Comorbidities PA

COMORBIDITES OF PEDIATRIC OBESITY: 

COMORBIDITES OF PEDIATRIC OBESITY William J. Cochran, MD, FAAP Geisinger Clinic

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WHY WORR ABOUT PEDIDATRIC OBESITY?: 

WHY WORR ABOUT PEDIDATRIC OBESITY?

INTRODUCTION: 

INTRODUCTION Pediatric obesity is of epidemic proportion Pediatric obesity is the most common chronic disease of childhood

Figure IV: Percent of obese children and adolescents: 

Figure IV: Percent of obese children and adolescents

IS PEDIATRIC OBESITY A REAL HEALTH ISSUE OR JUST A COSMETIC PROBLEM?: 

IS PEDIATRIC OBESITY A REAL HEALTH ISSUE OR JUST A COSMETIC PROBLEM?

ADULT OBESITY: 

ADULT OBESITY Type II Diabetes Coronary Heart Disease Hypertension Cancer Joint Disease Gallbladder Disease Pulmonary Disease

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RISK OF CHILDHOOD OBESITY PERSISTING INTO ADULTHOOD: 

RISK OF CHILDHOOD OBESITY PERSISTING INTO ADULTHOOD Guo 1999 20% at 4 years of age 80% in adolescence

IMPACT OF CHILDHOOD OBESITY ON ADULT HEALTH: 

IMPACT OF CHILDHOOD OBESITY ON ADULT HEALTH Childhood obesity has significant impact on health in adulthood Hoffmans 1998 Dutch adolescent males followed for 32 years Increased mortality in obese vs. lean

IMPACT OF CHILDHOOD OBESITY ON ADULT HEALTH: 

IMPACT OF CHILDHOOD OBESITY ON ADULT HEALTH Mossberg 1989 Swedish adolescents studied after 40 years Increased mortality in obese vs. non-obese

IMPACT OF CHILDHOOD OBESITY ON ADULT HEALTH: 

IMPACT OF CHILDHOOD OBESITY ON ADULT HEALTH Must, 1992:Harvard growth study 13-18 year old adolescents 1922-1935, evaluated 1988 Obesity: BMI andgt;75% on at least two occasions during adolescence

IMPACT OF CHILDHOOD OBESITY ON ADULT HEALTH: 

IMPACT OF CHILDHOOD OBESITY ON ADULT HEALTH Increased all cause mortality in males and females Increased mortality from CAD in males Increased morbidity from CAD in males and females Increased risk of colon cancer in males Increased risk of arthritis in females

IMPACT OF CHILDHOOD OBESITY ON ADULT HEALTH: 

IMPACT OF CHILDHOOD OBESITY ON ADULT HEALTH Obesity in childhood was a more powerful predictor of these risks than obesity in adulthood!

CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY: 

CHILDHOOD COMPLICATIONS OF PEDIATRIC OBESITY

PSYCHOSOCIAL: 

PSYCHOSOCIAL Most common complication of childhood obesity Self Increased rates of depression Poor self esteem May carry over into adulthood Children are sensitized to obesity at young age

PSYCHOSOCIAL: 

PSYCHOSOCIAL Self Mellbin, 1989 Increased rates of behavior and learning problems in those gaining weight rapidly Etiology uncertain, ? Sleep apnea

PEER RELATIONSHIPS: 

PEER RELATIONSHIPS Richardson, 1961 10-11 year old children prefer friends with various handicaps vs. obese Staffieri, 1967 Children 6-10 years of age associate obesity with laziness Obese children may choose younger friends, less judgmental

PSYCHOSOCIAL: 

PSYCHOSOCIAL Adult Relationships May have false expectations of child based on their size

SOCIETAL DISCRIMINATION: 

SOCIETAL DISCRIMINATION Canning, 1966 Acceptance rates at college lower for obese than non-obese females with the same credentials National Longitudinal Survey of Youth 1993 Obese adolescent females as young adults had less education, less income, higher poverty rate, and decreased rates of marriage

ENDOCRINE COMPLICATIONS: 

ENDOCRINE COMPLICATIONS Non-insulin-dependent diabetes mellitus Pinhas-Hamiel 1994 The incidence of NIDDM has increased 10 fold One third of new diabetic children 10-19 years of age had Type II DM 92% of these had a BMI andgt;90% Geisinger weight management program 1-2% have type II DM

