APPROACH TO AN ADOLESCENT WITH OBESITY By: Camille-Marie A. Go Darker font kasi very light blue and background mo..please do the same for those na may ganitong ka-light na background.medyo defective kasi ng projector natin

Objectives To present a case of a child with obesity To discuss the burden of disease, pathophysiology, management and possible complications of obesity

Our Patient P.N. 14 year old Male Filipino Roman Catholic San Mateo, Rizal

Rapid weight gain and hyperglycemia Chief complaint Rapid weight gain and hyperglycemia

3 years PTC 1 year PTC Annual Physical Examination FBS (2.98 mmol/L) ; cholesterol (360 mg/dl) Low fat diet 1 year PTC rapid weight gain + dark pigmentation of skin creases and flexural areas FBS (5.78 mmol/L), SGPT 109 U/L, cholesterol (240 mg/dl) Given Polyenylphosphatidylcholine (Essentiale)

2 months PTC elevated fasting blood sugar, elevated cholesterol, and elevated liver transaminases Polyenylphosphatidylcholine (Essentiale) + strict low fat and low cholesterol diet 1 week PTC Persistence of weight gain Fasting Blood Sugar, transaminases, cholesterol, triglyceride, LDL and HbA1c Referral to Pediatric Endocrinologist

Review of Systems General: (-) weight loss, (+) voracious appetite Cutaneous: (-) rashes, (-) discoloration, (-) jaundice HEENT: (-) blurring of vision, (-) nasoaural discharge, (-) epistaxis, (-) gum bleeding Cardiovascular: (-) cyanosis, (-) chest pain, (-) orthopnea, (-) easy fatigability (-) palpitation Respiratory: (-) cough, (-) colds, (-) difficulty of breathing, (-) sneezing Gastrointestinal: (-) vomiting (-) abdominal pain, (-) diarrhea, (-) constipation, bowel movement once a day

Review of Systems GUT: yellow urine, (-) edema of the hands and feet, (-) frothy urine Metabolic: (-) polydipsia, (-) polyuria Extremities: (-) swelling, (-) joint swelling, (-) limitation in movement Nervous/Behavioural: (-) headache, (-) dizziness, (-) nausea, (-) tremors, (-) convulsions , (-) change in sensorium (-) behavioral change Hematopoietic: (-) pallor, (-) easy bruisability (-) prolonged bleeding

Family History (+) DM – both parents; maternal GM (+) HPN - maternal GM (+) obesity - father (-) PTB (-) Heart disease (-) Thyroid disorders (-) Blood dyscrasia (-) Mental retardation, (-) Seizure Please add age sa mga shapes mo..remove asterisk sign kasi redundant na with the + and – signs.. Do not forget to put the DM and obesity ilalalim ng tatay (please refer to proper way of making genogram..yung may mga sakit ilalim sa may mga sakit to indicate their being ill with the disease)

Immunization History BCG 3 doses of Hepatitis B DPT x 3 OPV x 3 Measles MMR Boosters: of BCG and MMR No untoward reactions

Birth and Maternal History Born to a 30 year old G2P1 (1001) nonsmoker nonalcoholic mother Prenatal check up since 1 month AOG; (+) MVS, Feso4 (+) GDM at 6 months AOG, advised diet modification; repeat exam after 1 month normal Delivered Full term via NSD assisted by OB; (+) good cry and activity (+) small for gestational age Newborn Screening and Hearing Screening not done;

Nutritional History Breastfed until two months old Milk formula thereafter Complementary feeding at 6 months High carbohydrate and high fat diet prepared by the mother Fastfood 2x – 3x weekly Fond of junk foods and chocolates

Food CHO (g) CHON (g) Fats (g) Kcal Breakfast 3 pcs hotdog 4 cups of rice Water   184g 24g 16g 18g 258 kcal 800 kcal Snacks 6 pcs Biscuits Orange juice 23g 10g 2g 100kcal 40 kcal Lunch 2 cups Pork Sinigang vegetables 3 cups of rice 6g 138g 32g 12g 344kcal 32 kcal 600 kcal Dinner 3 cups Chicken Adobo water 32 g 24 g 344 kcal Total ACI RENI % intake 3,458 kcal 2,800 kcal 123.5%

Psychosocial History Home: Education: Concrete house with 6 household members Nuclear patriarchal clan Education: Second year high school at school in San Mateo, Rizal Favorite subject: Math Average grade - 89%. Aspires to be a successful accountant when he grows up Tinanggal ko ang eating kasi nasa next slide mo cya eh

Psychosocial History Activity: Fond of computer games Spends 4 to 6 hours per day Most of activities are sedentary Drugs: No intake of alcoholic beverage or cigarette use Does not know anyone using prohibited drugs Sexual: Has female crushes among his schoolmates No girlfriend. He has not courted any girl.

