Obesity Comorbidi.es: It s About Your Health, Not Your Weight. Elizabeth Estrada, MD Pediatric Endocrinology

Transcription

1 Obesity Comorbidi.es: It s About Your Health, Not Your Weight Elizabeth Estrada, MD Pediatric Endocrinology

2 Conflict of Interest NOTHING TO DISCLOSE

3 Objec.ves 1. Recognize the most common comorbidi.es associated with childhood obesity. 2. Improve skills for screening and management of obesity comorbidi.es in the pediatric popula.on. 3. Understand the pathophysiology of obesity comorbidi.es

4 JAMA Pediatr. 2014;168(6): Prevalence of severe obesity has con.nued to increase Overweight: 32.2% Obesity: 17.3% Obesity Class 2: 3.8 to 5.9% Obesity Class 3: 0.9 to 2.1%

5 Obesity Classifica.on: Percent of the 95 th percen.le American Heart Association Scientific Statement Aaron S. Kelly et al. Circulation. 2013;128:1689 Severe Obesity Class 3: BMI > 140% of the 95th percen5le or BMI > 40 kg/m2, whichever is lower Severe Obesity Class 2: BMI % of the 95th percen5le or BMI = 35-39, whichever is lower Obesity: BMI % of the 95th percen5le and BMI < 35 whichever is lower

6 BMI Charts Alka K. Gulati et al. Pediatrics 2012;130:

7 Obesity Epidemic Is Genera.ng Another Epidemic Obesity Comorbidi.es

8 Childhood Obesity Associated Condi.ons Type 2 diabetes and pre-diabetes PCOS Metabolic syndrome Hypertension Hyperlipidemia Non-alcoholic fafy liver disease Sleep apnea Asthma Orthopedic complica.ons: Joint pain SCFE, Blount s disease Gallstones Depression, body image Ea.ng disorders Cancer GERD

9 Addi.onal Complica.ons Associated with Obesity More visits to emergency room Longer hospital stay during intercurrent illness More frequent anesthesia and surgical complica.ons Higher health care expenditures

10 Risk Factors For Obesity Comorbidi.es

11

12 POWER (Pediatric Obesity Weight Evalua8on Registry) Ini.ally sponsored by the Children s Hospital Associa.on (CHA) Currently housed at Cincinna. Children s Mul.disciplinary teams from weight management programs 13 Sites Data from 6737 pa.ents with a BMI >95th pc.le

13 75% pa.ents presented with Obesity class 2 or 3 Groups more impacted by severe obesity: Males Preschool age Black race Public/Medicaid insured Most pa.ents presented with significant comorbidi.es Jasik et al. Childhood Obesity 11(5): , 2015

14 Class 3 obesity was associated with higher odds for abnormal: Hemoglobin A1c ALT LDL, HDL and triglycerides Insulin Systolic blood pressure Jasik et al. Childhood Obesity 11(5): , 2015

15 POWER Late to care! Youth with obesity present to weight management programs when they already have severe obesity and significant comorbidi.es

16 Cross-sec.onal analysis of data from overweight or obese children (3 to 19 y) Na.onal Health and Nutri.on Examina.on Survey from 1999 through 2012 N= % were overweight 36.4% class I obesity 11.9% class II obesity 4.8% class III obesity

17 Severity of obesity was associated with higher risk for: Low HDL High BP High triglycerides High glycated hemoglobin Prevalence of cardiometabolic risk factors was higher among boys than girls

18 More than 37,000 men Mean follow up 17 y through the Staff Periodic Examina.on Center of the Israeli Army Medical Corps Star.ng at 17 y Outcomes: Angiography-proven coronary heart disease Diabetes

19 Elevated BMI in adolescence has dis.nc.ve rela.onships with type 2 diabetes and coronary heart disease Diabetes: influenced mainly by BMI and weight gain at.me of diagnosis Coronary heart disease: elevated BMI in adolescence and at.me of diagnosis were independent risk factors Hypothesis: The processes causing coronary heart disease, par.cularly atherosclerosis, are more gradual than those resul.ng in diabetes Findings may suggest that diabetes preven.on programs and those for coronary heart disease should be designed differently

20 Screening for Depression and Self-Concept E Estrada, M Santos. Children Par8cipa8ng In Weight Management Programs Should Be Screened for Medical and Psychological Co-Morbidi8es AAP Na8onal Conference. Boston, MA The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Piers-Harris is a self report measure assessing how children and adolescents view their behavior and personal quali8es

21 Not all factors influence comorbidi5es, but the constant across all studies is severity of obesity Guidelines should be stra5fied based on obesity severity, more aggressive for class 2 and 3 Preven5on remains the primary goal in the management of obesity Iden5fying and trea5ng complica5ons associated with obesity is also of great importance

22 Some of My Pa.ents 21 y old AA male presents to Hartford Hospital Stroke Center with stroke Diagnosed with type 2 diabetes at 15 y 25 y old AA male with retinopathy, nephropathy and an amputated toe Diagnosed withy type 2 diabetes at 13 y His sister became my patient with type 2 diabetes at 12 y