ENDOCRINE COMPLICATIONS: 

ENDOCRINE COMPLICATIONS Insulin resistance Elevated fasting insulin levels with normal Hgb A1C Ratio of fasting insulin to glucose Adult female: normal andlt;1:4 Normal for children not established First step towards developing Type II DM

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Insulin Resistance Obesity Metabolic Syndrome Syndrome Type 2DM NASH PCOS Dyslipidemia Hypertension

ENDOCRINE COMPLICATIONS: 

ENDOCRINE COMPLICATIONS Geisinger weight management program 60% have insulin resistance 10% have fasting insulin level andgt; 100 (Nl andlt;17)

ENDOCRINE COMPLICATIONS: 

ENDOCRINE COMPLICATIONS Acanthosis nigricans Velvety, hyperpigmented, thickened skin Associated with obesity and insulin resistance Not sensitive for insulin resistance Resolves with weight loss

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ENDOCRINE COMPLICATIONS: 

ENDOCRINE COMPLICATIONS Increased linear growth initially Growth plates may close earlier Advanced bone age Earlier onset of puberty

POLYCYSTIC OVARY SYNDROME: 

POLYCYSTIC OVARY SYNDROME Hyperandrogenism Ovarian dysfunction Oligomenorrhea Amenorrhea 55% of adolescent females have polycystic ovaries on US Cutaneous manifestations Hirsuitism Acne Acanthosis nigricans

POLYCYSTIC OVARY SYNDROME: 

POLYCYSTIC OVARY SYNDROME Insulin resistance Hyperlipidemia Infertility Premature adrenarche Bacha F, Arslanian S. Enod Trends 11(1)2004

HYPERTENSION: 

HYPERTENSION Hypertension Primary hypertension uncommon in childhood 60% of children with persistently elevated blood pressure had weight andgt;120% IBW Lauer J Pediatr 1975;86:697-706. Use pediatric standards Geisinger weight management program 45% have hypertension

HYPERTENSION: 

HYPERTENSION Risk Overweight adolescents have 8.5 fold risk of hypertension as adults. Srinivasan Metab 1996;45:235-240. Cardiac hypertrophy/LVH on ultrasound. Long term risk of CVD and stroke

DYLIPIDEMIA: 

DYLIPIDEMIA The atherosclerotic process beings in childhood (Bogalusa Heart Study) Lipid levels tend to track with age

DYLIPIDEMIA: 

DYLIPIDEMIA Overweight during adolescence associated with 2.4 fold increase in prevalence of cholesterol andgt;240mg/dl 3 fold increase in LDL values andgt;160mg/dl 8 fold increase in HDL valuesandlt;35 mg/dl in adults 27-31 years Srinivasan Metab 1996;45:235-240.

DYLIPIDEMIA: 

DYLIPIDEMIA Geisinger weight management program 45% have hypercholesterolemia Range of abnormal cholesterol: 175-338 Freeman 1999 65% of obese 5-10 year old children have at least one cardiovascular disease risk factor 25% of obese 5-10 year old children have 2 or more risk factors

NON-ALCOHOLIC FATTY LIVER DISEASE: 

NON-ALCOHOLIC FATTY LIVER DISEASE Hepatic steatosis Increased fat in the liver Steatohepatitis associated with liver inflammation and elevated liver enzymes 20%-25% obese children have evidence of steatohepatitis Tazawa Acta Paeditr 1997;86:238-241

INSULIN RESISTANCE AND FAT DEPOSITION: 

INSULIN RESISTANCE AND FAT DEPOSITION Insulin resistance Free Fatty Acids Insulin resistance Insulin resistance insulin Liver Muscle

NON-ALCOHOLIC FATTY LIVER DISEASE: 

NON-ALCOHOLIC FATTY LIVER DISEASE Liver disease can progress to fibrosis or frank cirrhosis 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):1356-62

NON-ALCOHOLIC FATTY LIVER DISEASE: 

NON-ALCOHOLIC FATTY LIVER DISEASE Rashid 83% of children with steatohepatitis were obese 75% had fibrosis-cirrhosis Geisinger weight management program 50 % have hepatomegaly 15% have elevated liver enzymes