Psychosocial History Suicide: Safety: Spirituality: No personal history of attempted suicide Sees himself as overweight, not happy or proud of it Safety: Walks on the sidewalk to school Does not ride in cars with drivers who are intoxicated Spirituality: Hears mass every Sunday together with his whole family Actively participates in church activities

Past Medical History No previous history of hospitalization, or transfusions, or allergies No history of communicable diseases (measles, varicella) Underwent Circumcision at 10 years of age

Physical Examination: Conscious, coherent, oriented to 3 spheres, not in cardiorespiratory distress, ambulatory, over-nourished, well-hydrated, well-looking Wt: 75kg (z> 3) ; Ht: 163cm (z<0); BMI: 28.2 (z>3) CR 110 beats/min; RR 30 breaths/min; T 36.5 C; BP 110/60 mmHg (p 25) Warm and moist skin, dark pigmentation of skin creases and flexural areas, most prominent along the nape Pink palpebral conjunctivae, anicteric sclerae

Physical Examination: No alar flaring, no nasoaural discharge, intact tympanic membrane, AU Moist buccal mucosa, no dental carries, non-hyperemic posterior pharyngeal walls, tonsils not enlarged Supple neck, no cervical lymphadenopathies, no thyroid enlargement No retractions, symmetrical chest expansion, clear breath sounds Adynamic precordium, PMI at 5th left intercostal space midclavicular line, regular rate and rhythm no heaves, thrills, lifts or murmurs

Physical Examination: Globularly enlarged abdomen, no striae, normoactive bowel sounds, no organomegaly, no tenderness, no masses Grossly male, bilaterally descended testes, Tanner St. II Full and equal peripheral pulses, capillary refill time less than 2 seconds, no cyanosis, no edema No limitation in range of motion of all joints

Neurological Exam: Cerebrum: conscious, coherent, oriented to 3 spheres Cranial nerves: pupils isocoric, 2-3mm equally reactive to liht, (+) direct and consensual light reflex, extraocular movements full and intact, can clench teeth, (-) gross facial asymmetry, gross hearing intact, (+) gag reflex, can turn head from side to side against resistance, tongue midline Cerebellum: (-) no involuntary movements, able to do tandem gait

Neurologic Examination Reflexes: ++ on all extremities Motor: (-) rigidity, (-) spasticity, (-) flaccidity, (-) deficits Sensory: (-) deficits Meningeal Signs: (-) nuchal rigidity, (-) Brudzinski’s, (-) Kernig’s, (-) tonic neck reflex

Diagnosis: Obesity Hyperglycemia probably secondary to Diabetes Mellitus Type II Middle Adolescent with Psychosocial Issues (Body Image)

Obesity “Excessive storage of energy as FAT relative to lean body mass” Energy intake exceeds expenditure

Definition based on BMI Pediatrics Obese - BMI> 95% for gender and age At risk/overweight - BMI=85-95% Adults Obese – BMI> 30 Overweight – BMI=25-30

Measurement Weight Weight:Height BMI Skin Thickness Waist:Hip Ratio kg÷m2 Skin Thickness Waist:Hip Ratio Growth Charts

Patient

Incidence: Worldwide Variable definitions Increasing incidence in developed and developing nations Similar prevalence to US: Latin America, Caribbean, Middle East, Northern Africa, Central-Eastern Europe Asia and Africa: no increase in incidence DELETE SLIDE.. You may say this while presenting slide after this..

Worldwide Gayya et. al (2008) FNRI – DOST digest January 2014

Asian Prevalence Thailand – 23% Taipei – 28% Vietnam – 14 – 16% DELETE SLIDE..DO YOU HAVE A SLIDE NA COMPARING THIS TO THE PHILS? Gayya et. al (2008) FNRI – DOST digest January 2014

Philippine Data Prevalence of childhood obesity 1989 – 5.7 % 1993 – 6.8 % 2015 – 7% Gayya et. al (2008) FNRI – DOST digest January 2014

Trends in children and adolescents Phlippine data na to diba? Gayya et. al (2008) FNRI – DOST digest January 2014

Etiology Heterogeneous and Multifactorial Environmental Psychosocial Genetic

Sex Difference Males – Increased visceral fat Females – Increased hip fat At all ages females have more adipose tissue than males

Genetics vs. Environment Weights of adopted children correlate better with biological parents BMIs of identical twins reared apart= together Monozygotic twins more similar in fat deposition and weight than dizygotic twins Rference? Reference

Obesity Differential Diagnosis Idiopathic Endocrine: Hypothyroidism Hypercortisolism Growth hormone deficiency Genetic Prader-Willi Turner

Differential Diagnosis CNS conditions: hypothalamic damage Medications Glucocorticoids Phenothiazines Lithium Amytryptiline Estrogen/progesterone

Physiology of Regulation Of Energy Expenditure Polypeptide Y From L cells of small intestine Reduce food intake Ghrelin Stimulates food intake Elevated in Prader Willi

Pathogenesis LEPTIN - Adipostatic signal (1994) produced by adipose tissue Acts on Hypothalamus Decreases food intake Increases energy expenditure

Leptin Low neuropeptide Y  stimulates appetite High MSH  inhibits appetite Fasting  decreases Leptin Eating  increases Leptin

Leptin and Obesity Common obesity due to multiple allelic variations in hundreds of genes Monogenic obesity Leptin deficiency Leptin insensitivity

