ADOLESCENT

Obesity: Management
NOR HASLINDA ISHAK

SUPERVISORS:
DR RAZLINA
Objectives
1. To define obesity in childhood and adolescent
2. To know the causes of obesity in childhood and adolescent
3. To know the complication of obesity in childhood and adolescent
4. To know how to manage obesity in childhood and adolescent
5. To know treatment options for childhood and adolescent obesity
6. To know when to refer
Case scenario.
An 11 year old boy, Harith, came for review of symptom. He has
been recently admitted to the general paediatric unit with an acute
exacerbation of asthma. His symptoms have improved. His lungs
are clear. You noted he weighs 82kg and is 1.6m tall.

1. What should you do next?

2. Evaluate Hariths weight using the CDC growth charts provided:
What is Hariths BMI percentile? How is his weight status classified?
Introduction
Malaysia: Prevalence of obesity in children and
adolescents
20.7%
1. in 26.5% in 2008 in 6-
34.2%
(reported in
20022 12 year-old
2011) 1

1. Wee et al. BMC Public Health 2011,

11:333
2. Ismail MN, Ruzita AN, Norimah AK,
Poh BK, et al: MASO 2009 Scientific
Conference on ObesityTee et al, 2002
 Being an obese adolescent was
associated with an increased
risk of multiple comorbidities in
adulthood even if the obesity
did not persist.2

Almost half of overweight

adults were overweight as
children. 1
Etiology of childhood obesity

GENETIC???

ENVIRONMENTAL FACTORS
 Genetic Influence
Greater similarity seen in monozygotic twins than dyzygotic twin
Childs BMI relates better with biologic parents
Child with one obese parent had 5 fold increase risk of becoming
obese adult.
Child with 2 obese parents had 12 fold increase risk

National Centre for Social Research (2005) Obesity among children under 11. Department of Health Publications.
London
Evaluation of obesity in children and adolescents is important for
several reasons:-
Prevent the progression of the condition and its related co
morbidities into adulthood.
Genetic and hormonal causes of obesity warrant consideration,
although rare.
Prevention of psycho-social problems e.g. low self-esteem.
To instil healthy lifestyle in children and their families throughout
their life.
Evaluation of Obesity
History
Do a complete history including HPI, past medical history,
medications, family history, development, immunizations, allergies
and social history.
For an adolescent include a HEEADSSS assessment.
 Identify Family factors
Familys nutritional patterns and finances
Shopping habits
Frequency of family meals and who is present at meals
Whether foods are self-serve or served by parent/caregiver
How child spends time after school, and who supervises this time
Work schedules of parents or other caregivers
Meal location
Whether television or other media is used during meals
Assessment to identify a few key dietary
habits
1. Frequency of eating meals in restaurants
2. Intake of calorie containing beverages
3. Frequency and portion size of energy-dense foods
4. Servings of vegetables and fruits
5. Number of meals each day, and frequency of skipping meals
6. Typical snacking patterns
7. School lunch
 Activity assessment
Brief qualitative assessment of physical activity &
sedentary activity patterns
Sedentary behaviors
Hours watching television, playing video games
Hours on computer
Hours talking on telephone or texting
Hours doing productive sedentary behaviors, such as homework, reading,
and computer-based learning

Physical activity behaviors

Type, frequency, duration, and intensity of structured physical activity
Time spent in unstructured play
 Barriers to activity and
opportunities for increasing physical activity
Home
Television in bedroom
family physical activity routines
access to and frequency of free play and organized sports

School
Physical education classes

Lifestyle activity
Current habits that require walking or use of stairs
Physical examination
Physical exam, including assessment of vital signs
Weight and height taken with the patient dressed in a hospital gown,
to calculate BMI
Comparison of patients BMI with diagnostic criteria and recording on
a growth chart
Waist circumference
Examine for cushingoid facies, acanthosis nigracans, striae, and a
buffalo hump.
How to define obesity in
children
WHO definition:
Overweight : BMI 85th
percentile
Obesity : BMI 95th percentile
Severe obesity: BMI 99th
percentile, or >120 percent of
the 95th percentile
Longitudinal weight gain
A rapid increase in BMI is an
important predictor of future
obesity even in children who are
currently within a healthy weight
category
 Waist circumference

simplest clinical measure of central obesity

midway between the lowest rib and the superior border of the iliac crest with
an inelastic measuring tape at the end of normal expiration
WC is age dependent
interpreted against appropriate established reference standards
Case scenario continue
Hariths mother states He is only a little bit fat, I dont understand
what all the fuss is about, why is it so bad anyway?

3. How would you respond to this mother?

Case scenario continue.
Hariths mother states Ok dr, what are you going to do next?

