction and weight loss.

26 SCFE-Pathology Medial and posterior displacement of the femoral epiphysis through the growth plate relative to the femoral neck Busch MT, Morrissy RT. Orthop Clin North Am 1987;18(4): The preferential site of slipping within the epiphysis is a zone of hypertrophic cartilage cells under the influence of both gonadal hormones and growth hormone Kempers MJ, Noordam C, Rouwe CW, Otten BJ. CanJ Pediatr Endocrinol Metab 2001;14(6): .

27 SCFE - Associated CausesContinued weight gain. Renal failure History of radiation therapy Primary hypothyroidism. Loder RT, Greenfield ML.. J Pediatr Orthop ;21(4):481-7. Gonadotropin-releasing hormone agonists Growth hormone therapy Kempers MJ, Noordam C, Rouwe CW, Otten BJ. J Pediatr Endocrinol Metab 2001;14(6): Grumbach MM, Bin-Abbas BS, Kaplan SL. Horm Res 1998;49(Suppl 2);41-57.

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29 Blount’s disease Bowing of tibia and femureither unilateral or bilateral. 2/3 of patients with Blount’s disease may be obese. Dietz J Pediatr 1982:101:

30 Blounts Disease

31 Blount’s Disease - Obesity Related Orthopedic MorbidityEtiology Injury to the growth plate, fissuring and clefts in the physis as well as fibrovascular and cartilaginous repair tissue at the physeal-metaphyseal junction. .Wenger DR, Mickelson M, Maynard JA.J Pediatr Orthop Jan;4(1):78-88. Results from overgrowth of the medial aspect of the proximal tibial metaphysis. Treatment Requires evaluation and correction by orthopedic surgeon. Weight loss

32 Blount’s disease

33 Points to Remember A careful hip and knee examination should be a routine part of the evaluation and follow-up of every obese child. An obese child complaining of or presenting with hip, knee, groin, or thigh pain should have a complete and thorough examination of his/her hips, including radiological studies. In an obese child, an unusual or abnormal gait should not be attributed to “excess weight” but should be thoroughly investigated with a careful hip and knee examination.

34 2.bp.blogspot.com/.../GCODtaW6Av4/s320/bipap.jpg /www.airecoremedicalservices.com/pic02.jpg

35 Upper Airway Obstructive Sleep Apnea SyndromeStructure Adipose tissue in upper airway contributes to Upper Airway Obstruction Shelton KE, et al Pharyngeal fat in obstructive sleep apnea. Am Rev Respir Dis. 1993;148(2):462–466 Abdominal adiposity may compromise respiratory excursion Kessler R et al The obesity-hypoventilation syndrome revisited: a prospective study of 34 consecutive cases. Chest. 2001;120(2):369–376. Function Infiltration of adipocytes into diaphragmatic muscles may alter respiratory mechanics Fadell E et al. Fatty infiltration of the respiratory muscles in the Pickwickian syndrome. N Engl J Med. 1962;266(17):861–863.

36 Obstructive Sleep ApneaOSAS 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.

37 Airway Mechanics: Dynamic relationship:Negative intra-thoracic pressure during inspiration: Always a closing pressure Airway size and shape: This may favor airway opening or closure Airway tone: Tissue rigidity Neuromuscular: Too much: Airway constriction Too little: Airway collapse Fricke, BL et al: Korean J Radiol 8(6), December 2007 Courtesy of Dr. Aaron Chidikel

38 Obstructive Sleep Apnea EffectsCognitive Decreases in learning and memory. Rhodes J Pediatr 1995;127: Deficits in attention, motor efficiency and graphomotor ability. Greenberg GD, Watson RK, Deptula D.. Sleep 1987;10(3): Cardiopulmonary Pulmonary hypertension,systemic hypertension, right heart failure. Tal A, Leiberman A, Margulis G, Sofer S. Pediatr Pulmonol 1988;4(3): Marcus CL, Greene MG, Carroll JL. Am J Respir Crit Care Med 1998;157(4 Pt 1): Massumi RA, Sarin RK, Pooya M, Reichelderfer Dis Chest 1969;55(2):110-4. Sleep disturbance Weight >200% above ideal had oxygen saturation <90% for half to total sleep time. 40% of severely obese children demonstrated central hypoventilation. Silvesti Pediar Pulmonol 1993;16:

