GRACE C. PAGUIA, MD DPPS DPBCN

Nutrition Dilemmas, WEIGHT MANAGEMENT IN CHILDREN AND ADOLESCENTS: THE EXISTING GUIDELINES GRACE C. PAGUIA, MD DPPS DPBCN

Overweight & Obesity in Pediatrics Nutrition Dilemmas, q results from a chronic state of positive energy balance due to an excess of nutritional intake relative to energy expenditure

Definition Overweight BMI between 85 th - 94 th percentile for age and gender - z score of >+1 (WFA/BMIFA) Obese BMI at or >95 th percentile for age and gender - zscore > +2 (WFA/BMIFA) The Journal of Clinical Endocrinology and Metabolism, Prevention and Treatment of Pediatric Obesity:An Endocrine Society Clinical Practice GuidelineBased on Expert Opinion

PSPGHAN, 2012; Preventive Pediatrics PPS

Prevalence of obesity in the Philippines 8 th National Nutrition Survey Results: 2008 to 2013, total overweight children: 3% to 5% 2013: from 0 to 6 years old: 5%

Obesity in pediatric patients St. Luke s Medical Center 1995 vs. 2012

St. Luke s Weight Management Center Approach to weight loss Diet Exercise Psychological Drugs Combination Surgery Tan- Ting AM, Llido LO. Outcome of a hospital based multidisciplinary weight loss program in obese Filipino children. Nutrition 2011; 27(1): 50-4.

St. Luke s Weight Management Center Tan- Ting AM, Llido LO. Outcome of a hospital based multidisciplinary weight loss program in obese Filipino children. Nutrition 2011; 27(1): 50-4.

St. Luke s Weight Management Center Conclusion: The use of a multidisciplinary 3- mo staged program resulted in an effective weight loss in obese Filipino children, which was directly related to the frequency of sessions attended. Tan- Ting AM, Llido LO. Outcome of a hospital based multidisciplinary weight loss program in obese Filipino children. Nutrition 2011; 27(1): 50-4.

St. Luke s Weight Management Center Tan- Ting AM, Llido LO. Outcome of a hospital based multidisciplinary weight loss program in obese Filipino children. Nutrition 2011; 27(1): 50-4.

Management of childhood & adolescent Obesity Childhood Obesity predisposes to: 1. insulin resistance 2. Type 2 Diabetes 3. Hypertension 4. Hyperlipidemia 5. Liver disease 6. Renal disease 7. Reproductive dysfunction Inge TH, King WC, Jenkins TM, et al. The effect of obesity in adolescence on adult health status. Pediatrics. Dec 2013;132(6):1098-104

Common Goals of Management Reduction of dietary calories and fat increasing dietary fiber Diets that are lower in carbohydrates may be useful in some individuals basic goal should be reduction in energy intake and increase in energy expenditure Any increase in physical activity is good, with regular aerobic exercise being the goal decrease in television viewing and computer games

Recommendations by the American Academy of Pediatrics (AAP) 5 : servings of fruits and vegetables per day 2 : 2 hrs of screen time 1 : 1 hour of physical activity per day 0 : no added sugar from beverages make water accessible

Weight Recommendation according to age and BMI Percentile ASPEN Core curriculum 2015

Physical Activity/Lifestyle Modification American Academy of Pediatrics Philippine Pediatrics Society Recommends that children and teens should be "physically active for at least 60 minutes per day," At least 30 minutes 1 hour of physical activity/ excercise

Nutrition Dilemmas, Controversies & Issues

Physical Activity Nutrition Dilemmas, Controversies & Issues

Philippine Dietary Referrence Intake PDRI 2015 Includes nutrient requirements and intakes The end points are to ensure nutrient adequacy and prevention of deficiency as well as avoid excess

Physical Activity American Academy of Pediatrics exercise programs, including active free play and organized team and individual youth sports Get the whole family involved Philippine Pediatrics Society Increased number of times of PE classes per week.(>3x a wk) Promotion of sports in the community (playgrounds and sports fest) PPS Policy Statements 2009

Physical Activity American Academy of Pediatrics encourage use of active transportation Play active video games Philippine Pediatrics Society Limit Screen time to 2 hours a day

Dietary Modifications 5 servings of fruits and vegetables per day Reducing saturated fat intake for children > 2yrs old (30% of total energy) Avoiding sugary beverages Eating timely and regular meals Portion control The Journal of Clinical Endocrinology and Metabolism, Prevention and Treatment of Pediatric Obesity:An Endocrine Society Clinical Practice GuidelineBased on Expert Opinion

