12 5 16 Childhood Obesity Syllabus

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12/5/2016

1

Childhood Obesity

and Type 2

Diabetes

ILENE FENNOY, MD, MPH

COLUMBIA UNIVERSITY MEDICAL CENTER

Disclosures

I serve as a Novo Nordisk Advisory Board

Consultant

I am funded for pharmaceutical studies by

Roche-Genentech and NovoNordisk

I will discuss unapproved uses of

medications

Definition of Obesity

Organization

Overweight

Obese

US CDC

BMI 85th to < 95th percentile

BMI≥95th percentile

IOTF

Provides international BMI cut points by age and sex for

overweight and obesity for children 2 to 18 years. Cut

points correspond to an adult BMI of 25 kg/m2 (overweight)

or 30 kg/m2 (obesity)

WHO

Birth to 5yr old: BMI=2

standard deviations above

the WHO growth standard

median

5-19yr old: BMI > 1 standard

deviation above the WHO

growth standard median

Birth to 5yr old: BMI >3 SD

above the WHO growth

standard median

5-19yr old: BMI > 2SD above

the WHO growth standard

median

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Obesity Classification

Adult

Overweight- BMI= 25.00 to 29.99

kg/m2

Class 1 Obesity-BMI= 30.00 to

34.99 kg/m2

Class 2 Obesity-BMI=35.00 to

39.99 kg/m2

Class 3 Obesity- BMI≥40.00

kg/m2

Adolescent

Overweight= BMI ≥ 85th and <

95th percentile

Class 1 =BMI ≥ 95th %ile and

<120% of 95th percentile

Class 2=BMI≥ 120% of 95th

percentile

Class 3=BMI≥ 140% of 95th

percentile

Jasik CB, et al. Childhood Obes. 2015; 11,#5:

630-637

Kuczmarski RJ & Flegal KM. Am J Clin

Nutr. 2000; 72:1074-1081.

Prevalence of Obesity

0

2

4

6

8

10

12

14

16

18

20

Class 1 Obesity

Class 2 Obesity

Class 3 Obesity

Obesity in Youth 2001 vs 2014

2001-2002

2009-2010

2013-2014

Skinner A, et al. Obesity 2016; 24:1116-1123

Prevalence of Diabetes by Type,

2001-2009

0

0.5

1

1.5

2

2.5

Type 1

Type 2

Diabetes in Youth per 1000

2001

2009

Dabelea D, et al. JAMA 2014;311(17):1778-1776

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Prevalence of abnormal HgbA1c and

FBS by Weight Category, 3 -19 yrs of age

0

5

10

15

20

25

30

35

Overweight

Class 1 Obesity

Class 2 Obesity

Class 3 Obesity

Prevalence (%)

HgbA1c>5.7%

FBS>100mg%

Skinner AC et al. NEJM 2015;373, #14:1307-1317

Summary

Obesity prevalence is increasing among youth

Both Type 1 diabetes and Type 2 diabetes have increased in

prevalence during this same period making weight less useful as a

key determinant of who has Type 2 diabetes

Obesity severity is associated with progressively abnormal measures

of glucose intolerance suggesting that continued increases in

obesity are likely to lead to increasing Type 2 diabetes.

Type 2 diabetes in youth

CHILDHOOD OBESITY AND TYPE 2 DIABETES

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Testing for Type 2 DM in Children*(1)

Criteria

Severe Obesity (BMI >99th percentile, or BMI>120% of

95th%ile);

OR at onset of puberty with

Obesity (BMI≥ 95%ile)

Overweight (BMI>85th percentile but less than 95%ile with

risk factors)

Patients on second generation antipsychotics,

Or Any two for the following risk factors:

Family history of type 2 DM in first or second degree relative

Race/ethnicity (American Indian, African-American, Hispanic,

Asian/Pacific Islander)

Signs of insulin resistance or conditions associated with insulin

resistance (acanthosis nigricans, hypertension, dyslipidemia,

PCOS)

*Pediatrics 105,#3:671-680, 2000. and Haemer MA, et al. Childhood Obesity 2014; 10, #4:292-303.

Testing for Type 2 DM in Children(2)

Age of initiation: 10yrs, or

at onset of puberty

(if puberty occurs at a younger age)

Frequency: Every 2 years when normal or more often if new

risks emerge

Test: Fasting Plasma Glucose

Pediatrics 105,#3:671-680, 2000. and Haemer MA, et al. Childhood Obesity 2014; 10, #4:292-303.

