Transcript Expert Committee Recommendations

Childhood Obesity in Practice:
A look at the obese
& the extremely obese
Robert Murray MD
Marc Michalsky MD
Nationwide Children’s Hospital
Aims of Presentation
• a synopsis national guidelines
• the risk of extreme obesity
• bariatric surgery
and resolution of health risk
The Expert Committee
• American Medical
Association
• Dept of Health and Human
Services
• CDC & Prevention
• American Academy of
Pediatrics
• American Dietetics
Association
• Natl Assoc of Pediatric
Nurse Practitioners
• National Medical Association
• American Heart Association
• National Association of
School Nurses
• American college of Sports
Medicine
• The Obesity Society
• The Endocrine Society
• American College of
Preventive Medicine
• American Academy of Child
& Adolescent Psychiatry
• Association of American
Indian Physicians
Pediatrics, December 2007, 120:supplement 4
The Primary Physician’s Role
Prevention Identification Intervention
Nine Evidence-Based Messages
1.
2.
3.
4.
Support exclusive
breastfeeding 4-6
months
Limit sweetened
beverages
Eat 5 servings per day
of fruits & vegetables
Participate in moderate
to vigorous physical
activity for 60 mins/ day
5. Limit screen time to a
maximum of 2hrs/ day
6. Do not allow your child
to have a television in
his or her bedroom
7. Eat a nutritious breakfast
every day
8. Engage in regular family
meals 5-6 times/ week
9. Limit portion sizes
For Prevention & Counseling
An OUNCE of PREVENTION:
Anticipatory Guidance for obesity prevention
Ohio Chapter, American Academy
of Pediatrics
Ohio Department of Health
Ohio Dietetics Association
American Dairy Council, Mid-East
www.NationwideChildrens.org/HealthyWeight/
Normal at 10 yrs
“At risk” or overweight at 10 yrs
= 10% risk of obesity as adult
= 80% risk
Media
Societal Level
Policy
Community Level
The Workplace
Food Industry
Schools
Pre-schools
Early
Childhood
Providers
Family
CHILD
Neighborhood
Environment
Medical
Community
Community
programs
Out of school
time/Faith
Based
Inter-personal Level
Health & Fitness Takes Many Teachers
Parental Perceptions of
their Overweight Child
– Only 1/3 recognized it
– Only 1/4 worried about it
– Only 1/5 recalled MD concern
In most studies
parental recognition
of overweight
occurs around age 8-12 yrs -Even later for boys
Eckstein, Pediatrics 2006; 117:681
At every well-child visit, discuss weight
nutrition, activity
and health risk
Pediatric Obesity Management
Pocket Guide
Create a Risk Profile
Place the BMI in Context
• Family health history
– Obesity
– Diabetes
– Cardiovascular disease
• Targeted review of systems
• Targeted physical exam
• Blood pressure
Review of Systems
• Abdominal pain
• Joint pain
• Snoring, apnea, daytime
sleepiness
• Polyuria, polydipsia
• Irregular menses
• Signs of mood disorder
– Depression, anxiety
– social or school avoidance
• Exercise tolerance
• Diet
• Screen time
Physical Exam
•
•
•
•
•
•
•
•
Papilledema on eye exam
Tonsillar hypertrophy
Abdominal pain
Hepatomegaly
Tibial bowing
Hip or knee pain
Signs of precocious puberty
Skin findings
– acne, striae, hirsutism
– acanthosis nigricans
insulin resistance
hyperinsulinemia
skin changes
Fat mass
insulin resistance
Identify
this
early
altered metabolism
• diabetes
• hypertension
• abnormal lipids
• inflammation
• cardiovascular ds
• asthma
• liver disease
• sleep apnea
• orthopedic problems
Blood Pressure
a critical risk
•
•
•
•
Children >3 years of age
Auscultation is preferred
Use appropriate sized cuff
Must be plotted on curves
adjusted for age, sex, and
height
• Measurements that exceed
the 90th percentile should be
repeated
Do I have to check labs?
BMI Percentile
85-94%
No risk factors
Labs
Fasting Lipid Profile
85-94%
With risk factors
Fasting Lipid Profile
ALT, AST, Fasting glucose
>95%
Fasting Lipid Profile
ALT, AST, Fasting glucose
Consider Fasting Lipid Profile age >=2 years, Additional hepatic function and
fasting glucose should be considered at age >= 10years. Clinical judgment may
dictate additional labs in the younger child with higher risk.
Motivation/Attitude
Nine Evidence-Based Messages
1.
2.
3.
4.
Support exclusive
breastfeeding 4-6
months
Limit sweetened
beverages
Eat 5 servings per day
of fruits & vegetables
Participate in moderate
to vigorous physical
activity for 60 mins/ day
5. Limit screen time to a
maximum of 2hrs/ day
6. Do not allow your child
to have a television in
his or her bedroom
7. Eat a nutritious breakfast
every day
8. Engage in regular family
meals 5-6 times/ week
9. Limit portion sizes
Prevention & Counseling
Algorithm For Intervention
Resources to Help You
• Ounce of Prevention
– Birth to 5 years
– 6 to 19 yrs NEW!
