Children and Obesity A

Major Health Challenge

Facing the Next Generation
Seema Kumar, MD
Associate Professor of Pediatrics
Division of Pediatric Endocrinology
Mayo Clinic, Rochester

No Financial Disclosures

Outline
Review the epidemiology of childhood
obesity
Discuss risk factors for childhood
obesity
Review immediate and long term
consequences of childhood obesity
Review strategies for prevention and
treatment of obesity in children

Definition of Overweight and

Obesity
Weight for Supine Length in < 2 years of
age
Body mass index in > 2 years of age
Between the 85th and 94th percentile:
Overweight
At or above the 95th percentile: Obese

BMI Curves for Severe Obesity in Girls

US Population
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0

1995
2005
2015

SOURCE: U.S. Census Bureau, Current P

Obesity Trends in Children and

Adolescents in US

et al. JAMA. 2014;311(8):806-814. JAMA, 295 (13): 1549-1555 and JAMA, 288 (14): 1728-1

Trends in Global Prevalence of

Childhood Overweight

Global Prevalence of Childhood

Overweight, 1960s to 1990s

Global Prevalence of Childhood

Overweight, 2000s

Prevalence of Childhood Obesity

in the US
18% of 6-11 year old
21% of 12-19 year old
The overall prevalence of obesity among youth
remained unchanged compared with that in 20092010
Obesity among children aged 2 to 5 years decreased
from 14% in 2003-2004 to just over 8% in 2011-2012
Highest prevalence: African Americans, Hispanics,
Native Americans
Ogden, et al. JAMA.
2014;311(8):806-814

Statewide Prevalence of
Childhood Obesity

Data Resource Center for Child and Adolescent Health, a project of the Child
and Adolescent Health Measurement Initiative

Severe Obesity: No plateauing

yet
Severe obesity among children 2 to 19
years increased from 1.2 % (19761980), to
3.0% (19881994), to 4.9 % (19992004)
In 2012, 5.9 % of children had severe
obesity
2.1% had very severe obesity (BMI 140 %
of the 95th percentile or 40 kg/m2)
Association with comorbidities and
persistence into adulthood
Skinner AC, Skelton JA.JAMA Pediatr. 2014;168(6):561.

Causes of Obesity
NUTRITIONAL
99%
Endocrine
Cushing syndrome
Hypothyroidism

Genetic
Chromosomal
syndromes
Single gene
disorders

Hypothalamic
Tumor
Radiation
Infiltrative/Autoimm
une

Drugs
Antipsychotics
Antiepileptics

Growth Chart an Important Tool

Increased Caloric Intake

High caloricdensity foods
Sugar containing
beverages
Supersized
portions
Eating out

Environmental Factors:
Decreased Energy Expenditure

TV
Computers
Transportation
Inadequate safe
areas for physical
activity
Sedentary lifestyle

Adverse Childhood
Experiences
Potentially traumatic events with
potential lasting impact on health
Physical, emotional or sexual abuse
Collaborative research between
Kaiser Permanente and CDC
Association with obesity

Case..
AAS (13 yr F) presents for evaluation of
obesity since age 4.
Has tried various types of diets and
exercise programs with no success
Primary amenorrhea and fatigue
Wt 114 kg BMI 54
Cyanotic ( SaO2 88%), Tachycardic (HR
120/min)
Acanthosis nigricans

Case
Blood glucose 305 mg/dL, HbA1c 11.2 %
Lipids: HDL 25, Triglycerides 522, AST/ALT
normal
Elevated androgens
Severe obstructive sleep apnea and
hypoventilation on overnight
polysomnogram
CT abdomen: Hepatosplenomegaly

Liver Biopsy: Nodular Cirrhosis

Case
Medically Complicated Obesity
Type 2 Diabetes Mellitus
Central Hypoventilation
Obstructive Sleep Apnea
Cirrhosis secondary to NAFLD
Polycystic Ovarian Disease

Medical Complications of
Obesity
Pulmonary disease
abnormal function
obstructive sleep apnea
hypoventilation syndrome

Nonalcoholic fatty liver

disease

Idiopathic intracranial
hypertension
Stroke
Cataracts

steatosis
steatohepatitis
cirrhosis

Coronary heart disease

Diabetes
Dyslipidemia
Hypertension

Gall bladder disease

Severe pancreatitis

Gynecologic abnormalities
abnormal menses
infertility
polycystic ovarian syndrome

Osteoarthritis
Skin
Gout

Cancer
breast, uterus, cervix
colon, esophagus,
pancreas
kidney, prostate

Phlebitis
www.obesityonline.org
venous stasis

Complications of Childhood Obesity

Lakshman R et al. Circulation. 2012;126:1770-1779

Prediabetes and Type 2

Diabetes
Type 2 formerly adult onset diabetes
Prediabetes seen in upto 25% of children
40% of new onset diabetes in children in
some centers

Sinha R, Fisch G,
Teague B, N Engl J Med. 2002;346(11):802.