Pinggang Pinoy FNRI DOST fnri.gov.ph

Pharmacologic Intervention Considered if a formal program of lifestyle intervention has failed to prevent weight gain or modify comorbidities Should be done in coordination with lifestyle modification Offered by experienced clinicians The Journal of Clinical Endocrinology and Metabolism, Prevention and Treatment of Pediatric Obesity:An Endocrine Society Clinical Practice GuidelineBased on Expert Opinion

NICE guidelines pharmacologic intervention not generally recommended for children <12 years. <12 years = drug treatment may be used only in exceptional circumstances, if severe comorbidities are present. Prescribing should be started and monitored only in specialist pediatric settings Obesity: identification, assessment and management of overweight and obesity in children, young people and adults NICE clinical guideline 189

NICE guidelines pharmacologic intervention >12 y/o: treatment with orlistat is recommended only if physical comorbidities i.e. orthopedic problems or sleep apnea or severe psychological comorbidities should be started in a specialist pediatric setting, by multidisciplinary teams with experience of prescribing in this age group. Obesity: identification, assessment and management of overweight and obesity in children, young people and adults NICE clinical guideline 189

NICE guidelines pharmacologic intervention Do not give orlistat to children for obesity unless prescribed by a multidisciplinary team with expertise in: drug monitoring psychological support behavioral interventions interventions to increase physical activity interventions to improve diet

NICE guidelines pharmacologic intervention If orlistat is prescribed for children, a 6 12- month trial is recommended, with regular review to assess effectiveness, adverse effects and adherence.

Indications for Weight Loss Surgery in Adolescents BMI >40 with comorbidities BMI >50 with more minor comorbidities Failed more than 6 months of organized weight loss attempts Skeletal maturity Reference: Baker C, et al (2005)

Weight Loss Surgery: Laparoscopic Adjustable Gastric Banding in adolescents, greater percentage of patients achieving a loss of 50% of excess weight, compared with lifestyle intervention. 50 patients aged 14-18 years with BMI higher than 35 kg/m 2, 21 patients (84%) in the gastric banding and 3 (12%) in the group assigned to supervised lifestyle intervention lost more than 50% of excess weight, corrected for age. [Best Evidence] O'Brien PE, Sawyer SM, Laurie C, et al. Laparoscopic adjustable gastric banding in severely obese adolescents: a randomized trial. JAMA. Feb 10 2010;303(6):519-26

Surgical Intervention: Laparoscopic Adjustable Gastric Banding Overall, the mean changes in the gastric banding group were a weight loss of 34.6 kg, representing an excess weight loss of 78.8%, 12.7 BMI units, and a BMI z- score change from 2.39 to 1.32. [ The mean losses in the lifestyle group were 3 kg, representing an excess weight loss of 13.2%, 1.3 BMI units, and a BMI z- score change from 2.41 to 2.26 [Best Evidence] O'Brien PE, Sawyer SM, Laurie C, et al. Laparoscopic adjustable gastric banding in severely obese adolescents: a randomized trial. JAMA. Feb 10 2010;303(6):519-26

Indications for Weight Loss Surgery in Adolescents Nutrition Dilemmas, 1. The child has attained Tanner 4 or 5 pubertal development and final or near- final adult height. 2. The child has a BMI greater than 50 kg/m2 or has BMI above 40 kg/m2 and significant, severe comorbidities. 3. Severe obesity and co- morbidities persist despite a formal program of lifestyle modification, with or without a trial of pharmacotherapy. The Journal of Clinical Endocrinology and Metabolism, Prevention and Treatment of Pediatric Obesity:An Endocrine Society Clinical Practice GuidelineBased on Expert Opinion

Indications for Weight Loss Surgery in Adolescents Nutrition Dilemmas, 4. Psychological evaluation confirms the stability and competence of the family unit. 5. access to an experienced surgeon in a medical center employing a team capable of long term follow- up of the metabolic and psychosocial needs of the patient and family 6. The patient demonstrates the ability to adhere to the principles of healthy dietary and activity habits The Journal of Clinical Endocrinology and Metabolism, Prevention and Treatment of Pediatric Obesity:An Endocrine Society Clinical Practice GuidelineBased on Expert Opinion

Indications for Weight Loss Surgery in Adolescents ESPGHAN 2015, Indications and Limitations of Bariatric Surgery in Pediatrics