– Parent handouts
•
•
•
•
•
BMI wheels and tables
Parent Tip Sheets
Pocket management book
Coding sheet
Acanthosis training NEW!
www.NationwideChildrens.org/HealthyWeight
What to do with
Extreme Obesity
Medical Sequelae of Obesity












Hypertension
Lipid disorders
Diabetes
Ischaemic heart disease
Cardiomyopathy
Pulmonary hypertension
Asthma
Hypoventilation
syndromes
Obstructive sleep apnea
Gallstones
NASH (Non-alcoholic
steatohepatitis)
Urinary incontinence












Gastroesophageal reflux
Arthritis – weight bearing
Low back pain
Infertility and menstrual
problems
Obstetric complications
DVT and thromboembolism
Depression
Immobility
Cancer
Venous/stasis ulcers
Intertrigo
Accident prone
Adipocytes are Endocrine Cells
Secretion of > 50 Adipokines
• Leptin
•Adiponectin
•Resistin
•TNF- alpha
Adipose Actions
• stimulate inflammation
• increase insulin resistance (block receptor
signaling)
• attract macrophages into fat & vessels (foam cells)
• alter metabolism
• lower sensitivity to insulin’s actions
• shift glucose-based to FFA-based metabolism
• fat storage in non-adipose tissues
Obesity & Endothelial Dysfunction
Adipose Tissue
leptin
IL-6
FFA
fibrinogen
Angiotensin II
TNF- alpha
Adhesion Molecules
•
•
•
•
•
inflammation
thrombus formation
plaque destabilization
lipid accumulation
poor distensibility
Nitric
Oxide
Macrophage
Chemoattractives
Vascular Endothelial Cell
Pharmacol Reports 2006; 58: s81
Extreme Obesity in Children
• BMI > 99th percentile or BMI > 35
• 2-6% of all kids
• > 50% have metabolic syndrome
• Significant cardiovascular changes
• Multi-organ complications
Weight Loss Pediatric Programs
• NACHRI identified 80 pediatric centers
with weight management programs
• Only 15 had an associated surgical
weight loss program
• 6 to 8 “high” volume programs
• August, 2008 – NACHRI formed
Obesity Steering Committee
The Bariatric Program
at Nationwide Children’s
• Surgeons:
–
–
–
–
Marc Michalsky, MD
Steve Teich, MD
Allen Browne, MD
Bradley Needleman, MD
(OSUMC)
– Scott Melvin, MD (OSUMC)
• Medical Director
– Robert Murray, MD
“First 50 Patients”
Co-morbidity
Hypothyroidism
Insulin
Resistance
Hypertension
Depression
GERD
Type II DM
Asthma
OSA
Overall (%)
7
28
New Dx (%)
33
54
24
42
26
19
21
26
10
5.5
13
25
22
42
Co-Morbidities in Bariatric Patients
NCH and OSU Experience
50
45
40
35
30
25
20
15
10
5
0
50
Adults
%
Peds %
45
40
35
30
25
20
15
10
5
OSA DM
HTN
0
OSA
DM
HTN
Resolution of Co-morbid Conditions
5 months post-pediatric bypass
80
70
60
50
% Patients
Pre-Op
20 Weeks
40
30
20
10
0
OSA
HTN
DM
Gastric Bypass: Effect on HOMA
Body Mass Index
Insulin Resistance
55
7
50
6
5
IR
BMI
45
40
4
3
35
2
30
1
25
0
4 wk
8wk
12wk
20wk 32wk
52wk
4 wk
8wk
12wk
20wk
32wk 52wk
Homeostatic Model Assessment (HOMA)
β Cell Activity vs. Insulin Sensitivity
400
%B
350
%S
Percent
300
250
200
150
100
50
0
4 wk
8wk
12wk
20wk
32wk
52wk
Quality of Life Measures
6 months post- bypass
Healthy
Mean (SD)
Pre-Op
Mean (SD)
Post-Op
(6 month)
Mean (SD)
Total Score
83.8 (12.6)
55.7 (15.4)
77.3 (12.3)
Physical Score
87.5 (13.5)
54.2 (18.5)
78.0 (14.0)
Psychosocial
81.8 (14.1)
56.6 (16.6)
77.0 (14.0)
Emotional
Function
79.3 (18.1)
57.2 (21.0)
80.8 (19.3)
Social
Function
85.1 (16.8)
56.6 (23.7)
80.0 (18.3)
School
Function
81.1 (16.5)
55.1 (18.2)
69.5 (21.3)
Washington State Healthcare
Authority
Health Technology Clinical
Committee
• Evaluated healthcare coverage for
adolescent bariatric surgery
• Assessment of the strength of current
peer-reviewed evidence
• Determine safety, efficacy and cost
• Guide decisions regarding state
program coverage
Health Technology Clinical
Committee
• 2004: Estimate 2000 bariatric
procedures were performed in patients
under 21 years
• 75% of bariatric surgeons surveyed
report planning to perform a procedure
on an adolescent in the near future
Health Technology Clinical
Committee
• Review 17 peer-reviewed studies
• 553 pediatric patients
• Studies were assessed for
validity/quality
Meta-analysis Results
• Majority: academic medical centers
• Mean age 15.6 to 18.1 years
• Average BMI
– RYGB 51.8 kg/m2
– LAGB 45.8 kg/m2
Questions
1. Does PBS lead to significant (> 7%EBWL) and
durable weight loss?