39 Evaluation- History Nighttime symptoms Daytime symptomsSnoring Morning headache Restless sleeping Daytime tiredness Heavy or noisy breathing Napping Orthopnea Poor school function Frequent night awakening Inattentiveness Enuresis Short term memory Observed apnea deficit Diaphoresis Irritability Cyanosis Elevated blood pressure

40 OSAS-diagnosis Symptom checklists in research settingsChervin RD et Sleep Med. 2000;1(1):21–32 History, audio and video taping, and overnight oximetry and daytime nap polysomnography are poor predictors of OSAS. The definitive diagnosis of OSAS is made by nighttime polysomnography. Clinical practice guideline: Pediatrics 2002;109(4): Severity of obstruction may not correlate with either degree of obesity or severity of sleep symptoms.

41 Treatment Definitive treatment is weight lossWilli SM et al Pediatrics. 1998;101(1 Pt 1):61–67. Tonsil/Adenoidectomy-temporizing CPAP/BIPAP-Titrated in sleep lab Marcus CL et al.J Pediatr. 1995;127(1)(((3):88–94. Extreme cases unresponsive to weight loss/BiPap/CPAP uvulopharyngopalatoplasty, craniofacial surgery, and, in severe cases, tracheostomy Section on Pediatric Pulmonology, Pediatrics. 2002;109(4):704–712. Gastric Bypass/Banding in adults

42 Points to Remember Ask specifically about sleep disturbances, snoring, and sleep position. Families will often disregard these symptoms. Obstructive sleep apnea syndrome should be especially considered in obese children with poor school performance and concentration difficulties. Sleep symptoms can evolve over time. Keep asking about sleep disturbance as you follow these children. Weight gain, intercurrent upper respiratory infections, and Tonsillar enlargement can provoke symptoms.

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44 Asthma and obesity: Respiratory physiologyClassic example of an obstructive lung disorder Airway obstruction: Inflammation Bronchospasm Mucus plugging Airway reactivity: Response to triggers Reversible airflow obstruction Obesity Classic example of a restrictive lung disorder Chest wall restriction: Body mass Abdominal fat Decreased breathing movements Lung compression Tissue deposition of fat: Airway narrowing Fixed airflow obstruction Courtesy of Dr. Aaron Chidikel

45 Pulmonary - Asthma Pulmonary mechanics change with obesityDecreased lung volumes and thoracic distensibility Fung KP, et al. Arch Dis Child. 1990;65(5):512–515. Breathing pattern: Higher frequency, lower tidal volume. Weiss S, et al.Obesity and Asthma Direction for Research NHLBI Workshop. Am J Respir Crit Care Med. 2004;169;963–968 Obesity may contribute to severity of asthma Obese asthmatic children have more missed school days, receive more medication and have lower peak expiratory flow rates than non obese asthmatic children. Luder E, et al. J Pediatr. 1998;132(4):699–703. Increase cough, wheeze and dyspnea. del Rio-Navaro B, et al. Allergol Immunopathol (Madr). 2000;28(1):5–11.

46 Pulmonary- Asthma Bronchial hyperreponsiveness increases in obesitySzilagyi PG et al. Pediatr Ann. 1999;28(1):43–52 Weight reduction in obese patients reduces asthma symptoms. Weiss S, Shore S. Am J Respir Crit Care Med. 2004;169;963–968 Gastroesophageal reflux is increased in obesity Leptin is increased in obese children and in normal weight asthmatic boys vs. non asthmatic boys. Inflammatory cytokines may exacerbate asthma. Guler N et al. J Allergy Clin Immunol. 2004;114(2):254–259.

47 Asthma- Evaluation and TreatmentObese children, if inactive may not report symptoms unless specifically asked. Altered activity patterns Dropping out of sports Slowing down Losing interest As exercise increases during treatment of obesity, symptoms of exercise induced asthma may emerge It is important to optimize asthma treatment in every obese, asthmatic child

48 NAFLD to NASH Obesity Fatty Liver/Steatosis Genetic Predisposition2nd “Hit” Inflammation Fibrosis Cirrhosis Day CP, James OF. Gastroenterology 1998;114(4):842-5. Harrison SA, Diehl AM. Semin Gastrointest Dis 2002;13(1): 3-16.