Criteria for Diagnosis of DM

1. Symptoms of diabetes plus casual plasma glucose

concentration >=200 mg/dl (11.1 mmol/l).

Casual is defined as any time of day without regard to time since last meal.

The classic symptoms of diabetes include polyuria, polydipsia, and

unexplained weight loss

2. FPG >=126 mg/dl (7.0 mmol/l)*.

Fasting is defined as no caloric intake for at least 8 h.

3. 2-h PG >=200 mg/dl (11.1 mmol/l)* during an OGTT.

 The test should be performed as described by WHO, using a glucose load containing the

equivalent of 75 g anhydrous glucose dissolv ed in water.

4. HgbA1c ≥ 6.5%

Performed in a lab that is NGSP certified and uses an assay

standardized to DCCT

Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 37(suppl 1)L/s81-S90, 2014

*Abnormal blood glucose values should be confirmed by repeat testing on a different day

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How do we screen for Type 2

diabetes in youth

IS HGBA1C AN APPROPRIATE SCREENING TOOL IN THE CHILD OR, IS FBS

OR AN OGTT MORE APPROPRIATE?

Which test is best for diagnosis of

DM in youth?

4848 Obese Children and Adolescents aged 7 to 17yrs

oGTT & HgbA1c testing identified 2.4% of children with diabetes (n=115)

68.7% had HgbA1c>6.5%

46.1% had FPG≥126mg% and/or 2Hr glucose≥200mg%

43.5% had diabetes confirmed

Ehehalt S. et al, Eur J Pediatric Diabetes 2016: DOI 10.1007/s00431-016-2807-6

Association between oGTT measure

of IFG, IGT, and HgbA1c in children

4848 Obese Children and Adolescents aged 7 to 17yrs

Correlation entire population:

FPG and 2-hr glucose= r=0.26

FPG and HgbA1c= r=0.18

2-hr glucose and HgbA1c= r=0.17

Correlation IFG

2-Hr glucose vs HgA1c, r=0.30

Confirmed diabetes

FPG and 2-Hr glucose, r=0.73

2Hr glucose vs HgA1c, r= -0.47

Ehehalt S, et al. Pediatric Diabetes 2016:1-8, DOI 10.1111/pedi.12461

12/5/2016

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Summary

In a general asymptomatic obese population of children, different

results are obtained as indicators of diabetes by HgbA1c and oGTT

The best correlation between values occurs in patients with

confirmed diabetes not those at risk for diabetes

How persistent is Glucose

intolerance?(1)

Weiss R, et al. Diabetes Care 2005; 28,#4:902-909

117 obese children, 4 to 18yrs of age, BMI>95%ile, mixed ethnicity had

oGTT done at baseline and 18 to 24 m later

84 wth NGT, 33 with IGT

76(90.5%) with NGT maintained NGT

8 (9.5%) with NGT progressed to IGT

15 (45.5%) with IGT reverted to NGT

10 (30.3%) with IGT persisted with IGT

8(24.2%) with IGT progressed to T2DM

7 of the 8 who progressed to T2DM were African American females with

much higher BMI than the group

How persistent is Glucose

intolerance?(2)

Kleber et al. Diabetic Medicine 2010, 27,#5:516-521.

79 obese white children, mean age 13 with IGT

32% at 1yr with persistent IGT, 66% converted to NGT

1 chld with IFG, 1 child progressed to diabetes

Libman, et al. JCEM 2008;93, #11:4231-4237

85 overwgt/obese children, mixed ethnicity, mean age=12.4yr

Repeat oGTT 1 week later

10 with IGT, 30% concordonace at 2nd oGTT

Those with discordant oGTT had more measures of insulin resistance than

those with concordant results as measured by HOMA or WBISI

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Summary

Results of oGTT are subject to change in children and adolescents

Only about 30% of those with IGT persist with IGT and an even

smaller fraction progress to Type 2 DM

Those who progress to Type 2 DM are likely to be of heavier weight

and African American Heritage.

