Obesity in Children

Julius anzar
Malnutrition:

1. Undernutrition
2. Overnutrition Obesity

Indonesia
Double Burden

Mead Jhonson seminar and workshop, March 20,2011, Horison Hotel,Palemban

 Dampak dari malnutrisi di Indonesia
(Riskesdas 2010)

STUNTED

UNDERWEIGHT OVERWEIGHT
WASTED & OBESITY

Damayanti Rusli Sjarif 2014

 Introduction
Incidence of obesity
body fat in children is
accumulation of increasing rapidly
excessive
Obesity is the Obesity is leading
cause of morbidity and
mortality
Obesity inexpensive
children
Between 25-74% frustating, difcult, and
obese children will time-consuming,
become obese overweight/ obese is
adults at risk for children who are
comorbidities in adults Treatment for

Hendricks et al. Manual of Pediatric Nutrition 3rd

 Obesity in childhood and
adolescent is important

In the future the next generation

of every nation

Mead Jhonson seminar and workshop, March 20,2011, Horison Hotel,Palemban

 Persistence of obesity: childhood into
adulthood
hitlock EP, Williams SB, Gold R, Smith PR, Shipman SA. Screening and interventions for childhood

weight and obesity in childhood and adolescence1,2,3

associated with adverse socioeconomic outcomes
ncreased health risks and morbidities
ncreased mortality rates in adulthood

Strauss RS. Risks and consequences of childhood and adolescent obesity. Int J Obes Relat Metab Disord. 1999;23(suppl
, Methven E, McDowell ZC, et al. Health consequences of obesity. Arch Dis Child. 2003;88:748752
k EP, Williams SB, Gold R, Smith PR, Shipman SA.Screening and interventions for childhood overweight: a summary of ev
US Preventive Services Task Force. Pediatrics. 2005;116(1).

Mead Jhonson seminar and workshop, March 20,2011, Horison Hotel,Palemban

Etiology of Obesity
Multi Factorial and complex

Environment
Genetic
Metabolic programming

Obesity

Taitz LS, Obesity in Mc.Laren DS, Burman D, Belton NR and Williams AF. Textbook of Paediatric
Nutrition, third Mead Jhonson seminar and workshop, March 20,2011, Horison Hotel,Palembang
ed. Churchil Livingstone UK, 1991
Global prevalence of obesity
How obesity occurs?
 Development of obesity
Positive
energy balance
Endogen
- Endocrinology:
Geneti
- Excessive caloric Food
Cushing syndrome,
intake intake
NOTcs
Parental obesity GH deficiency
MODIFIABLE
- DecreasedMODIFIABLE
physical - Syndromal: Prader
doubles the risk of
intake
90% cases
becoming obese adult Willi
- Decreased < 10% cases
Tall staturesresting
(usually - Genetics: Leptin
metabolic Short stature (usually < P5)
>P50) deficieny
Obesity family
Obesity family history:
history:uncommon
common
Mental function: often
Mental function: normal
impaired
Bone age: MODIFIABLE
normal or MODIFIABLE
Bone age: delayed
advanced
Sedentary Less physical
Physical examination:
Enviroment
Posiif energy balanced
stored as adipose tissue

Excessive energy intake

Inadequate exercise (sedentary life

style)
low metabolic rate to body composition
and mass
increased insulin sensitivity

Mead Jhonson seminar and workshop, March 20,2011, Horison Hotel,Palembang

Genetic

- gen mutation: leptin2

propiomelanocortin (POMC),
prohormone convertase (PCSK1)
reseptor melanocortin 4 (MC4R)
(130 obese 42 mutasi,2003)
-90 gen lain (2003):
ghrelin,
peroxisome proliferation-activated receptor
gamma,
uncoupling protein
beta3-adrenoreceptor
2
Montague CT, Farooqi IS, Whitehead JP, et al. Congenital leptin deficiency is
associated with severe
early-onset obesity in humans. Nature. 1997;387:903-908.
Mead Jhonson seminar and workshop, March 20,2011, Horison
Hotel,Palembang
 Obesity

Syndrome (-) Syndrome (+)

Non endocrine Endocrine
tall stature Short stature

Primary Secondary

Mead Jhonson seminar and workshop, March 20,2011, Horison

Hotel,Palembang
 Obesity and syndrome

Syndrome Signs

Prader-Willi short stature, small hands and feet, almond-

shaped eye, round face, hypogonadism,
devop. delay

Albright hereditary round face, short 4th , 5th metacarpals ,

dev.delay, osteodystrophy hypocalcemia
(pseudoparahypothyroidism)