Hypothalamus Central role of energy intake Lesions cause hyperphagia and obesity

Environmental Factors: Increased Energy Input High caloric-density food Supersized portions Eating out Working parents Advertising

Environmental Factors: Decreased Energy Expenditure TV Computers Transportation Inadequate safe areas for physical activity Sedentary Lifestyle

Complications Diabetes (Type 2) Hypertension and Heart Disease Neurologic Complications Respiratory Disease Orthopedic Condition Psychosocial Disorders Hyperlipidemia GI Manifestations Menstrual Disorders

Metabolic Syndrome Clustering of CV risk factors related to insulin resistance Not well defined in Pediatrics Insulin resistance Dyslipidemia Hypertension Obesity DOES OUR PATIENT HAVE MS?

Childhood Obesity Hypertension Percentage of Overweight Children With BP in 95th Percentile Note: Based on a retrospective study of 18,618 patients. Source: Dr. Rappaport

Course in the Clinics First consult Laboratories: Type 2 Diabetes Mellitus with Obesity Metformin (20 mkday) Referred to Nutrition Clinic for dietary modification Increase physical activity

Universal Assessment of Obesity Risk: Steps to Prevention and Treatment American Academy of Pediatrics. Pediatric Obesity Clinical Decision Support Chart. Elk Grove Village, IL: American Academy of Pediatrics; 2008.

Steps to Prevention and Treatment of Pediatric Obesity

Steps to Prevention and Treatment of Pediatric Obesity

Prevention Plus BMI >85% Diet Modification Build on prevention Eating behaviors Family meals at least 5 to 6 times per week Allow child to self-regulate his or her meals Avoid overly restrictive behaviors—“Parents provide, child decides.” Structured activity American Academy of Pediatrics. Pediatric Obesity Clinical Decision Support Chart, 2008

Prevention Plus BMI >85% Diet Modification Goal: weight maintenance with growth  a decreasing BMI as age increases Monthly follow-up for 3 to 6 months If no improvement go to Stage 2 In the patient….. American Academy of Pediatrics. Pediatric Obesity Clinical Decision Support Chart, 2008

Prevention Plus BMI >85% Physical Activity/Inactivity 60 minutes of moderate physical activity per day or 20 minutes of vigorous activity 3 times a week Community activity programs Family activities Pedometer use Limit screen time to <2 hours per day No TV/computer in bedroom In the patient, advised American Academy of Pediatrics. Pediatric Obesity Clinical Decision Support Chart, 2008

American Academy of Pediatrics American Academy of Pediatrics. Pediatric Obesity Clinical Decision Support Chart, 2008

Global IDF/ ISPAD Guideline SUGGESTION: use different color to empahsize..eg yellow or red  kasi di masyado obvious pag blue lang din…

Pharmacotherapy: Metformin Approved for Type 2 diabetes and hyperinsulinemia Decreases hepatic glucose production Enhances insulin sensitivity Results in modest weight loss Side effects: nausea, flatulance, bloating, diarrhea, lactic acidosis

Pharmacotherapy Not approved for pediatrics Drug options Appetite suppressants Serotonin agonists Inhibitors of fat absorption Antihyperglycemic agents HINDI BA PAREHO LANG ANG THOUGHT NG NOT APPROVED FOR PEDIATRICS AND NO TESTS FOR PEDIATRIC AGE GROUP? DI PWEDE SABIHIN MO NLNG? 

Course in the Clinics Second consult Gradual weight loss of 1.8% 75 kilograms to 73.6 kilograms BMI from 28.2 to 27.7 (z > 2) TABLE OF LABS TABLE OF LABS?

Steps to Prevention and Treatment of Pediatric Obesity

Structured Weight Management Dietary and physical activity behaviors Balanced macronutrient diet with low amounts of energy-dense foods Increased structured daily meals and snacks Supervised active play: 60 minutes a day Screen time: 1 hour or less a day Increased monitoring

Structured Weight Management Weight maintenance Decreases BMI as age and height increases Weight loss 1 lb/month: 2–11 years old or 2 lb/week: older overweight/obese children and adolescents If no improvement in BMI/weight after 3 to 6 months  Stage III

Counseling

Steps to Prevention and Treatment of Pediatric Obesity

Obesity Treatment: Surgery Gastric bypass Gastic plication Gastric banding Jejuno-ileal bypass no longer performed Not routine for children

Course in the Clinics Sustained weight loss BMI 73.6 kilograms to 72.7 kilograms BMI 27.7 to 27.3 (z >2)

Course in the Clinics Regular follow up at the Endocrinology clinic every three months Continuation of weight loss 70kg, with a BMI of 25.9 (z > 1) Disappearance of the skin hyperpigmentation around the nape area

Overweight Diabetes Mellitus Type II, controlled ADOLESCENT? Final Diagnosis: Overweight Diabetes Mellitus Type II, controlled ADOLESCENT?

Childhood Obesity Conclusion Heterogeneous disorder Multifactorial causes Global epidemic Genetics Sedentary lifestyle Too much in Too little out