Cardiovascular Disease Risk

Factors

Hypertension
Dyslipidemia
Endothelial dysfunction
Early aortic and coronary arterial
fatty streaks and fibrous plaques
Increased risk for major
cardiovascular events during
adulthood

Tirosh A, Shai I, Afek A, N Engl J Med. 2011;364(14

Respiratory Diseases
Causes both restrictive and obstructive
disease
Sleep apnea 7-33%
Asthma 30%

Sutherland ER. Immunol Allergy Clin North Am. 2008;28(3):589-602

Polycystic Ovarian Syndrome

Oligomenorrhea/Amenorrhea
Acanthosis Nigricans
Insulin Resistance
Hirsutism
Acne
Hyperandrogenism

Psychosocial Consequences
Social & psychological
problems
Discrimination
Poor self-esteem
Continues into
adulthood

Whitlock EP et al. Pediatrics. 2005;116(1):e125144

Gastrointestinal Manifestations
Steatohepatitis
Fatty infiltration of the liver
Can progress to fibrosis and cirrhosis
Gall bladder disease
Increased cholesterol excretion
30% of gallstones in children

Vitamin D Deficiency
Vast majority of obese teenagers are
vitamin D deficient
Low 25(OH)D levels correlate with
cardiometabolic risk markers
Scarcity of data on effect of vitamin D
supplementation on cardiometabolic risk
markers in obese children
Johnson MD, et al. Journal of Pediatrics,
2010 Mar;156(3): 444-9
Javed A et al. Pediatric Obesity, 2015

Orthopedic Conditions
Ankle, Knee and Hip Pian
Genu varum/valgus deformities
Blount Disease
bowing of legs
tibial torsion

Slipped Capital Femoral Epiphysis (SCFE)

Femoral epiphysis slips off of metaphysis

Slipped Capital Femoral

Epiphysis

Neurologic Complications
Pseudotumor cerebri
Headache, vomiting, diplopia, blurred
vision

Cancer Risk
Breast, colon, endometrium, esophagus,
kidney, pancreas, gall bladder, thyroid,
ovary, cervix, prostate, multiple myeloma
and Hodgkins lymphoma
40% for some cancers, particularly
endometrial cancer and esophageal
adenocarcinoma
500,000 additional cases of cancer in the
United States by 2030

Summary
The prevalence of childhood
overweight and obesity has
increased substantially globally
Serious morbidities, short term and
long term
Prevention of obesity is extremely
crucial

Determinants of Childhood Obesity

Tracking of obesity during

childhood

Cunningham SA, Kramer MR, Narayan KM. N Engl J Med 2014; 370:403

Risk of Obese Children

Becoming Obese Adults

What Determines Persistence of

Obesity into Adulthood

Age: higher with older age

Parental obesity
Severity of obesity:

Sleep Duration and Childhood Obesity

Chen, X. et al. Obesity, 2012, 16(2), 265-274

Prevention Initiatives
Structures within government to
support policies and interventions
Leadership, dedicated funding for
health promotion
Networks and partnerships
Standards and guidelines

Population wide policies and

initiatives
Environments that support healthy
eating and physical activity
Taxes and subsidies
Social marketing campaigns
Restrictions on the marketing of
unhealthy foods and nutrition labeling
Transport policies and school based
physical activity policies

Community Based Interventions

Multi-component interventions
tailored to the local environment
Early childcare settings, schools and
other community settings
Strong community engagement at all
stages of the process
Sustainability
Governance and transparency

School Programs
Beneficial effect on physical activity
in school or outside school (APPLE
schools in Canada)
Effects may not be sustained unless
intervention continued
No consistent effect on body weight
or BMI

School Programs
New school lunch standards by USDA
Increasing fruits, vegetables and
whole grains
Effect on eating habits and BMI
known

Catch
Overweight Early

http://www.cdc.gov/growthcharts/

Under Diagnosis of Overweight and Obesity

Nader N et al. Journal of Primary Care & Community Health

2013;5:44-49

Treatment Options for Obese Children

Lifestyle modifications cornerstone

Multi-tiered approach
Family oriented approach

Staged Treatment
Stage 1- Prevention Plus
Stage 2 - Structured Weight Management
Stage 3 - Comprehensive Multidisciplinary
Intervention
Stage 4 Tertiary Care Intervention

Barlow et al. Pediatrics Vol 120 Supplement Dec 2007 ppS164-S192

Maintain Appropriate Caloric Balance

ep it Simple for Kids and Care Givers

Which diet is most effective in achievement

and maintenance of weight loss in children?