Association of IFG and IGT with

cardiometabolic risk in children

972 children and 2116 adolescents (OW/Ob) between 2003 and

2013 received oGTT tests

Prevalence same between children and adolescents

 IFG =3.2% vs 3.3% respectively

IGT= 4.6 vs 5.0% respectively

Isolated IGT vs NGT

Children: 2 to11-fold increased risk of elevated LDL-C, non-HDL-C,

Tg/HDL-C ratio and low insulin sensitivity

Adolescence: Similar increased cardiometabolic risk profile

DiBonito P, et al. J. Endocrinol Investig. 2016: DOI:10.1007/s40618-016-0576-8

What is treatment for Pre-

Diabetes?

SHOULD WE TREAT PRE-DIABETES WITH METFORMIN OR IS LIFESTYLE

SUFFICIENT?

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Pre-Diabetes

Impaired Fasting Glucose

Fasting plasma glucose ≥100 and ≤ 125mg%*

Impaired Glucose Tolerance

2-Hr glucose ≥ 140 and <200mg% in a 75gm (or 1.75mg/kg to a max of

75gm) oGTT*

Category of increased diabetic risk

HgbA1c =5.7% to 6.4% *

*Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 37(suppl 1):s81-S90, 2014

Prediabetes therapy

Limited pediatric data available to determine optimum therapy

Garnett S, et al. BMC Pediatrics 2014; 14, #1:289

110 obese children, age 10 to 17, treated with metformin but randomized to

high carb diet vs high protein, moderate carb diet showed improvements

with 6.8% decrease in BMI, 2.4% decrease in percent body fat and an

increase in insulin sensitivity

There were no dietary differences in response to combined intervention

Haemer M, et al. Childhood Obesity 2014;10,#4:292-303.

Systematic review of clinical practice (25 pediatric obesity clinics), plus

literature review to come to consensus statement

“The Committee takes no position on the use of pharmacological agents to

prevent T2DM in children with prediabetes or elevated fasting insulin, given

the limited studies in children and evidence that many children ith

prediabetes may revert to normoglycemia without pharmacological

treatment (Evidence C).”

Conclusion

Increased obesity associated with increase prevalence of T2DM and

prediabetes in youth

Pre diabetes is associated with adverse cardiometabolic risk profile in

children and adolescents

Results of oGTT, either fasting or 2-Hr, have poor correlation with each

other and with HgbA1c in an asymptomatic obese population of

children,

Prediabetic results in children frequently remit to normal results

All 3 tests may be used to diagnose T2DM, but results of any one episode of

testing must be cautiously interpreted given the variability in results over

time.

More severe obesity, African American heritage and female status is

most associated with progression from pre-diabetic to diabetic state.

12/5/2016

1

Sheldon E. Litwin, M.D.

Alicia Spaulding-Paolozzi Professor of Cardiology

Medical University of South Carolina

Ralph H. Johnson VAMC

Disclosures:

None

Cardiovascular Consequences of Obesity in

Children

Key Points

•Obese children more likely to become obese adults

•Coronary risk factors increased in obese children (DM,

HTN, dyslipidemia, NAFLD, OSA)

•Childhood obesity associated with increased markers

of atherosclerosis and CV death in adulthood

•Return to normal weight in adulthood may attenuate

risk from childhood obesity

•Lifestyle modification programs disappointing

•Limited data on pharmacological therapy

•Bariatric surgery effective option for severe obesity

(long term data lacking)

NEJM 2009; 361:2252-60

NEJM 2005; 352:1138-45

“The negative effects of increasing

BMI overwhelmed the positive

effects of declines in smoking in

multiple scenarios.”

“Assuming that current rates of death

associated with obesity remain

constant in this century, the overall

negative effect of obesity on life

expectancy in the US is a reduction of

1/3 to 3/4 of a year. This is not trivial –

it is larger than the negative effect of

all accidental deaths combined…and

there is reason to believe it could

exceed the negative effect that

ischemic heart disease or cancer has

on life expectancy.”

We all face consequences of the obesity epidemic

12/5/2016

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NEJM 1997; 337:869-73

Obese children more likely to become obese adults. Strong parental influence.

Genetic? Behavioral? Both?