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CHOLELITHIASIS: 

CHOLELITHIASIS Uncommon in children Increased risk in those with hemolytic disorders Obesity accounts for 8%-33% of gallstones in children Friesen Clin Pediatr 1989.7:294 May be associated with weight loss Crichlow Dig Dis. 1972;17:68-72

CHOLELITHIASIS: 

CHOLELITHIASIS Relative risk of gallstones in adolescent girls with obesity is 4.2 Honore Arch Surg 1980;115:62-64 50% of cholecystitis in adolescents associated with obesity Crichlow Dig Dis. 1972;17:68-72

SLIPPED CAPITAL FEMORAL EPIPHYSIS : 

SLIPPED CAPITAL FEMORAL EPIPHYSIS 50%-70% patients with SCFE are obese. Wilcox J Pediatr Orthop 1988:8:196-200 Suspect and immediately evaluate in an obese patient who presents with limp. Can also present with complaints of groin, thigh, or knee pain

SLIPPED CAPITAL FEMORAL EPIPHYSIS: 

SLIPPED CAPITAL FEMORAL EPIPHYSIS Diagnosis Physical examination Motion of the hip in abduction and internal rotation is limited on examination. Xray AP view of pelvis to include both hips Bilateral disease occurs in up to 20% of patients Medial and posterior displacement of the femoral epiphysis through the growth plate relative to the femoral neck Busch MT. Orthop Clin North Am 1987;18(4):637-47

BLOUNT’S DISEASE: 

BLOUNT’S DISEASE Diagnosis Bowing of tibia and femur either unilateral or bilateral. Etiology Results from overgrowth of the medial aspect of the proximal tibial metaphysis 2/3 of patients with Blount’s disease are obese Dietz J Pediatr 1982:101:735-737 Treatment Surgery associated with weight loss

OBSTRUCTIVE SLEEP APNEA: 

OBSTRUCTIVE SLEEP APNEA OSAS 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.

OBSTRUCTIVE SLEEP APNEA: 

OBSTRUCTIVE SLEEP APNEA 40% of severely obese children demonstrated central hypoventilation Silvesti Pediatr Pulmonol 1993;16:124-139 Abnormal sleep patterns reported in 94% of obese children studied Kahn A, Mozin MJ, Rebuffat E, Sottiaux M, Burniat W, Shepherd S, et al. Sleep 1989;12(5):430-8.

OBSTRUCTIVE SLEEP APNEA: 

OBSTRUCTIVE SLEEP APNEA Symptoms of sleep apnea Nighttime awakening / restless sleep Excessive snoring / apnea Difficulty awaking in the morning Daytime somnolence Nocturnal enuresis Decreased ability to concentrate Poor school performance. Gozal D. Sleep-disordered breathing and school performance in children. Pediatrics 1998;102(3 Pt 1):616-20.

OSAS - ETIOLOGY: 

OSAS - ETIOLOGY Increased fat mass in pharynx, neck, chest and diaphragm Increased muscle relaxation during sleep Enlarged tonsils and adenoids Silvestri JM, Weese-Mayer DE, Bass MT, Kenny AS, Hauptman SA, Pearsall SM. Pediatr Pulmonol 1993;16(2):124-9

OSAS-DIAGNOSIS: 

OSAS-DIAGNOSIS History, audio and video taping, and overnight oximetry are poor predictors The definitive diagnosis of OSAS is made by nighttime polysomnography Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. [No authors listed.] Pediatrics 2002;109(4):704-12 Severity of obstruction may not correlate with either degree of obesity or severity of sleep symptoms

OBSTRUCTIVE SLEEP APNEA: 

OBSTRUCTIVE SLEEP APNEA Children with sleep apnea demonstrate significant decreases in learning, attention span and memory Rhodes J Pediatr 1995;127:741-744. Greenberg GD, Watson RK, Deptula D.. Sleep 1987;10(3):254-62.