NICE guidelines surgical intervention Surgical intervention is not generally recommended in children or young people. Bariatric surgery may be considered only in exceptional circumstances, and if they have achieved or nearly achieved physiological maturity. Obesity: identification, assessment and management of overweight and obesity in children, young people and adults NICE clinical guideline 189

NICE guidelines surgical intervention Surgery for obesity should be undertaken only by a multidisciplinary team that can provide pediatric expertise in: preoperative assessment, including a risk- benefit analysis that includes preventing complications of obesity, and specialist assessment for eating disorder regular postoperative assessment, including specialist dietetic and surgical follow up Obesity: identification, assessment and management of overweight and obesity in children, young people and adults NICE clinical guideline 189

NICE guidelines surgical intervention management of comorbidities psychological support before and after surgery information on or access to plastic surgery (such as apronectomy) when appropriate access to suitable equipment, including scales, theatre tables, Zimmer frames, commodes, hoists, bed frames, pressure- relieving mattresses and seating suitable for children and young people undergoing bariatric surgery, and staff trained to use them.

NICE guidelines surgical intervention All should have had a comprehensive psychological, educational, family and social assessment before undergoing bariatric surgery. Perform a full medical evaluation, including genetic screening or assessment before surgery to exclude rare, treatable causes of obesity. Obesity: identification, assessment and management of overweight and obesity in children, young people and adults NICE clinical guideline 189

NICE guidelines surgical intervention Monitoring of obesity comorbidities (respiratory problems, atherosclerosis, insulin resistance, type 2 diabetes, dyslipidemia, fatty liver disease, psychological sequela) in children and young people with obesity is limited because of the lack of dedicated tier 3/4 paediatric obesity services in the UK. Centralised collection of cohort data is lacking in the UK when compared with elsewhere in Europe (Flechtner- Mors 2013) and the USA (Must 2012). Current data on longer- term outcomes (more than 5 years) in young people undergoing bariatric surgery are also sparse (Lennerz 2014, Black 2013), demonstrating a need for research in this area.

Similar recommendations from AAP, PPS, PSPGHAN, ESPGHAN, ASPEN, NICE 1. 60 mins daily vigorous activity 2. Balanced, age appropriate amount of food (avoidance of sugary drinks; reduction of saturated fat intake in kids >2 3. Medication and surgery is recommended for adolescents who have reached physical maturity or have severe comorbidities(type 2 diabetes, dyslipidemia, fatty liver)

Summary Nutrition Dilemmas, Physical activity: 60 mins/day Dietary restriction of sugary beverages & saturated fat Pharmacologic intervention Surgical intervention: AAP PPS/PSPG HAN ASPEN ESPGHAN NICE Endocrine society + (orlistat, metformin?)

What can we say? Surveys are needed to determine the local practice in the management of obese and overweight children Further studies on bariatric surgery for children Dietary modifications should be based on patient s measured intake. Very controlled energy diets cannot be recommended for the vast majority of children and adolescents with obesity due to uncertainties in long term effects on growth and reproductive development. Lifestyle modifications should involve the whole family and even the community

References Nutrition Dilemmas, ASPEN Pediatric Core Curriculum 2014 8 th National Nutrition Survey FNRI/DOST 2013 American Academy of Pediatrics Policy Statement. Active Healthy Living: Prevention of Childhood Obesity Through Increased Physical Activity. PEDIATRICS Vol. 117 No. 5 May 2006, pp. 1834-1842.The President's Council on Physical Fitness and Sports. Exercise and Weight Control Tan- Ting AM, Llido L, Outcome of a hospital based multidisciplinary weight loss programin obese Filipino children, Nutrition (2010), doi:10.1016/j.nut.2009.11.028 Obesity: identification, assessment and management of overweight and obesity in children, young people and adults NICE clinical guideline 189; 2014 Fundamentals of Pediatrics, 2014 Philippine Pediatric Society Policy statements 2009 Nelson s Textbook of Pediatrics 19 th edition The Journal of Clinical Endocrinology and Metabolism, Prevention and Treatment of Pediatric Obesity:An Endocrine Society Clinical Practice GuidelineBased on Expert Opinion O'Brien PE, Sawyer SM, Laurie C, et al. Laparoscopic adjustable gastric banding in severely obese adolescents: a randomized trial. JAMA. Feb 10 2010;303(6):519-26 Inge TH, King WC, Jenkins TM, et al. The effect of obesity in adolescence on adult health status. Pediatrics. Dec 2013;132(6):1098-104

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