N=854

Retrospective

Born 1965-71

16% obese age 21-29

NEJM 2015; 373:1307-17

Increased CV Risk Factors in obese children and adolescents

Age 2-19, 6% severely

obese (NHANES 2011-12)

Prevalence of cardiometabo lic risk factors (%)

Low

HDL

NEJM 2007; 357:2731-9

•Adolescent overweight projected to  prevalence of obese 35 yr olds in

2020 to 30-37% in men & 34-44% in women.*

•Estimated that prevalence of CHD will  5-16%

* 37.7% in all adults NHANES 2013-14

12/5/2016

3

NEJM 2010; 362:485-93

•4587 American Indian children (11.3 yrs), median f/u 23.9 yrs

•Rates of death from endogenous causes in highest quartile BMI >

double that in lowest quartile

•Obesity, glucose intolerance and HTN in childhood strongly associated

with premature death

Obesity and age of first MI.

Madala et al. JACC 2008

CRUSADE registry,

189,000 patients,

2001-2007

Most obese

subgroup (BMI >

40) were 15 years

younger than

leanest subgroup

at time of first MI

Curr Opin Lipidol 2013, 24: 57-64

•3596 Finnish children & adolescents 3-18

years

•Followed up at 3-9 year intervals

•Currently at 30 year follow up (middle age)

•Intermediate phenotypes (CIMT, CAC, echo,

FMD, PWV) 2001, 2007, 2010, 2012

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NEJM 2011;365:1876-85

•International Cardiovascular Cohort

Consortium (IC3)

•Bogalusa, Muscatine, Childhood

Determinants of Adult Health

(Australia), CV Risk Young Finns

•6238 subjects

Group 1

Group 2

Group 3

Group 4

Child

-

+

+

-

Adult

-

-

+

+

High risk outcomes:

LDL > 160, HDL < 40, TG > 200, T2DM, HTN,

CIMT > 90th %

Obese children who become normal weight adults have lower risk

Weight loss pharmacotherapy

•Perception of physicians

–Unproven

–Ineffective

–Unsafe

•Reality

–> 17,000 patients in clinical trials

–>10% weight loss~ 50% of patients

–No evidence of adverse CV effects

Pharmacological Rx of Obesity

Drug Class Current status

Orlistat Lipase inhibitor

(blocks fat absorption) OTC (small weight loss, GI

side effects)

*Approved for children*

Phentermine/Topiramate

(QsymiaTM) NE reuptake blocker

Anticonvulsant, migraine Approved for adults

Liraglutide (SandexaTM) GLP-1 agonist

Injectable Approved for adults

Lorcascerin (BelviqTM) Serotonin agonist

(selective) Approved for adults

Bupropion/Naltrexone

(ContraveTM) Dopamine reuptake

inhib/Opioid receptor

antagonist

Approved for adults

Metformin was associated with a significant reduction in BMI-SDS compared with

placebo at 6 months [mean difference 0.1 SD (95% CI 0.18 to 0.02), P 0.02].

12/5/2016

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A proud and happy

participant in our study at

the time of his 2 year

follow up visit

Average weight loss in

GBS subjects at 2 years

= -100 lbs

Average change in BMI at

2 years = -15 units

Bariatric Surgery

Roux en Y GBP

Restrictive/malabsorptive

Lower coronary Calcium Scores After Bariatric Surgery

ResultsofCACSubstudy(6yearfollowup)



GBS(n=71)

NoSurgery(n=62)

Pvalue

CACscore(mean)

33+114

107+340

<0.01

CACscore=0

67%

43%



<0.01

CACscore1-10

16%

22%

CACscore11-100

10%

18%

CACscore>100

7%

17%



Priester T….Litwin SE: Coronary calcium scores 6 years after bariatric

surgery. Obes Surg 2015; 25:90-96

NEJM 2016; 374:113-23

Teen LABS (Longitudinal Assessment of Bariatric Surgery

242 adolescents (17 yrs, BMI 53, 75% female, 72% white)

3 year follow up

Remission of:

type 2 diabetes 95%

prediabetes 76%

elevated blood pressure 74%

dyslipidemia 66%

abnormal kidney function 86%

Improved weight related quality of life

Low ferritin 57%

Reduced vitamin B12, A, D levels

13% had repeat abdominal procedures

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38 adolescents (13-19 yrs, 29 female, 33 white)

Pre and post bariatric surgery (mean f/u 10 months)

BMI 60 => 40 kg/m2

Summary

•Obese children more likely to become obese adults

•Coronary risk factors increased in obese children (DM,

HTN, dyslipidemia, NAFLD, OSA)

