1. 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

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

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

4. Rapid weight gain and hyperglycemia
Chief complaint
Rapid weight gain and hyperglycemia

5. 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)

6. 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

7. 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

8. 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

9. 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)

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

11. 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;

12. 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

13. 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%

14. 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

15. 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.

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

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

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

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

25. 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

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

27. Patient

29. 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..

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

31. 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

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

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

34. Etiology Heterogeneous and Multifactorial Environmental Psychosocial
Genetic

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

36. 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

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

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

39. 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

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

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

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

43. Hypothalamus Central role of energy intake
Lesions cause hyperphagia and obesity

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

45. Environmental Factors: Decreased Energy ExpenditureTV
Computers
Transportation
Inadequate safe areas for physical activity
Sedentary Lifestyle

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

47. 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?

48. 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

49. 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

50. 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.

51. Steps to Prevention and Treatment of Pediatric Obesity

52. Steps to Prevention and Treatment of Pediatric Obesity

53. 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

54. 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

55. 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

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

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

58. 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

59. 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? 

60. 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?

61. Steps to Prevention and Treatment of Pediatric Obesity

62. 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

63. 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

64. Counseling

65. Steps to Prevention and Treatment of Pediatric Obesity

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

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

68. 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

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

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