2. Does PBS improve co-morbidities, QOL and
survival compared to medical therapy?
3. Safety Profile (surgical v. medical)
4. Cost Profile (surgical v medical)
5. Does efficacy, safety and cost vary according to
demographics (age, sex, BMI)
Conclusion
Clinical Research
NIH Sponsored
• TeenLABS (Longitudinal Assessment of Bariatric
Surgery)
– NIH-sponsored,
– Multi-centered observational study
– 2 year follow-up
– 5 centers
– N = 200 teens
Clinical Research
NIH Sponsored
• Teen-Intake (Nutritional Assessment of Bariatric Surgery)
– NIH-sponsored,
– Multi-centered observational study
– 2 year follow-up
– N = 200 teens
• TeenVIEW (Controlled Longitudinal of Psycho-social
Development)
– NIH-sponsored,
– Multi-centered observational study
– 2 year follow-up
– N = 200 teens
Clinical Research
Industry Sponsored
• LBA 001 (Allergan)
– Industry-sponsored IDE, 5 year follow-up
– Multi-institutional safety/efficacy trial
• n = 150 subjects (14 to 17 years)
– Local: n = 26, enrollment closed Dec, 2007
Reversal of Type II Diabetes
• 11 teens > 1 year after Roux-en-Y bypass
• Mean BMI 50 + 5.9; 50% metabolic synd
• Post-op
– BMI fell by 34% to 33 + 7 kg/m2
– Improvement of fasting glucose, insulin,
HOMA-IR, Hb A1C, AST, ALT, LDL,
triglycerides, total cholesterol, blood pressure
– Remission of diabetes in 10 of 11 cases
– Removal of oral hypoglycemics in 10 cases
Inge et al, Pediatrics 2008; 123:214
Cardiovascular Risk &
Extreme Obesity in Teens
•
•
•
•
BMI > 99th %ile or BMI > 40
N=38 13-19 yrs old
Pre- and post- gastric bypass surgery
Echocardiogram, doppler studies
– Adequate studies in only 38 of 67 cases
– LV geometry (size, ventricular shape, mass, wall thickness)
– LV systolic function (contractility, wall thickness)
– Diastolic function (atrial size, pulsed doppler assessment)
Ippisch et al, J Am Coll Cardiol 2008; 51:1342
Weight Loss & Cardiovascular Risk
• ¼ showed high risk concentric LVH
– Adults: with concentric LVH, 53% had a cardiovascular event
– Teens: 28% had concentric LVH pre-op, only 3% post-op
• LV mass increased
– Adults: > 51 g/m2.7 had 4-fold higher CV mortality
– Teens studied: averaged > 54 g/m2.7, max 86 g/m2.7
• LV dimensions, systolic function: abnormal
– Normal LV geometry: only 36% pre-, up to 79% post-op
• Elevated cardiac workload, BP
– Decreased HR and systolic BP, rate-pressure product
• Abnormal diastolic function
– Improved mitral valve and filling dynamics post-op
Ippisch et al, J Am Coll Cardiol 2008; 51:1342
Cardiovascular Status Pre-surgery
CMR Results
50
*
150
100
50
40
20
*
4
3
2
*
1
0
0
0
60
D
5
MPRI
100
LV EDV (mL)
LV MASS (g)
*
C
80
B
200
EF (%)
A
150
0
NW OB
NW OB
Comparison of CMR results from obese (OB) adolescents to published normal weight
(NW) normative reference values.
(A) Left ventricular (LV) mass, (B) LV end diastolic volume, (C) LV ejection fraction,
(D) Myocardial Perfusion Reserve Index (MPRI). * p<0.01
NW
OB
NW
OB
10 patients pre-bariatric surgery show striking
cardiovascular abnormalities and risk
Conclusions
• Extremely Obese Teens
– Have many serious co-morbidities
– High risk of type II diabetes
– Extreme cardiovascular risk
• Bariatric Surgery
– Shows effective metabolic resolution
– Resolution of co-morbid conditions
– Resolution of cardiovascular abnormalities
– Minimal risk
Center for Healthy Weight & Nutrition
Prevention
Public
Health
Healthcare
Provider
Support
Child &
Family
Education
Treatment
Medical
Weight
Loss
Programs
Bariatric
Surgery
www.NationwideChildrens.org/HealthyWeight
Research