4. Is there any investigations you would like to oder for Harith? State
your reason.

5. How do you manage Hariths obesity problem?

What is the goal for your management?
What are your treatment plans?
 Fatty liver Ds

Non alcoholic fatty liver disease is the most common cause of chronic liver disease in children and adolescents in
the US
Detected by U/S in about 50% of obese children
Raised liver enzymes in about 25% Shneider BL et al. Hepatology 2006
Loomba R et al, Hepatology 2009
Higher prevalence of IGT, T2DM, metabolic
syndrome with higher liver fat content
 When to screen for diabetes mellitus?
Children and adolescents who are overweight (BMI >85th percentile for
age and sex, or weight >120% of ideal) and have any two of the
following risk factors should be screened for pre-diabetes and diabetes.
Family history of T2DM in first- or second- degree relative
Maternal history of GDM
Ethnicity (those of Indian ethnic background are at higher risks of
developing T2DM) 1 (Level III)
Signs of insulin resistance or conditions associated with insulin
resistance (acanthosis nigricans, hypertension, dyslipidaemia, PCOS)

Malaysian Clinical Practice Guidelines for the Management of Type II Diabetes Mellitus, 2009.
 Other investigations

Lipid profile
Liver function test
Ultrasound liver
Management of Childhood
Obesity
Garispanduan Pelaksanaan
Perkhidmatan Kesihatan
Remaja di Peringkat
Kesihatan Primer, 2009
GARIS
PANDUAN
PENGURUSAN
MASALAH
BERAT BADAN
BERLEBIHAN
REMAJA

Garispanduan Pelaksanaan
Perkhidmatan Kesihatan
Remaja di Peringkat
Kesihatan Primer, 2009
 The aim is to reduce the amount of body fat.
Children who are growing, and thus gaining both height and weight, often
do not need to lose weight. They can maintain their weight and be allowed
to grow into it.
Older adolescents who have attained their final height should make efforts
to lose excess weight.
The components of obesity management in children and adolescents are:
Reduction of energy intake by dietary modification
Increase energy expenditure by increasing physical activities and decreasing physical
inactivity.
Behaviour modification associated with eating habits and activity pattern.
Involvement of the family in the process of change.
 Goals of treatment
children and adolescents who are overweight or mildly obese :
maintaining current body weight
BMI > 99th percentile with comorbidities
2-11 y.o : weight loss of up to 1 pound per month
Adolescents: weight loss up to 2 pounds per week ( 1-2 pounds per month
more realistic
emphasize behavior goals for specific dietary habits and activities
Components of a Successful Weight Loss Plan
Reasonable weight-loss goal
Dietary management
Physical activity
Behavior modification
Family involvement
Malaysian Dietary Guidelines for Children and Adolescents, 2013

Key recommendation for dietary

Encourage overweight and obese children to practise healthy eating.
Eat according to calorie recommendations by age, sex and physical activity
level.
When hungry, eat only to satisfy needs but do not overeat.
Eat 3 main meals per day, plus 1 or 2 nutritious snacks between meals. Avoid
skipping meals as it will lead to eating bigger meals or snacks later.
Replace calorie-dense foods with healthier options.
Eat smaller serving sizes of high calorie foods.
Replace sugar sweetened beverages with plain water or low fat milk.
Avoid using special diets such as meal replacements, slimming tea or pills to
reduce weight as they can cause side effects.
 Behavioral intervention
Family-centered communication
engage the family in a conversation to select specific behaviors to change

Motivational interviewing
The clinician employs reflective listening to encourage patients to identify their own
reasons for making a behavior change, as well as their own solutions.
Clinicians should help the family focus on specific and achievable behavioral goals

Focus discussion
focus discussion on health consequences, such as persistence of obesity into
adulthood, reduced mobility or athletic ability, and any personalized health concerns
experienced by the patient and family.
Malaysian Dietary Guidelines for Children and Adolescents, 2013

Physical activity
Children and youth aged 5 to 17 should accumulate at least 60 mins
of moderate to vigorous-intensity physical activity daily. (WHO, 2010)
Those who are overweight or obese should involve in moderate to
vigorous-intensity physical activity for 30 to 40 minutes per day and
for at least 3 to 5 days a week.
Physical activity can be designed to create realistic goal that they can
build over time
Exercise for 10 minutes initially then increase to 15 minutes per week

Developmental Family Personal

stage schedule preferences
Malaysian Dietary Guidelines for Children and Adolescents, 2013

Key recommendation 1
Be physically active everyday in as many ways as you can
How?
Walk or cycle to school.
Engage in some physical activity during school, especially during recess time.
Participate actively during physical education classes.
Help with household chores, such as sweeping, washing your own school
shoes and mopping the floor.
Choose to walk up the stairs, instead of taking the lift or escalator.
Whenever you have free time, engage in outdoor activities with your family
and friends.
Malaysian Dietary Guidelines for Children and Adolescents, 2013