•Childhood obesity associated with increased markers

of atherosclerosis and CV death in adulthood

•Return to normal weight in adulthood may attenuate

risk from childhood obesity

•Lifestyle modification programs disappointing

•Limited data on pharmacological therapy

•Bariatric surgery effective option for severe obesity

(long term data lacking)

Effects of low dose, controlled release, phentermine plus topiramate

combination on weight and associated comorbities in overweight and obese

adults (CONQUER): A randomized, placebo-controlled phase 3 trial

Gadde KM, et al Lancet 2011; 377:1341-52

TC LDL HDL TG

12/5/2016

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Abdominal CT Scans

Nonsurgery Subjects Surgery Subjects

11/30/2016

1

Orthopedic Implications of

Childhood Obesity

VuMedi webinar 12/5/16

Dave Shenton MD

•I have nothing to disclose

General thoughts regarding

childhood obesity and

orthopedic problems

•Disclaimer – I am not a Pediatric Orthopedic surgeon. I specialize in

Sports medicine (esp. shoulders, knees)

–However, I have seen the dramatic change in childhood obesity in my

practice over the past 30 years, became alarmed, participated in

education of parents

•Children inherently have special orthopedic risks with obesity

versus adults because they are growing and developing

–Orthopedic Conditions - Growth plate injuries (SCFE, Blounts, etc)

•Other musculoskeletal problems – Perthes, etc

–General musculoskeletal complaints and injuries

•Increased risk of injury and compromised recovery

•Back, lower extremity, ankle and foot problems

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The problem with childhood obesity:

•As a society we

Americans are

overfed and

undernourished

•Inactivity is

epidemic

–Nearly 40% of kids

physically unfit

Society has taken notice

The Causes:

•“The biggest factor for obesity in the young is

still parental overweight”!

B. Healy MD, USN&WR Sept 4, 2006

Children who are overweight or obese as preschoolers are five times

as likely as normal-weight children to be overweight or obese as

adults.

11/30/2016

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U.S. Adults by State and Territory, BRFSS,

2015

¶ Prevalence estimates reflect BRFSS methodological changes started in 2011. These

estimates should not be

compared to prevalence estimates before 2011.

*Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.

The Problem:

•Health issues:

–Obesity care costs for kids more than

tripled between 1979 and 1999 in US

($127 million) Nat’l Acad of Sciences

– Kids increasingly with “adult” diseases

•Type 2 diabetes

–1 in 3 expected to develop

•High blood pressure

•Heart disease

•Respiratory ailments

•Sleep apnea

–(poor concentration and attention

problems)

–Also multiple Orthopedic

problems

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Slipped Capital Femoral Epiphysis

•Orthopedic condition in adolescence where the femoral head slips

posterior and inferior relative to the femoral neck

–This can happen either acutely or more slowly and chronically.

–Usually presents with hip and/or knee pain and limping.

–Often occurs during periods of rapid growth or shortly after adolescence

–This is a surgical problem classically requiring screws or pins to stabilize the slip

and effect healing

•Multiple complications possible including avascular process of the femoral head, chondrolysis,

persistent pain and stiffness

•The surgery is more difficult with increased risk of complications reported in obese children

–Risk factors include obesity – resulting in increased shear forces

Multiple studies show association between

overweight/obesity and slipped capital femoral

epiphysis (SCFE) – e.g.:

•Aversano MW, et al. Association between body mass index-for-age

(CDC ref) and SCFE: the long term risk for subsequent slips in

patients followed until physeal closure. J Child Orthop 2016.

–Association between obesity measured by BMI-for-age percentiles and SCFE

–All but one patient (79/80) greater than 85th percentile

•Nasreddine AY, et al. a reduction in body mass index lowers risk for

bilateral SCFE. Clin Orthop Relat Res 2013

•Loder RT. The demographics of slipped capital femoral epiphysis. Clin

Orthop. 1996; 322:8–27.

–reviewed the cases of 1630 children with 1993 SCFE.

–worldwide - 47.5% white, 24.8% black, 16.9% Amerindian, 7.4% Indonesian-Malay, 2.1%

Native American/Pacific Islands, and 1.3% Indo-Mediterranean children

– 671 were girls (41.2%) and 959 were boys (58.8%) avg age 12 and 13.5 years, respectively

– The age at diagnosis decreased with increasing obesity

–weight status (at the time of the first slip) was known for 1337 children - 51.5% were obese

(body weight >95th percentile), 11.7% were overweight (body weight in 90th to 95th

percentile

Blount’s Disease

•Orthopedic condition with severe bowing (varus deformity) of the

legs

–Thought to result from increased and uneven stress on the growth plate caused

by excess weight leading to irregular growth and deformity.