Laurence-Moon/ retinitis pigmentosa, polydactily, short stature,

dev.
Barder-Bliedl delay

Mead Jhonson seminar and workshop, March 20,2011, Horison Hotel,Palembang

Complications of obesity
 Health condition associated with obesity
System Condition
Cardiovascul Hypertension, hypercholesterolemia,
ar hypertriglyceridemia, increased LDL, VLDL,
decreased HDL
Gastrointesti Hyperinsulinism/ insulin resistance, NIDDM,
nal achantosis nigricans, early puberty and
menarche, decreased testosterone, Cushing
syndrome, hypothyroidism
Pulmonary Pickwickian syndrome, OSAS, primary alveolar
hypoventilation
Musculo Slipped capital femoral epiphysis, Blounts
skeletal disease, osteoarthritis
Neurologic Pseudotumor cerebri, recurrent headaches
Genetic Prader Willi, Laurence Moon Biedl syndrome
factors
 What we have to do

dentification
Assessment
Prevention ( No health risk):
ntervention for Treatment (Health Risk)

Barlow SE and the Expert Committee. Expert Committee Recommendations Regarding

the Prevention, Assessment and Treatmentof Child and Adolsecent Overweight and
Obesity : Summary Report Pediatrics 2007;120; S164 S 192

Mead Jhonson seminar and workshop, March 20,2011, Horison Hotel,Palembang

1. Identification:
How to assess obesity to measure
body fat1 :
1. underwater weight measurements
2. dual energy x-ray absorptiometry
3. magneting resonance imaging
4. computed tomography
5. stable isotop methods

expensive/ not routinely

1. Goran ML, Treuth MS.Energy expenditure, physical activity, and
obesity in children.
Pediatr Clin North Am 2001;48:931-53
Mead Jhonson seminar and workshop, March 20,2011, Horison Hotel,Palembang
 Clinical findings in obesity
Heavier
Taller
Advanced bone age
Acanthosis nigricans
Gynaecomastia
Pedunculous abdomen
White/purple striae
Peripheral/truncal obesity
Burried penis
Early puberty/advanced menarche
Genu valgum
Stigmata/syndrome
Easily in clinical/ epidemiological setting

1. Skinfold thickness
2. Bioelectric impedance analysis:
- acceptable for clinical/ public health purposes
appropriate standards and available ??
3. W/L-H : - > 90th percentile on NCHS growth chart
- or W > 120% of the median (A,H,Sex)
4. BMI : W (kg)/ H (m2)
useful standard measure of adiposity

Mead Jhonson seminar and workshop, March 20,2011, Horison Hotel,Palembang

 Anthropometric measurement of
obesity
Method Definition
Body mass BMI > P95 for age and sex
index
Triceps TSF> P95 for age and sex
skinfold
measurement
Relative Mildly obese: 120-149% IBW
weight Moderately obese: 150-199% IBW
Severely obese: > 200% IBW
Growth charts Body weight increases of > 2
major percentile channels (NCHS
 BMI

snt directly measured body fat

luate as predictor adiposity in child, adoles, adult
dicts risks : present/ future medical complication
ldren - blood pressure1
- lipids2 and insulin3 levels

1. Gutin B, Basch C, Shea S et al.Blood pressure, fitness, and fatness in 5 and 6 year old
children.JAMA
1990;264:1123-7
2. Laskarzewesky P, Morrison JA, Mellies MJ et al. The relationships of measurements of body
mass to plasma
lipoproteins in school children and adults. AmJ Epidemiol 1980;111:395-406
3. Ronnema T, Knip M, Lautal P et al. Serum insulin and other cardiovascular risk indicators in
children and
adults. Ann Med 1991;23:67-72.Mead Jhonson seminar and workshop, March 20,2011, Horison Hotel,Palembang
 Body mass index (BMI)
BMI is weight (kilograms) divided by
height (meters) squared
Clinical measurement of body fat
It controls the influence of height
 Recommended Terminology1

Underweight <5th
Healthy weight 5th 85th
At risk Overweight2 85th <95th
Overweight3 >= 95th