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50 Non Alcoholic Steatohepatitis - ObesityDiagnosis Increased liver enzymes and fatty liver on ultrasound in the absence of other causes of liver disease. Rule out other causes of fatty liver Liver Biopsy Etiology 20%-25% obese children have evidence of steatohepatitis. Tazawa Acta Paeditr 1997;86: 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):

51 Schwimmer, J B et al Pediatr 2003 143(4), 500-505NASH risk Predictors of elevated serum ALT in obese children Male gender Hispanic ethnicity Elevated BMI Schwimmer JB, McGreal N,Deutsch R, Finegold MJ, Lavine JE. Influence of gender, race, and ethnicity on suspected fatty liver in obese adolescents. Pediatrics. 115(5):e561-5, 2005 May. Predictors of fibrosis Obesity (BMI z score) Insulin resistance Leptin (?) Schwimmer, J B et al Pediatr (4), “A liver NAFLD runs a higher risk of being damaged by other factors, from viruses to endotoxins, from alcohol to industrial toxic compounds” Yang SO, Lin HZ, Lane MD, Clemens M, Diehl AM. Proc Natl Acd Sci USA 1997; 94:

52 NASH - Treatment Loss of at least 10% of their excess weight normalized ALT and AST values and decreased ultrasound evidence of fatty infiltration Vajro P, Fontanella A, Perna C, Orso G, Tedesco M, De Vincenzo A. J Pediatr 1994;125(2): Clinical trial (TONIC) Metformin normalizes liver enzymes in 40%-50% of children with Reduction in heapatosteatosis by 23%-30%biopsy proven NASH. Improved insulin sensitivity Schwimmer JB, et al Alimentary Pharmacology & Therapeutics (7):871-9,

53 Cholelithiasis- Obesity Related Gastrointestinal MorbidityDiagnosis Abdominal pain, tenderness . Ultrasound, laboratory studies. Etiology Obesity accounts for 8%-33% of gallstones in children. Friesen Clin Pediatr :294. May be associated with weight loss. Crichlow Dig Dis. 1972;17:68-72.

54 Cholelithiasis- ObesityRisk 50% of cholecystitis in adolescents associated with obesity Crichlow Dig Dis. 1972;17:68-72. Relative risk of gallstones in adolescent girls with obesity is 4.2 Honore Arch Surg 1980;115:62-64. Hormonal contraception increases risk Schweizer P, Lenz MP, Kirschner HJ. Dig Surg. 2000;17(5): Surgical Intervention

55 Chronic - Obesity Related Co Morbid ConditionsInsulin Resistance Pre diabetes Type II Diabetes Polycystic Ovary Syndrome Hypertension Hyperlipidemia Psychological

56 Acanthosis Nigricans Courtesy Dr. G Dattohttps://online.epocrates.com/data_

57 Acanthosis Nigricans Hyperpigmentation and velvety thickening that occurs in neck, axilla, groin, can occur over knuckles Also seen in malignancies and other insulin resistant syndromes. Obese pediatric pts with acanthosis have higher fasting insulin and lower insulin sensitivity than acanthosis negative obese patients Insulin resistant pts were more likely to be obese (88%) than have acanthosis (65%) Yanovski et al, Journal of Peds 2001

58 Normal Glucose ToleranceProgression from Normoglycemia to Type 2 Diabetes DIABETES 2 Hr P P Glucose (mg/dL) 199 Impaired Glucose Tolerance 140 Impaired Fasting Glucose Normal Glucose Tolerance Fasting Glucose (mg/dL) Courtesy Dr. J Silverstein 100 125 Note: HgbA1C is not a diagnostic criteria for pre-diabetes

59 Progression from Pre-Diabetes to Diabetes in Adolescents117 obese children and adolescents At T=0: 33 (28%) had IGT At 2 years: 8 IGT subjects developed T2D (24.2%) 15 IGT subjects reverted to NGT (45.5%) 10 IGT subjects remained IGT (30.3%) Best predictors of development of T2D: Severe obesity (BMI ≥ 97th percentile) and persistent weight gain Relative with T2DM Increased insulin resistance (puberty, ethnicity, inactivity, visceral fat distribution, PCOS Weiss R. et al. Diabetes Care 2005; 28: American Diabetes Association Diabetes Care 2000;23(3) Courtesy Dr. J Silverstein 59