•Probably preceded by physiologic varus in the child combined with overweight

–Infantile and adolescent types (both uncommon, reported at less than 1%)

–Usual presenting complaint is the progressive deformity, rather than pain

–Treatment can consist of leg braces or orthotics in younger patients and with less

severe deformities.

–Surgery is required in older patients and those with more severe deformities.

•Complications can include malunion, gross deformity, infection, delayed healing, recurrence

•Surgery is more difficult in obese patients and a higher risk of complicationsis reported.

Radiographic features

include varus at

epiphyseal/metaphyseal

junction

• Widened irregular medial

physis

• Medial sloping of

epiphysis

• Beaking of medial

metaphysis

11/30/2016

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Blount’s disease - Relationship to obesity

•Obesity has been linked with the prevalence and degree of

angulation of the deformity in infantile Blount disease

•Dietz WH, Gross WL, Kirkpatrick JA. Blount disease (tibia vara):

another skeletal disorder associated with childhood obesity. J

Pediatr. 1982;101:735–737

–Retrospective study of 18 cases of children with Blount disease. Of these, 16 had

infantile Blount disease, and all the patients described as obese (>120% of ideal

body weight) had infantile Blount

•the relationship of the onset of obesity and the onset of the Blount disease could not be determined

•More than 90% of the reported cases of adolescent Blount’s disease

have been in black males who are morbidly obese

•Henderson RC, Kemp GJ, Hayes PRL. Prevalence of late-onset

tibia vara. J Pediatr Orthop. 1993;13:255–258.

–Studied all boys area high-school football teams who weighed >210 lb

•(210 lb - 95th percentile for 18-year-old males - National Center for Health Statistics)

–Of the 1117 boys, 140 boys (80 black and 60 white) met the weight criteria

–Radiographs of the seven boys who clinically screened positive showed that two

boys had adolescent Blount disease. resulting prevalence was 2.5% (two of 80

boys) in the adolescent black male population described as obese

Perthes disease – relationship to childhood obesity

•Loss of blood supply to femoral head leading to necrosis

–typically occurs in children who are between 4 and 10

years old. Boys 5:1 girls. 10% to 15% bilateral.

–4 stages: necrosis, fragmentation, re-ossification,

healed -can take years

–All require prolonged bracing or traction and some

require surgery.

–Increased risk of hip osteoarthritis later in life

•Prevalence of Obesity in Patients With Legg-Calvé-

Perthes Disease.

–Neal DC, et al. J Am Acad Orthop Surg. 2016.

–Retrospective, 150 patients

–16% overweight and 32% obese

–Obese with 2.8 times likelihood of requiring bony

operation

–Obesity common in Perthes patients and associated

with a later stage of disease presentation

Various musculoskeletal complaints

•Orthopedic specialists commonly see overweight

children complaining of hip, back, knee and foot pain.

•Overweight and obesity are associated with

musculoskeletal complaints as early as childhood: a

systematic review.

–Review article Paulis WD, et al. Obes Rev. 2014.

–40 articles included

–Concluded that “overweight and obesity are associated with

musculoskeletal pain, injuries and fractures as early as

childhood”

•More high quality prospective core studies are needed.

•Krul, M et al, Ann Fam Med Jul-Aug 2009). Musculoskeletal

problems in overweight and obese children.

–Overweight/obese children with more musculoskeletal, lower extremity and ankle

and foot problems versus normal weight

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Fractures/Sprains and Related Complications

•Obese/overweight children may have a higher risk for

fractures

– Increased forces with falls

– Awkwardness, decreased coordination?

– Possibly relatively weaker bones secondary to inactivity

•Treatment of fractures can be complicated/compromised

–traditional metal implants more likely to fail –

•Guidelines for use of elastic nails for femur fractures versus IM rods etc.