Low Carbohydrate Diets vs Low

Fat Diet
Patient
Patient
Median
Median

Weight
lost
(kg)

LF group
Sondike at al:

LC group
J Pediatr, 2003

Sondike at al: J Pediatr, 2003

CP1286535-4

Reduced Glycemic Load Diet

Ebbeling et al. Arch Pediatr Adolesc Med. 2003;157(8): 773-77

Medical and Behavioral Weight

Loss
Medium-to-high intensity behavioral
interventions most effective
1.9 to 3.3 kg/m2 BMI difference favoring
intervention groups at 12 months

Family involvement crucial

Need for continued intervention

Whitlock EP. Pediatrics. 2010 Feb; 125(2):e396-418.

Pharmacotherapy

Only medication approved for weight

loss is orlistat (age 12 years and
above)
Should be offered only after failure of
lifestyle modifications

Orlistat
Intestinal Lumen

Mucosal Cell
SE
LIPA

LIPASE

Orlistat

MG

TG

FA

E
S
A
LIP

Bile Acids
Micelle
TG=triglyceride; MG=monoglyceride; FA=fatty acid.

Change in Mean Body Mass Index

Mean
change
in BMI

Placebo
Placebo

Orlistat
Orlistat

0
Chanoine,
Chanoine, JAMA
JAMA 2005
2005

12 16

20 24 28 32 36 40 44 48 52

Week

Orlistat Use in Obese

Adolescents
Weight loss of 6.3 kg in orlistat vs gain of
4.1 kg in control group
(Ozkan, European Journal of Pediatrics, 2004)

No statistically significant difference

between the orlistat and placebo groups
for decrease in BMI from baseline to 6
months (P = 0.39)
(Maahs, Endocrine Practice 2006)

Meta-analysis :Loss in BMI 0.7 kg/m2

(McGovern, JCEM 2008)

Other Weight Loss Medications in

Children and Adolescents
Off label use: metformin, phentermine,
topiramate
Lack of short term and long term safety
and efficacy

Candidates for Bariatric

Surgery
BMI 35 kg/m2 with major co-morbidities
DM2, moderate-to-severe OSA (apneahypopnea index >15), pseudotumor
cerebri, or NASH
BMI 40 kg/m2 with other co-morbidities
HTN, insulin resistance, glucose
intolerance, substantially impaired QOL
or ADL, dyslipidemia, OSA with apneahypopnea index >5)

Candidates for Bariatric Surgery

Failed 6 months of organized attempts at weight
management
Physiologic maturity (at least 13 years in girls and
15 years in boys)
Informed assent to surgical treatment
Be capable of and willing to adhere to nutritional
guidelines postoperatively
Commitment to comprehensive medical and
psychologic evaluations both before and after
surgery
Supportive family environment

Inge, Pediatrics 2004

Roux-en-Y Gastric
Bypass

Laparoscopic Sleeve Gastrectomy

Laparoscopic adjustable gastric band

Roux-en-Y Gastric Bypass

Equivalent safely and efficacy compared
with historic adult data
Meta-analysis (6 RYGB studies with 131
adolescents, mean BMI 51.8 kg/m2)
Significant and sustained decrease in BMI
Perioperative morbidity similar in nature
and severity to adults; severe
complications rare but reported

ne in Body Mass Indexafter Bariatric surgery in Adole

Inge TH, Courcoulas AP, Jenkins TM, et al. N Engl J Med 2015.

olution of Comorbidities after Weight Loss

gery in Adolescents

Inge TH, Courcoulas AP, Jenkins TM, et al. N Engl J Med 2015

Summary
Pediatric obesity is increasing at an
alarming rate
Pediatric obesity is associated with
significant adverse effects in childhood
and adulthood
Prevention and early diagnosis are crucial
Lifestyle modifications remain
cornerstone of therapy
Surgery and pharmacotherapy are
indicated in a small subset of patients

Unless effective population-level interventions to

reduce obesity are developed, the steady rise in
life expectancy observed in the modern era may
soon come to an end and the youth of today may,
on average, live less healthy and possibly even
shorter lives than their parents

Thank you