23 Obesity And Disease Pathogenesis

24 Obesity And Disease Pathogenesis Lipotoxicity and inflamma.on Adipokines released from white adipose.ssue are inflammatory and lipotoxic Gene.c predisposi.on FTO gene: browning of adipocytes Switch from storage to energy u.liza.on Ethnic background Asian popula.on: Higher risk for CVD and diabetes at lower BMIs Mexicans: higher rates of fafy liver

25 Obesity And Disease Pathogenesis Fat distribu.on: OSA correlates with neck circumference, independent of BMI Intraabdominal/visceral adipose.ssue is a marker for insulin resistance and dyslipidemia Abnormal bone and car.lage metabolism Non-weight bearing joins are affected by osteoarthri.s

26 The Healthy Obese Some obese pa.ents are metabolically normal (2-50%) Lower waist circumference Lower triglycerides and higher HDL Healthy obese are 5.mes more likely to develop metabolic complica.ons than non-obese

27 Screening for Childhood Obesity Comorbidi.es

28 PEDIATRICS Volume 120, Supplement 4, December 2007 Screening recommenda5ons for children with BMI >95 th percen5le: Fas5ng lipid profile Fas5ng glucose AST, ALT

29 Shortages of pediatric subspecialists Inadequate access to care for obesity comorbidi.es Lack of tools for the primary care provider

30 Topics Ini8al evalua8on Lipids Liver enzymes Hypertension PCOS

31 Lipid Management

32 LDL-c Management Triglyceride Treatment

33 Liver Enzymes

34 Hypertension

35 PCOS Evalua.on

36 PCOS Treatment

37 Childhood Obesity Treatment Is there hope?

38

39 Case C.F. Age 13 y Type 2 diabetes Insulin + oral meds HTN Lisinopril Hyperlipidemia Lipitor PCOS OCP Back pain Pain meds Age 16 y Necrobiosis lipoidica diabe5corum Yigit, S., Estrada, E. J Peds 141(2):280, 2002

40 Case C.F. Six months post -bariatric surgery: Lost 70 lb. BMI down to 48 from 60 HgbA1c: 6.9% Minimal insulin requirements No oral meds Normal BP no meds Normal lipids no meds

41 15 y old girl presents with type 2 diabetes BMI 42 kg/m 2

42 Follow-up BMI HbA1c % % % % (off meds) %

43 These pa.ents are s.ll obese, why healthier? How Much Weight To Lose?

44 Weight loss of 5% to 10%: Profound benefits and is more frequently achievable The Diabetes Preven.on Program: Mul.center study 3,234 adult with pre-diabetes Follow up 4 years: Each kilogram of weight lost decreased the risk of progressing from pre-diabetes to diabetes by 16%

45 Look AHEAD study 5% to <10% weight loss in overweight and obese individuals with T2DM Significantly improved CVD risk factors and hepa.c steatosis at 1 year Quality of Life showed improvement beginning with modest weight loss

46 Sleep AHEAD study (subset of Look AHEAD for OSA) The Significant reduc.on in apnea index at 1 y in pa.ents who lost 10% weight

47 Non-alcoholic steatohepa..s (NASH) Promrat K, et al. Hepatology. 2010;51: Lifestyle interven.on in subjects with histologically proven NASH 9.3% weight reduc.on at 48 weeks was associated with histologically improvement in NASH ac.vity score

48 Modest weight loss, 5% to 10%, can produce health improvement Associated with selec.ve mobiliza.on of visceral adipose.ssue Dispropor.onate 30% decrease visceral vs subcutaneous fat Goal for weight-loss effort: 10% Once the 10% goal has been achieved, another goal can then be set

49 Beyond Lifestyle Changes

50 Teen-LABS (Teen-Longitudinal Assessment of Bariatric Surgery) Mul.center study Longitudinal data on teenagers undergoing bariatric surgery 3 year follow up data N = 242 adolescents Roux-en-Y gastric bypass par.cipants Sleeve gastrectomy 67 par.cipants Inge TH et al. N Engl J Med 2016;374:

51

52 Inge TH et al. N Engl J Med 2016;374: Mean total body-weight loss of 27% Remission of: Type 2 diabetes in 95% Abnormal kidney func.on in 86% Prediabetes in 76% Hypertension in 74% Dyslipidemia in 66% Adverse events: Ferri.n deficiency in 57% Addi.onal abdominal procedures in 13% No deaths

53

54 Conclusions Children with obesity need to be screened for comorbidi.es Providers should ac.vely inquire for symptoms of comorbidi.es (OSA, pain) Factors associated with higher risk for comorbidi.es Degree of obesity Medicaid insurance Non-White race Older age Male Modest weight loss may results in significant improvement in health status

55 YES! There is hope Manchester, CT Road Race FINISH LINE!

56