•Weiss et al 2008- Increased risk complications flexible nails with increasing

BMI - wound infections, nonunion , skin ulcers, nerve palsy, re-fracture

–crutches may be difficult to use –

•mobilization of lower extremity fractures complicated (Hayashi, 2009)

–Cast/splint immobilization may be more difficult and inadequate

•E.g. hip spica cast not effective for fatter kids

•Trouble controlling fx alignment with extremity casts -soft tissue envelope

•Timm NL, et al. Arch Pediatr Adolesc Med. 2005. Chronic ankle morbidity

in obese children following an acute ankle injury. Arch Ped Adolesc

Med 2005 -Overweight children increased Sx 6 mo post ankle sprain

Multiple studies showing increased frequency or severity of

fractures with childhood obesity

•Seeley MA, et al. Obesity and its effects on pediatrics

supracondylar humeral fractures. JBJS 96A (3), Feb 2014

–354 patients

–Obesity was associated with more complex fractures, preoperative and

postoperative nerve palsies, and postoperative complications

–Obese patients were more likely to sustain complex fractures from a simple fall

on outstretched hand.

•Goulding A, Jones IE, Taylor RW, et al. More broken bones: 4-yr

double cohort study of young girls with and without distal forearm

fractures. J Bone Miner Res. 2000;15:2011–2018

–girls, aged 3 to 15 years

–100 who had each recently traumatically fractured a forearm was compared with

a group of 100 who were fracture free.

– previous fractures, low total body area bone mineral density (g/cm2), and high

body weight each independently increased the risk of new fractures in growing

children.

–Also, spinal volumetric bone mineral apparent density (g/cm3) was a predictor of

new fractures.

– Fracture group- 8 to 19 year olds 4.7 kg (~10 lb) heavier

Impairments in mobility and balance

associated with obesity?

•McGraw B, McClenaghan BA, Williams HG, et al. Gait and

postural stability in obese and nonobese prepubertal

boys. Arch Phys Med Rehabil. 2000;81:484–489.

–Boys aged 8 to 10 years who were obese spent a greater

percentage of the gait cycle in dual stance and had diminished

dynamic stability.

•A study of 93 boys aged 10 to 21 years supported that

adolescents who are overweight have poorer balance

than those of healthy weight

–Increased risk of falling

–Difficulty halting forward progress when they began the fall

–Increased force applied to bones with fall.

•Taylor MS III found that overweight children report a

significant impairment in mobility compared to non

overweight children.

• Developmental coordination disorder (DCD)?

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Back and Spine problems with childhood obesity

•Samartzis D, et al. A population-based study of juvenile distant

generation and its association with overweight and obesity, low back

pain…. JBJS 2011

–Obesity increases the risk of degenerative disc disease by 14 times.

•A review of 65 epidemiologic studies of low back pain did report that

32% of the 65 reviewed studies showed a statistically positive link

between weight and low back pain

•Milbrandt, TA – Increased complication rates following scoliosis

surgery in adolescent girls

–Overweight and obese patients had 70% complication rate.

– Most common complication was persistent wound drainage.

–heavier girls had significantly longer surgical times and hospital stay.

•Difficult bracing for scoliosis etc.

Other –foot pain, etc with childhood obesity

•Foot pain in the obese child is not uncommon.

–Contributing to fatigue and exercise tolerance

•Overweight -increased foot length/width, decreased navicular height,

lower medial arch height, and higher plantar pressure

•a rigid idiopathic flat foot that is negative for any type of coalition or

other cause has been described in obese children.

–Could be sequelae of obesity and increased pressure on the foot with midfoot

collapse and tight Achilles tendon

The Cure:

•Parents must embrace their

responsibility to raise a healthy child

–Set a good example

–Be supportive

–Create a healthy environment

•Healthy food, exercise, family time/outings

•Limit TV, video games, computer

–NO TV in child’s bedroom !

•Adequate rest (8-9 hrs min)

–ACTIVE ; hike, swim, bike, camp, wash car,

chores, sports,etc

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The Cure:

•Schools

–PE – daily, emphasize personal fitness/cardio

– “School-age youth should participate daily in 60 minutes or

more of moderate to vigorous physical activity that is

developmentally appropriate, enjoyable, and involves a

variety of activities. (J Pediatr 2005; 146:732-7)

–Youth strength training

•Safe and effective

•OK with ACSM, AAP, NSCA

•As early as 9-10 yrs

•Not = adults; emphasize:

–Safety, form, technique, lifetime fitness, FUN

–Lighter wts/ more reps

–Core, balance

–cafeterias – nutritious choices

–Vending machines – healthy snacks, no sodas

The Cure - Exercise SCUBA

?