1. Barlow SE and Expert Committee. Expert Committ

Recommendation Regarding to Prevention, Assessme
And Treatment of Child and Adolescent Overweight a
Obe sity: Summary Report. Pediatrics 2007;120:S164
2.,Overweight, 3. Obesitas. Modul Obesitas Anak dan
Remaja PS IKA.

underweight, less than the 5th percentile

healthy weight, 5th percentile up to 85thpercentile
at risk of overweight, 85th to less than the 95th
percentile overweight >95th percentile
Mead Jhonson seminar and workshop, March 20,2011, Horison
Hotel,Palembang
 BMI WHO 2005

UKK NPM : =< 5 years WHO

2005
CDC No reff data <2
years

>5
Meadyears CDCand
Jhonson seminar 2000
workshop, March 20,2011, Horison
Assessment:
Medical Risk : Child growth, Family history
Behavior Risk: sedentary, physical activity
Attitudes : concern to motivation

3. Prevention ( No health risk):

Target Behavior: problem behaviors,
current practices
Parent/ Family counseling

low SE and the Expert Committee. Expert Committee Recommendations Regarding the Prevention,
essment and Treatmentof Child and Adolsecent Overweight and Obesity : Summary Report Pediatrics
S164 S 192

Mead Jhonson seminar and workshop, March 20,2011, Horison Hotel,Palembang

Intervention for Obes child
Treatment
(Health Risk) BMI

2 7 years >= 7 years

85 <94 >=95 th 85 <94 >=95 th

th th

Comorbidity Comorbidity

Yes No Yes No

Weight WeightWeight WeightWeight Weight

maintenance loss maintenance loss maintenance loss

Pediatrics 2003;112:424-30

Mead Jhonson seminar and workshop, March 20,2011, Horison Hotel,Palembang

 Dietary Intervention
1. Balanced macronutrient/ Low energy diets
Acute treatment phase 6 12 y
Not less than 1200 kcal/day

mixed, effective for weight management

light diet
n, low density energy, free consumption
w, moderate density energy, moderate consumption
high density energy, very limited consumption (<4/W)
12 years
rovide nutrition with the lowest energy intake
00 1200 ( 1500) kcal/day

Food Guide Pyramide

Mead Jhonson seminar and workshop, March 20,2011, Horison Hotel,Palembang
Mead Jhonson seminar and workshop, March 20,2011, Horison Hotel,Palemban
Medical
1. Sibutramine
- >= 16 y
- Behavioral
Weight
side effect
long-term safety ??

2. Orlistat
effective
side effect: abd. cramp
flatus + discharge

Mead Jhonson seminar and workshop, March 20,2011, Horison Hotel,Palembang

 Bariatric Surgery
Morbid Obesity
Malabsorptive, Restrictive and combination

Recommended1
1. Physical mature
2. BMI >= 50 / >40 kg/m2 + signicant comorbidity
3. Failure to 6 mo conventional treat. (weight loss program)
4. Be capable of life style changes after surgery
5. Experience and capable to long term follow up care

Limited data (risks and benefits)

Conservative approach

TH, Krebs NF, Garcia WF et al.Bariatric surgery for severely overweight adolescents: concerns and
mendations.Pediatrics.2004;114:217-23

Mead Jhonson seminar and workshop, March 20,2011, Horison Hotel,Palemban

Summary
1. Obesity is chronic dis.

2. Early prevention/ treatment best response

3. Management:
3.1. Diet modification
3.2. Increase of physical activity
3.3. Behavioral changes
3.4. Medications
3.5. Surgery

4. Involving all family members

Mead Jhonson seminar and workshop, March 20,2011, Horison Hotel,Palemban

 BMI charts (CDC)

Obese
Obese

Overweigh
Overweigh
t
t
 MANAGEMENT OF
OBESITY IN CHILDREN
 Nutritional treatment
(food groups and childhood overweight)

Fruits and vegetable

Fruit juice

Sweetened beverages

Dairy foods & calcium

Dietary fiber
 1. Fruits and vegetables

8 cross sectional studies

The evidence was more compelling for fruits
alone or fruits and vegetables combined than
for vegetables alone in preventing obesity
Some vegetables are relatively high in energy
because of the way they are prepared
More than 1/3 total vegetable intake in US
consists of iceberg lettuce, frozen potatoes
(usually French fries), and potato chips
 2. Fruit juice
10 articles review
Intake of 100% fruit juice does not seem to
be related to childhood obesity unless it is
consumed in large quantity
Children with a higher intake of fruit juice were
more likely to have a lower Ponderal index
AAP Recommendation
(indicator
(based of weight status
on considerations analogous
of nutrient to BMI)
and gastrointestinal
condition)