OBSTRUCTIVE SLEEP APNEA: 

OBSTRUCTIVE SLEEP APNEA Pulmonary hypertension,systemic hypertension, right heart failure .Tal A, Leiberman A, Margulis G, Sofer S. Pediatr Pulmonol 1988;4(3):139-43 Marcus CL, Greene MG, Carroll JL. Am J Respir Crit Care Med 1998;157(4 Pt 1):1098-103 Massumi RA, Sarin RK, Pooya M, Reichelderfer Dis Chest 1969;55(2):110-4

OSAS - TREATMENT: 

OSAS - TREATMENT Weight loss Willi SM, Oexmann MJ, Wright NM, Collop NA, Key LL Jr. Pediatrics 1998;101(1 Pt 1):61-7 Continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BPAP) Tonsilladenoidectomy

PSUEDOTUMOR CEREBRI: 

PSUEDOTUMOR CEREBRI Definition Raised intracranial pressure with papilledema and a normal cerebrospinal fluid in the absence of ventricular enlargement Obesity occurs in 30%-80% of children with psuedotumor cerebri Scott Am J Opth 1997; 124:253-255

PSUEDOTUMOR CEREBRI: 

PSUEDOTUMOR CEREBRI May present with headaches, vomiting, blurred vision or diplopia Neck, shoulder, and back pain have also been reported Lessell S. Surv Ophthalmol 1992;37(3):155-66 Papilledema is part of pathology but may not occur at presentation

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John A Moran Eye Center, Salt Lake City UT

PSUEDOTUMOR CEREBRI: 

PSUEDOTUMOR CEREBRI 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):1681-6. Increased intracranial pressure may lead to visual impairment or blindness.

PSUEDOTUMOR CEREBRI: 

PSUEDOTUMOR CEREBRI Weight loss Newborg B. Arch Intern Med 1974;133(5):802-7 Acetazolamide Lumboperitoneal shunt in severe cases

CONCLUSIONS REGARDING PEDIATRIC OBESITY: 

CONCLUSIONS REGARDING PEDIATRIC OBESITY

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PEDIATRIC OBESITY IS NOT JUST A COSMETIC PROBLEM!

COMPLICATIONS ARE COMMON IN PEDITRIC OBESITY: 

COMPLICATIONS ARE COMMON IN PEDITRIC OBESITY All children with BMIandgt; 95% should be evaluated for associated co-morbidities Physical examination BP Fundiscopic exam Hip and knee examination Acanthosis nigricans Hirsutism / acne Hepatomegaly

COMPLICATIONS ARE COMMON IN PEDITRIC OBESITY: 

COMPLICATIONS ARE COMMON IN PEDITRIC OBESITY Laboratory evaluation Fasting lipid profile Liver panel Fasting insulin and glucose Hgb A1C To be considered Polysomnogram Abdominal US

THANK YOU!: 

THANK YOU!

SCFE: ASSOCIATED CAUSES: 

SCFE: ASSOCIATED CAUSES Continued weight gain Renal failure History of radiation therapy Primary hypothyroidism Loder RT, Greenfield ML.. J Pediatr Orthop . 2001;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):729-34

Pseudotumor Cerebri - Associated Conditions: 

Pseudotumor Cerebri - Associated Conditions Mastoiditis. Lateral sinus thrombosis. Hypoparathyroidism, Steroid treatment and withdrawal. Thyroid replacement, SLE. Green M. Pediatr Clin North Am 1967;14(4):819-30. Palmer RF, Searles HH, Boldrey EB.. J Neurosurg 1959;16(4):378-84. Baker RS, Baumann RJ, Buncic JR. Pediatr Neurol 1989;5(1):5-11. Walker AE, Adamkiewicz JJ. JAMA 1964;188:779-84. Neville BG, Wilson J.. Br Med J 1970;3(722):554-6. Huseman CA, Torkelson RD.. Am J Dis Child 1984;138(10):927-31. DelGiudice GC, Scher CA, Athreya BH, Diamond GR.. J Rheumatol 1986;13(4):748-52.

Drugs Associated With Pseudotumor Cerebri: 

Drugs Associated With Pseudotumor Cerebri Growth hormone therapy Nalidixic acid,Ciprofloxacin,Tetracycline therapy No clear dose-response relationship Lessell S. Surv Ophthalmol 1992;37(3):155-66. Vitamin A and isoretinoin therapy are established causes of pseudotumor cerebri. Morrice G Jr, Havener WH, Kapetansky F. JAMA 1960;173:1802-5. Roytman M, Frumkin A, Bohn TG. Cutis 1988;42(5):399-400.