60 Incidence of Type 2 DiabetesEthnicity 10-14 yrs 15-19 yrs Native American 25.3/100,000person yrs 49.4 African American 22.3 19.4 Asian/Pacific Islander 11.8 22.7 Hispanic 8.9 17.0 Non Hispanic White 3.0 5.6 Dabelea D, et al “JAMA 2007;297:

61 Diabetes - Diagnosis Hemoglobin A1C >6.5%Symptoms of diabetes plus random plasma glucose >200mg/dl (11.1mmol/l) or Fasting plasma glucose >126 mg/dl (7.0 mmol/l) or 2 hour plasma glucose >200 mg/dl during an oral glucose tolerance test American Diabetes Association Diabetes Care 2000;23(3) Diabetes Care July 2009 vol. 32 no Associated findings Polycystic ovarian syndrome, Acanthosis nigricans Dyslipidemia, Hypertension

62 Goals of Treatment T2DM Physical well being, Psychological well beingWeight loss or no further weight gain/Continued normal linear growth Long term glycemic control Control hypertension and hyperlipidemia Hassink SG, Pediatric Weight Mgmt and Obesity, 2007 Lippincott Phila, Pa Family involvement Education including a basic knowledge of pathophysiology and short and long term complication Nutrition and meal planning Exercise Pharmacologic management Self monitoring. Ongoing monitoring of glucose, HgbA1C, Bun/Crt, LFT’’s, microalbuminuria, lipids, dilated eye examination, neurologic and foot

63 Pharmacologic Management -MetforminIn patients with both IFG and IGT + 1 of the following: <60 yo BMI >35 kg.m2 FH DM in first degree relatives High TG Low HDL-C HTN A1c >6% Metformin approved in children >10 years Decreases hepatic gluconeogenesis, increases insulin sensitivity, and lower triglycerides and LDL cholesterol Nausea, vomiting, fullness, constipation, heartburn Lactic acidosis Nathan DM, et al. Diabetes Care. 2007;30:

64 Pharmacologic Management- InsulinIf metformin contraindicated Renal insufficiency, Liver disease Alcohol abuse, Hypoxemia Hypoperfusion Sepsis Discontinue with contrast dye, serious illness Vitamin B12 deficiency reported in adults with long term use. If metabolic control cannot be achieved with lifestyle and metformin If beta cell failure ( in adults 6-8 yrs after diagnosis)

65 Polycystic Ovarian SyndromePolycystic Ovary Syndrome. Hyperandrogenism Oligomenorrhea/amenorrhea. Hirsuitism Acne Polycystic ovaries and eventual infertility. Increased risk Girls with premature adrenarche Bacha F, Arslanian S. Enod Trends 11(1)2004

66 Hypertension Use tables to classify Classification on three occasionsPrehypertension 90%-95% or BP >120/80. Stage 1 hypertension 95%-99% plus 5 mm Hg Stage 2 hypertension >99% plus 5 mmHg. Goal Blood pressure <90% for age and gender Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood Pressure in Children and Adolescents Pediatrics 2004;114(2 Suppl)

67 Hypertension TreatmentPrehypertension Recheck in 6 months Weight management counseling Pharmacologic therapy not indicated unless chronic kidney disease, diabetes heart failure of LVH Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood Pressure in Children and Adolescents Pediatrics 2004;114(2 Suppl)

68 Stage 1 Hypertension TreatmentRecheck in 1-2 weeks or sooner if symptomatic Evaluate or refer within 1 month if elevated on 2 additional occasions Weight management Pharmacologic therapy if; Symptomatic hypertension Secondary hypertension Hypertensive target organ damage Diabetes (1 or 2) Persistent hypertension despite non pharmacologic measures. Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood Pressure in Children and Adolescents Pediatrics 2004;114(2 Suppl)

69 Stage 2 Hypertension TreatmentEvaluate or refer within 1 week or immediately if patient is symptomatic Weight management Pharmacologic therapy Angiotensin converting enzyme inhibitors Angiotensin receptor blockers Beta blocker Calcium Channel blockers Diuretics Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood Pressure in Children and Adolescents Pediatrics 2004;114(2 Suppl)