Fruit juice consumption be limited to:

- 4 to 5 oz/day for children 1 to 6 years of age
 3. Sweetened beverages

US National survey soft drinks 6th leading

food source of energy among children (50% of
total beverage intake for US adolescents)
Soft drinks related to increased energy
intake
19 studies reviewed
high levels of consumption of
sweetened beverages were associated
with increased BMI
RCT: non caloric beverages inveresely
associated with BMI
 4. Dairy foods and calcium
Calcium intake was related inversely to BMI
in adult
Relation between low dietary calcium intake to
human adiposity
7 studies in children
- 4 studies: no association
- 3 studies: inverse association
Calcium intake was lower among overweight
than non overweight adolescents
Calcium intake was associated with lower
body fat
 5. Dietary fiber
High-fiber foods induce
greater satiety
Adults were recommended to consume at least
20 to 25 g of fiber per day
Children require less total energy age+5
rule e.g: a 5-y.o child should consume at least 10
g/day
Fiber-rich diets:
nonstarchy vegetables, fruits, whole grains,
legumes, and nuts effective in the prevention
and treatment of obesity in children
 Nutritional treatment
(Macronutrient altertions)
 1. Carbohydrates and fat
Very low- carbohydrate diets
seem to be more efficacious than
energy-restricted, low-fat diets over
the short term
Greater weight loss for adolescents
who were following a very-low-
carbohydrate diet, compared with an
low-fat diet, for 12 weeks
Long-term compliance issue
 2. Protein
High-protein, low-carbohydrate diet (protein-
sparing modified fast/PSMF) limited evidence
PSMF with the very low energy intake may
compromise childrens growth
PSMF is not used for long-term treatment of
overweight
PSMF diet (< 200 kcal/day) vs balanced
macronutrient diet: acute treatment phase
statistically significant decrease overweight
Atkins diet
3. Alternative approaches
3. Alternative appr.(cont.)
Glycaemic index
Food behaviours
 1. Breakfast Skipping

Obese children are more likely to skip breakfast or

to eat smaller breakfasts than leaner children
Breakfast skipping risk factor for
increased adiposity
Skip breakfast tend to consume more food later
in the day
Overweight children reported to eat smaller
breakfasts and larger dinners
Eating breakfast reduces fat intake and
limits snacking over the remainder of the day
 2. Snacking
American Diet Association:
snacking frequency might not be associated
with adiposity in children
Majority of the studies reviewed no association
between snacking and adiposity
Only fat intake from energy-dense snacks was
associated with increased BMI
1/3-1/4 total energy intake in adolescents is
derived from snacks
The primary snacks selected by teens:
potato chips, ice cream, candy, cookies, breakfast
cereal, popcorn, crackers, soup, cake, and carbonated
beverages
 3. Eating out
Consuming food away from
home, particularly at fast food
and fried food associated with
adiposity and BMI Z-score
Study in Japan:
no association
Dietary Interventions
Food pyramid
Physical activity
Modifiable component of energy
expenditure
The measurement is complex
Increasing physical activity
decreasing BMI and improved
cardiovascular risk factors
Physical activity
Physical activity (cont.)
AAP Recommendation on physical
activity:
 AAP recommendation on
Televison viewing and media usage
 Behavioural approaches
Removing unhealthy foods from the home
Monitoring behavior by asking children or parents to
keep track of the foods consumed
Setting goals for energy consumption and physical
activity
Rewarding childrens for successful changes
Training in problem solving
Multidisciplinary team of providers, including a
psychologist
Group treatment is more cost-effective
Targeting and reinforcing behavioral changes in parents
and their children was more effective than targeting
children alone
 Other interventions
1. Medication
Pharmacotherapy alone has not proved to
be an effective
obesity treatment
Medication used as part of a structured lifestyle
modification produces an average weight loss of
5% to 10%
Weight regain is common if the drug is
withdrawn
P99BMI for age threshold for very high risk
for biochemical abnormalities and severe adult
obesity candidates for more-aggressive
treatment such as pharmacotherapy
2. Bariatric surgery
Cutoff Points for 99th Percentile of BMI
According to Age and Gender
THANK YOU