Key recommendation 2
Accumulate at least 60 minutes of moderate-intensity physical activity
daily.
How?
Allow young children to play as much as possible in a safe outdoor environment.
Emphasise participation and enjoyment, rather than competition and winning, when
conducting structured sports programmes for pre-schoolers.
Encourage to engage in moderate-intensity activities, such as playing badminton,
riding a bicycle, rollerblading, brisk walking or a game of catch and throw.
Encourage to engage in vigorous-intensity activities suitable for their age, such as
running and chasing, football, basketball, tennis, swimming, riding a bicycle, jumping
rope, martial arts (e.g. taekwando, karate) or vigorous dancing.
Accompany children for longer walks, visits to park or swimming pool and bike rides
during weekends.
Malaysian Dietary Guidelines for Children and Adolescents, 2013

Key recommendation 3
Participate at least 3 times a week, in activities that increase muscle and bone
strength.
Muscle-strengthening by age group are as follows:
a. Children below 7 years: Playing at playground, adult supervised exercises (e.g.
squats, chin-ups, crab walk, jumping jacks).
b. Primary school-aged children and adolescents: Climbing trees/ walls, playing at
playground (e.g. monkey bars), push-ups, pull-ups, sit-ups, tug-o-war or
working with resistance bands.
Moderate physical activities that help to strengthen bones by age group are as
follows:
a. Children below 7 years: Jumping, hopping, skipping or running.
b. b. Primary school aged children and adolescents: Hopscotch, jumping rope,
running, gymnastics, basketball, volleyball or tennis.
Malaysian Dietary Guidelines for Children and Adolescents, 2013

Key recommendation 4
Limit physical inactivity and sedentary habits.
Discouraged from extended periods of inactivity and should not be
sedentary for more than 60 minutes at a time.
Limit screen time to not more than two hours a day. For example: Watching
television, playing video games and using the computer or surfing the
internet.
If children are into electronic games, encourage them to play active video
games rather than sedentary ones.
More severe obesity: Non-competitive active games ( moderate levels of
physical activity, replacing sedentary time )
walking program (boosted by use of a pedometer or walking partner
trial memberships at local gyms
home fitness videos, and non-traditional sports such as yoga, tai chi, fencing, and
martial arts
Nitendo Wii (activity levels achieved is modest, but certainly higher than sedentary
activities)

Typical goals in adults are to walk more than 10,000 steps a day to improve
health.
measure current step counts using the pedometer and then set a goal of increasing
the number of steps by approximately 10 percent
Case scenario continue
Hariths parent ask about using over-the-counter diet aids and
surgery to lose weight.

6. What would you tell them?

Pharmacologic intervention: Limited role
IN ADDITION TO LIFESTYLE INTERVENTION
Orlistat (Dec 2003) Obesity in children 12-
17 years
Side effects ++

Metformin (Dec 2000)

NOT approved for obesity RX
For obese T2DM children >10 y.o

Sibutramine (1997)
Obesity in children >16 years
Removed from market in Oct 2010
 Bariatric surgery systematic review
Gastric banding (13 studies) Sleeve gastrectomies, vertical
mean decreases in BMI : 8.5 to banded gastroplasty,
43 kg/m2 biliopancreatic diversion, or a
combination of procedures (14
weight gain reported in 1 case articles)
study.
mean BMI decreases 9 to 24
kg/m2
Roux-en-Y gastric bypass (RYGB) (8 weight regain in several cases,
studies) and 3 deaths related to surgery.
Mean BMI reductions ranged
from 9 to 25 kg/m2

Clin Obesity. Published online March 3, 2011

Bariatric surgery - complications
ulcers, intestinal leakage, wound infection, anastomotic stricture,
nutritional deficiencies, bowel obstruction, pulmonary embolism,
disrupted staple lines, band slippage, psychological sequelae, and
repeated vomiting.
postoperative complications, compliance and follow-up may be
more problematic in adolescents than adults, and availability of long-
term data on safety, effectiveness and cost-effectiveness remains
largely unknown

Clin Obesity. Published online March 3, 2011

Pending an improvement in the quality of available
evidence, a cautious approach to child and
adolescent bariatric surgery is warranted, and
reversible techniques are advisable compared to
approaches that permanently alter anatomy

Clin Obesity. Published online March 3, 2011

Case scenario continue
7. What would you assess during follow-up?
 Follow up
Measurement of body mass index (BMI)
plotting of results on a BMI chart to track changes over time

Routine assessment of all children for obesity-related risk factors

to allow for early intervention

Signs of eating disorder/ depression/ low self esteem

 When to refer?
severe obesity
Overweight/obesity with comorbidities
All children with T2DM (Paed endocrinologist)
depression (psychologist/ Psychiatrist)
Conclusion

Health care providers plays an important role in combating obesity.

T2DM is often asymptomatic. Appropriate screening should be done in high risk
individuals.
Obese children with comorbidities especially T2DM should be referred to
Paediatric Endocrinologist for further management
Lifestyle changes is the first line treatment for obese children and adolescents.
Pharmacological treatment for childhood obesity is very limited.
A cautious approach to adolescent bariatric surgery is warranted in view of high
risk of short term and long term operative complications.
Thank You!!!