Play

Hiking

Sports

Additional Resources

•www.supersizedkids.com

–Super Sized Kids, Larimore MD, et al.

•www.nih.gov

•www.cdc.gov

•Am Obesity Assoc

(www.obesity.org)

•US Preventative Services Task

Force (USPSTF)

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The End

12/5/2016

1

OBESITY RELATED HYPERTENSION IN CHILDREN

Bonita Falkner, MD

Thomas Jefferson University

Philadelphia

•Disclosures: None

2-5 yr 6-10 yr 11-15 yr 16-19 yr

0

5

10

15

20

25

fBMI < 85th

f85th < BMI <95th

fBMI > 95th

Prevalence of systolic hypertension -

girls

Age grouping

SBP ≥ 95th%

2-5 yr 6-10 yr 11-15 yr 16-19 yr

0

5

10

15

20

25

BMI < 85th

85th < BMI <95th

BMI > 95th

Prevalence of systolic hypertension -

boys

Age grouping

SBP ≥ 95th%

12/5/2016

2

Sorof J, Daniels S. Obesity hypertension in children. Hypertension 40:441-55, 2004

Estimated Prevalance of Prehypertension-Hypertension in childhood

Relative to BMI Percentile

Tu et al;

Hypertension

2011

Systolic BP (mmHg) Diastolic BP (mmHg)

Age BP Percentile of Height Percentile of Height

(Year) Percentile 5th 10th 25th 50th 75th 90th 95th 5th 10th 25th 50th 75th 90th 95th

12 50th 102 103 104 105 107 108 109 61 61 61 62 63 64 64

90th 116 116 117 119 120 121 122 75 75 75 76 77 78 78

95th 119 120 121 123 124 125 126 79 79 79 80 81 82 82

99th 127 127 128 130 131 132 133 86 86 87 88 88 89 90

Blood Pressure Levels for Boys

by Age and Height Percentile

The fourth report; Pediatrics 2004

12/5/2016

3

Ambulatory Blood

Pressure Monitoring

Patient wears lightweight BP monitor that

takes BP at regular intervals for 24 hr

Readings are recorded by monitor and later

downloaded to a personal computer

Study is analyzed by comparing the

patient’s BP to a set threshold value

Equipment available for use in children

Validity confirmed in children

Metabolic Syndrome

(dysmetabolic syndrome)

Diagnosis (ICD-9 code 277.7) requires 3 or more of the following:

Obesity (BMI >95th %)

Elevated BP (systolic and/or diastolic >90th %)

Abnormal blood lipids (HDL-C < 40 mg/dl, and/or Triglycerides >

150mg/dl)

Impaired glucose tolerance (fasting glucose >100 mg/dl, 2 hr

glucose >140, or any glucose > 200 mg/dl)

(*source: modified for youth from JAMA 2002;287:356-359)

Metabolic Syndrome in Adolescents

0

5

10

15

20

25

30

35

NHANES

1988-92

NHANES

1999-00

NHANES

1988-92

NHANES

1999-00

All Adolescents Adolescents

BMI > 95th%

% Metabolic Syndrome

Duncan et al,

Diabetes Care 2004

12/5/2016

4

Effects of Obesity and High BP On left ventricular

mass in adolescents

Falkner J Peds 2013

Association of Risk Factors with Vessel Pathology

0

5

10

15

20

25

30

35

40

% of Aorta

with Fatty

Streaks

0 1 2 3 or 4

Number of Risk Factors

Berenson et al, N Engl J Med 1998

Causes of Obesity Associated Hypertension

Increased sympathetic nervous system activity

Blood pressure sensitivity to sodium intake

Microvascular injury

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5

What About Sodium?

Yang Pediatrics 2012 online

12/5/2016

6

Classification of HTN in Children &

Adolescents, With Therapy Recommendations

Pharmacologic Therapy

Normal —

Prehypertension None unless compelling indications such

as CKD, diabetes mellitus, heart failure,

LVH

Stage 1 hypertension Initiate therapy based on indications or if

compelling indications as above

Stage 2 hypertension Initiate therapy

The fourth report; Pediatrics 2004

Systolic Blood Pressure Trajectories from Childhood to Early Adulthood.

Theodore et al, Hypertension, 2015

Number to Remember

120/80 mm Hg