70 Hyperlipidemia Diagnosis EtiologyElevated LDL cholesterol, triglycerides and lowered HDL cholesterol . Component of the metabolic syndrome Etiology Increased central fat distribution Hyperinsulinemia

71 Lipid Levels Low Normal High TChol HDLChol LDLChol Trig <170mg/dl

72 Hyperlipidemia Risk Overweight adolescents2.4 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 as adults years. Srinivasan Metab 1996;45:

73 BMI>99% Cardiovascular Risk39% two cardiovascular risk factors 65% had adult BMI >35% BMI >99% 59% two cardiovascular risk factors 88% adults BMI >35 4% US children BMI >99% Freedman DS et al Cardiovascular risk factors and excess adiposity among overweight children and adolescents; the Bogalusa Heart Study J Pediatric (1) 3-5.

74 Treatment Nutritional Weight lossLower fat, cholesterol intake, Increase fiber Weight loss Pharmacologic Therapy (after trial of dietary therapy for 6 months) Children >10 yr LDL cholesterol>190mg/dl or LDL>160mg/dl with 2 major risk factors. AAP Cholesterol in Childhood ;

75 Treatment- HypercholesterolemiaCholestyramine Approved for use in children Absorption of medications affected Worsening of bleeding problems, constipation, gallstones, hemorrhoids, ulcers, hypothyroidism, renal disease and PKU. Gastrointestinal side effects, constipation, flatulence and bloating Contraindicated when TG>400mg/dl

76 Studies HypercholesterolemiaLovastatin, Pravastatin, Simvastatin, Atorvastatin, HMG CoA reductase inhibitors Have been studied for up to 48 weeks in children, no long term studies, not approved in pregnancy

77 Treatment - HypertriglyceridemiaDecrease simple sugars Weight loss If persistent evaluate for diabetes, thyroid disease, renal disease, alcohol abuse Fish oil (omega-3 fatty acids) 2 gm/d if TG> mg/dl. Restrict contact sports (risk of bleeding) Gidding. Cardiovascular risk factor in adolescents Curr Treat Options Cardiovascular Med

78 Psychological MorbidityObesity Associated Psychological Conditions Depression Anxiety Low self esteem Teasing/Bullying Binge eating disorder

79 Psychological MorbidityAdditional psychological conditions with may impact treatment ADHD/ADD Bipolar Illness Adjustment Disorder Oppositional Defiant Disorder

80 Depression and ObesityIn adolescents 7-12 grade depressed mood predicted follow-up obesity Baseline obesity did not predict follow-up depression Data from the National Longitudinal Study of Adolescent Health (Add Health), a nationally representative, comprehensive, school-based study of youth in grades 7 to 12 Goodman E, Whitaker RC Prospective Study of the Role of Depression in the Development and Persistence of Adolescent Obesity Pediatr (3)

81 Obesity Trajectory and Depression/ODDChronically obese children had significantly higher rates of oppositional defiant disorder, and (for boys) depression. No difference among groups in gender, family structure, parenting style, family history of mental illness, drug abuse, crime, or traumatic events. Chronic and childhood obesity were associated with having uneducated parents and low family income. Study of children over a 4 year period in Appalachia Mustillo S et al.Obesity and Psychiatric Disorder: Developmental Trajectories Pediatr (4)

82 Health related quality of lifeObese children and adolescents 5.5 times more likely to have impaired health related quality of life than normal weight child Reported lower pediatric health related quality of life cores in all domains, physical, psychosocial, emotional, social, and school functioning than healthy children and adolescents Parents scores were even lower than children's Schwimmer JB, et al JAMA. 2003;289:

83 Health related quality of lifeObese children and adolescents with OSA reported lower quality of life scores than other obese children Health-related QOL did not vary by age, sex, SES, or race BMI z score among obese children and adolescents was inversely correlated with physical functioning. Schwimmer JB, et alHealth-Related Quality of Life of Severely Obese Children and Adolescents JAMA. 2003;289:

84 Comorbidities of ObesityComplete evaluation of an obese child includes history, review of systems and physical which includes obesity related comorbidities. Treatment of obesity reduces morbidity Modest weight loss is effective in ameliorating effects of obesity related comorbidities.